As a surgical resident in a tertiary care center, I have seen a lot of patients in consultation for surgical evaluation. A typical consultation request includes age, gender and diagnosis of the patient. When I decided to pursue surgical training, I specifically acknowledged that I would forego much of the diagnostic process as typical referrals come to us diagnosis already known.

However, being here in Kijabe has made me realize how much this diagnostic knowledge influences my interactions with patients, specifically with regards to the physical exam. For instance, if the consultation page says “21-year-old female with acute appendicitis,” I would look at the CT scan prior to seeing the patient and then mostly ask specific questions related to appendicitis. My physical exam would be brief and the abdominal exam is performed anticipating pain in the region of the appendix and often not intentionally performing other diagnostic exams. After all, I have already seen the CT scan and confirmed the stated diagnosis.

Things are different at Kijabe Hospital. All labs and imaging must be paid for in cash upfront. A CT scan can cost more than a month’s salary. The first clinic patient I saw was referred with the following note: “Suspect spine metastasis causing severe pain, please assist in finding primary.”

In other words, a 70-year-old woman sat before me with crippling back pain and an MRI showing multiple lesions that were most likely cancer that spread to her spine from somewhere else. A spinal biopsy would not be easy because of the location of the lesions and thus a surgical evaluation was requested to see if any simpler biopsy could be performed to obtain an answer as to what disease is ravaging this woman’s body.

Ummm… excuse me?

I have never seen a consult like this. I read the five pages of her medical record, looked at the results of a basic blood count and an abdominal ultrasound. The answer was not there. I paused. I took a deep breath. And then I asked more questions than I have asked a patient, perhaps ever.

I did the most thorough exam I have performed in a very long time, including a gynecological exam. I used skills that were carefully taught to me in school and, I am sad to say, infrequently used in the US. I wish I could tell you that I found the cause of her illness but my exam turned up empty.

I ordered a small number of tests that might detect a cancer that I cannot feel, like lung cancer or liver cancer. Still nothing. Ultimately, she will proceed with spine biopsy as this is the most high-yield test for the family’s limited resources.

But despite not discovering the diagnosis, I was revitalized by getting back to basics. Real medicine in practice rather than what I now call “computer medicine.” I am challenged to use these skills on a more regular basis and so thankful for the opportunity to sharpen those skills at Kijabe Hospital.