An Ambulatory Care Experience in Kurdistan

A picture taken from Australian Diabetes Association Week.

After three weeks of work at the Diabetes Center in Duhok, I felt the need to share some of the experiences I have had with my fellow readers especially with those who are clinicians treating chronic ailments or with those who are patients getting treated in an ambulatory care setting.

This experience that I am about to write about is one of its type that I can imagine myself come across to here in Kurdistan. This experience is about my interaction with patients in Kurdistan.

First of all, I thought to myself that before I start my practice here in Kurdistan, I have to do the following; I have to keep myself up to date, I have to remember the ethics of how to interact with patients. I have to remember patient consultations and tools that will enhance patient compliance, which may include anything from the use of a pill-box, alarm, chart, calendar and a log book to the involving all family members in the management of the patient.

I am a strong believer in empowering my patients in the clinic, and by that, I mean that I need to lead my patients to tell me how we should go about managing their medication condition, e.g., so you tell me what time of the day works for you? Patients have far more power over their body than doctors.  Hence our role as health care provider should encompass an understanding of this role.  We need to bring awareness to every patient about this power that they fail to grasp; listen to your body and tell the provider what your body is telling you. 


Having a practice site at an ambulatory clinic was one of the ideal jobs that I dreamed of doing after graduation. You might be wondering what ambulatory care is composed of.  Ambulatory care is any medical care delivered on an outpatient basis. Ambulatory care over-looks medical conditions that can be managed without admission to a hospital. Many medical investigations can be performed on an ambulatory basis, including blood tests, x-rays and even biopsy procedures of superficial organs. Some disease states that we look at include diabetes, hypertension, hyperlipidemia, asthma, COPD, smoking cessation, etc. 

How I have come across ambulatory care?  Being a PharmD student, I was required to do six clinical rotations in my last year of the curriculum.  One of the six rotations was an ambulatory care clerkship at a diabetes center in a predominately African American neighborhood in Boston.  While there, I had direct patient contact where I had to monitor patients with diabetes along with patients who had other complications including hypertension, hypercholesterolemia, osteoporosis, asthma, etc.  My role did not by any means involve diagnosing.  I would follow up with patients and monitor their conditions, adjust their therapy based on the lab results that I would ask for from the laboratory.  If my patient was a smoker, I would work really hard to motivate them to stop smoking.  My role was hardcore counseling and consulting with the acting physician with the medical changes that I had made.

On a daily basis I would see 5-10 patients.  By the third week of this clerkship, I thought to myself that this is the job that I really want to do.  “Direct patient contact” sounded heavenly to me.  When I would see a patient lose weight and reach her goal A1C (a surrogate marker indicative of fasting blood sugar, which has to be assessed every 3 months), fasting blood sugar, blood pressure, etc, I would get so excited to a point I would hug my patient.  I did the impossible to put a smile on the patient’s face and make them feel that with a push from their side that their condition will be resolved.

Going into Pharmacy school, my goal was to be a pharmacy educator. Being an educator does not necessarily translate into becoming an academic, my role as a pharmacist demands constant teaching, teaching patients about diabetes, hypertension, etc.  My role as an educator requires that I empower my patients and actively involve them in managing their condition. Studies show that patient involvement will not only prevent medical errors from happening but will also lead better outcomes. 

One of the first things that caught my eyes driving into Duhok for the first time last summer was the Duhok Diabetes Center.  I thought to myself that I somehow have to get involved in this center to manage diabetic patients to do what I used to do in Boston with my diabetic patients.  Luckily the center is right next to the medical campus, where I teach.

Now that I have a practice site at the diabetes center, I am suffering, not from the work-load, but from the number of patients I have to see a day.  I am not happy because I fail to find the suitable time to give my patients the needed care they deserve.  I fail to counsel them the way I have wished.  Plus how is counseling even possible when I have to check 100+ patients a day in 2-3 hours?  How can patient empowering make any sense when I see 20 patients at once in a checking room rushing me to shut my mouth up and to simply write a script for medications?

Some patients refuse to present themselves to the clinic, instead they send a family member with their medication book for their next month supply of free medication.  When I ask for the patient, I hear that s/he is doing fine or that s/he was not able to come and I am to simply write for their next month supply of free medication.  

I once had a family member with 3 medication books for three family members and she wanted to get a month supply for all three. Now can I call the service I am giving a medical care?  Is this even a care or am I simply a recorder where I simply write medication names?  Some patients complain that they can’t commute for 2 hours to Duhok and instead I am to write 3-month supply of medication instead, this way they don’t have to come to the clinic every month.

We were taught that diabetes managements is to start by lifestyle modification first because studies show that lifestyle modification (exercise, diet change, etc) is as effective as drug therapy.  If patients fail to get a good control of the sugar level with lifestyle

modification, then perhaps they need extra help by the intake of drug therapy.  As clinicians, we fail to educate patients that taking a pill will not terminate diabetes.  We also fail to teach patients that diabetes is a progressive disease.  Most of the patients are in need of awareness.  My patients fail to grasp the long-term consequences of having an uncontrolled sugar level for years.

