Reflections from the Global Health Front: The Whole Patient

On my first day in Uganda, I went to the hospital early to join the team on rounds. I wore my bright white coat, wrinkled from the long trip, and my stethoscope was looped around my neck. I wanted to learn some clinical medicine and hoped that my modest research project might yield useful data for my Ugandan advisors. The team gathered around a patient’s bed. The young man, called Emmanuel, sat silently with his legs buried in the folds of a red blanket. I watched Dr. Sadigh’s hands deftly percuss his lung fields, outlining an area of consolidation in the right lower lobe. “You should feel a difference in the tissue, not just hear it,” he said.A novice in the world and language of medicine, I understood only a few stray words as Dr. Sadigh conducted the exam and discussed the clinical significance of each finding with the residents. When he was done, he stood, resting his hand gently on Emmanuel’s shoulder, and asked the team for its thoughts. Lobar pneumonia. Tuberculosis. PCP. There was talk of ordering a chest film and sending sputum samples for analysis. Would it be possible to get a CD4 count? The ultimate arbiter of health at Mulago Hospital encroached on the conversation — cost. A CD4 count was out of the question. Could this patient afford the $6 chest X-ray? Caroline, a Ugandan intern, spoke in dulcet, muted tones as the rest of the team strained to hear her: “He has a positive blanket sign. He can probably afford a chest film.” Mulago Hospital is the national referral hospital of Uganda. Anyone can seek treatment at Mulago, but each patient must pay for all of his own tests and most of his medications. Each patient also must supply his own bed linens. Some patients rest propped up on pillows and under sheets and wool blankets. Some wrap themselves in a single cloth; others lie on a bare plastic mattress. The house staff at Mulago uses a patient’s location along this spectrum as a crude indicator of what studies and therapies he may be able to afford. The professors who teach physical exam at Yale had instructed me to look for this sign. “Take in the whole patient,” they said. “Do not focus solely on the patient’s physical findings or chief complaint.” Their words came back to me that first day in Uganda when we assessed Emmanuel’s red blanket. Caroline quickly recorded the team’s assessment and plan for the patient on a sheet of loose-leaf paper, slid it back into the pink tagboard chart, and placed the