The first patient I admitted on the adult medicine wards at Moi Teaching and Referral Hospital was BK, a 17 year-old female who presented with cor pulmonale and volume overload. Common things being common, our initial impression was that her presentation was a consequence of rheumatic heart disease, although, on examination, we found clubbing of all digits (including her toes) and dry crackles in all lung fields. Her echocardiogram failed to show any significant primary valvular lesions but revealed severely elevated pulmonary pressures, likely a consequence of chronic lung disease and long-standing hypoxia. Imaging of her chest revealed honeycombing and interstitial changes. Despite treatment with anti-TB medications and eventually corticosteroids (she was found to be HIV negative), she passed away on the Amani women's ward off of oxygen, a therapy she would not have been discharged to home on due to its extraordinarily high cost and limited availability.

At the time, fresh off the Duke Medicine wards the week prior to coming to Eldoret, BK's case was very unsettling to me, even though (realistically) her course and outcome would not have been drastically different in the US in the absence of transplantation, given her advanced stage at the time of presentation. Her case does illustrate- I think - some of the many challenges to the practice of medicine in a resource-limited setting. Because access to care is frequently impeded by geographical, cultural or financial barriers, patients often present later and with more advanced disease, which often influences outcomes in profound ways. Diagnostic limitations compel clinicians to rely more heavily on their examination skills and to make decisions with a greater amount of uncertainty than to which we are ordinarily accustomed, often prescribing therapies without definitive diagnoses. Finally, therapeutic limitations (often great and unpredictable) mean that untimely, sometimes otherwise unavoidable deaths will occur and that some degree of creativity is often necessary in optimally caring for very ill patients.

With these challenges comes the opportunity to rise to them: to develop strategies for health promotion and the prevention and early recognition of chronic medical conditions; to hone one's own individual diagnostic skills; to work with the available resources to identify and manage complicated conditions that at times are quite different than those one sees in everyday practice in the US; and to witness the extraordinary resilience of the human body and spirit. The experiences I have had in Kenya - from home-based visits for HIV counseling and testing to the management of a busy inpatient general medicine service - have been some of my most transformative to date and the lessons I have learned here will undoubtedly shape and direct the course of my future career. As a physician training during a time where diseases are increasingly blind to borders and boundaries, the experience gained in working in these settings - I believe - is invaluable and for me has been one of the most rewarding experiences during my medical training.

Eileen Maziarz is currently the Internal Medicine Assistant Chief Resident at Duke. This spring, she spent 3 months working at Moi Teaching and Referral Hospital in Kenya.