Saturday, April 18, 2015

Sustainable echocardiography in Mbarara, Uganda

Good morning from Mbarara, Uganda!

I am just over halfway through my month at Mbarara Regional Referral Hospital (MRRH).  I have been having a hard time sitting down to write a first installment for this blog.  Despite having spent time here before, there is always so much to do, so much to think about, and so much to figure out how to express in words.

For this first post, I’ve decided to talk about brain drain as a way to express just some of intimately linked frustration and inspiration I feel acutely here.

Brain drain is a big topic and one that I want to address only on the scale of the echo lab at MRRH.  While the burden of disease here is swayed towards infectious disease, mainly HIV and TB, there is a remarkable amount of heart failure, too.  In the past, this was diagnosed clinically.  But a few years ago, MRRH received a Philips echo machine and in late 2012 and early 2013, a Ugandan doctor and a SEED volunteer used online courses and a textbook to teach themselves how to perform and interpret echocardiograms.  Using echo as a tool, they were able to elucidate the etiology of the heart failure burden amongst MRRH patients.  The majority of patients being referred for echo for “dyspnea” and “swelling” had normal echos.  But of those who truly had cardiac pathology the majority had evidence of diastolic dysfunction secondary to hypertensive heart disease, dilated cardiomyopathy of unclear etiology, and rheumatic heart disease leading to severe mitral regurgitation, mitral stenosis and aortic regurgitation.  What powerful data to have!  Not only did it allow providers to expand differentials of those with normal echo findings but it also allowed them to tailor heart failure treatment to the etiology of a patient’s pathophysiology.  What’s more, it provided information as to what conditions need to be addressed earlier in this community to prevent heart failure: namely hypertension and rheumatic fever.

But a big question remained, were the echo reads produced by these two doctors who did not have formal echocardiography training accurate enough? Could we extrapolate data on prevalence of heart failure etiologies from them? Could we base primary prevention programs on them?  If the answer was Yes, then maybe we could establish a solid echo lab at MRRH and prevent the already limited number of providers from leaving Mbarara for further echo training in far flung cities, many of whom do not return.  If the answer was No, then we had to go back to the drawing board to figure out how to make echo a sustainable tool in this community.

To answer this question, the two doctors who were doing echos here last year, a generous echocardiography attending at MGH, and myself designed a study to compare the echo reads between the two providers at MRRH and a board-certified echocardiographer at MGH.  While we await final results, the prelim data is encouraging.  Maybe all you need to make the majority of diagnoses is access to online courses, a textbook, and, of course, time and motivation!  Could this prevent the need to brain drain providers away from their community for more more formal echo training?

But, when I arrived back in Mbarara this year, the echo machine was mostly gathering dust.  The SEED volunteer had left after his tenure at MRRH and was back in San Francisco.  The Ugandan doctor who was doing echos last year had recognized the importance of echo and had gotten funding for further training in Kampala.  She is supposed to take a 5hr bus ride every Friday morning to MRRH to perform and interpret echos during echo clinic.  This does not happen consistently.  Last week she arrived at 12p for a 9a clinic and was only able to perform 10 echos before having to catch to bus back.  Rumor has it she likely won’t bring her skills back to MRRH when she is done with training.  It’s a shame and frustrating from the perspective of this privileged, and still sometimes idealistic, western resident.  But I also understand it from her perspective: she now has this powerful and profitable skillset that she can market anywhere, particularly in places where she is guaranteed a salary, which isn’t always the case in this government-funded hospital.  What’s more, I want her to be professionally fulfilled, challenged, to advance to the highest level of her ability, and to be compensated for it.  We all want that.

So how do we remedy that desire with the need for consistency and accuracy in the echo lab here? The answer to this question is where my initial frustration over the brain drain issue begets inspiration, creativity, and the resolve to ask more questions, find more answers, and work to implement sustainable solutions. Could mid-level providers who are more likely to stay at MRRH perform and interpret echos?  What is the best way to teach someone how do a good echo and interpret it accurately?  Based on the cardiac pathology in this community, is a more limited echo sufficient to make most diagnoses?  Would having a telemedicine link to board-certified echocardiographers as backup for difficult cases help at all?  Can we make staying at MRRH appealing to providers with a higher level of training?  These are the questions that get me excited, that make me realize that the frustrations and set backs eventually lead to renewed creativity and professional motivation.  These are the challenges that drew me to medicine in the first place and that get me jazzed about pursuing a career in global cardiology.  I am thankful that my very brief visits to MRRH give me the opportunity to get frustrated, get inspired, get creative, and reconfirm my career goals.

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