Richard Donkor, OD, and I were tired after two days of performing 4th year optometry student qualifying examinations. As I mentioned in my last post, there were five stations. The three Kenyan optometrists worked the refraction, slit lamp, and ophthalmoscopy stations, Richard did binocular vision and confrontation tests, and I did the history taking, case analysis, diagnosis, and treatment plan station. The first day I devised various clinical scenarios, but I realized that it was difficult to compare between students with cases of varying complexity. It was also a lot of work.
On Friday, I settled on one case which happens to be very similar to my actual case. I will briefly describe the typical interaction. The student would enter the room and introduce themselves. “Hello, I am Dr. Twelker,” I would reply. They would shake my hand while holding their right elbow with the left hand, and a slight bow. The first time this happened on Thursday, I thought the student had a sore elbow. With every student sporting a sore elbow, I asked a student why she held her elbow like that. “It is a sign of respect,” she said. “Oh, how nice,” I said, “Thank you.” The culture is similar enough to America that I feel quite comfortable most of the time, but there are enough significant differences that I am sure I make mistakes all the time without even knowing it. I am glad that the vast majority of Kenyans are good natured, gracious, and forgiving.
“This is an evaluation of history taking, case analysis, diagnosis, and treatment plan. You will be the optometrist and I will take the role of a patient. We have twelve minutes. Do you have any questions?” I said. Usually there were none, and there was a nod of understanding. I would take off my glasses, “Okay, begin,” and I pressed the stopwatch on my phone.
The student would introduce themselves and ask my name and age. “What brings you to our clinic?” the student would ask. “I purchased these reading glasses five years ago. They worked for many years but now they have lost their power while reading. I can see well through them for distance vision, however, which was not the case before.” I said. “How old are you?” the student would ask. “Fifty-five,” I answered, which is not far from the truth. I chose 55 because at that age there should be no ocular accommodation remaining and I did not want that to be a confusing factor. The student would then dutifully and carefully work through the history taking point of general health, ocular health, family history, medications, and allergies. I kept it simple. “Do you have any hobbies?” they were trained to ask. “Reading at night,” I answered. “Do you smoke or drink alcohol?” they asked. I usually said no, or sometimes answered that I had an occasional beer. Once, and perhaps I was bored, I answered that I occasionally smoked marijuana. I was curious what might happen. It did not phase the student one bit. “Very well,” he replied and continued. Marijuana is illegal in Kenya but I hear that it is not that uncommon for some people to use it.
Sometimes there was an awkward pause after the history. I sat there. The student sat there. He or she would quietly say, “I am done with the history.” “What would you do next?” The vast majority of the time the student would respond, “I would take visual acuities, distance and near,” which is the right answer. Occasionally the student would say, “You might have cataracts. I will take you to the slit lamp to look.” I encouraged the student to take a straightforward approach to the exam flow and, at least in the first years of practice, use the same order almost all the time. History, visual acuities, confrontations including cover test, retinoscopy, refraction, tonometry, slit lamp, and ophthalmoscopy. That should be the order. If a practitioner jumps to the slit lamp, for example, then it would be most efficient to do applanation tonometry at that time which means instilling eye drops. The eye drops could interfere with refraction. Thus, it was best to stick to a simple and consistent exam flow, I recommended.
I encouraged every student to become proficient at retinoscopy because it is quick, inexpensive, and provides so much information about the refractive and ocular health status. I was happy to have some input into their education, even if it was in the last days of their four year degree. “The retinoscopy shows significant ‘with motion’,” I would say. “What does that imply?” The vast majority replied, “Hyperopia” and I was glad for that.
“The refraction shows +1.00 diopter (D) of refractive error in the distance, both eyes, and the patient holds his material at 50 centimeters. You decide to prescribe bifocals, what add to you prescribe and what to you write on the pad of paper?” “The majority said, “+1.00 D, both eyes, and +2.00 D add,” which is the right answer. Some wanted to calculate the add based on a formula of “Age – 10, divided by a half,” which in this case would be +2.25 D. I told them that was not incorrect, but that at age 55 years there was no accommodation left and suggested they prescribe based on the working distance. Several students forgot to incorporate the distance refraction in the Rx, and answered Plano, +2.00 D add, which is quite incorrect. I told the students kindly but firmly that the distance refraction must be taken into account, and from now on to never forget it.
