Tuesday, February 26, 2013

Medical Education in Resource-Limited Settings - Rebecca Cook, MD, MSc

February 19, 2013

For most of my time in Uganda I've been based at Mbarara University of Science and Technology MUST / Mbarara Regional Referral Hospital (MRRH) on the internal medicine team.

Every morning we start the day with "post-take" which is review of new patient admissions, followed by work rounds on patients already on the medical ward. These rounds are attended by the medical house staff, a large crowd of medical students and an attending physician. The structure and cadence is very similar to that of the inpatient medicine rounds at MGH, but the disease pathology, the physical space and human resources are vastly different. On an open long hall with 30 beds and extra patients lying on mats on the floor, we go bed-to-bed; vigilant to not step on a patient or family member who is lying on the floor. Despite the rather low-tech set-up on the wards, our patients are often quite sick and I am amazed at the ability of the medical staff here to provide advanced care with limited resources, such as managing cardiogenic shock on a medical ward, titrating IV drips of pressors in drops/minute. Aside from a huge burden of advanced infectious diseases such as advanced HIV/AIDS and every opportunistic infection one can imagine, disseminated TB, severe malaria, we also have patients with the sequealae of non-communicable diseases: strokes, diabetes, and heart failure.

Interns and nursing student after morning “post-take”

One of my favorite aspects of daily life on the medical ward has been learning from and teaching medical students. Unlike at MGH where we may have 2-4 medical students on a team, here there are 10-15 and form a core part of the workforce in patient care. These third year students who are in their infancy of exposure in the hospital not only have the usual intense experience of learning how of integration into clinical medicine; they are also an integral part of the patient care due to the overall low number of nurses and physicians in the hospital. They are frequently the only ones to check vital signs; are responsible for placing IV catheters, drawing labs and filling out forms for investigations and updating the patient and family members outside of rounds.

Because nursing and allied health workers are scarce, the family, as in many resource-limited settings are integrally involved in patient care; her they involved in providing nutrition (including supplying and administering food through nasogastric tubes), administering oral medications, and much more. For those without loved ones, there is great tragedy and inequity in a system that relies so heavily on a patient’s family for basic care. At the same time, for patients who do have family, especially those with ongoing nursing needs at discharge, the family are often well positioned to continue care at home. It is ironic that because of the lack of trained health care workers; the families are more organically equipped to provide home health care.

I have been fortunate to have my visit here coincide with the Department of Internal Medicine's First "International Medical Update Conference." The three days of sessions have been high-yield learning from both local and international speakers on areas of clinical medicine that are not common in Massachusetts such as TB meningitis, as well as practical and innovative solutions on how to care for non-communicable diseases like diabetes and cancer in resource-limited settings. Beyond the individual clinical learning; the conference has been yet another reminder of what a privilege it is to work alongside and learn from the Ugandan internal medicine residents at MUST. Many of them presented their own research or areas of interest at the conference; I am so impressed with not only their intelligence but also their dedication. They not only maintain tremendous clinical responsibilities but also are committed to medical scholarship to real-life bedside-to-bench and back again

A few of the stellar internal medicine senior house officers

As my time in Uganda draws to a close, I'm really humbled by the opportunities I've had and excited to continue to keep of both the professional partnerships and personal friendships. I’m excited to work with Ugandan housestaff and co-residents at MGH who visit MUST on a handbook of clinical protocols that will help both visiting and local clinicians improve uniformity and quality of care for key medical conditions

Medical Education in Uganda - Rebecca Cook, MD, MSc

February 7, 2013

This week we visited Bugoye which is a town nestled in the hills of Southwest Uganda. The MGH Global Primary Care Program is partnering with Mbarara University of Science and Technology and Bugoye Health Center to improve primary care in the area, particularly focusing on under five mortality. It has been a refreshing change from the dark and overcrowded wards of the regional hospital to learn about healthcare in action at a completely different level: in the community.

We have traveled with the village health teams home-to-home through some of the villages in the catchment area of the health center; learning the realities of the social determinants of health and how they are being addressed at the grassroots level. Village Health Team members are community members who are elected by their communities to be health advocates and a liaison with the health care system. They go home to home educating households on the most basic fundamentals of health; such as hygiene measures like a proper latrine, hand washing, and a drying rack for dishes.

The “tippy tap” a hands-free way to wash hands without running water

A women's group we visited in Bugoye has also received education in how to make indoor stoves out of mud that are more energy efficient and where smoke goes outside -- addressing two important aspects of health -- exposure to indoor smoke and environmental degradation through deforestation which affects rain patterns and soil erosion ultimately effecting the food supply. Interestingly, these women, of their own accord have made building the stove and other such "household improvements" a requirement for membership in the women's group – here they model ownership and support to make positive changes.

The Village Health Team at Bugoye is in the early stages of a new initiative: community case management of common childhood illnesses. A spin-off of the WHO Integrated Management of Childhood Illnesses IMCI village health workers have been trained in identification of danger signs in children, and appropriate basic management including treatment with basic antibiotics and anti-malarial and appropriate referrals. This week at a health outreach, we had the privilege of witnessing the unveiling of a drama they have written and perform in to help sensitize the community to this new initiative.

Village Health Team performing a drama to sensitize the community to new health initiatives