Friday, February 10, 2017

Teaching and Learning in Botswana

Jonathan Cunningham
Resident in Internal Medicine at Brigham and Women's Hospital
PGY 3



One of the most rewarding parts of my 4 weeks at Scottish Livingstone Hospital in Molepolole, Botswana was learning from and teaching the local medical team. My application for a limited medical license says I came for “capacity building,” but I had so much to learn as well. 

The skill set of the local team was dramatically different from my own. At first I felt useless. Many patients had medical issues I had never encountered in the United States. Extra-pulmonary tuberculosis and opportunistic infections such as cryptococcal meningitis and Kaposi’s sarcoma in AIDS patients are among the most common diagnoses. I was also unaccustomed to practicing with so little objective patient data. At Scottish Livingstone, labs come back the next day and must be drawn by the physician. Physical exam is more important. At home I often examine patients after imaging has made the diagnosis. In Botswana, CT scan is a scarce resource that requires transfer to the national tertiary care hospital. It was a privilege to learn from the skills of my local colleagues. 

"The multi-disciplinary team on the male medical ward”
I eventually found that I had something to contribute as well. In Botswana, medical school graduates receive only one year of post-graduate training before becoming independent doctors; only 3 months are devoted to internal medicine (the rest is pediatrics, surgery, and OB/GYN). On issues like asthma and congestive heart failure, which are prevalent in Boston, I was able to share the standard of care we provide in Boston. I led a teaching session on cardiac tamponade, an under-recognized issue in Botswana. We were also able to present difficult cases to specialists in Boston over the phone to bring their expertise to Botswana.

The two-way street of teaching between our Harvard team and local doctors fostered camaraderie and was great fun. I hope that I was able to build a small bit of capacity by sharing my excitement about internal medicine. Just as important, my time at Scottish Livingstone will change my practice in Boston by helping me to rely less on advanced testing. I’m grateful for the chance to work with these dedicated doctors in a very different setting.

The Challenges of Acute Care in Botswana

Jonathan Cunningham
Resident in Internal Medicine at Brigham and Women's Hospital
PGY 3



My first patient at Scottish Livingstone Hospital in Botswana was 60-year old woman with a new diagnosis of diabetes and ketoacidosis. She had actually been admitted three days earlier over the New Years holiday, but no physician had seen her since the Emergency Room. At Brigham & Women’s Hospital where I am a resident, the care of patients with diabetic ketoacidosis is standardized. Patients with the degree of acidosis this patient had (pH of 7.1) are admitted to the ICU, where they receive IV fluids and blood tests every 4-6 hours to facilitate the potassium supplementation. This patient had received little fluid and no blood testing. When we checked her potassium that morning it was extremely low; thankfully she appeared well. The local medical interns with whom I was rounding taught me that the standard of care at Scottish Livingstone was to start oral potassium and check lab tests every other day. We implemented this plan, and the patient did well heading into my first weekend, when we do not go to the hospital. 

When I returned on Monday, I learned that she had passed away suddenly from respiratory failure. My attending felt that acute muscle paralysis from low potassium was most likely the cause. I was devastated. I felt (as I still do) that I could have prevented this outcome by organizing more aggressive potassium checks over the weekend, or coming in to do them myself. But the local members of our team felt differently. They reminded me that there are only two physicians at the hospital over the weekend who must draw all laboratory testing as well perform urgent procedures such as Cesarean sections. Checking labs daily on well-appearing patients, they said, prevents other patients from receiving necessary care.
"Learning to draw blood is an important part of working at Scottish Livingstone"

I believe the truth lies somewhere between my feelings and those of my local colleagues. Both poor medical care—our failure to recognize that she required more careful monitoring—and limited resources contributed to this outcome. To raise the quality of care in Botswana, it will be necessary both to fight for more resources (such as a phlebotomy service or more staffing on weekends) as well as to train local physicians to allocate them more efficiently. I would be na├»ve to think I contributed to these goals in my short time in Botswana. However, this patient and others helped me gain an appreciation for the challenges faced by physicians in resource-limited settings.