A diagram showing the vital organs impacted by uncontrolled diabetes

I recommend that my patients exercise yet how is exercising even possible when we fail to have suitable parks for jogging and running?  It is recommended that patients walk 30 minutes a day most days of the week. I myself was a runner back in the States yet I had to stop due to cultural restrictions for a woman to walk or run alone in the public.

In the States I use to freak out to simply see a patient’s fasting sugar level to exceed 10 units.  Please note the goal reading for a fasting sugar should be in the 70-130 mg/dl range. The mode number of fasting sugar reading I see in the clinic here in Duhok is in 300-440 mg/dl range and I find it interesting to see clinicians and patients to take this number as a norm.

Every diabetic patient per American Diabetes Association Guideline (ADA), has to have a glucose log book, where the patient sticks him or herself twice to three times daily and log the reading in their book.   For their monthly follow-up, the patient brings the log-book along with drug therapy for the clinician to see a pattern in the sugar reading. The medical provider based on the monthly reading of glucose can modulate the medical therapy topped with the patient diet.

Diabetes management relies heavily on a single-finger-stick reading that the patient gets from a nurse as soon as they get to the clinic.  Did you read that? Yes a single fasting sugar reading.  How reliable is a single read?  Sometimes the patient comes to the clinic with a full stomach and we end up relying on a random sugar reading.  

I ask if they utilize a Glucose-meter at home, they question me what a Glucose-meter is suppose to mean?  Do you stick your self? I ask.  The answer is no!  Not a single patient has a glucose log-book.  Then how can we rely on a single sugar reading?  


I witnessed a serious diabetic foot infection case where I referred the patient to the emergency room immediately.  I freaked out to a point the patient ended up calming me down that it is not that big of a deal and that she will be fine.  Her fasting blood sugar was 440mg/dl.

Patients are over-dosed with insulin yet their fasting sugar readings continue to be in the 300-400mg/dl range.  The only insulin we have at the clinic is the Mixtart.  As for orals agents, we have Glucophage 500mg and 850 mg and Daonil 5mg.  Daonil is a first generation Sulphonylurea, out of the market in the States and hardly ever used.  Some patients have been on Daonil for years as their only anti-diabetic agent. No surprise their sugar continues to be on the horizon.  Daonil works by secreting insulin but overtime it exhausts the pancreas, hence its efficacy dies out over-time.  Again we fail to teach patients this fact and fail to tell them how these medications work.  

Patients complain of gaining weight with the intake of Daonil, where we know for a fact that Daonil is an agent that does cause weight gain just like insulin.  Many patients are on both insulin and Daonil; both are contraindicated to be taken together due to the enhanced incidence of hypoglycemia and weight gain.

As clinicians we are recommended to prescribe sulphonyurea to newly diagnosed patients with diabetes. I find some patients with 10-12 years of diabetes with Daonil being their only drug to control their sugar level.  No surprise their glucose continues to be in the 300-400 mg/dl range. And we complain of patient overload in the Emergency rooms with complications due to uncontrolled sugar level?

I have timed myself and the maximum time I can spend per patient is 2-3 minutes, where I have to counsel them on diet change, lifestyle modifications, prescribe medications, interpret their lab results, etc.  We fail to have other specialists at the center other than an

ophthalmologist.  We need nutritionists, podiatrists, etc. We have 1 physician specialized in internal medicine to take care of 100-200 patients a day. And he is acting as a podiatrist, nutritionist, nurse, etc. 

Many patients complain of foot pain.  I know for a fact that their pain is nothing but a diabetic neuropathy as soon as I hear them explain the pain as them walking on needle sticks.  We fail to have a podiatrist on-site and the internal medicine on site automatically advises patients to take Tegetrol, which I recently advised to be stopped due to the loads of adverse events that come with it

I for the first time had the chance to spend 20 minutes with a very old patient.  I modified his therapy.  He came to me with a bag full of tablets and he was lost and begged for guidance to see what medication he should stop and which one he should continue taking.  I had many angry patients waiting but I asked that they bear some patience until I am done and to allow me help him because of his old age. This example shows that as a provider, we strive to give care but when we have to see 100+ patients in 2-hours, I find giving health care to be impossible.  I refuse to just write medications for patients and measure their blood pressure.  We often rush in complaining about doctors yet fail to understand the stress load they are being placed under in a clinic room. We have a deficiency in specialists, in nurses, in pharmacists, in physicians, etc. 

I have now managed to put a sample of a log-book together for my patients and I am hoping for a quick approval by the department of health here in Duhok so we can start passing them to every single patient we see in the clinic.  I am teaching patients how to stick themselves twice daily. I am stopping almost every patient from taking Daonil and switching them all to Glucophage accordingly with no contraindications.  I try my best to have 10 patients listen to me at once when I counsel on life style modifications since I have 10 of them at once in the clinic room anyway.   I am in touch with the director of the center and in the process of running seminars for patients on  how to take care of their feet, modify their diet, use the finger stick and the log book, etc.  I am also hoping that I can start having my pharmacy students involved as soon as they start hitting the therapeutic courses. Pharmacy service can play a vital role in the ambulatory care sitting and we are in high demand.