Hotel Tropicana, Part II
After two weeks on the HTD inpatient floor, I moved over to the clinic side, housed in an older building just down the road close to where the school is located. These clinic days gave me a rapid tour through the sorts of things one sees every day in tropical regions; whereas the inpatient ward houses only a dozen or so cases at a time, the clinic of course sees that many or more every day.
The clinic is split between the travel medicine side (mostly for people going abroad who want to get vaccinations and antibiotics lined up), the walk-in clinic (which takes anyone who has "been in a foreign country and has a fever"), and a series of specialty clinics for everything from leprosy to tropical eye conditions to dermatological complications of HIV. Each day was new and different, and on the quieter days I headed back over to the ward to go on rounds with them.
The leprosy clinic was an interesting one, particularly because it's a disease almost never seen in the US. Certainly there are no cases of leprosy that arise in the States; when cases are seen, they are usually in immigrants who bring it with them from the endemic region they come from. The same is largely true in Britain, but because of migration patterns from ex-colonies (particularly India and Pakistan). And the disease is very slow-moving and can go on for years causing quiet damage before it's caught, so even immigrants who have been in Britain for decades sometimes still carry active disease. Fortunately for leprosy patients (who suffer from chronic degenerative neurological symptoms that often end up causing slow amputation of the far extremities, fingers and toes and the like) in London, one of the foremost experts on clinical and epidemiological aspects of the disease works at this clinic. Hers is a name that is all over the leprosy literature (and she is known for openly challenging World Health Organization dogma about the conditions needed to eradicate leprosy - which she maintains are not based in any reasonable evidence, despite the fact that international policy on the disease is based on it), and it's always a surprise to see the same name tag on the door that matches the journal papers I'd just been reading.
On other days I sat in on the HIV clinics. While this is not a tropical disease per se, it seems that it has been linked into that clinic because of the heavy prevalence in recent immigrants from countries heavily affected by the disease. The disease has very different patterns in the developing world than in the developed world, and the expertise that the tropical medicine doctors bring is often helpful in dealing with some of the tropical aspects of the disease even in very temperate London. The clinic I sat in on most was a dermatology session, which consisted of a large number of skin biopsies interspersed between common and rare complications of HIV - everything from possible manifestations of Kaposi's sarcoma (once the most common outward sign of HIV in temperate regions, now decidedly rare since the advent of anti-retroviral drugs) to a fulminant case of human papilloma virus that had scarred a young man's face with thousands of tiny wart-like lesions. In this clinic I quickly learned to pick out the stigmata of anti-retroviral drugs; where once AIDS patients could be identified by their gaunt look and purplish lesions, now those same patients can be picked out by the metabolic changes caused by the drugs - especially the lipodystrophy that deranges the deposition of fat, stealing it from the puffy pads around normal cheeks and replacing it in regions around the torso where it should not be. That is just one of many reminders that while HIV has become a chronic disease rather than an inevitably fatal one, prevention is still a far better option than years of treatment.
The miscellaneous clinics in between included everything from ophthamology to the general post-travel walk-in clinic where anyone who had been out of the EU and has a fever can be seen on short notice. The eye clinic was a slow day, which gave the doctor a good opportunity to quiz me on everything under the sun that had remotely to do with eyes. I had warned him that I had almost no experience in ophthamology, so I was surprised that I could actually answer most of his rapid-fire questions. He did drag out a slit-lamp apparatus with a second lens to one side that allowed for me to see the same thing he could see in the patients' eyes while he described the findings. We only saw two or three patients, but they were interesting - one especially came over from the hospital ward to rule out a nasty little skin-and-eye parasite called onchocerciasis. Fortunately or not, he didn't have the particular infection - which was good in that he didn't have the kind of chronic eye inflammation that could lead to blindness, but not so good in that this left his chronic intolerable skin problems firmly undiagnosed. Since the end of my rotation was near, I was not around to find out if the skin biopsies eventually gave him a satisfactory answer or left him still with the mystery of his affliction.
