Disclaimer: The views and information presented here represent those of Beta Pleated Chic and of Sara Rendell and do not necessarily represent the World Health Organization or the World Council of Churches.
This article is also a follow-up to our first conversation with Sara from last summer. If you like, you can dive into the Year 1 article before hearing about her latest adventures.
In addition to coursework, Sara has spent much of her free time volunteering in the Refugee Women’s Clinic, where she does pre-visit counseling as well as research. She has found herself completely absorbed in this world, wanting to learn more about health outcomes for these women who immigrate to the United States.
“I was just lost in reading—what is refugee care like in other places. I had these interviews with women and I just wanted to do more and to know more. I was just reading and reading and reading, not medical school stuff… I was like dammit Sara you are so privileged to be here, you have all these brilliant experts teaching you [medicine]…and here you are being ungrateful, not able to buckle down and do the thing that you committed to…look at you trying to run away…I was really critical.” She laughs as we come to the end of this description, realizing that she might have been just a little hard on herself. Her father, an endocrinologist, offered her a piece of advice after hearing these concerns. “You said you’re not intelligent…I don’t know that memorizing all the information they pour at you is intelligence. There is always too much of anything. Tell me about the work you’re doing in the Refugee Clinic…now that, that’s intelligence.”
Since we last interviewed Sara, she decided to pursue a PhD in anthropology in addition to her MD degree. This month, she completed her second year of medical school, including a challenging sequence of clinical rotations, and is transitioning into her PhD program. When we interviewed her, she was in the midst of studying for the Step 1 exam, an important assessment of basic science knowledge and its application to the practice of medicine.
We met Sara at a beautiful pop-up beer garden on South St in Philadelphia. Once we had parmesan fries and grilled cheeses in hand, we started chatting about Sara’s experiences over the past twelve months.
“I saw something last night that captured what being in a hospital doing medicine is like. There was a resident, walking home in scrubs, when the storm was at its height—it was pouring, trees were swaying, people were running and covering themselves, people pulling their bikes aside and trying to get under a tree. And then there is this women walking in scrubs, with her stuff, drenched completely. Things are flying, people are running, and she is just going. And I was like, that is what it’s like to be on the healthcare side. And the crazy part is that it’s not rain falling on people, it’s threats. Threats of death, threats of loss, change in what your life is like and identity. Change in your relationships.”
For Sara, clinics were challenging, eye-opening, and rewarding. Her interest in anthropology, the study of humanity, as well as medicine, leads her to see situations from both scientific and sociocultural perspectives.
“[Going into clinical rotations] the question was: do I want to do something surgical, or not? So I did internal medicine, general medicine, surgery, urological surgery, thoracic surgery, emergency medicine, and anesthesia. And I loved internal medicine. It’s all about people and their relationships. And people’s stories.”
“I think for me, I’m more interested in how things happen and why things happen. And relationships, understanding what people mean to each other. There’s something really special about internal medicine; watching people in the hospital, seeing who visits, who they call, the kinds of things they bring to their room.”
And there is simply nowhere like the hospital environment to study human behavior, social organization, and culture. “I tell people all the time. The hospital is like this crazy spaceship. No one acts normal! People come into your room and they are like, ‘Did you poop today? How many times? What did it look like?’ And then they poke around your belly. And they’re like take this, drink that! So many times patients would feel like they’re going crazy. [And my response was,] ‘No, you’re in a crazy place. This is Crazyland—you’re the normal one!’”
“There was this couple, they were so sweet. They came into the hospital because the woman had this rash and just wasn’t feeling right. And over the course of ten days when she was in the hospital, more and more tests were run and we found out she had end-stage cancer. And she passed away in the hospital. One day I was running around charting and I was just rushing back and forth. And he [the husband] gives me this look when he sees me—I don’t know what he was actually thinking—but it [felt] like, ‘How dare you? What are you doing acting like things are normal? Things are not normal!’ And I was like, no they’re not—but they also are.”
“I think for me, I’m more interested in how things happen and why things happen. And relationships, understanding what people mean to each other. There’s something really special about internal medicine."
