In many respects it was just another Wednesday morning in the emergency department of the Hospital da Restauração, but I was about to witness one of the most impressive pieces of teamworking I have ever seen.
Never before had I seen a group of people spring into action with such efficiency and creativity in response to a new challenge.
I was only a few days into a new role in Brazil, working on a research project on the recent Zika virus outbreak. We had fallen behind with our recruitment of ‘healthy control’ participants for our study and needed to make up the numbers.
Strictly speaking, these ‘healthy controls’ were meant to be relatives of the patients in the study and we needed four of them for every patient. Unfortunately, we had been struggling to find four ‘healthy controls’ for each patient and the gap in our numbers looked increasingly like it couldn’t be filled using the patients’ relatives alone.
My Brazilian colleagues took it upon themselves to find a solution. After a quick team-huddle one of the nurses started to march up and down the hospital corridors announcing our study as far as her voice would carry:
“Roll up! Roll up! Get your free test for Zika, Dengue and Chikungunya viruses and help support medical research!”
It wasn’t long before we had nurses and porters queuing around the corner to sign up. In fact, they were joining the queue faster than we could get them to fill in our forms and take blood from them. I was beginning to feel a bit overwhelmed!
To cope with the numbers of volunteers flooding in, we commandeered use of the hospital chapel, which we turned into a makeshift consulting room. This use of the hospital chapel was, of course, completely unofficial and without anyone’s permission, but it provided the space we needed to get on with the job.
In the chapel we set up a little ‘production line’ with one nurse explaining the study and getting the participant’s written consent, the next taking blood and the next a saliva sample. Finally, the volunteers for the study were seen by me for a very quick medical history and neurological examination.
And so we continued, for the rest of the day, by which point we had not only made up for the gap in our numbers, but had recruited enough controls to last us for the next few months!
Learning from example: what the team did so well
The ‘Jeitinho Brasileiro’ leads to a remarkable efficiency
I’ve picked this story as an example of Brazilian efficiency, but the team were equally dynamic and creative in their use of resources on many other occasions.
In Brazil it seems that rules, protocols and established systems can be overlooked in favour of simply getting the job done. Although in the developed world we might instinctively look down on such a tendency to bypass established procedures, this approach to work led to a remarkable efficiency.
It’s not that Brazilians don’t care about the rulebook, it’s that they care more about getting the job done – which is what’s important at the end of the day. They embrace this culture of resourcefulness and creativity with pride, and refer to it as the ‘jeitinho Brasileiro’ or ‘little Brazilian way’.
This opportunism and pragmatism is something I feel we could learn from back in the UK.
Close-knit teams with an open environment for communication also contributed to the research group’s efficiency
The research team I worked with in the hospital were very close-knit. They communicated frequently and efficiently, mainly via WhatsApp.
This use of WhatsApp helped flatten the leadership hierarchy within the team. It created an environment where any team member could freely raise an issue or make suggestions and this contributed to the efficiency of the team.
WhatsApp is clearly a great tool for exactly this reason, although having sensitive patient data lying around on health-professional’s phones leaves concerns when it comes to the confidentiality of patient data. Fortunately, there are some solutions to this in the way of apps designed specifically for messaging among medical teams, such as medCrowd and Medic Bleep, but these are yet to be widely adopted.
Drawing on outside support created a wider informal team working on the project.
Another factor which aided the team was their ability to pull in other members of hospital staff to help them out. The group of people who ended up contributing to the project was far larger than the core team of researchers who were officially on the pay-roll for the project.
For example, we frequently asked other hospital staff to help us in collecting blood, saliva and urine samples from patients and they would gladly help, even though it wasn’t technically part of their responsibilities in their hospital job.
By contrast, here in the UK I think we tend to stick slightly more rigidly to the boundaries of our ‘formal teams’. It seems the typical Brazilian charm and friendliness acts a sort of ‘social lubricant’ which facilitates asking for favours of colleagues and the creation of a wider informal team.
Reflections on being at the heart of the Zika virus outbreak
Based in Recife, truly in the thick of the Zika virus’s territory, I heard countless stories of how the whole health system pulled together to respond to this unknown and unpredictable threat at the start of the outbreak. Indeed, the Brazilian response to Zika has been widely praised by the international community for being so well co-ordinated.
Finding myself at the centre of a such a huge global health ‘success story’ was inspirational and hinted to me that there must be lots to learn from the Brazilian way of doing things!
Reflections on the healthcare system in Brazil
What was the hospital like and how are the neurology services set up?
Hospital da Restauração, Recife’s busiest public hospital, is an enormous, concrete edifice based in the heart of the city. If its brutalist façade could speak, it would declare: “I am a hospital who is here to do business” and when it comes to patients, the Hospital da Restauração does a LOT of business. It’s crammed emergency room makes overflowing NHS A&E departments seem like hotel lobbies!
Compared with neurology departments in UK hospitals, the neurology department was huge, with a total of 27 neurologists and 50 in-patient beds on the neurology ward.
Half of these 27 neurologists are dedicated to seeing patients in the emergency department (A&E) and don’t work at all on the hospital wards or in the out-patient clinics.
In the emergency department, there were 80 beds set aside just to receive patients with neurological problems. It was almost as if there was a separate ‘neuro-emergency department’ with its own ‘neuro-emergency doctors’.
This neuro-emergency department cares for 3000-3600 patients per month – a huge figure in comparison with the numbers coming through the doors of most UK A&E departments!
This is quite different from the British set-up for neurology, where neurologists spend most of their time working in out-patient clinics and seeing patients in the hospital wards, but not in the emergency department.