I spent the rest of the time with the general tropical medicine providers, seeing more mundane cases than medical oddities. By happenstance one day seemed to be all about unhappy bowels and the uncomfortable individuals walking around town with them. It was in this clinic that I learned that the NHS brand of socialized medical care does not exactly protect the public from the depredations of private providers and labs out to make a buck on a gullible populace. One woman who had returned from exotic travels with a case of what looked a lot like post-gastroenteritis irritable bowels; she paid a private commercial lab to culture her stool (I suppose that's a mail-order transaction, though I didn't actually want to ask!), from which they gravely informed her that she had a colonization of Citrobacter and Blastocystis in her colon - and she came to us to ask for the appropriate treatment for such a terrible condition. The only problem is that Citrobacter is considered normal flora for the bowel, and eradicating it would not only be a lengthy and unpleasant affair, but would also probably leave her wide open for opportunistic bacteria that would take over in the absence of the usually bugs. The second bug, Blastocystis, is a matter of some controversy. Some think this is an important pathogen that might explain a large proportion of general bowel upset that usually falls under the catch-all of irritable bowel syndrome. The opposite camp points out that no one has actually been able to correlate the presence of the parasite with consistent symptoms. In any case, a whole cottage industry of private providers has sprouted up give the grave diagnosis and solemnly advice that patients immediately consult their the physicians for a course of metronidazole. This usually clears up low-level (and difficult to detect) giardia infections along the way, which makes it seem as if the lab was indeed correct that the Blastocystis was the problem. In any case, the lab makes its money, and any cases of cure reinforce their reputation for finding a mythological pathogen that mainstream medicine refuses to recognize - all this despite the stubborn little fact that not even those with a vested financial interest have been able to prove there's any symptoms at all from the bug itself.
In any case, after nearly a month with the tropical medicine teams, it strikes me that this is an area that I would like to keep one eye on, even as it's not the most common or lucrative profession in the decidedly temperate US. There is one stumbling block there, which is that the infectious disease training comes as a fellowship after an internal medicine residency. And since I want to go into family medicine - not internal medicine - that makes it a difficult path to follow. But I was also struck by the difference between medical care in the UK versus the US: in the UK, everyone with any access to the NHS can access the full breadth of the system - so a new immigrant with persistent pathogens left over from their homelands can go right to the specialist ID doctors who are most expert in those conditions. In the US, however, anyone without insurance (as is the case with most recent immigrants) usually ends up in the care of general practitioners in the community or government system of county clinics and the like. Most of the infectious diseases that I am interested in - TB, HIV, imported tropical pathogens - affect people who rarely reach specialized care unless their conditions are so bad as to require hospitalization. As such, with my intent to practice in the US, it makes more sense for me to train as a primary care generalist; were I intending to practice in the UK, I could quite well see myself going into the ID specialty.
And that was my month on tropical medicine - a perfect end to a year of tropical studies in the cold north lands of Britain.
The clinic is split between the travel medicine side (mostly for people going abroad who want to get vaccinations and antibiotics lined up), the walk-in clinic (which takes anyone who has "been in a foreign country and has a fever"), and a series of specialty clinics for everything from leprosy to tropical eye conditions to dermatological complications of HIV. Each day was new and different, and on the quieter days I headed back over to the ward to go on rounds with them.
The leprosy clinic was an interesting one, particularly because it's a disease almost never seen in the US. Certainly there are no cases of leprosy that arise in the States; when cases are seen, they are usually in immigrants who bring it with them from the endemic region they come from. The same is largely true in Britain, but because of migration patterns from ex-colonies (particularly India and Pakistan). And the disease is very slow-moving and can go on for years causing quiet damage before it's caught, so even immigrants who have been in Britain for decades sometimes still carry active disease. Fortunately for leprosy patients (who suffer from chronic degenerative neurological symptoms that often end up causing slow amputation of the far extremities, fingers and toes and the like) in London, one of the foremost experts on clinical and epidemiological aspects of the disease works at this clinic. Hers is a name that is all over the leprosy literature (and she is known for openly challenging World Health Organization dogma about the conditions needed to eradicate leprosy - which she maintains are not based in any reasonable evidence, despite the fact that international policy on the disease is based on it), and it's always a surprise to see the same name tag on the door that matches the journal papers I'd just been reading.
On other days I sat in on the HIV clinics. While this is not a tropical disease per se, it seems that it has been linked into that clinic because of the heavy prevalence in recent immigrants from countries heavily affected by the disease. The disease has very different patterns in the developing world than in the developed world, and the expertise that the tropical medicine doctors bring is often helpful in dealing with some of the tropical aspects of the disease even in very temperate London. The clinic I sat in on most was a dermatology session, which consisted of a large number of skin biopsies interspersed between common and rare complications of HIV - everything from possible manifestations of Kaposi's sarcoma (once the most common outward sign of HIV in temperate regions, now decidedly rare since the advent of anti-retroviral drugs) to a fulminant case of human papilloma virus that had scarred a young man's face with thousands of tiny wart-like lesions. In this clinic I quickly learned to pick out the stigmata of anti-retroviral drugs; where once AIDS patients could be identified by their gaunt look and purplish lesions, now those same patients can be picked out by the metabolic changes caused by the drugs - especially the lipodystrophy that deranges the deposition of fat, stealing it from the puffy pads around normal cheeks and replacing it in regions around the torso where it should not be. That is just one of many reminders that while HIV has become a chronic disease rather than an inevitably fatal one, prevention is still a far better option than years of treatment.
