My first full day on the wards felt like a dunk in cold water. I knew I would feel useless, and boy did I live up to expectation. The infrastructure to get things done was rife with pitfalls that only a local could navigate. To start, the patient lists were recorded by hand in a blue book labelled ‘Blue A,’ which I tried to find but failed. When I attempted to pre-round from memory after the day before, I found the patients in their beds, but finding charts against the hustle of medical students, interns, and nurses fighting for dominance proved fruitless. I examined most of the patients and made some mental notes for rounds.

As rounds began, I realized quickly that my expectations for forward progress in care would have to be tempered. Most of our patients made little or no progress from the previous day waiting on specialist review or results from a scan or the lab. Bloodwork was only collected once a day and followed up the next morning, and booking any scan meant waiting a few days until it was done and then a few more for a radiologist’s review. Even then, it was still the responsibility of the medical team to visit radiology to pick up the physical report, which could be ready at any time. This meant once-daily trips to the radiology dungeon just to check. I wasn’t necessarily surprised as much as I realized how spoiled I have become. This led to inevitable delays, which was unfortunate for one of the sicker patients on our list.

He was a man in seventies, who had been brought in for seizure-like activity. When I joined the team he was already on our list and the story was as follows: he had a relatively uncomplicated medical history and started having progressively more frequent seizure-like movements in his arms and some generalized confusion. On admission, he was found to be intermittently responsive but appeared to be in a lot of pain, especially in his limbs. He was found to have lab derangements that partially explained his issues: he had a kidney injury, causing the buildup of toxic products that can lead to confusion and seizures. Additionally, he was anemic with low red blood cells, and his calcium was impressively low, which can cause muscle twitching and seizures. In an attempt to investigate the cause for his pain, the overnight medical team got an X-ray and the clinical physician on-call identified what he called lytic lesions in his bones, which is a type of bone erosion mediated by over activity of special cells that break down bony tissue. This man was very sick.

We were considering several different possibilities for him. For one, this almost certainly represented some form of metastatic cancer, the question was what kind. The admitting resident had characterized the lesions as lytic, which is an important distinction from blastic, because different types of cancers cause either form of bone disease. For this patient, the distinction was even more important because our workup was limited and slow. We took the diagnostic route of prioritising cancers causing lytic disease, most commonly multiple myeloma, and sent the appropriate lab work and scans. We waited a day for results, then another, and another, until a week had passed by and we had nothing to show for it. In the meantime, our patient got sicker and sicker, with continued seizures as his calcium dropped further despite aggressive repletion.

One look at him told a somber story. He was pure bones, mumbling sounds and rigid in his bed. He was displaying clear signs of encephalopathy, a term to describe brain dysfunction, likely from all his toxin buildup and horribly low calcium. His outlook was grim. Still, the diagnosis wasn’t adding up. Lytic lesions should usually cause high calcium, as the bones get broken down and spill their elements into the bloodstream. Blastic lesions on the other hand, can cause your calcium to drop as your bones take it up from the blood to grow ugly masses from metastatic cancer.

I remember the resident, Dr. Neo, and I evaluating him together as his condition worsened. Neo was in her early thirties and her second year of residency, having done two house officer years before starting internal medicine and was seasoned beyond what her rank would suggest.

‘We can’t seem to get enough calcium into this guy,’ I said. ‘What if these bony lesions are actually blastic? Seems that would make more sense.’

‘I was thinking the same thing,’ she said. ‘Another form of cancer could still cause all of his other lab derangements.’

‘Where did the lytic disease impression even come from?’ I asked.

‘I don’t know. How about we take a trip to radiology?’ she said.

So we did.

We stepped out into the heat and followed the shaded path between more wards until coming up to another building. We entered past a front desk into the imaging archive, where two clerks sat on computers, unconcerned with our arrival. To my left, stacks and stacks of CDs and manila folders arranged themselves in a semi-organized fashion. Our fingers flipped and flipped through folders, pile after pile with no luck finding our film. Dr. Neo then led me through the hall into an empty reading room with more folders, and again we searched, this time finding the X-ray in question. We took the file in hand and walked to the other reading room. The whole process took around twenty minutes.

We found two radiologists inside, one attending and one resident. The resident was one of the Penn residents, also on rotation; I had met her before. She told me that the absence of radiologists over the holidays meant she had spent the entire month of January catching up. Her eyes were bloodshot from reading images all day.

‘Hey docs,’ I said. ‘Just coming to interrupt whatever you are doing.’

‘Of course,’ they said.

‘So we have a gentleman here who was admitted last week,’ we started. ‘He likely has some form of metastatic disease with bony lesions on his X-ray and a history concerning for malignancy. We were hoping to go over the X-rays together. Our question specifically is whether they are lytic or blastic lesions, as that will impact our workup.’

‘Name? Sounds familiar,’ the resident said.

We gave the name.

