During my summer in Kenya, I worked through challenging cases with incredibly resourceful and intelligent providers at Port Reitz Psychiatric Hospital and The Gender Based Violence Recovery Centre. The standard of care was often unavailable due to financial constraints, but it took just as much mastery of medicine to provide valuable alternative therapeutic plans. The clinics were short staffed, compelling me to work to the limit of my medical knowledge in order to contribute meaningfully to the team. Working with these dedicated providers helped me appreciate the integral roles that creativity and critical thinking play in medicine. This was particularly evident in the case of a patient who was having a psychotic episode.
This patient was exhibiting violent and bizarre behavior; he was completely non- functional and required 24-hour supervision. He was strong and lunging at providers during his entire exam. His four friends who brought him in had to hold him down the whole time.
Socioeconomic factors complicated his care. It was very clear that he needed to be admitted, but he could not afford it. I had to figure out how to do inpatient management as an outpatient on someone who was very unstable. I prescribed him every injectable antipsychotic and benzodiazepine we had, but knew this would only be a short term solution. What would happen when he was home and they wore off? I also prescribed oral antipsychotics, mood stabilizers, and benzodiazepines and instructed his friends to give him this medicine while he was still calm from the injectable medications but not fully sedated in order to prevent aspiration. I may have treated him less aggressively if he was inpatient and being monitored, but keeping him calm while out in the community was a priority. I also had to think about the safety of the patient and others while he was at home. I instructed his friends to find his wife and two young
children somewhere else to stay until he was stabilized. The patient was also a danger to himself, so I told them that he would need 24-hour supervision by enough men strong enough to hold him down, if necessary. I asked them to bring the patient back for close follow up.
There were many other experiences that made me realize the difficult decisions practitioners in Kenya make daily. While working at the GBVRC, I found it important to learn both the guidelines made by the Ministry of Health in Kenya and understand why those guidelines were implemented. This too proved challenging. For example, as standard of care, metronidazole is recommended for coverage for Trichomonas as first line therapy for STI prophylaxis when Ceftriaxone and Azithromycin are given. However, in the recommendations made by the Ministry of Health, when switching to second line treatment with a fluoroquinolone and doxycycline, it is not recommended that you add metronidazole. I was never able to find any medical justification for this recommendation. I could only hypothesize that it has something to do with the cost-benefit analysis and use of available resources.
As a provider, this choice creates a conflict: do I make a decision based on medical knowledge or based on public health recommendations that take overall health resources into consideration? I often operate on the principle when making decisions with my patients: “What would I want done for a loved one?” If someone I cared for was sexually assaulted, would I want to give them prophylaxis for Trichomonas? Would I want them to avoid potentially getting PID and losing their fertility in the future? Of course I would. But in the bigger picture, how much would this metronidazole cost over the years? Where else would that money have gone? Who else’s life could have been saved with that money? How many people would have actually gotten Trichomonas or PID or had serious consequences like loss of fertility?
Being able to operate on the principle of “What would I want done for a loved one?” is huge privilege of working in the United States. Providers in Kenya have the difficult task, in any medical decision, to think about both what is best for the patient in front of them and what is best for all patients. Experiencing having to make these kinds of difficult decisions myself while I was there gave me so much respect for the providers in Kenya and the unique challenges they face working in a resource poor country.
I learned so much from the providers I worked with, but I also learned lessons from the culture in Kenya. A common theme during my time in Kenya was seeing communities come together to take care of one another. One patient who came to Port Reitz was severely agitated. At first I thought the crowd that brought him to our care were his family, but it turns out they were just members of his community. While one of the friends was filling the patient’s prescriptions, the other held him in his arms and sang to the patient until he was calm. I was so deeply moved by the depth of their love and caring. It’s something I will hold on to for a very long time. This sense of community is big part of the culture in Kenya, but it is something we do not regularly see in the United States. I hope to incorporate it more in my life and how I practice medicine.
This strong sense of community was not just apparent with patients but also with my colleagues. My coworkers made an effort from day one to make me feel welcome. That friendship became such an important part of how well we worked together. There was no ego on the team. Every opinion was equally valued and we would always discuss challenging cases together. We were quick to ask each other for help and learn from one another. The goal was always for everyone to do their best and to bring out the best in each other. This feeling of being a team not only helped us provide the best care for our patients, it made working together a pleasure. Practicing medicine is always a team effort, and I hope moving forward to always bring this kind of spirit to any team I am on.
One of the most unexpected and treasured parts of my time in Kenya was making friends in the earlier stages of their medical careers. From tentative pre-meds, to post-bachelors, to just fledgling med students, I became close with colleagues at different steps of the path to becoming a doctor, and I saw myself in all of them. It reminded me of some of that initial passion I had for medicine, some of which I had lost along way. Or rather, I realized it was not really as lost as I thought it was. It was important for me to reconnect to that earlier me and to feel hopeful and excited about this profession again.
I went to Kenya with an open mind. I didn’t know exactly what I was looking for, but I knew something was missing from my career. I had just left my family medicine residency program and I knew I wanted to continue in medicine, but I was still trying to figure out the path I wanted to carve out for myself moving forward. I didn’t expect to find the answers to these difficult questions while I was in Kenya, but I am grateful that I did.
I hoped that my work in Kenya would help me learn more about psychiatry while having a unique experience abroad, but it ended up being so much more. Before medical school, I worked as a nurse assistant at Christ House, a homeless shelter clinic in Washington D.C. It was a very meaningful part of my career in medicine and was the reason I decided to become a doctor. While I was working there, I remember looking forward to going back to work on Mondays. I distinctly remember this feeling because, to some extent, I have been chasing it ever since. Working in mental health this summer was the first time since my job at Christ House that
I looked forward to Mondays again. During my time in Kenya, I really felt like I had found in Psychiatry the joy in my work that I was searching for. I feel like my life was set back upon the right path- I’m excited about medicine again and excited to move forward with a career in psychiatry.