Patient choice

Weather - Maximum temperature 45 degrees Celsius

- Weekly rainfall 4mm

Highlight of the week

Our air conditioning is fixed

Lowlight of the week

A sudden death at one of the camps

Whatever you think best Dr Keith. The standard retort in Sunderland more than a decade ago. The practice of medicine is slowly changing. We are starting to move away from a doctor knows best approach. Enter stage left: shared decision-making. Keith has been teaching shared decision-making for years. He has even founded a website that puts patients on a level pegging with doctors: Patientcentre.org. The vogue seems to be here to stay.

With this approach, options are shared between clinician and patient. Together, they weigh up the pros and cons of each option. Patients are asked to engage in understanding their own choices. Clinicians have not abdicated. Doctors are not trying to shirk their responsibilities. Patients are not being left on their own to choose from a limitless smorgasbord. Instead, there is a growing realisation, from both clinicians and patients, that figuring out the right way to manage a health dilemma is complex and personal. The patient is an expert in what might work for them. Clinicians are expert guides who try to lead patients to appropriate personal choices.

The shared decision-making model works pretty well in the UK. We still have an NHS that values access to care. Free at the point of delivery. Here in Zambia our contract to provide care is a little hazy. We work as volunteers and do not get paid. We work for the ministry of health by morning. At all other times we are contracted to provide care for the purveyors of the tourist industry. But if we are asked to provide care for a guest in a camp, the guest is not our patient until they make a verbal contract to ask for help via the camp manager. Bill proved a challenge to our shared decision-making model. Bill needed help, but did not want to make a donation to the medical fund. Bill teetered on the knife edge of making a bad decision that might cost him his life. More of that later.

It is estimated to cost about $40,000 per year to have a doctor in the valley. We are volunteers. We do not receive a salary. The money is raised via donations to the South Luangwa medical fund. Anyone who wants ready access to the doctor must join the fund There are individual members and corporate (mainly camps) members. For a tourist who needs care, we are available provided the camp is a member of the scheme. There is a call out “donation” which goes into the fund.

David chooses to continue smoking. Joseph chooses to pickle his liver. Clinicians don’t just accept poor patient choices. They challenge. They motivate. They parent. Clinicians are on the same team with the patient. But patients ultimately have the casting vote. But Bill our potential patient this weekend, was camping by the Luangwa river at Larry’s camp. Bill seemed sick but did not want help. Bill did not appear to have the capacity to make a reasoned decision. Larry decided to go over his head. Larry decided to give Keith a call. Remember, Keith is the Valley doctor. Keith looks after Larry and all of his staff. But Keith has no jurisdiction over Bill.

Before I tell you anything more about Bill, I need to tell you about what we were doing when Larry called: Keith and I had been invited to stay at Kuyenda camp that weekend, just over an hour from the main gate. Kuyenda is a remote bush camp. There is no wifi at Kuyenda. The place is paradise. The phone signal at camp is perfect, but there are patches of the bush where phones are useless. We were going dark.

The medical fund committee were well aware of this potential break in service. But Larry did not know where we were. Larry knew to contact the medical fund committee, if he couldn’t reach us directly. But by the time he managed to talk to Keith directly Larry was almost frantic. Doctor Keith, what am I meant to do with this guy? He urgently needs to see a doctor, but he’s totally broke. He’s covered in mosquito bites, and he looks dreadful. I’m not sure I could get him to talk to you now, never mind to see you.

Let me colour in some more detail for you before we get back to our dilemma with Bill. That Saturday night we had gone in search of lions. We had seen lions that morning, so we knew roughly where they might be hanging out. They had just finished a zebra supper. Stripes and all. The pride had some serious digesting to do. Our guide Fannuel has an uncanny knack for being in the right place at the right time with carnivores. He found them doing what lions do best. Sleeping. Not exactly end to end stuff. For thirty minutes we prayed for action. The prayers were answered with more action than we had been hoping for. Our tyre went down and dominos fell.

As we limped off to change the tyre: two phones sprang into action. Synchronised. Mobile phone coverage had removed our cloaking device. Fannuel spoke to the Medical Fund who were frantically trying to locate us. Keith spoke to Larry, the worried camp manager. Meanwhile, we sought a relatively safe spot for a wheel change. Just 100 metres from the sated pride. Those not directly engaged in practical activities: telephone triage; or resuscitating the sickly land rover – sought solace with gin and tonic, as the sun made a sharp getaway. It was helpful for me to distract myself from the uncertainty of a worrying combination of enforced immobility and nearby lions. Keith and Fannuel dealt with more uncertainty. Larry was vexed. The medical fund wanted to know that Keith was on the job.