Although there are moves in the UK to create more of an ‘acute neurology’ service, with neurologists seeing patients in A&E, this service is still new, relatively small and the British neurologists who work in ‘acute neurology’ don’t dedicate 100% of their time to the emergency department; they work in other areas of the hospital as well.
The professionalism and proficiency of the Brazilian doctors left me inspired
The emergency department is nicknamed the “campo de guerra” or “war zone” due to the awful working conditions and sheer number of emergencies coming in. Patients are regularly attended to in the corridors while lying on the floor and the stench of the place is overwhelming. In the resus room, the beds are crammed in so much so that some of the beds are touching one another. The resus room is the part of the emergency department where the most unwell patients are looked after, and really there should be more space around these beds (so that you can fit more doctors, nurses and equipment), not less.
Under such conditions, performing a proper neurological examination can be challenging. But this didn’t stop the doctors being extremely thorough. To make up for the limited access to blood tests and medical imaging, the doctors had to pay attention to every physical sign that could possibly be elicited from the patient. This care and attention to detail, despite the demanding environment, hugely impressed me.
NHS hospital wards are a challenging environment in a different way: junior doctors feel overwhelmed by the number of patients they are left to look after, their attention is spread thin with the constant distractions of requests from nurses and relatives and back-up from a more senior colleague is often much further away than one feels comfortable with.
However, when I start work in my first NHS job in a few days time, I will try to remember these Brazilian doctors and how they did not let their standards slip, even under the most difficult conditions. Like the Brazilian doctors, I will focus on providing the best possible care for the patient in front of me, not matter how much pressure I am under!
Contrasting the public and private sectors
Although most of my work was in the government-funded Hospital da Resturacao, I also visited some private hospitals. The poor conditions in the public hospital were a stark contrast from the plush private facilities.
Not only did this strike me as unfair – that select patients should receive a higher standard of care, just because of their ability to pay for it – but it was also clear that the division between public and private sectors created inefficiencies and made for a less effective health service overall.
For example, one patient had been investigated thoroughly in the private sector for a small hole in the heart, which had been sold to them as a potential cause of their recent stroke. In all likelihood, the small hole in the heart was completely unrelated to their recent stroke but the patient’s cardiac surgeon was recommending an unnecessary operation to close the hole.
The best medical evidence shows that the risks of this operation outweigh the benefits and it’s not an operation that would be offered on the NHS, for example. I could only assume that private surgeon was at least partly motivated by financial reward.
The neurologist in the public hospital was then left to ‘pick up the pieces’. Not only did he have to spend time explaining why the operation was unnecessary but he also had to treat the patient’s real underlying risk factors for a further stroke (high blood pressure and high cholesterol), that the private cardiac surgeon had simply ignored.
What have I learned about myself?
- I’ve learned that I can be adaptable and that I have what it takes to cope with working on a project like this. Before I arrived in Brazil, my precise role within the research team wasn’t well defined, but I soon found my way and worked out what I could do to contribute as best as possible.
- I’ve learned that I want to do more of this sort of work. Working on an ‘emerging infectious disease’ was really exciting. It was exciting to be part of such a fast-moving field and to see patients with conditions which simply hadn’t been described before. Knowing that people around the world would be interested in the results of our research was a great source of motivation and it was rewarding to think that the project would really make a difference in people’s lives.
- I’ve decided that working abroad is something I want to incorporate into my future career. Working abroad was ‘professionally enriching’ – it gave me a new perspective on my profession and how I can be a better doctor – but, more than that, it was ‘life enriching’ – discovering another country and learning about its people and culture was extremely fulfilling. If I can combine my love for travel with my career interests, then why not go for it?
- I’ve been persuaded of the importance of community. People seemed happier in Brazil than they are back home. Perhaps this is because they feel a greater sense of communal belonging and have more in the way of social support. Reflecting on this, I’ve decided to really get involved in my local community when I return to the UK and start work in the small town of Bury St Edmunds. I have been thinking I will start volunteering for a local group as a way to help build links with my local community.
- I’ve realised that speaking a foreign language is a great skill to have. There is no doubt that being able to speak Portuguese allowed me to get a lot more out of my experience in Brazil. This has prompted me to invest some time in learning other languages, which might help, particularly if I am serious about working abroad as part of my future career.
- Opportunities happen when you ‘put yourself out there’ and just start speaking to people! This whole project came about because I opportunistically approached some people and asked to get involved. There was no official position being advertised, I simply sent off a few emails explaining what I had to offer – my Portuguese language skills and a healthy dose of enthusiasm!
Many of the best learning opportunities I had while in Brazil also arose as a result of just talking with people. My visit to the indigenous tribe was arranged after I simply got chatting with a GP who I met in a bar. She was just a friend of a friend of a friend and, had I not gone out that night and got talking about my interest in Brazil’s healthcare system with her, this once-in-a-lifetime opportunity to go on a medical visit to the indigenous tribe would have never occurred!
Now I’m back in the UK and just about to start my first job as a doctor in the NHS at West Suffolk Hospital, which already seems like an unbelievably nice place to work (scattered conversations with HR and previous employees make me think I have struck gold in the minefield of notoriously arduous junior doctor jobs).
I have no doubt my experiences in Brazil have helped form me into a better doctor, but I am not sure that anything could quite prepare me for stepping out onto the wards on Wednesday and becoming responsible for human lives for the very first time.
Nonetheless, if I can bring just a little bit of that Brazilian energy back to my job in the NHS and can emulate some of the verve and ingenuity displayed by the team I worked with in Recife, my time in Brazil will have been worthwhile!