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ECU Field Journal: Africa

Marie's Blog from Lambaréné, Gabon<-- back

The dynamics of the physician-patient relationship…what “school of thought” do I attend?
August 23, 2008

What kind of relationship should exist between a physician and patient? Should the physician lead and the patient follow? Or should it be egalitarian of sorts, where each plays an equal role in the relationship?

The physician-patient relationship is quite different here from what I am used to. The approach is rather paternalistic, almost the antithesis of what we are taught as medical students in the United States. I believe this may be explained by the culture, and also in terms of how people use healthcare here. I am left speechless sometimes, witnessing the interactions between nurses, physicians, and patients. To my eyes it seems is as if the patient is being scolded. But I now understand that in this culture, this severity in tone is a means of communication. It is used to express the necessity of buying a certain medication, seeking a certain treatment, or whatever the case may be. As I have said before, the culture is very warm and welcoming here. You are treated as family upon your arrival. Even in family units, they do not distinguish aunt, uncle, cousin, etc. Everyone is a brother or a sister. Elders, no matter family or not, are referred to as “Mama” and “Papa,” since “Monsieur” or “Madame” are considered more aloof than proper. I believe therefore, what I perceive as paternalistic may actually be the family unit showing through, and the manner in which everyone takes care of one another.

Although not unique to Gabon, patients seek care only if they are in great discomfort from their illness or disease. The major difference I see here lies in the gravity of their illnesses. The diseases, especially with respect to tropical medicine, have severe consequences if they are not treated quickly. For example, toxoplasmosis (a protozoan parasite that loves to take up residence in the brain) is as prevalent as the common cold. Patients with this disease show mental status changes—severe headaches, agitation, or even seizures. As a result, anyone who comes to us complaining of a headache gets an immediate serology exam to check for toxoplasmosis. Imaging, other than basic radiographs, are not available at this hospital so we cannot get a CT to look at the brain for the telltale ring enhancing lesions caused by this bug. In severe cases, the patients are sent to Libreville, three hours away, which is quite a journey for most of them.

Frustration comes when patients say they are going to buy the medication to treat their infection, but don’t, and then come back later in far worse condition. Or they may buy only some of the medications, which renders the treatment ineffective. The paternalistic side, where voices are raised, not in anger but in dire need, shows itself when faced with such difficult circumstances. It is in the patient’s best interest to understand the gravity of their illness and the necessity of treatment.

Let me digress from the medical aspect to that which helps the patient most here—the family. The family unit here is something we all should admire. If someone gets sick and comes to the hospital, the strong family network is never more evident. When someone is admitted to Hopital d’Albert Schweitzer, a family member, referred to as “le guardien,” is required to stay at the hospital with the patient. This person is responsible for supplying and changing linens, bathing the patient, making meals, and even some of the health management as directed by the physicians and nurses. I have had several patients admitted for strokes where the family does all of the physical therapy. The nurses are responsible for administering intravenous fluids and medications, closely monitoring the most ill patients, and any other physician orders. This is quite a contrast to the American system, where families are mostly spectators during a loved one’s hospitalization. Does this really work well at Hopital d’Albert Schweitzer? You might think it would be a difficult task for both family and healthcare professionals, but based on my observations thus far, it seems to work wonderfully.