‘That does sound familiar…hold on,’ she said, eyes furrowing as she turned to her attending. ‘Do you remember this patient? We read a CT abdomen yesterday.’

‘CT abdo?’ we said.

‘Yes I remember.’ she said again. ‘We read this guy’s CT abdomen. It was definitely blastic disease. Suspicious for prostate cancer most likely.’

Neo and I both looked at each other perplexed. The radiologists showed us the report and printed it out, patient’s name and all. Like dumb and dumber we walked out of the room still holding the week old X-ray in hand.

‘CT abdo? When did that happen?’ I asked.

‘I don’t know,’ she answered. ‘Maybe it was ordered on admission and then never communicated, or lost somewhere in the notes.’

‘And if we don’t know it’s been done, nobody comes to pick up the report and it sits here forever,’ I said

‘Right.’

So our patient spent days waiting for a diagnosis that we had but didn’t know about. Not a good look for us.

This is the ugly side of paper charts and unrefined infrastructure. Maybe somewhere in the paperwork it was documented that the scan was ordered, but without a proper system to keep track, things get lost. In Ireland we were on paper charts as well, and things got missed at times, but they had a more cohesive network. The patient’s charts didn’t even have names or bed numbers on the front here, sitting one on top of the other in a drawer for the entire cubicle. The lab portal was down half the time, meaning that labs had to be ordered by paper, manually sent to the lab and the papers picked up again the next morning. The X-ray machine was broken for a week twice in the month I spent here. The interns were overburdened with dozens of time consuming tasks, so they relied on the medical students to carry some of the load, which led to inevitable breakdowns and jobs not completed, or paperwork filled out incorrectly. Combine this with lengthy ward rounds full of redundancy and it was almost a miracle than anything got done at all. A damn shame.

With regards to our patient, his fate was sealed. Any amount of calcium we gave him went straight into his bony cancer. No amount of anti-seizure drugs or antibiotics would change his outcome. Even if we had clinched his diagnosis on hospital day one, we could forget him starting on prostate cancer treatment on that quick of a turnaround. He died in the bed two days later, to nobody’s surprise. Sad, yes, but hey, we are just people doing medicine. We are not Gods.

Throughout the first few days of rounding, I got more accustomed to the pace and culture. Patient care progressed slowly, whether I liked it or not. Rounds were aggravatingly long, and tedious, but I kept my jittery frustration to myself and took part with gusto whenever I could. After all, I was here as a guest, and grateful to be so. I will say however that despite rounds being tedious, they were rich with knowledge and a commitment to the ritual of teaching I don’t see in the US, more akin to my time in Ireland. Rounds were long because student presentations were so dense with information they took 15 minutes each, with histories fleshed out in ways far above and beyond the expectation at Penn. The physical exam was more laden  with clinical information, highlighting features we don’t even look for in America. The droning of teaching points from the attendings were more robust than any specialist I have rounded with as a resident. I came to understand that our rounds prioritised a different need. In the US, our rounds are sharp, limited by the constant pressure for efficiency and forward progress, but Princess Marina was a true academic hospital in that sense. Teaching was the priority, and the rest would have to wait. The quality of medical knowledge from the attendings was so goddamn impressive they blew US hospitalists completely out of the water. The students as well, despite their constant guile of self-doubt, were tremendously knowledgeable. There were morning conferences three times a week, and the attendings held student presentations to such an incredibly high standard with no sympathy. I was well and truly blown away at the level of medical expertise at Princess Marina, full stop.

This is what I feared about coming here. The questions peppered to the residents about physical exam features of severe versus moderate mitral valve disease, nuances of different forms of finger clubbing, and findings to distinguish the anatomy of cerebral lesions by exam alone were skills I did not refine in my three years of residency. I had become so comfortable in my system that I felt intimidated here without my usual tools. Did I really have anything to offer here if they hired me as an attending? Maybe. That remains to be seen. What I can say is that to work in this system, while it may lead to slower progress for patients, produces tremendously smart physicians. Neo was evidence of that; she was a graduate of one of the first cohorts of medical students in Botswana, a wicked sharp clinical thinker with incredible knowledge. The University of Botswana and their partners at Princess Marina Hospital have built something very impressive

In truth, I was on this elective to learn, not to bear clinical weight, and it took me a few days to come to terms with this. If patient outcomes were obstructed, I took mental notes, nudged gently, and moved on. I leaned into my position as clinical teacher, doing daily sessions with the medical students to highlight topics related from our cases of the day, citing the guidelines and standards that I knew while being respectful of the processes here. On rounds I contributed, and over time the attending and Neo came to respect my opinion, turning to me for my perspective to inform their decision making. When the team was running around doing jobs, I offered my help but didn’t linger endlessly like I would have otherwise. I took lunch breaks, left early when things were slow, and took the chance to observe and learn. One week in, I had a role and felt comfortable in it.

The real fun was in the medicine, and there was never more fun than on long call admitting days, courtesy of the well-known tandem of HIV and Tuberculosis.