Will your doctor recognize Ebola?

Ebola's brutal lesson: U.S. docs need more infectious disease training

The failure of staff at Dallas' Texas Health Presbyterian Hospital to follow proper protocol when a Liberian visitor presented himself to the emergency room with a febrile illness will stand as one of the more significant errors in the recent history of medicine in this country.

Though there were many contributing factors to the delay in his diagnosis of Ebola virus disease, the most significant is that medical students and residents in the United States learn little about tropical diseases.

Such lapses are neither necessary nor inevitable.

In January of 1975, I arrived in Walvis Bay, Namibia — a quaint oceanside town located in what was then known as South West Africa — as a conscript to the South African Army Medical Corps. I had just completed a yearlong internship in internal medicine and surgery, after graduating from the University of the Witwatersrand's rigorous six-year program, which included the subject of tropical medicine in the fifth year.

I barely had time to acclimate to my new environs when I was ushered into the sick bay and asked by the charge nurse to consult on a 19-year-old conscript infantryman. I was informed that the young man had been admitted five days earlier after being examined and treated for a fever by the local town family practitioner. The fever was unremitting, despite a number of antibiotic prescriptions, and the patient's clinical condition appeared to deteriorating.

In reviewing the history, I asked the nurse and patient about any recent travel outside of the army base and was greeted with stony silence. After some insistence on my part that I could not evaluate and treat the soldier without the information, I was told in hushed words that "he had been up north at the border with Angola." The South African military at the time was engaged in a clandestine border conflict with insurgents from the South West African People's Organization and with Cuban forces as part of the Cold War, covertly backed by Washington.

The travel details combined with the examination suggested to me that the soldier was suffering from a tropical disease for which the antibiotics the soldier had been prescribed would be of little benefit. I obtained a sample of his blood to send for laboratory analysis and prepared to perform my own blood smear analysis, as I had been trained to do in these clinical circumstances.

"But," said the charge nurse in her native Afrikaans, "who is going to read the slide — there is no one in the laboratory trained for this purpose."

I replied that I would read the slide, confident that I would be able to do so. The stained slide was returned to the sick bay within hours, and I was able to discern under the microscope the sinuous trophozoites of Trypanosoma Rhodesiense — the causative parasite of "sleeping sickness," which is transmitted by the bite of a tsetse fly.

Clearly, the soldier, by dint of his deployment to an endemic area of known tsetse fly infestation, had acquired the parasitic illness after being bitten. Later that day, the stricken young man was air evacuated to Pretoria for definitive treatment of his illness. I was sworn to secrecy for the duration of my military service lest there be panic and fear among the conscripts and their parents of the dangers the troops were facing by being "up north."

I was reminded of my experience by the events surrounding the diagnosis and treatment of the first patient with the Ebola virus to reach the United States. It was a difficult day for the practice of medicine in this country, made worse by having to watch on television the mea culpas of the officials representing the hospital. I observed with sadness their excuses as they tried to exculpate those responsible for the initial evaluation and treatment of the stricken Liberian, who died Wednesday.

It seemed disingenuous to me for the hospital officials to blame the electronic medical record — a system supposedly designed to obviate communication errors in the health care setting — or an anonymous, hapless triage nurse who evidently had properly performed her duties.

In addition, the revelation that the patient had also been prescribed ineffective antibiotics for a presumed viral illness is odd, given proscriptions against this practice by the Centers for Disease Control and Prevention.

How is it possible, I wondered, that with our expensive and much vaunted health care system, such a failure could occur?

I remembered that in my own training all those years ago, we were taught that for any individual with a fever and recent travel history to the tropics/subtropics/known endemic disease area, the patient is presumed to have a tropical disease (malaria, yellow fever, Ebola, etc.) until proved otherwise. Keeping the patient in the hospital until a tropical disease is excluded is a necessary requirement for the successful diagnosis and management of these often morbidly ill patients.

But then, since medical students and graduate resident physicians in the United States receive little if any training in tropical medicine and hygiene, why should I expect that they would be competent in this field of medicine?

Yet, there is the tacit — perhaps misinformed — presumption by the public and the media that health care personnel here are being prepared to deal with an increasingly globalized world in which these formally "exotic" but potentially fatal tropical diseases are likely to reach our shores.

The reality is that the traditional, intensive four-year graduate medical school curriculum in this country has little time for the inclusion of the subject of tropical medicine. Neither are physicians in graduate residency programs schooled in tropical medicine, unless they are among the few who pursue a fellowship in infectious disease.

The recent enactment of the Affordable Care Act similarly did little to correct this deficiency. Rather, in response to the projected shortage of primary care physicians in particular, some medical schools have proposed even shorter three-year curricula to mint new physicians to meet the demands of a burgeoning pool of needy and now recently insured patients.

The combined eight years of schooling required of graduating physicians in the United States actually produces an inferior product at enormous cost. Indeed, figures published in October 2013 by the Association of American Medical Colleges demonstrate that 86 percent of physician graduates are in debt, with mean medical school debt burden estimated at $170,000.

One solution — already being implemented at a number of universities — is to create six- or seven-year medical programs that transcend the four preliminary years of a liberal curriculum, integrating basic core subjects in the humanities with an intense medical training. This innovation would allow students the time necessary to gain broad competency — not, as in the present system, the ability to opt out of tropical disease nor any other clinically relevant subjects.

The result would likely be the production of a greater number of more highly skilled general practitioners, who could more easily meet the needs of a growing insured population at lower cost, and whose skills would be more appropriate to the challenges of a globalized economy. It would also reassure an apprehensive public that the debacle in Dallas is unlikely to be repeated.

Dr. Raymond Pollak is a former professor of surgery and the CEO of the Skokie-based Hippocrates Consulting LLC.

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