A 60 year old gentleman presented to Bayalpata Hospital today describing several months oflower back pain. A large proportion of adult patients who come to Bayalpata Hospital describe back pain. It is significantly challenging to determine which of these patients have a problem that is actually amenable to medical therapy. In the course of a day when some one hundred patients need to be seen, many of these patients can only have a brief examination and a prescription for symptomatic relief. Patients have real symptoms; medical knowledge unfortunately rarely can approximate reality. This patient, was different, but it required a patient and thoughtful clinician to elicit the history. Dr. Bikash Gauchan, Bayalpata’s Hospital medical director and the patient’s treating physician asked some more questions. In addition to back pain, the patient described intermittent fevers for the last several months. On chest examination, he had crepitus in the upper lung fields, worse on the right. As such, Dr. Bikash was concerned about tuberculosis. A chest x-ray in fact revealed bilateral apical opacities consistent with his assessment. Films of the lumbosacral spine suggested Pott’s disease (tuberculosis of the spine).
In the villages in Achham, large numbers of patients present, as they do at Bayalpata Hospital, with back pain to local minimally trained providers. Many such patients do not in fact have anything particularly treatable, but more subtle cases of tuberculosis such as this gentleman are often missed. Those missed diagnoses are due to what researchers who study this problem call the “anchoring heuristic,” where clinicians make presumptive diagnoses based on common patterns they see.
Having a likely diagnosis, Dr. Bikash wanted to perform a sputum examination, but unfortunately our laboratory is operating at minimal capacity since a staff member is away. Hopefully in a few days we will get that done; in the meantime, Dr. Bikash decided, to initiate him on an anti-tuberculosis regimen. Now, the treatment of tuberculosis is quite formulaic. There are highly standardized protocols for the delivery of several months’ worth of treatment. A cure is very much possible. Yet in settings like ours, delivering high-quality tuberculosis treatment is challenging. Treatment regimens have significant side effects, and patients’ lives are quite busy and complex. He lives relatively close, only about one hour’s walk from the hospital. Throughout Nepal, the location for provision of anti-tuberculosis medicine, through Directly Observed Therapy (DOT) or otherwise, is through the health system’s infrastructure of hospitals, primary health centers, health posts (small clinics), and sub-health posts (smaller clinics). Since we are the closest health institution to his home, we are the providers of his anti-tuberculosis medicines. Dr. Bikash calmly sat him down and discussed his diagnosis treatment, and how he would need to walk to the hospital to receive his medicines. He reassured him that he would get better. They discussed, and the patient was receptive, to the notion of DOT given that he felt he would receive better care and that the walk was not too long (an hour-long walk is perceived very differently in Achham than elsewhere). Dr. Bikash counseled him on the side effects, and he discussed with him about quit smoking. Our HIV counselor was not available for the next few days, but he would provide an HIV test when he returns. He told the patient and our registration helper Huijalji that he could bypass the one hundred-deep registration line to come in, take the medicines, and head back. In a healthcare setting where so many interactions are overly rushed, where patients are often disempowered, and where there is just no time for counseling, I was moved by Dr. Bikash’s gentle and patient manner.
We do not currently have a female community health volunteer (FCHV) in his village, although within the next few months we will be expanding there. At that time, hopefully she would assist in our endeavor for a cure for this gentleman. The FCHV program is found throughout Nepal and forms a cornerstone of public health in rural areas, but its potential is far from maximized currently. As part of our overall mission to strengthen the public sector, we have hired community health workers who supervise the FCHVs, refer patients, and help to train them. While per government mandate, the FCHVs are strictly volunteers, we provide the FCHVs a financial incentive for their work with us. As we expand the program, we hope to be able to provide adherence support and direct treatment to patients such as this gentleman.
So, our system is far from perfect; our timeliness in getting this patient an HIV test, a sputumexamination, and a village-level outreach worker is far from optimal. I do not know if we will cure this man. Yet I was struck by the compassion of Dr. Bikash’s approach to his care. It was a reminder to me that, even with highly protocolized, vertical programs such as those for tuberculosis, necessary to get cures out on a large scale, the fundamental experience of patients is based upon their interactions with their providers. I can safely say that, at least for this gentleman at the start of receiving difficult medicines for a terrifying diagnosis, we have provided him a moment of solace and compassion.
Duncan Maru, MD, PhD is one of the co-founder’s of Nyaya Health. He is currently a resident in the Internal Medicine – Pediatrics program at Brigham and Women’s Hospital and Children’s Hospital of Boston.