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Retaining my licence to practise medicine in UK

I have just completed fifty sessions of general practice in an inner city practice in Leicester. This demonstrates that I intend to continue to work as a GP here, so I can remain on the “Performers’ List”. My work will be appraised annually and I will hopefully be successfully revalidated (every five years) by the responsible officer in Leicestershire. This means I can keep my licence to practise medicine in UK. Of course, as well as seeing patients, I still have to do at least 50 hours of continuing professional development, audits, reflection, feedback and planning my personal development, just like all full-time GPs in UK.

If I stopped working as a GP in UK, I would have to find another way of being appraised and revalidated. Although I would still be registered with General Medical Council as a doctor, I could not practise in UK. I would be prevented from working as a doctor overseas, too. What country would permit a foreign doctor (me) to work there if that doctor was not allowed to work in their own country?

The GMC insists I do not need a licence here if I want to work abroad.

Medecins Sans Frontieres insists I do need a licence to work here before I can be posted overseas.

I honestly don’t think that the GMC fully appreciates the problems created by the new regulations for a few doctors who volunteer or work for aid agencies overseas. But as Saul found out (Acts 26:14), “it is hard to kick against the pricks”, so I did the required fifty sessions. And I quite enjoyed it.

Working in GP here in UK is just like a curate’s egg. http://upload.wikimedia.org/wikipedia/commons/3/3d/True_humility.png (Bishop: “I’m afraid you’ve got a bad egg, Mr Jones”. Curate: “Oh, no, my Lord, I assure you that parts of it are excellent!” George du Maurier, originally published in Punch, 9 November 1895.) Some bits are good, others are bad.

This post will now become a “listicle” – defined by the Oxford Dictionary (and just included in the Dictionary last week) as “an Internet article presented in the form of a numbered or bullet-pointed list” – comparing and contrasting health care in Leicester and Mfuwe.

  • Even working in England, not all my patients speak English. At every surgery session, I need to have an interpreter helping me to communicate with at least one patient. In Zambia, 99% of the patients at the health centre were Zambian but most of those who completed primary school could speak a little English. My patients in Leicester are much more cosmopolitan, mostly originating from the Indian subcontinent, but some from Eastern Europe and Africa (even one from Zambia). I suspect that more than a few patients here nodded their heads politely as if they understood what I was talking about, just like in Zambia.
  • The work of a General Practitioner is incredibly complicated. Not only do GPs have to deal with clinical, psychological and social aspects of the patient’s problems, they have to feed the computer with data which is accurate (and complete enough to protect you from being sued) and they need to liaise with a fragmented army of specialist nurses to co-ordinate the patient’s care. The more information you have, the more difficult it can be to formulate what the problem is and how best to manage it. All this has to be done in ten minutes.
  • This is impossible unless you know the patients well and there is good continuity of care. Unfortunately, few young doctors want to become partners in a general practice. There are many more doctors working temporarily in surgeries, acting as locums. This corrodes the strength of traditional general practice, where the doctors knew their patients well.
  • In Zambia, consultations usually consist of simple problems, such as deciding if someone needs a malaria test or not, and acting on the result, lancing an abscess or suturing a laceration. Apart from having a different doctor every three months, the continuity at Kakumbi Health Centre in Mfuwe is provided by the nursing staff posted to the centre, usually for several years.
  • Computer systems contain so much information that it can be difficult to find what is important among the dross. For some reason, the most popular clinical programme used by Leicester GPs, SystmOne, insists on recording entries by district nurses or health visitors, twice. In different colours. The computer screen is awash with checklists mostly recording the absence of some factor. Usually GP notes are brief and to the point, avoiding long lists of “negatives”. In contrast, medical records in Zambia are very simple, consisting of handwritten entries in a school exercise book. If a patient doesn’t want a record made of their sexually transmitted infection, they destroy the old book and get a brand new one which doesn’t contain the sensitive information.
  • A great deal of time is spent in both settings collating clinical data and submitting reports. It may be heresy, but I wonder about the true value of this activity, which takes clinicians away from patients and does not seem to result in improved services.
  • It can be difficult for patients to access care at their general practice in UK because of the limited number of appointments with doctors, nurses and health care assistants. If you want to see your doctor and telephone the practice after 10 am, you might be told to ring back tomorrow because today’s appointments have all been allocated. In Zambia, the patients might find it difficult to get to the health centre because of lack of public transport, but once they arrive, they will sit and wait until they see the doctor or nurse. It was not unusual for a nurse and doctor at Mfuwe to see over 150 patients in a day.
  • Financial considerations are important in both countries. UK primary and secondary care are trying to cut £20 billion from the annual cost of the NHS Budget by next year. The entire Gross Domestic Product in Zambia was just £13.4 billion last year, but the Ministry of Health is still trying to save money, hopefully by spending it more efficiently, rather than just cutting the supply of drugs.
  • Medication prescribed by GPs is costly. The clinical commissioning group in Leicester tries to cut costs by pressurising GPs to change their prescribing habits. Generic drugs are usually cheaper than branded versions (for example paracetamol vs Panadol), but not always – Ventolin inhalers are cheaper than generic salbutamol inhalers, for asthma. Standard tablets cost less than modified release capsules, but need to be taken several times a day. Just when the health authority has decided, for example, that the cheapest version of simvastatin is Simvador, and encouraged GPs to save the NHS some money by switching their prescribing, the prices change yet again. I seem to have spent a lot of time trying to chose the best drug for my patients, taking into account all these factors as well as what the patient wants, and still I get a message on the computer screen suggesting another option. If I ignore this message, the practice might have to justify it to a prescribing advisor. In Mfuwe, we often lacked the most basic drugs for common illnesses such as hypertension and diabetes. Sometimes, the only “choice” was to suggest the patient might travel 120km to Chipata to buy drugs at a pharmacy.
  • I used to enjoy doing minor surgery for my patients in Leicester as well as in Mfuwe. It didn’t pay well, but the patients in Leicester appreciated it. However, it still costs the practice time and money to do minor operations, whereas referring the patient to hospital costs the practice nothing. Different budget, you see?
  • Finally, I must say I have found the patients to be courteous and grateful in both Leicester and Mfuwe.

