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Am Fam Physician. 2024;109(2):184

Author disclosure: No relevant financial relationships.

8:30 a.m.

Because the flexibility of my practice allows me to offer out-of-office support visits, I walk around the block with my neighbor. I check with her about the trial of lifestyle interventions for her adolescent daughter whom I diagnosed with mild depression a few weeks ago. I am the only American family physician in the capital city of Malawi, and I have provided care for all of the children in this family, who are from Texas, over the past seven years.

10:30 a.m.

I arrive at the clinic to discuss vaccines for an 18-month-old. She was born in the United States, but her mother is from Japan and wants her to have the option to attend school in either country. I administer an MMR vaccine to meet U.S. vaccination guidelines and give her a HepB/Hib/DPT vaccine booster to meet Japanese guidelines. We also start a course of rabies prophylaxis because there is a high rabies prevalence here and no access to rabies immune globulin.

1:30 p.m.

I orient a new Canadian volunteer to the health risks and health care infrastructure in Malawi. I am concerned about the cold she picked up on the airplane, and she agrees to COVID-19 testing.

3:00 p.m.

A longtime patient brings in his mother. I optimize her blood pressure medication and advise her to discontinue her calcium tablet because supplemental calcium has been linked to adverse cardiac events in older women.

7:00 p.m.

I look up guidelines and public health resources for cholera. We are in the midst of Malawi's biggest cholera outbreak to date, and tomorrow I will go to a village to talk about cholera prevention and treatment. I will work with a local pastor to teach the community how to create an oral rehydration solution to treat the dangerous dehydration that cholera causes.

You can read about her day of cholera training at

7:00 a.m.

I begin by assisting Dr. T. with a cesarean section. Dr. T. is a family physician from a neighboring town, but he does his deliveries at our hospital because the hospital in his town does not offer obstetrics. We are 90 miles from the closest secondary or tertiary facility. The 9-lb, 4-oz girl comes through the Alexis retractor, and we smile behind our masks. We have helped each other with deliveries for 15 years.

8:00 a.m.

Next on my schedule: two colonoscopies. I also need to see two inpatients and two swing bed patients. One of the inpatients was admitted last night for gastrointestinal bleeding. His hemoglobin was stable, and I put him on the esophagogastroduodenoscopy schedule for the next day.

1:30 p.m.

My lunch hour ends with a farmer who got his finger caught in the chain of a feed wagon. He came to the clinic because he did not want the expense of the emergency room. There are no fractures or tendon injuries, so I am able to take care of his 18 stitches and Tdap vaccination.

4:30 p.m.

There are patients who touch my feelings more than others or ones with whom I can identify personally. My last patient of the day is a favorite for the first reason. She is a one-year-old who is here for a well-child visit. She had severe tetralogy of Fallot that was repaired when she was four months old. She has some developmental delays and is not yet crawling. I make sure she is still getting physical and occupational therapy. It has been a bit overwhelming for her mother to manage all of the specialists, but our office has helped her keep track of everything. Her mother is determined that she will have a normal life. I am here to make that dream come true.

5:45 p.m.

I finish my last clinic chart and, instead of heading to the hospital to do evening rounds, I call the nursing floor to make sure there are no questions about my inpatients. I then relax and reflect on the day. When I matched in a program for rural family physicians 37 years ago, I dreamed of days like today.

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This series is coordinated by Jennifer Middleton, MD, assistant medical editor.

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