Systems Based Practice

The Accreditation Council for Graduate Medical Education (ACGME) has six core competencies around which American residency programs are to design their educational curriculum. One of these six is Systems Based Practice. Among other things, the Systems Based Practice competency states that residents are expected to “work effectively in various healthcare delivery settings and systems relevant to their clinical specialty, coordinate patient care within the health care system relevant to their clinical specialty,” and “incorporate considerations of cost awareness and risk benefit analysis in patient care.” To be honest, I have never given much thought to the SBP competency. The transition from medical school to residency was relatively easy from a systems standpoint, as I remained at the same training institution. Now, practicing clinical medicine within a completely foreign (in every sense of the word) system, I have finally started to think about what Systems Based Practice may actually mean.

My team leader had warned me that week two on the wards is usually the hardest for residents, and she proved to be quite correct. The excitement and novelty of working on the Kenyan wards has worn off, and the systems and structures here that tend to frustrate the Westerners start to become more apparent. In short, week two proved to be an extraordinarily frustrating one for me. First and foremost, my firm (team) had not had a registrar (Kenyan resident) since the first day I rounded. We had a new intern start this past week, so of course she didn’t know any of our patients overly well. Also, this week was the first week for our American pediatric team leader to act as Consultant (staff physician) on the wards, and while she is great, she knows only a little more than me about the way the hospital system functions here (this being only her third week in Kenya in the team leader position). The combination of all of these factors, in addition to some very sick patients, made me dread rounds every morning. We stumbled and fumbled through rounds most mornings, with our patients getting sicker by the day.

To use a patient example – on Monday we admitted a 10 year old boy with DKA (diabetic ketoacidosis). This is a very serious condition caused by diabetes (usually because of new-onset or very poorly controlled diabetes) that can be life threatening if not treated appropriately. In the US, kids in DKA will usually go to the ICU, as they require large amounts of IV fluids, continuous insulin infusion, and blood sugar and electrolyte monitoring every 30 to 60 minutes. At MTRH, ICU care is relatively limited, with few beds in the ICU, almost all reserved for patients needing ventilators, so our DKA patients here are cared for on the regular ward. I have taken care of my fair share of kids in DKA in the US; however, when we were rounding on this particular patient, it just seemed as if no one (including myself) had any idea what to do. Problem number 1: blood glucose values are reported with a different scale here (ie range of normal at home is 100-200; here is 4-10); Problem number 2: No one was sure if the strips used in the accu-check machine were good or actually working, as the patient’s blood sugars fluctuated greatly and didn’t make sense with his clinical picture, not to mention they were only being checked once every 2-4 hours; Problem number 3: Kids don’t get insulin drips (continuous infusions) here, they get hourly injections of insulin, but not at the same time every hour; Problem number 4: We were worried about his electrolytes, but to send a set of blood electrolytes to the lab would take at least a day if not two to come back, and then we’re making decisions based on old data; Problem number 5: MTRH does have a protocol for treating DKA (great!), but no one seems to know what it is, where it is, or how to get ahold of it (one of a few key times this week a registrar would have been extremely helpful).

These are five of about fifteen different problems we had with this one patient, multiply that times 30 patients on the ward, and I left the hospital most days feeling utterly defeated and completely exhausted. There is so much medical need here, and really not an insignificant number of resources to address those needs, but it is matching up the patients with the resources that is proving to be the most difficult. Effective delivery of appropriate medical resources to patients? Sounds like systems based practice to me. Now if only I could figure out how to do it here.

So I wonder: is that why week two is the hardest? Because I’m working in a different system? Possibly. The more I think about it though; I think it may actually be because I spent almost all of last week working against the system. The majority of week two for me was ruminating on the various limitations we had in caring for our patients, and beginning every sentence and thought with “Well, in America, I would…” Clearly this is counterproductive. All of that energy and time could have been put toward learning exactly what IS available and how to obtain it; ie finding a registrar on another team who may know what or where the DKA protocol is, finding out how to get accu-check strips that are, well… accurate, or strategizing with the nurses to ensure that our patient would receive his insulin precisely every hour. I can see the need here, I often know what SHOULD be done, but I’m still figuring out the HOW. If I learned one thing this week, it is that patient care cannot be delivered without at least a rudimentary understanding of the system in which it will be administered. As much as we physicians often loath the systems aspects of medical care, it is essential that we operate effectively within those systems if we are to care for our patients, which should be our ultimate goal.

In the end, I think the true benefit of learning systems based practice is that once you understand the system, you can start working to improve it; for yourself and for your patients. The ACGME also acknowledges the value of systems-wide change, stating that in SBP residents are also expected to “advocate for quality patient care and optimal patient care systems, work in inter-professional teams to enhance patient safety and improve patient care quality,” and “participate in identifying system errors and in implementing potential systems solutions.”

Clearly I cannot hope to master the Kenyan medical system in two short months here, and the noble goal of system-wide change is one more appropriately tackled by the long-term presence here (IU-Kenya partnership, AMPATH), and is indeed one of its greatest benefits. I think that the lessons in systems based practice that I have and will learn here are much more valuable as personal changes and improvements that I will take back with me to the US. I have already learned the value of a good, thorough physical exam in guiding diagnosis and management, as well as judicious use of laboratory and imaging studies, as patients all pre-pay for these studies before they are done. Operating within this very different system, while still taking care of patients to the best of my ability, will clearly make me a more efficient and effective physician in the US. One more of many things that working in Kenya has taught me, that I can only hope to repay over the next six weeks.