Medecins sans Frontieres still has me on their books and I have been offered a posting to a remote part of India, close to the Myanmar border. Last month, a posting to Swaziland fell through at the last minute. I am not counting my chickens before they are hatched. I will write again once I have more concrete information.

On the road

Photographs from my trip to Mambwe to say goodbye to the District Medical Officer, Dr Zulu.

The new road from Mfuwe to Chipata. I can see for miles and miles

The new road from Mfuwe to Chipata. I can see for miles and miles

Kamoto Mission Hospital built by the United Reformed Church of Zambia, and run by the government.

Kamoto Mission Hospital built by the United Reformed Church of Zambia, and run by the government.

I like the bicycle park in the hospital grounds.
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Mission Hospital Mission Statement. I love the "bouncing baby bit"

Mission Hospital Mission Statement. I love the “bouncing baby bit”

The shops have a predominantly religious theme to their names. I like the “Small beginnings” shop. The invoices from the Faith Kills Fear shop have missed off the Fear bit, giving a more quixotic emphasis.

Some other travellers on the road

I need to start packing…

Last night in Zambia

It’s my last night. I have had my farewell sundowner at Kapani Salt Pans, been serenaded with “For he’s a jolly good fellow” and received a great present – coffee table book of photographs from the valley. I had my last game drive this morning and saw half a dozen lions and a leopard, as well as the usual wonderful animals.

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I am still convinced I have been bewitched. Someone has put a spell on the vehicles I drive. In the past ten days, I have had four punctures in three different cars. A device which keeps one of the belts running in the engine fell off. The petrol pump failed, because of a dodgy sensor. I’ve been informed that white folks are immune to local witches, but perhaps I am seen as indigent now and have become susceptible. I ought to consult a more powerful witch.

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I have had a wonderful time here. Everyone, without exception, has been kind and supportive. My efforts have been appreciated. I tried to be a good GP to the people in the valley and an efficient, compassionate clinician at the health centre. Having said this, I did meet some strange folks.

I don’t want to sound like a London cabbie (“I had that Russian Ambassador in the back of my cab last month. Diamond geezer he was, an’ all”), listing all the minor celebs who have stayed here at the Lodge. I did meet a Chinese TV production team who spent most of their time taking selfies or photographs on the latest tablets, even when they were eating. They were all decked out in the latest US fashions. I wonder what the people of Beijing will think of their film.

Another group of Chinese visitors arrived at 5pm one evening, after the afternoon game drive had departed. They decided to take a stroll in the park. On foot. Without a torch. They managed to walk a few kilometres without being eaten, before someone picked them up and took them to safety. Another Chinese amateur photographer walked upto within a metre of a male elephant which had strayed into the lodge grounds. He needed a wide-angle lens, never mind his head examining. Even the lodge staff were too afraid to pull him back in to safety. He survived.

