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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