Sipan Shahnazari
Sri Lanka & Healthcare
Today, Sri Lanka’s healthcare system is on the verge of collapse. Following the failure of the government to make foreign debt repayments, the government has been unable to provide basic resources to its population including fuel, energy and medical resources. A dire situation for a country where more than 95% of the population relies on public healthcare (1). Since the establishment of its free national healthcare service since 1951, Sri Lanka has been an exemplar demonstration of “strong health outcomes over and above what is commensurate with its income level” (2).
I had been fortunate enough to have been able to experience this first-hand during my medical elective in ophthalmology in 2018. I spent my time with the Ophthalmology department at the Karapitiya Teaching Hospital and I was able to appreciate how structural decisions ensured that the highest level of care was provided to the greatest number of patients but in ways very different to that in the UK. While it is saddening to learn about the current situation in Sri Lanka, it has served as a personal reminder to reflect on my experience as an elective student. Indeed, looking back, it might be the case that the things that initially startled me during my time there might actually serve as lessons as to what we can do to improve our own healthcare system overburdened by extensive waiting times.
Karapitiya Teaching Hospital, Galle
Karapitya Teaching Hospital is the third largest hospital in Sri Lanka. It is the largest hospital in the Southern Province catering to a population of 3.5 million people (3). It contains 1560 beds and 54 wards (4). It is linked to the Faculty of Medicine of the University of Ruhuna, established in 1980. It prides itself on being “one of the best medical schools in the country” and has an extremely popular international Elective Programme (5).
This is unsurprising considering it is located near the beautiful UNESCO protected Old Town of Galle and its Fortifications. It is a vibrant city with much to explore including its very own surf spots. It is also a fantastic place to use to explore the rest of the country. And while Galle and Sri Lanka left its mark on me so did the time I spent with the Ophthalmology department.
Ophthalmology Clinic
Anxious to attend the clinic, I arrived early. However, I clearly had not been early enough. Surrounding the entrance of the clinic was at least one hundred patients pushing their way forward to get to the front. They were all shouting at one individual at the door of the clinic who was handing out raffle tickets indicating their place in the clinic. Unlike in England, where patients are given appointments to attend a clinic, here it was a first come, first serve. Being a tertiary hospital, the majority of patients would have travelled long distances to get here. It was understandable, therefore, that no-one wanted to be the one that was turned away and told to come back another time.
I had to join the brawl and make my way through to the other side. Fortuitously, the lanyard and white coat was helpful in ensuring I made it through. The layout of the clinic was also different from what I had been used to. Instead of each physician having their own room or booth, there were multiple school benches which surrounded the perimeter of the room with tables and slit lamps evenly distributed. “You sit here” told me one of the trainees indicating to one of the slit lamps in the middle. I apologised and informed him that I didn’t know how to operate a slit lamp. “You will learn” he smiled back. Then clinic started.
The patients started at the front door and moved along the bench linearly to the next available ophthalmologist. Something that was striking was that all the patients were holding children’s notebooks with cartoons on the front and back. My intrigue as to what these notebooks contained was soon answered: a patient came to my slit-lamp tapping at a page. This was the patient’s medical records and unlike in the UK where records are kept at the hospital, it was the patient who kept their documentation. I struggled to decipher the acronyms and diagrams on the page. It didn’t matter, as the patient had already positioned themselves at the slit-lamp for their examination. After fearfully doing my best impression of an ophthalmologist using a slit-lamp but being very unsure what I was looking at, I gesticulated to a very disappointed patient that it was better they see the actual ophthalmologist next to me.
Despite this inept first attempt, the pace and turnover of patients was relentless. Gradually I start to understand how to focus on different parts of the eye and move across smoothly and under control. Notwithstanding, I was still uncertain as to what I was looking at. Thankfully the consultant and trainees would call me over to them whenever they had found a patient of interest; of which there were a lot. I was shown pathology from Munson’s sign and corneal hydrops with ulceration and neovascularization in a patient with trisomy 21 through to Weiss’ ring in a patient with posterior vitreous detachment. The quantity and variety of pathology was certainly a lot greater than that expected in a regular ophthalmology clinic in the UK.