An Australian family with three hyperactive young boys caused havoc at the lodge last month. The parents looked frazzled and probably needed a holiday after this one. The boys climbed over two walls and walked across the dried up mud of the lagoon to the small rivulet where I have seen crocodiles. Amazingly, all three returned safely. Even the croc was intimidated by their behaviour.

I met the financial director of the medical school in Lusaka, who found it almost impossible to persuade a restaurant to accept his order for dinner to be ready at the regional capital at 10pm.

I was sceptical when a homeopathic doctor claimed to have treated over fifty people successfully for malaria with remedies. When the same doctor asked me for some strong painkillers for a minor injury, I was even more sceptical.

Tonight there was a flying plastic surgeon who does a power of good treating patients throughout the country. He is the only plastic surgeon in Zambia. No Zambian surgeons want to train in this specialty for some reason.

Some people love Zambia with an extreme passion. One guest has visited this National Park eight times in twelve years, staying here at the lodge. She did 18 game drives on her last visit.

Harrison, the barber with attitude

Harrison, the barber with attitude

No visit to a country is complete for me without my having a haircut. It has been over three months since my last cut. I went to one of the hairdressers in the village and asked if he could cut muzungu hair. He said he could, and we negociated a price. Now, 50p is at the bottom of the range of prices for my haircuts across the world. So I should have guessed that the quality would match the price. I asked for a trim. He proceeded to oil the electric clippers and shave off a swathe of hair.

“Can you put that back on again, please?” I asked him.

“No, you are the doctor, you can do that for yourself,” he replied.

There was no going back now. The reggae music on the radio set his foot tapping and he completed a dodgy number two cut in about five minutes. The new doctor, who was looking on in horror, said, “I’m dreading having my hair cut at some time during the next three months.”

Performance Management at the Health Centre

Kakumbi Rural Health Centre

Kakumbi Rural Health Centre

We had a meeting at Kakumbi Rural Health Centre last month, chaired by the Public Health Officer, Mr Chulu. He had just returned from a regional meeting which discussed how well each health centre was meeting its targets. I was fascinated by his report on our failings, which had been pointed out by the health planners.

Extrapolating from the data of the last census, six years ago, the health planners expect us to deliver 44 babies each month in the clinic. Mr Chulu had plotted our data on a bar chart, showing how miserably we had performed. One month, we only managed 19 deliveries. An arrow drew our attention to this shorter column, with a speech bubble saying, “What happened here, team?” My facetious answer was, “Not a lot, nine months previously.” This went down like a lead balloon.

We discussed other possible reasons for our underperformance. More women might be giving birth at home or in the local hospital where they can do Caesarian Sections. But our referral rate for C-Section is just 2%, not enough to account for the discrepancy. Home births do occur, because women living far from the health centre do not want to walk or bicycle (!) in labour at night, as they are frightened of meeting hippos or elephants en route. We know about these births because the women bring their newborns for vaccinations at the health centre or outreach Mother and Child Health clinics. We did not know how many there were because we had not been asked for these figures. All it needed was to compare our immunisation ledger with our birth ledger.

There was a suggestion that the reason for some clinics’ “poor” performance was that the women were voting with their wombs. In other words, if the women did not like the attitude of midwives, or felt they were not being respected, they would not attend. They would reject the services of a dirty or inefficient clinic. This caused some murmurings of dissent among the clinical staff at the meeting.

Baby Clinic - far from unpopular with the mothers

Baby Clinic – far from unpopular with the mothers

Health planners sometimes forget the human factor. For example, on the Thai/Myanmar border, more Karen babies are born in the final quarter of the year than in all the other three quarters put together. This is because the first quarter of the year is a slack period in the agricultural calendar. Putting it bluntly, the farmers have more time and energy to have sex during these months. I reckon that nine months from now there will be fewer births because of the present Football World Cup. “What happened here (to your) team?”

I asked Mr Chulu how the Ministry came up with these figures. He didn’t know how they had arrived at the numbers, but felt he had to accept their accuracy. Our locality is not typical of Zambia. It is a boom town, with lots of people coming to the area because of the jobs provided by the tourist industry. There are more single men, more commercial sex workers, higher rates of HIV infections and more disposable income. We discussed whether this might have been taken into account by the planners, but decided it probably hadn’t.

