Specialists and health care for the poor

I recently had a long chat with young general practitioners in south Ethiopia. «Our aim is to become specialist doctors», they said. I replied that most specialists do not return to the rural areas they come from and where they first intended to work in. Their answer was there was a need for specialist in the large city hospitals, and after having endured hardship as General Practitioners and with established families, they found it natural not to return to the rural and poor South Ethiopia.

And the tendency is that general specialists in fields as internal medicine and surgery want to continue training and become subspecialists.

A recent Naturejobs paper discusses the career of PhD graduates. Some PhD graduates end up doing very specific tasks, often in academic institutions. However, through their PhD training they gain valuable general skills that qualify them for more general careers. Industry usually wants highly skilled and trained people with a flexible attitude. The PhD researcher who insists on limiting their work to a narrow area of research specialisation sometimes end as «Research Geek».

In research, as in practical medicine, most of the work is routine, and deals with everyday problems. Specialist gain general skills during their training that they could and should use for the benefit of patients and health problems beyond their narrow specialisation.

A few days ago I was working at the remote Saula Hospital in South-west Ethiopia. During the rounds in the inn-patient ward I realised that many of the seriously sick patients had not been diagnosed properly. A patient with pyomyositis (multiple abscesses) had an underlying leukaemia. A patient with grossly swollen breasts did not have a breast disease, but a severe heart failure. A three-year-old child with fast breathing had been treated for pneumonia, but had severe falciparum malaria infection.

Poor diagnostic work leads to poor treatment and care, and is probably the reason only 10 patients were admitted to Saula Hospital from a population of 800.000 people in its catchment area. Hospitals as Saula needs specialists, but of a kind that is willing to go beyond their own specialisation.

Unfortunately, the international trend, now also affecting developing countries, is to increase specialisation and thus leave a large part of the work to nurses, non-physician clinicians, and to newly educated doctors doing compulsory services in remote hospitals.

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