Keith probed for more information from Larry. The tourist was called Bill. A 62-year-old man. Bill had travelled from Malawi. He was roughing it. He had slept outside whilst on his travels. Without a mosquito net. He was covered with mosquito bites. He was not taking antimalarials. Some of you might question whether his IQ was in double figures. Keith might tell me this is a form of patient choice. As long as Bill has all the facts to hand and still chooses to behave in this manner. Bill had a headache and had vomited twice. The camp manager was worried about him as he looked dreadful. However, Bill just wanted to go to bed and sleep it off.

So, what do we do now? We are in the middle of the bush. The patient, Bill, is not seeking medical care. A camp manager is worried. Where does our responsibility lie?

Keith suggested he speak to Bill directly. Larry agreed and Bill relented. Bill told Keith the same story. He felt rubbish. He had no fever, no muscle soreness. Just a headache and he felt knackered after travelling in from Malawi. He had vomited twice on the previous day, but he was sure that this was not malaria or anything nasty. He repeatedly told Keith that he did not want to see a doctor. Keith suggested that Bill get a malaria test urgently all the same. Now Keith has been around the block a couple of times. Keith knew to trust an old hand’s instincts. Larry was anxious. Keith and Larry came up with a cunning plan.

Money seemed to be the main stumbling block. Keith suggested that we arrange free care for Bill. All Bill would have to do would be to pay for a cheap taxi to the Kakumbi rural health clinic to get an instant rapid antigen malaria test. Bill would also get seen by a clinician at Kakumbi. Having eyes on Bill by a trained clinician would also let Keith sleep easy that night. All Larry needed to do was nag. Larry is good at nagging. Et voilà! Bill would be spirited off in a taxi to Kakumbi rural health clinic. It’s open 24/7. Free care for a free spirit.

Whenever we venture into the bush there is a constant tug of war between our wish to enjoy the freedom and adventure that the safari lifestyle offers and the medical responsibilities that we shoulder. The occupants of our land rover never voiced any objection to having the Valley doctors on board. Despite the ever-present uncertainty. Despite the constant possibility that a game drive might have to be cut short for us to deal with an emergency. By now, our land rover had a new tyre. G an T had worked some sort of magic on the mood of the vehicle. But there was still a tension inside the Valley doctors. Would the cunning plan work? Just how good at nagging was Larry? Fannuel started the engine. There were no aardvarks spotted that night. Perhaps Fannuel’s eyes were a little hazy. Perhaps our hearts weren’t fully on the job. We slowly wound our way back to camp.

Keith checked in with Larry an hour and a half later. Larry turned out to be a great nag. Resistance was futile. He had organised Bill a taxi and bundled him in. Bill had never wanted to see a doctor nor have any tests. Bill was convinced that he did not have malaria. Yet the malaria test was positive. Patient choice. Suicide without a note. Some might call it inertia. But inertia kills. Intervention saves lives. With or without patient choice. Sometimes decisions have to be taken in the best interests of a patient who does not appear to be able to make a rational decision.

We all breathed a sigh of relief. Malaria. Common as muck here. And we have plenty of muck. The treatment here for malaria is very straightforward. Co-Artem. Four tablets twice a day for 3 days. Cure. Co-Artem only fails to cure if the patient keeps vomiting. And if that happens we can resort to the intravenous or intramuscular equivalent of Co-Artem. Malaria in the UK is a whole new kettle of fish: The nation would go on red alert. Hospital admission is de rigueur. The infectious disease team would be consulted. A blue light ambulance would transfer the patient to an Ivory tower. The patient would be plagued by junior doctors and medical students. The patient would become a local celebrity. People would be dining out on their personal involvement for years.

Bill would be fine. Free care, designed for locals, enjoyed by Bill. Bill did not wish to foot any bill. The voluntary donation that we ask for, when tourists access care with us, was too much of a barrier to Bill. Our ethics would never permit us to not provide emergency health care. If the malaria test had been negative, what would we have done?

If a patient has all the facts and figures and they have capacity, they are allowed to make bad choices. Even if that would result in serious illness, or even death. However, neither us nor Larry would have let that happen. If Bill had not been assessed by a clinician. If he had not been tested and treated: we would have left our bush camp and gone to see him. For us, the cost is immaterial. We would not refuse to provide medical care due to a lack of money. That is not the reason we trained to become doctors. Nor the reason we have chosen to come and work in a resource poor setting.

Bill is now fighting fit and has left Larry's camp. Both Larry and Keith are relieved.

Choices, choices, choices

It appears we have competition in the valley.

The lion sleeps tonight

Stripes and all

Deep in the bush at Kuyenda