Kakumbi is the lucky recipient of a Swedish International Development Agency programme to support obstetrics. By the end of the year, we will have a new maternity block and a shelter for women at the end of their pregnancy who live far from the health centre.

Family planning animator

Family planning animator

After half an hour’s fruitless discussion we moved on to the second item on the agenda. This was our over performance in Family Planning. We regularly use up our entire stock of DepoProvera injections half way through the month, and have to requisition further supplies from less successful Family Planning clinics in the area.

Female Condoms for All

Female Condoms for All

“Wait a minute,” I interjected. “If we are seeing more women for Family Planning, this is going to reduce the birth rate. Surely this is an additional reason explaining the gap between the numbers of observed and expected deliveries.”

“Well, yes it could, doctor,” said Mr Chulu. “But the planners say we are still exceeding our targets in prescriptions of the contraception pill and DepoProvera.”

“Is that a bad thing,” I asked.

“Yes, because they haven’t increased our supplies of Family Planning items. You don’t understand how we do things in Zambia. We should be meeting the targets set by HQ, not exceeding them or falling short.”

Good grief, I said to myself. Is stultifying bureaucracy and the dead hand of the civil service the heritage we Brits have bequeathed to this brave new country? It is worse than the CQC.

Today the beast I have most enjoyed seeing is the Buffalo

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The Cape Buffalo looks mean. Its wide horns form a boss as they meet in the middle on the forehead. Beetle-browed, they resemble Martin Johnson, the Leicester Tigers and England rugby player. I once saw him shopping in Asda – MJ, not the buffalo – and you could shelter from the rain under his superciliary ridges.

This bone, in front of the brain, is so dense that only special bullets can penetrate it. In order to carry the heavy weight, the front feet are broader than the back feet.

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It looks even more out of proportion as the body seems too long for it. A bit like a stretched limo. With horns. Big males (kakuri) can weigh 900kg when fully mature. Unlike water buffaloes in India and South East Asia, the Cape Buffalo has never been domesticated.

As the water sources in the hills are drying up, buffalo herds move down into the valley at this time of year to drink. The smaller herds coalesce into a massive herd with up to 500 individuals, moving en masse towards the Wafwa or other ox bow lakes in the Park. If they cross the dirt road in front of me, the dust kicked up makes it difficult to see them. As it clears, I can feel their eyes upon me as they turn to inspect the car.

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There is not much safety in numbers. Buffalo are lions’ favourite food, providing enough nourishment to satisfy a large pride, like the Mwamba, for three days. Sometimes the lions will capture a buffalo calf, but let it cry out to attract the mother to her doom. Buffaloes are powerful creatures, but they lack manoeuvrability and stamina. Once they are tired, the lions can attack with impunity, often eating chunks out of the buffalo while it is still alive and standing.

Hunters find buffaloes wily prey. They have a reputation of being very aggressive when wounded and will turn on their pursuers, sometimes doubling back in a wide circle to attack the hunters from behind.

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12° 53′ 51″ South, 31° 56′ 53″ East

12° 53′ 51″ S, 31° 56′ 53″ E. These are the precise co-ordinates where Phyllis came to a gradual halt. I was doing an emergency home visit to see a patient in Lion Camp, about 42 km from the main gate. The engine cut out and I glided to a halt. The power steering failed, making it difficult to pull off the narrow track. It was 16:40 on Sunday afternoon and I was in a bit of a pickle. There was no cell phone coverage this deep into the South Luangwa National Park. I didn’t have a radio. I sat in the car and contemplated my fate.

Emma, the Lion Camp manageress, had called me out for the medical emergency, so she knew I was coming. I had told Mushroom Lodge where I was going. But as the tracks are not signposted, I could have strayed far from the route. The best advice I had been given was to “keep the river on your right”. Surely they would realise when I hadn’t appeared by 17:00 that something was wrong and they would send out a search party, eventually. Until then I just had to sit and wait.

But I didn’t. I clambered onto the roof of Phyllis and took a good look around. Nothing but what Dr John Seaman used to call “MAMBA” – Miles And Miles of Bloody Africa. But no lions, so far so good. Sadly, I am not the best spotter of predators and the dull, grey-brown of their skin perfectly matches the colour of the dusty earth. The Hollywood pride could be within 30 metres, perfectly camouflaged.