The clinic volume is somewhere between zero and five patients a day, and the clinic is not open every day. Many of the students have only seen five or six patients their entire third year, and perhaps seven or eight their fourth year. Much of what they have learned is from books and lectures. Despite this challenge, some students were sharp and answered the questions quickly and confidently. One student was excellent. I asked him where he intended to practice and the town is 60 kilometers from Kakamega. “Micah,” I said, “I recommend that you get some experience, then return to the University. You can study to get your master’s and then your doctorate degrees. You could run this program someday.” I hope I planted a seed, much like my mentors did many years ago. Thank you, Drs. Zadnik and Mutti.
“The patient states that he is a farmer and bifocals are too expensive. He wants reading glasses. What do you write as the reading prescription?” I said. Most replied, “+3.00 D,” the right answer. Some said, “+2.00 D,” indicating only the add. I reminded them that bifocals incorporate the distance power through all portions of the lens, including the bottom portion. “+2.00 D, while helpful, would most likely be insufficient for this patient to achieve the best visual acuity. They call it an ‘addition’ for a reason, that is, you add it to the distance power.” A few had an “ah-ha” moment.
Some students, and I did this when I was a fourth year and beginning practitioner, made the case more complex than it needed to be. When I mentioned that the distance was blurry at distance and near, some students immediately jumped to a diagnosis of significant cataract. I reminded them that almost all 55 year old patients have some cataract, and most are not clinically significant, and recommending sunglasses and/or a hat would be a very good idea. I said that as an optometrist, especially an optometrist in Kenya, our main work was to treat refractive conditions through optical means such as spectacles. This happens to be one of the most common causes of unnecessary visual impairment. Keep things simple. Only add complexity when the situation requires it, as it sometimes will. When faced with complex case, as in the patient with a diagnosis of ocular trauma or disease, concentrate on what benefit we might be able to provide, and refer to an ophthalmologist or other specialist.
One student on the first day, when hearing a case of a 19 year old complaining of blur at night, immediately diagnosed night blindness due to Vitamin A deficiency (thankfully, not a common condition in Kenya due to no shortage of affordable fresh fruits and vegetables) and recommended that her patient eat more vegetables. “Eating more veggies will be healthy for the patient,” I said, “But I was trying to get at a diagnosis of low myopia.”
I did this process 24 times on Thursday, and 20 times on Friday. It was exhausting, although streamlining the case the second day was most helpful. Dr. Donkor was tired too. We decided that after work we would rest then meet to go to a club. Fortunately, Richard lived just one floor below me and he had a vehicle. I walked downstairs a 9pm when we had agreed to meet.
Richard drove us to Signature, described as the finest dance club in Kakamega. There was a brief security check at the ground floor and we ascended the stairway. Entering the club there was a bar on the left with perhaps thirty people sitting in a modern, well laid out floor plan. It had many distinct fixed seating modules that might hold six or eight people. It was perfect for small groups and most Kenyans go out with friends.
We headed to the right where there was also a bar, and the area was much larger and dimly lit. The central feature of the club was a perhaps 20′ x 20 lighted dance floor with DJ. Laser light shows illuminated sections of the club. Monitors on the wall showed music videos that the DJ was selecting and mixing. The modular format was on this side too, with many small groups sitting in the periphery of the club, occasionally moving out to the dance floor. Richard and I sat at small, raised circular table with raised seats for four. For awhile the club manager sat with us.
Most songs were from African artists from various countries, and when a Kenyan artist came on, the energy level notched up significantly. There were some American artists selected like Rihanna or hip hop artists, but the majority were from Africa. Of course, being a dance club for mostly young folks, the emphasis was on modern dance music.
The Kenyan music was excellent. For example, there was Gabriel Karegwa, popularly known as Prince Otach. I was told he was currently based in the UK, and credited with popularizing Kenyan music abroad. Emmy Kosgei was a well known Kenyan gospel artist and was becoming better known abroad. Her music is here.
I have been impressed by the diverse and international nature of African life, especially musical life. Africa is vast, diverse, and full of continental pride. I have been to other countries that seemed to draw their music and entertainment from America. Not so in Kenya. There was a strong emphasis on African music, both traditional and modern, with clear Kenyan pride.
Just like most clubs, things started off pretty mellow. Mostly there were young men dancing together, nicely dressed and showing off their smooth moves. When a woman would join the men on the dance floor, there was some competition for her attention, and eventually she would usually pick one guy and dance with him. When the DJ mixed in the next song, perhaps one that was not as popular, the whole thing would usually break up and the cycle would start anew.
