Resistance to Change

Those of you who know me know that I can be very resistant to change. When my parents wanted to get rid of our 18-year-old worn, stained, crayon-graffitied coffee table I was so upset I insisted they store it for me; it now sits in all of its glory in my living room.  I am still reeling from the change of management in the Health Science Library coffee shop and have resorted to returning home for my afternoon coffee rather than buying the new coffee from the new baristas.

This is all to say that I am sympathetic to individuals and institutions who do not wish to undergo dramatic transformations or systematic restructuring.  Yet one of the most frustrating aspects of working at KCH is the staunch refusal to change inefficient and often broken systems. This has been a common frustration amongst the other medical students working here. Two years ago Mariah implemented a program to help better support the guardians at KCH. When she met with the hospital director this summer he had never heard of this program despite guardians being a constant problem for the hospital.

Similarly, Timica is working in the hospital lab, and planned to spend the summer doing an analysis of whether the lab tests offered at KCH were those that were clinically relevant and assess clinicians’ knowledge of what lab tests are available.  Yet when she arrived it was made clear that the administration was not interested in this study, and moreover was not interested in implementing any changes based on its results.

The study that I am working has thus far been well-received, but I realized on Friday night that my study is a response to resistance to change. One of the UNC undergrads was asking me about my work here, and when I told her that we were investigating alternatives to the DNA-PCR test currently used to diagnose neonates she didn’t understand why an alternative was needed. I explained that the DNA-PCRs take at least a month to get results from the lab, and that a benefit of the p24 antigen test is that it can be done at point-of-care. The student responded by telling me that DNA-PCRs should be able to be done within a week, and she didn’t understand why changes couldn’t be made in the lab to deliver DNA-PCR results more efficiently.

Though I have previously written about this issue in my grant applications and read about it in the IRB proposal this was the first time I really understood the ridiculousness of the situation that precipitated our study. The probability of the hospital lab initiating changes that enable efficient delivery of DNA-PCR results is so low that it is worth immense amounts of time, money and effort to do a new study on a test that will essentially circumvent the lab all together.

Yet even in these frustrating situations I find it a fine line to walk to be honest and critical of the hospital and it’s administration without being ethnocentric and close-minded. How do foreign students and professionals in Malawi work to identify weaknesses and improve on them without undermining the authority of the KCH administration? How do physicians balance the immediate need of patients with the need to respect their Malawian colleagues and create a sustainable system based on Malawian expertise and commitment?

 I think the answer to these questions lies in humility and cooperation on both sides. Just because we have one system in the U.S. does not mean implementing the same system here is the best course of action. Conversely, simply because the KCH lab has followed certain protocols for years and years does not mean these protocols are not without fault.  Yet these lessons are easier said than learned, I will try to remember when sipping my home-brewed coffee at my stained coffee table while the rest of my class enjoys Magical Mochas at the clean linoleum tables of the Friends Café.

T-Minus Two Days

Hello (soon-to-be) loyal readers!

Now that the whirl-wind that was the first year of medical school is done, I have time and energy to focus my energies on my next adventure: a summer of research in Malawi! This new-found time and energy is just in the nick of time, too, because I take off in exactly 48 hours and 30 minutes!

In Malawi I will be working with the UNC Project, a partnership between the Univeristy of North Carolina and the Malawian Ministry of Health. As such, I will be working with investigators from Baylor University and University of North Carolina to test a new method of diagnosing HIV in neonates.

Traditional HIV tests, which look for antibodies to the virus, cannot be used in children under 18 months because maternal antibodies which are acquired during gestation and delivery are still presesnt in the newborn (potentially giving false positives). This presents a problem because it has been found that if parents of potentially HIV-positive newborns take their children home, they may not have the ability, resources, or desire to return for testing 18 months later.

Thus to effectively initiate antiretroviral therapy (ART) in HIV+ newborns researchers and clinicians need to overcome a public health problem and a diagnositc problem. Clinicians need a diagnostic tool that doesn't look for antibodies and they need a tool that can be used at point-of-care (POC) so that the families don't have to return to the hopsital. The test that we will be evaluating this summer has already been shown to be diagnostically useful, it is called the p24 assay and it looks for a viral protein, which will only be present in children who are themselves HIV+, regardless of the maternal antibodies they carry. The study will also evaluate various manners of administering the test, in terms of which hospital personell are responsible, how the lab work is divided amongst responsible parties etc. The ultimate goal will be to find the most efficient way to identify HIV-positive newborns in order to initiate ART.

Contrary to what was believed in the early days of the HIV epidemic, it is now generally accepted that early initiation of ART therapy is critical to the patient's prognosis and can help sustain CD4 counts and prolong life expectancy. Thus this is an issue of critical importance to the estimated 91,000 Malawian children living with HIV.

While I have a background in HIV-related research in the 'developing world' and currently serve as an HIV testing counselor through the UNC student clinic, SHAC, I anticipate that this summer will be full of new lessons and new challenges. I am looking forward to learning about Malawian people and culture, putting the skills I learned this year into use, and contributing to an important project that has the potential to vastly improve the prognosis for children born with HIV in Malawi.

I'm thrilled and honored to be working with some of the best, brightest and most dedicated in this field, and alongside two of my classmates who are as committed and excited as I am. I'm glad that you all will be joining me on my adventures, some of you actively and some of you vicariously. As the summer progresses and I learn more about blogging I hope to improve the look of the blog and provide pictures, info on Malawi and more about the project. I look forward to your questions and comments and sharing what I'm sure is going to be a great experience with you!