Maybe I could get Phyllis’s engine started again. I turned the ignition, the engine whirred and clattered to a halt. It sounded like there was no fuel, but the gauge showed a good quarter tank. I opened the bonnet and had a look at the engine. It was totally bewildering. Where was the line feeding petrol to the engine?

I remembered the words of the bloke who used to service my old Volvo. I had told him what I thought was the problem. He said, “Stick to diagnosing people, let the expert mechanic diagnose what’s wrong with your car.”

The red oil pressure light had come on, so I checked the dipstick. Plenty of oil. A few days ago, something fell off the bottom of the engine, stopping various belts from working. It was replaced, and I checked the belts were all tight and in position. Not that I could do much if they weren’t; I wasn’t wearing tights.

So what was around me? Through the bushes to my right was a lagoon. Animals come to drink water at sundown. Lions and leopards set up ambushes near watering holes. Stay in the car, then. Check the rear view and side mirrors to see if any predators are creeping up to use Phyllis as a hiding spot before pouncing on unwary antelopes.

Listen for noises. Was that a baboon alarm call? Cape Turtle Doves incessantly cooing, “Work Harder, Work Harder.” Or at this time of day, “Drink Lager, Drink Lager.” No hippo grunts, leopard coughs or lion growls to be heard. Just the swishing of wings as a group of black headed herons fly over my head into a big ebony tree to roost in the topmost branches. Then silence. That gave me an idea. Perhaps if I make a noise, anyone in the area will notice. I parped out S-O-S in Morse code on the car horn. Three long, three short, three long – or is it the other way round? But if people were in the vicinity, they would be driving in a vehicle and I’d hear their engine, which would also drown out the sound of my horn.

Herons on high

Herons on high

Does anyone remember those team building awaydays, popular when the NHS had a bit of money a decade ago? The team exercises designed to give insight into group decision making? “Your plane has made an emergency landing in the desert, and luckily you have survived unhurt. Which three of the following articles will you take with you?” Lightweights chose the bottle of coke. I picked the raincoat. And no one picked the shaving mirror, which would be idea for flashing to alert passing aircraft. Ah, how about removing that daft mirror on the front passenger wing to help with parking to flash passing aircraft? Come to think of it, I haven’t seen an aeroplane for nearly three months, so that’s a non starter.

This was not the time to get maudlin and morose. Why don’t I keep my pecker up by playing some music? What’s on my MP3 player? Leonard Cohen comes up at random. Not such a good idea, spin the dial again. Just what I needed, Rod Stewart singing American classics, “S’Wonderful, S’Marvellous.” Check the time. I’ve been here just 30 minutes.

Was this to be my last sunset? Obviously not, I am still around to write this after the event.

Was this to be my last sunset? Obviously not, I am still around to write this after the event.

But where exactly am I? My new Canon 6D has a GPS feature. I normally keep it off because it drains the battery quickly, but I switched it on, took a snap of the sunset and read the data. 12° 53′ 51″ South, 31° 56′ 53″ East. Now I know where I am. I get the map out of the glove compartment and work out that I am just three kilometres south west of Lion Camp.

Walkable? Yes, but would I survive? I have Andy’s super strong Lenser torch, but apart from blinding any lions by the side of the track, it just would show them where I was. Bad idea. I’d just have to stay here until they sent out search parties. I could manage a cosy night in with Phyllis. There were two cans of mosquito repellent in the glove compartment. I’d be alright.

Then I saw dust ahead. It was the best view I had had from a car since seeing Slough in my rear view mirror on the M4. A vehicle drew up and stopped, waiting for me to get out of the way. The Zambian driver thought I was just some tourist, parked up to watch birds and the sunset. He looked annoyed and pulled off the road through the bush and passed me. I waved at him through the window, “I can’t move. I’ve broken down.” He nodded but just drove on. “Oi! I need help. Can you radio Lion Camp and tell them the doc is stuck at this location?” I think they heard.

Emotional roller coaster, or what? I reclined the seat and went back to my music. About twenty minutes later, Gavin from Lion Camp arrived with a gang of lads. They rigged up a tow rope and pulled me gently towards safety. I could not express how grateful I felt. At least now I could get to minister to the sick patient.

A kilometre down the road I saw a grizzly sight – the remains of a buffalo killed three days ago by lions. They hadn’t eaten since and were hungry. After another kilometre, I was towed past the Hollywood pride of lions, sitting majestically a few metres from the side of the road. Their eyes followed my vehicle as I rolled past. “Another missed meal.”

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