Tuesday, March 4, 2014

Pediatric Medical Education in Mbarara, Uganda

Before my arrival in Uganda I had read numerous articles on commonly seen conditions, spoken with residents and attendings who had previously worked at Mbarara Regional Referral Hospital (MRRH), and did my best to familiarize myself with cultural practices.  However, nothing could have prepared me for the reality of working at MRRH.  I am privileged to train in a country and hospital where essentially no resource or specialist is more than a phone call away.  There is almost always another test or procedure which can be performed to try to reach a diagnosis, and many third (or fourth or fifth) line treatments available before we tell a patient or their family that there are no further options.  At MRRH, the residents and students practice in an environment where they are never certain what resources might be available that day – do we have patient files or order forms, oxygen available for those in respiratory distress, or appropriate antibiotics for any of the numerous infectious processes encountered daily?  The answer is dynamic, changing from one hour to the next.  Too few nurses leads to the residents and students checking vital signs on rounds and family members administering most oral medications and alerting care providers to changes in a patient’s condition.  There are limited diagnostic tests available, and the providers learn to live with a high level of uncertainty. 

Many of us chose careers in healthcare because we strive to improve the health systems that we work in (locally or globally), but particularly in settings where we see such overwhelming need it is challenging to know where to begin, and many of our well intentioned efforts may have unintended or unexpected adverse outcomes.  The reality is that no matter what one’s prior experiences are, it requires a significant amount of time to adjust to a new way of life and practicing medicine, and even begin to understand the people you are caring for.  
View of entrance to Mbarara Regional Referral Hospital and Mbarara University of Science and Technology.
Outside you can see multiple "boda-boda" motorcycles waiting for potential passengers,
often 2-3 per vehicle and many traffic accidents result from this.

Throughout my month in Mbarara, Uganda working on the Pediatrics ward, I often reflected on how my involvement impacts the healthcare providers and the patients.  I am still a resident – I have no further subspecialty training, or particular expertise to offer to my colleagues at MRRH.  But what residency does prepare you for is learning how to approach patients and formulate a differential diagnosis and a plan, to navigate areas of uncertainty in your knowledge base, and to advocate for your patients and seek out assistance when something is beyond your capability.  You learn how to work with your colleagues to improve systems and share knowledge, and how to supervise while also teaching interns and medical students.  These skills are vital and universal in the practice of medicine, so focusing my efforts in working together with my Ugandan colleagues in medical education was a natural fit.
Walkway between hospital wards
In Uganda, undergraduate university and medical school education are combined into a five year program.  Years 1-2 are pre-clinical and principally didactic and then year 3 is the first year spent on the wards rotating through the primary specialties.  Interestingly, the fourth year is the “community” year, where students are assigned to work in various rural locations throughout the country in local health centers, alongside village health workers, and are even exposed to traditional healing practices.  The goal of the 3rd year, as it was described to me by one of the senior pediatricians on the ward, is to allow students who oftentimes grew up in more urban environments, to understand the reality of the living situations of many of their future patients - to fully appreciate the hard work and patience required of growing millet, the challenges of safely storing chemicals like organophosphates in a single room thatched hut with no shelving, and why a woman might not make it to the health center 1km away when in labor, because that kilometer is up a steep hill on a treacherous road during rainy season.  During the 5th year the students return to the wards for advanced clerkships.  During this year they will also be applying for paid internship spots where they will spend 3 months each on Internal Medicine, Surgery, Obstetrics and Gynecology, and Pediatrics.  After internship, the young doctors will typically work as medical officers until if interested and they are able to save up enough money, they may decide to return for their Masters in Medicine, or post-graduate education somewhat equivalent to a US residency to further specialize. 
Pediatric Lab area
While on Pediatrics, each week we would have a new group of 10-12 3rd and 5th year students arrive.  Each morning these students would round with the senior post-graduate, the intern, and me and then in the afternoons I along with other post-graduates and attendings would dedicate time in small groups with the students to allow them to “clerk” presentations.  In other words, we would listen to their presentations of the history and physical for patients they had admitted, discussing the differential diagnosis, and questioning them on their thoughts regarding evaluation and management of the patient.  Many things stood out to me during these sessions.  First and foremost, they impressed upon the students the importance of understanding every patient’s background.  Each presentation began with demographic information about the community the child came from, the tribe they belonged to, the occupation of their primary caregiver, the location of the nearest health center, and the cost to the family to transport the child to the hospital (typically by motorcycle called a boda-boda).  Given the limited diagnostics available at MRRH, a large emphasis is placed on the nuances in the history and details of the physical exam (Changes in the hair pattern or color? Grade of digital clubbing? Characterization on palpation of an abdominal mass?).  These basic skills are the foundation of the practice of medicine, and the ritual that unites the doctor with their patient, yet too often in the United States we find ourselves buried in computer screens or piles of documentation rather than looking at the person sitting right in front of us and listening to their story.  Lastly, the students were quite astute in their understanding and application of pathophysiology – when discussing jaundice the conversation wouldn’t just involve the total and direct bilirubin, liver function tests, and the ultrasound results- we would also review the breakdown of red blood cells and the points at which it is bound or converted, differentiating between forms that are excreted in the stool and the urine, and how these different processes are distinguished clinically.  This learning environment was a tremendous amount of fun and at the same time a great challenge to me as it required me to rely on my knowledge and skills as a clinician and teacher, rather than the myriad of technology I am used to having at my fingertips.
Rescuscitation equipment
As someone who is not an expert in the common conditions afflicting many patients at MRRH (malaria, TB, HIV, typhoid, malnutrition), I concentrated my efforts on helping the students and interns broaden their differential diagnoses and plans for management.  In a practice environment with limited diagnostics and where the ultimate diagnosis often remains uncertain, the tendency can be to focus (appropriately) on what is more readily detected or treated.  However, in a child whose clinical condition can rapidly change from one moment to the next, particularly when there is limited monitoring capability, prematurely narrowing in on a specific diagnosis can be devastating.  Additionally, due to the high acuity of illness there is often a focus on the acute presenting condition, but it can be very important to think about a child’s development and chronic co-morbidities in trying whatever way we can to prevent future complications.  These are teaching points that are of course emphasized by the Ugandan physicians as well, but cannot be overstated.
When it came to working with the post-graduates, I often found myself wondering what I could possibly have to add.  They are some of the brightest, most resourceful and hardworking people I have ever met, and to me, they are the strength and capacity of MRRH.  In getting to know them I found that they enjoyed being able to just discuss challenging cases, talk about differences in how we manage conditions, review how to read radiologic studies (since they less commonly have access to these), and just share general information such as how we run journal club conferences.  I don’t think you can underestimate the impact of building these relationships, and even just beginning to understand the day to day practice in another hospital.

Bins for collection of files with stack of patient files (to the right, green)
On my last day, one of the students said to me that he hoped I had learned as much from them as they had learned from me.  It was the exact thought I had in mind, and I think if we can continue to teach and learn from one another we will both be better physicians.  I look forward to continuing to learn from and with my new colleagues in the years to come. 

Thank you so much to Partners Center of Expertise in Global Health, MGH, MUST, and MRRH for your support in this tremendous experience.

Meredith Eicken, MD
Internal Medicine-Pediatrics, PGY-3
Massachusetts General Hospital

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