Richard and I sat drinking beer and occasionally chatting, although it was difficult to communicate with the loud music. I enjoyed seeing the various styles of dress and awesome dance moves. I watched the interactions among people. It did not bother me that the club, at least for me the only white guy in the place, was probably not going to be a great place to meet people. For one thing, I was significantly older than most, and as is often the case, most people were having fun with their friends and acquaintances. A few people throughout the evening stopped by the table, acquaintances of Richard, and he introduced me to them.
Most men wore dress shoes, dark pants, and a button down long sleeve shirts. Some men wore very pointy shoes, a style not popular in the US, but perhaps influenced by Middle Eastern culture. Most women wore dresses, but not all. Some wore layered tank tops and jeans or pants, similar to the US. One guy on the dance floor, more than once, unclasped his belt, unbuttoned his trousers, unzipped his pants and slowly tucked in his nicely ironed shirt and then put the whole ensemble back together, all to the music. “Huh, I wonder if that works for him?” I thought.
Another fashion trend I had never seen in Tucson was the Maasai blanket, also called a shuka, draped loosely over the shoulders. Maasai shukas are brightly colored red, blue, or green plaid small blankets. One man and one woman sported this uniquely African style. The man wore a khaki brimmed hat, shuka, and walked around the club as if he were an ancient mystic. The woman seemed much more approachable, although I did not approach, and she sat and chatted with friends as if she were at home on a cool evening.
Richard leaned over and said, “A lot of people here are first year students.” I could see them testing the waters, showing their smooth moves. There were definitely some professors and lecturers there, I thought, and many couples who danced or sat and talked, keeping to themselves. This was a university town, after all, and probably the best paid people in Kakamega worked for the university. They would be able to afford a night out.
To our right, and directly next to us, there were four women, all smartly dressed. They sat and talked, occasionally standing up to dance by themselves or with one another. One woman who almost never stood up or danced, wearing an elaborate lime green dress with fringe, seemed to be the leader. She was closely paired with a muscular, strong woman in a tight dark blue dress with short hair, square jaw. As the night progressed, got louder, the young men began to show interest. They would be firmly rejected with a few words or a palm held straight up, then brushed aside. Once gone, the women would celebrate and dance together more fervently. One guy, moving to the music, moved in toward their table from the dance floor, along with his buddy close behind. He too was asked to move on. He was bolder than the rest, however, and would not take no for an answer. There was more body language stating the obvious, and a few strong words from the women. He persisted. One of the women turned to the club security man, and the intruder was escorted away, his friend following closely behind.
As the night progressed the music got louder, the dance floor more crowded. I could tell when a woman settled on a man, either her partner or perhaps a new acquaintance. She would bend over, dancing to the music, and bump and grind her ass into his crotch. He would move to the music too, either becoming more animated and bend over her, dancing more passionately, or coolly stand straight up and act interested but distant. This was not common behavior in Tucson, I thought, or maybe it was that I did not go to dance clubs often and it would be similar at home. When going out in Tucson, I usually went to live music clubs or brew pubs. The vibe was different there, although I certainly have seen instances of sexy dancing and the occasional drunken make out session, so it wasn’t that different.
Two men talked near the bar, impeccably dressed, wearing identical ironed plaid shirts. Ah, the first obviously homosexual guys, I thought. But then again, I wasn’t sure. For a while, I thought the four women next to me were most likely lesbian. But as the night wore on, two began to flirt and dance with men including the one who seemed most anti-male and had called security. The woman in the lime green dress vigilantly maintained her post at the table, however, accompanied by the woman who resembled Grace Jones.
The night was reaching fever pitch, I had had four beers, and it was one in the morning. Richard was enjoying the company of a woman, an ex-girlfriend he explained, and deeply involved in conversation. I was ready to go. I mentioned to Richard I could catch a taxi home. One nice thing about Kakamega, among many nice things, was that the distances were relatively short and taxis were affordable. I could catch a boda-boda, or motorcycle taxi home for 100 shillings ($1) or, more likely and safer at night, a taxi for 300 shillings. He assured me, however, the he too was ready to leave. I insisted that I was fine on my own, and he insisted that he was truly ready to go. I believed him because a few days earlier while having a pint at the Golf Hotel bar, I had left him to his own devices and he was fine with it.
As we were preparing to leave, the server came up and said something in my ear. I did not understand. “Please write it,” I said. She came back with a piece of paper and handed it to me. “Del Monte, 300 shillings,” it read. She was asking me to buy her a carton of juice, in other words, to give her an extra tip over and above what we had tipped. I felt resigned to my fate. “Sure,” I said, and handed her a 500 shilling note. She brought me back 200 shillings and we left for home. This would be the dynamic, I thought. I would be the mzungu in the crowd, the white guy with money and I would have to get used to it.