Thursday, May 4, 2017

Cancer Care in Botswana

Daniela Buscariollo, MD
Harvard Radiation Oncology Resident
PGY-5

Cancer Care in Botswana: Entry 2
April 12, 2017

Gaborone Private Hospital Oncology Department
My time in Botswana is nearly coming to an end, and with just one week left, I reflect on the experience thus far. I have spent most days working at Gaborone Private Hospital (GPH), where Botswana’s only radiation therapy facility is located. The mornings typically start with a hop into a combi for a 15-minute ride to GPH. Once I begin seeing patients with Dr. Memory Bvochora-Nsingo and Dr. Sebathu Chiyapo, the hours of the day seem to evaporate as we move between the clinic rooms, brachytherapy suite, and the radiology department CT scanner for treatment simulations.

Throughout the month, I have been able to build upon my prior experience and to continue learning about cancer care in Botswana. Patients come to GPH from all over the country to receive radiation therapy. For those traveling far distances, the government can subsidize housing accommodations during treatment. In general, patients are responsible for maintaining their own medical records. They typically come bearing a stack of papers (“cards”) with hand-written physician notes, radiology, pathology and laboratory reports as well as oversized envelopes containing printed imaging studies. Clinical decision-making is, in some cases, based on less information, or at least different forms of information, than what I have been used to during training (CT and MRI scans, for example, are either only viewable as small printed frames or not available at all such that the simulation CT scan is the only form advanced imaging we can use to delineate the extent of disease). I have also learned that, at times, limitations in our ability to manage treatment toxicities can impact our ability to deliver optimal curative therapy (for example, locally advanced cervix cancer patients with renal dysfunction secondary to obstructive uropathy who are unable to undergo stenting or percutaneous drainage, or those with low hemoglobin who cannot receive transfusions are not candidates for concurrent cisplatin). Certainly, for me, these have been valuable lessons that quality patient care and quality improvement efforts must be prudently considered in the context of the available resources.
Gaborone Private Hospital, Brachytherapy Suite
The GPH oncology group has generously integrated me into their team and invited me to share any quality improvement ideas I may have during my rotation. The team here clearly prioritizes continuous evaluation and optimization of their workflow. For example, every weekly chart rounds meeting I have participated in thus far has involved discussions about workflow processes that culminate into a group consensus about specific strategies to address the issues at hand. One of the efforts we have worked on this month is development of a more detailed radiation simulation request form, with the goal of improving communication and optimization of the radiation planning process. The forms seemed to be helpful after a weeklong pilot; therefore, we subsequently initiated the process of integrating them into the MOSAIQ information management system for additional piloting.     
Gaborone Private Hospital, Linear Accelerator Unit
Overall, this past month in Gaborone has been immensely educational and fun. I look forward to continuing to help with the development of the vaginal dilator pilot, and I hope to return to Gaborone upon completion of my brachytherapy fellowship next year.

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