What impressed me greatly, however, was that by keeping patients in the same room and moving the patients through, the ophthalmology team was able to get through vast numbers of patients. Although one might raise concern surrounding patient privacy, the patients did not mind. Of course, cultural norms differ between the two countries but considering the patients express greater frustration in waiting than lack of privacy perhaps a factory-line approach to review might assist with patient flow instead of the current “sit- and-wait-to-be-called” system. I also believe that providing the patients with their own health records with an expectation that they would bring it to each session serves as a great tool to increase patient participation. Not only does it provide the patient with an active role, but it can also serves as location to store educational material.
Theatres
I had a number of memorable experiences attending the ophathalomology theatre at Karapitiya. This included seeing a trans par plana vitrectomy due to endophalmitis under local anaesthetic due to elevated blood pressure preventing general anaesthesia and internal limiting membrane peeling for a macula hole. However, what I found to be the most impressive was the organization of cataract surgery.
When I arrived in the morning for the session of cataract surgery, I found the patients of the day already sat outside the theatre door, in gowns with their notebooks. Inside the theatre, there were three operating tables arranged to form a triangle and two phacoemulsification machines and microscopes. One table was for the trainee who was able to perform the procedure at their pace. The other two tables were for the consultant who would immediately move on to the next patient at the adjacent table who had been prepped by the theatre staff. The consultant was also able to assist the trainee whenever they came into difficulty. It worked like clock-work with a minimum of twelve patients having had their operations performed by two surgeons by the end of the morning. One slight difficulty was the frequent stern reminder by the consultant that the patients needed to keep their eyes still through the whole procedure. The warning of the risks had to be repeated loudly on multiple occasions.
I believe there are two main advantages to this theatre set-up. Firstly, it allows the trainee to progress their independent training with supervision in order for consultant involvement for difficult stages or complex cases. Secondly, by using the theatre staff to prep the subsequent patient concurrently, time is not wasted moving from one patient to another and the theatre staff’s time is being used much more efficiently than allowing the current procedure to be the rate limiting step.
Conclusion
I still remember my time at Karapitiya Teaching Hospital with great fondness. From the hospital’s beautiful setting through to extraordinary variety of pathology there was a lot to see and learn. However, it was organization of the provision of care which has stayed with me. By focusing on maintaining patient flow in the clinic and theatre, a great number of patients can receive care without compromise on quality. It’s a team game with all members working concurrently to get through the workload. At the same time, trainees have the opportunity to improve their skills with direct consultant oversight. All these factors can serve as learning points as to how ophthalmology is delivered in the UK. It is therefore upsetting to think that much of this progress is at risk in Sri Lanka’s current climate. We hope that these governmental issues are remidified soon so that the people of Sri Lanka can regain their magnificent healthcare system which they created.
References
1. Sarkar S. The devastating health consequences of Sri Lanka’s economic collapse. BMJ. 2022:o1543.
2. Rajapaksa L DSP, Abeykoon A, Somatunga L, Sathasivam S, Perera S et al. Sri Lanka Health System Review. New Delhi: World Health Organization Regional Office for South-East Asia; 2021. 254 p.
3. MOH. Teaching Hospital Karapitiya: Ministry of Health, Sri Lanka; [Available from: http://www.health.gov.lk/moh_final/english/hospital_profile.php?id=82#about.]
4. HospitalsLK. Teaching Hospital, Karapitiya [Available from: http://hospitalslk.blogspot.com/2010/06/teaching-hospital-karapitiya.html.]
5. RUH. Faculty of Medicine, University of Ruhuna [Available from: http://www.medi.ruh.ac.lk/.]