Floating Doctors

Experiences and Benefits

It is so hard to know what to expect when going to practice in a place and in conditions so far removed from what we experience in the UK. However, I approached this elective ready to throw myself into any and every opportunity and to stretch my knowledge and learning beyond the UK medical curriculum.

A lot of patients that I was able to see on this placement were not complicated. They did not have exotic tropical diseases, or particularly unusual symptoms, they had regular problems, like diabetes and hypertension and headaches and backaches. The learning and differences came with how these problems had come about and how we could treat them with limited tests, limited pharmacy and little chance of follow up. This could be frustrating, but it was a very good way to challenge my understanding of disease pathology and drug mechanisms and encouraged lateral thinking for management. For example, a lady in her 80s has walked 2 hours from a neighboring village and presents with signs of heart failure.

In UK guidelines we have the 4 pillars of heart failure, but in our pharmacy box we only have enalapril, and dapagliflozin. The patient reports drinking only 2 glasses of water a day and has protein urea on a urine dip text. We have no way of testing her kidney function, but it is presumably poor from the history and urine dip, so we don’t give the ACEi. We can still give the dapagliflozin, but will that make much difference on its own? We could just treat her symptoms – oedema of her legs and lungs – with a diuretic, but we only have furosemide, which again could hurt her kidneys and might lower her blood pressure and put her at a falls risk. We would not be able to review this patient until the floating doctors return in 3 months time. So, I learned to weigh up the risks and benefits and evaluate a new type of patient lifestyle. Probably we give this lady a low dose of ACEi and SGLT2 that might address some of the heart failure and some of the symptoms, without putting her at too much risk of drug side effects, and advise her to drink more water.

Interestingly people in these communities were not often particularly receptive to lifestyle modifications as treatment solutions. I think there are several parts to this: 1 is that they have learned to expect medications from doctors not advice; 2 is that some of the lifestyle modifications aren’t feasible – the 70yr old farmer cant just stop farming to rest his back, because it’s his family’s source of food and income, there is no other support and no holiday pay; 3 is that there isn’t the level of health understanding to understand why it is so important to drink so much water, or to reduce the amount of plantain you eat if you’re diabetic. I definitely feel I have witnessed similar resistances in the UK, however, not so frequently as in rural Panama. This was certainly a challenge to overcome in patient consultations, and an even bigger challenge for my Spanish language proficiency.

Often with the assistance of other doctors and translators, we could reach an understanding with the patient. Sometimes we would offer 15 paracetamol tablets as light symptom relief and so the patient felt they had had some treatment. Is this the most ethical practice to prescribe paracetamol all the time? In an ideal world, I wouldn’t want to give any medicines that weren’t completely necessary, however these communities are not getting over-the-counter medicines like we would in the UK, so they have no way of managing their symptoms without the lifestyle advice or the medicines we give. If we give nothing and they don’t follow our advice we risk them losing trust in the service and not returning when they have worse problems, or advising friends and family not to come. Maybe paracetamol is just a placebo for these people, but it is doing more than just pain management or satisfying patient wishes, and that is important to remember with a lot of health care – it requires a holistic view of the patient and the world they come from.

I did, of course, learn a little about tropical diseases. Every 2 weeks there is a medical ‘charla’ – a medical teaching chat for all the people at floating doctors including lay people and other doctors from a variety of backgrounds. I helped another student and junior doctor to research and present on leishmaniasis after we saw a patient with a potential infection in their leg. It was exciting to learn about a new disease and to practice talking to people on different levels of medical understanding, as well as discussing how everyone would approach this in different settings vs how we approached it in the remote community. It was also enjoyable to do weekly case sharing and discuss patients we had seen in community throughout the week. I learned about TB testing and spoke about a woman with an unknown abdominal tumor, we discussed a baby with hydrocephalus and shared a lot of our thoughts, ideas and reflections on the clinic we had provided. This was a very good way to learn and share feelings, our love of patients and medicine.

I didn’t just get an insight into the Panamanian health care. I felt like this placement reawakened a lot of my sense of adventure and lust for learning and experience that had maybe dulled in the repetition of ward based learning at home. I was supervised and taught by doctors from across the globe, and learned from their experiences and the treatment pathways they are used to. I got to learn about different medical training and hospitals and care systems in the US, in Spain, in Netherlands, in Denmark, in Columbia, to hear about the many pathways through medical careers people had taken and the paths they had travelled. I got to see and learn about the doctor I aspire to be, all these people with all this different knowledge and all these experiences all sharing their passion for medicine and patients. It reaffirmed how much this is the career I want, how much I love people and patients, and learning at work.