“There was this woman who had a transplanted organ, and she has been in and out of the hospital. She had this bag—it was like she was expecting it [her visit to the hospital]. She had a stack of books and, because she knew she would be nauseated, she brought these little mints. Six different types of them. And nail polish, because she wanted to create normalcy and paint her nails. And she brought pajamas, and slippers and a pillow.”
If you flip back to our first interview with Sara, you may remember her experiences studying maternal healthcare in Burkina Faso. Despite the stunning differences between a US research hospital environment and a maternity hospital in Burkina Faso, some of the struggles are consistent. What is required to deliver the most humane and high quality care to patients? How can hospitals and clinics provide care that is efficient and excellent while also treating patients like human beings?
“So, it’s 120 degrees in the hospital, you haven’t slept in 22 hours, and you’re watching these women scream and deliver their babies. You would be frustrated, you would be tired. A lot of midwives would hit women—it was abuse.” This was before Sara began the interview process, but she was curious why this was the norm within the hospitals she frequented. Healthcare providers she asked told her that she didn’t understand because she came from the US, where women are pampered and given pain medication during the labor and delivery process. One midwife told her, “This is the reality of the African woman. She is habituated to pain. We don’t have pain-free conditions like you in occidental countries.”
Later, interviews with women told a different story. Women described being afraid to go to the hospital because they were unsure what type of midwife they would receive or if they would anger their midwife. One woman showed Sara the bruises up and down her arms after giving birth. Another woman, who was a 26-year old Burkinabe mother of two, told her: “The most awful part is the pain. They have the shot [lidocaine] and they see you suffer, but if you angered them and misbehaved while the child was coming, you won’t find it.” However, Sara saw that the midwives were suffering as well. She tells gives us some background information about the midwives: “These are young women, with two years of medical training after high school, who are forced into situations where many babies and young women are dying. It is a traumatic and stressful environment for the healthcare provider and the patients.”
This month, Sara is returning to Africa and will be based in the Democratic Republic of Congo (DRC) and rural Tanzania to study data reporting and provision of care in maternities and pediatric centers as a research consultant for the World Health Organization (WHO). “It’s a project to look at measuring quality of care and important steps in care. For example, how often a woman, who is coming in to have a baby, hemorrhages, and do they have the tools they need [to treat her]?” The WHO is looking for a more in-depth understanding of how to measure quality of care and how the patient care information is recorded, how it flows within the health information system, and what are the best questions to ask to assess the quality of care for mothers, newborns, and children. One of the issues is, “…how should these indicators be measured?” Great advances have been made in increasing coverage of interventions such as having a skilled birth attendant and giving birth at a health care facility, and also mortality for mothers and newborns has decreased, but not as much as expected. Poor quality of care is thought to be the missing link in decreasing mortality and improving outcomes.
“It’s not that these countries are behind in what they are doing [medically]—it’s more a question of if they record what they are doing and how do they record it. And, if a clinic with three beds gets 60 women in the period of four hours, are they really going to be able to take every woman’s blood pressure? Probably not. Without these recordings, we don’t know what the incidence is, for example, of pre-eclampsia [a life-threatening condition in pregnancy] is or if they are properly treating it.”
In addition to investigating particular measurements, Sara and WHO are interested in understanding, “What does data recording mean to people working in these clinics? They are delivering babies and trying to stay ahead of this stream of women coming in, and trying have them both [mother and baby] leave alive.” That does not leave much time or energy for meticulous data acquisition and charting.
When she returns from the DRC and Tanzania, the PhD adventure begins. “I’m looking forward to getting back into [the anthropology] mindset again. I think the medical way of thinking is a lot about recognition and application. I recognize this pattern, I know what this is, I give this thing, and I make it better. Or we cut them this way and remove these things. But I think there is a whole component to that paradigm—the acknowledgement of it. The acknowledgement of what is unfolding in front of you. What does this have to teach me? What can this show me?”
We can’t wait to find out.
What does data recording mean to people working in these clinics? They are delivering babies and trying to stay ahead of this stream of women coming in, and trying have them both [mother and baby] leave alive.”