Dispatch from Kenya: 'i can be just a doctor'.

Although Dr. Michael Chung works for the University of Washington, Seattle, his office is far from his colleagues in the Division of Allergy and Infectious Diseases. Based at Kenyatta National Hospital in Nairobi, Kenya, he also works at the Coptic Hospital and is a Visiting Scientist at the University of Nairobi.

In addition to helping establish a local HIV clinic called the Coptic Hope Center for Infectious Diseases, Dr. Chung is leading a randomized trial, funded by the National Institutes of Health, that examines adherence to antiretroviral medications. Since he first went to Kenya in the fall of 2002, Dr. Chung has spent roughly 11 months of each year there and returns to Seattle for 1 month annually to attend on the UW infectious diseases service at Harborview Medical Center.

Dr. Chung trained in internal medicine at the Beth Israel Deaconess Medical Center in Boston and in infectious diseases at the University of Washington.

Of his decision to go to Kenya, he said, "I wanted to engage in research and care that would directly impact the lives of people in this resource-limited setting."

What do you like most about practicing in Kenya?

What I like most is the fulfillment I derive from trying to serve the medical needs of the poor. The need is overwhelming and sometimes I feel I am just a drop in the ocean, but I also feel that I am making a difference, however small, from patient to patient.

I tell my students that if I'm not practicing in America, it doesn't matter because there is always another qualified doctor to take my place. If I left Kenya, I would leave some patients without a doctor, and some of them might die. There is little if any backup here. I like being on the front lines, trying to improve the health of people who deserve much better care and treatment.

Friends ask me why I practice in a resource-limited country, and I tell them that it's like what Willie Sutton said about money and banks, "It's where the sick people are."

Describe the clinical setting where you work.

Kenyatta National Hospital is the largest government hospital in Kenya and is based in Nairobi. It is a teaching hospital associated with the University of Nairobi and has 1,800 beds. My research office is located here, and I have enjoyed teaching and treating patients in its outpatient clinics and inpatient wards.

Although research activities form my primary duties, I also volunteer to see patients in the HIV clinic at the neighboring Coptic Hospital, a 60-bed hospital founded by Coptic Christian missionaries from Egypt. This relationship, which began in 2003 when I treated a mother and her daughter, has developed into a major collaboration between the UW and the Coptic Hospital to treat poor patients living with HIV It has led to the care of 7,000 HIV-positive patients and quality treatment of nearly 4,000 men, women, and children with free antiretroviral medications.

What are the key practice challenges in Kenya?

The key practice challenge is poverty. My time is spent not just practicing medicine but also trying to obtain funding or supplies to ensure that my patients can get adequate treatment. Half the time, I know what to do but can't do it because of the cost to the patient. I tell my students one aspect of taking a medical history that I never learned in medical school was asking a patient how much he earns in a month, and yet it is one of the first questions I have to ask here because it dictates what tests I can order or what diseases I can treat.

What have you missed most about U.S. medical practice?

I miss the intellectual satisfaction that comes from making a diagnosis by being able to order lab tests that we take for granted in the United States but are too expensive for most Kenyans. I miss clean, well-lit clinics that are fully equipped with supplies as simple as a tongue depressor. I miss being surrounded by the most recent books and journals that would allow me to look up information easily and keep updated on medical advances. I miss having a steady and constant drug supply I miss not having to worry about how my patients will afford their next meal or transportation to return to the clinic.

In light of your experience, what do you see as the main disadvantages of U.S. medical practice?

The irony is that I feel U.S. medical practice is too expensive and excessive. I think this is in part due to practicing "defensive" medicine in order to protect against medical malpractice suits. I think too many unnecessary tests are ordered as a result and too much money is spent on the business of medical practice rather than the actual care of patients.

For example, in Kenya I can treat an AIDS patient in an outpatient care setting for less than $1,000 a year at a standard of care nearly equivalent to that in the United States. This includes all antiretroviral medications, laboratory testing, and drugs for opportunistic infections. I believe the same costs to an American patient would be no less than 100 times this amount. Is this equivalent to good or better medical practice? I'm not sure.

Based on your experience in Kenya, what should be done to improve U.S. medical practice and health care?

One thing I appreciate about working in Kenya is the general freedom I have to spend time with a patient and actually practice medicine. There is little paperwork, no ICD-9 codes to memorize, and few of the forms we have to fill out and boxes we have to tick in order to keep hospital administrators and their lawyers happy. Patients can walk into the clinic and be seen for any ailment at any time, without a referral.

Here, I feel I can be just a doctor, talk to a patient, and practice medicine instead of doing clerical work. As a result, I am more accessible to my patients and can spend time building a relationship with them. It's this personal element that makes the practice of medicine more fun, and it's this aspect of health care that I believe patients want more of in the United States. In this way, we should advocate for our patients and be wary of medical practice as simply another business model.

What other thoughts would you like to share with our readers about international health issues, health care reform, or your own endeavors?

When I first came to Kenya, I thought I could make a big difference; however, I quickly realized that I was poorly equipped to treat patients. I lacked access to tests that I had taken for granted, such as echocardiograms, CT scans, and sometimes even a simple chemistry panel. I had to rely on my physical examination skills and to learn the diversity and presentation of local diseases. In many ways I was a drain on the system and used precious physical space to see patients at a rate that was half that of the Kenyan nurse-practitioner--whose monthly salary was one-quarter the cost of my round-trip ticket from America.

If I have been able to contribute at this point, I believe it is because I have spent considerable time learning how to be more effective. And although seeing patients is fulfilling, my most useful activity may be teaching and sharing medical knowledge with Kenyan health professionals.

If you want to work in a resource-limited country, I suggest identifying what medical need you will address and how you have adequately prepared yourself to make a contribution and be of service. While working in this setting, take the time to share your skills with your foreign colleagues or, even better, consider how to bring this doctor for training in the United States so he or she can then return home to practice a lifetime of evidence-based medicine.

Think globally. Practice locally.

U.S.-trained internists who have practiced abroad will receive a $100 stipend for contributing to this column. For details, visit www.worldwidemed.org or send an e-mail to imnews@elsevier.com.