The miscellaneous clinics in between included everything from ophthamology to the general post-travel walk-in clinic where anyone who had been out of the EU and has a fever can be seen on short notice. The eye clinic was a slow day, which gave the doctor a good opportunity to quiz me on everything under the sun that had remotely to do with eyes. I had warned him that I had almost no experience in ophthamology, so I was surprised that I could actually answer most of his rapid-fire questions. He did drag out a slit-lamp apparatus with a second lens to one side that allowed for me to see the same thing he could see in the patients' eyes while he described the findings. We only saw two or three patients, but they were interesting - one especially came over from the hospital ward to rule out a nasty little skin-and-eye parasite called onchocerciasis. Fortunately or not, he didn't have the particular infection - which was good in that he didn't have the kind of chronic eye inflammation that could lead to blindness, but not so good in that this left his chronic intolerable skin problems firmly undiagnosed. Since the end of my rotation was near, I was not around to find out if the skin biopsies eventually gave him a satisfactory answer or left him still with the mystery of his affliction.
I spent the rest of the time with the general tropical medicine providers, seeing more mundane cases than medical oddities. By happenstance one day seemed to be all about unhappy bowels and the uncomfortable individuals walking around town with them. It was in this clinic that I learned that the NHS brand of socialized medical care does not exactly protect the public from the depredations of private providers and labs out to make a buck on a gullible populace. One woman who had returned from exotic travels with a case of what looked a lot like post-gastroenteritis irritable bowels; she paid a private commercial lab to culture her stool (I suppose that's a mail-order transaction, though I didn't actually want to ask!), from which they gravely informed her that she had a colonization of Citrobacter and Blastocystis in her colon - and she came to us to ask for the appropriate treatment for such a terrible condition. The only problem is that Citrobacter is considered normal flora for the bowel, and eradicating it would not only be a lengthy and unpleasant affair, but would also probably leave her wide open for opportunistic bacteria that would take over in the absence of the usually bugs. The second bug, Blastocystis, is a matter of some controversy. Some think this is an important pathogen that might explain a large proportion of general bowel upset that usually falls under the catch-all of irritable bowel syndrome. The opposite camp points out that no one has actually been able to correlate the presence of the parasite with consistent symptoms. In any case, a whole cottage industry of private providers has sprouted up give the grave diagnosis and solemnly advice that patients immediately consult their the physicians for a course of metronidazole. This usually clears up low-level (and difficult to detect) giardia infections along the way, which makes it seem as if the lab was indeed correct that the Blastocystis was the problem. In any case, the lab makes its money, and any cases of cure reinforce their reputation for finding a mythological pathogen that mainstream medicine refuses to recognize - all this despite the stubborn little fact that not even those with a vested financial interest have been able to prove there's any symptoms at all from the bug itself.
In any case, after nearly a month with the tropical medicine teams, it strikes me that this is an area that I would like to keep one eye on, even as it's not the most common or lucrative profession in the decidedly temperate US. There is one stumbling block there, which is that the infectious disease training comes as a fellowship after an internal medicine residency. And since I want to go into family medicine - not internal medicine - that makes it a difficult path to follow. But I was also struck by the difference between medical care in the UK versus the US: in the UK, everyone with any access to the NHS can access the full breadth of the system - so a new immigrant with persistent pathogens left over from their homelands can go right to the specialist ID doctors who are most expert in those conditions. In the US, however, anyone without insurance (as is the case with most recent immigrants) usually ends up in the care of general practitioners in the community or government system of county clinics and the like. Most of the infectious diseases that I am interested in - TB, HIV, imported tropical pathogens - affect people who rarely reach specialized care unless their conditions are so bad as to require hospitalization. As such, with my intent to practice in the US, it makes more sense for me to train as a primary care generalist; were I intending to practice in the UK, I could quite well see myself going into the ID specialty.
And that was my month on tropical medicine - a perfect end to a year of tropical studies in the cold north lands of Britain.
posted by skylanda at 2:38 PM
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