International Health Studies Grant 2013-14 in Action: Pediatric Care and Medical Education in Southwest Uganda

By Rebecca Cook, MD
IM/Pediatrics Resident, MGH

January 22 – February 18, 2014

Rebecca Cook, Uganda - Toto WardAs a third-year Medicine-Pediatrics resident at MGH, this is my second time visiting Mbarara University of Science and Technology (MUST), one of a few academic medical centers in the country of Uganda and the main public referral hospital in southwest Uganda. The intention of my rotation is to focus on medical education in a resource-limited setting with the aims of refining my own clinical skills and effectiveness as an educator with the ultimate goal of serving after residency as a clinician educator in Africa. 

Main Activities/Outcomes

Daily participation in care on the Inpatient Pediatric Wards at MUST:

  • Morning rounds alongside Ugandan residents focusing mostly on medical student teaching and supporting interns and residents in clinical care. I focused my clinical care on the “Critical Ward” where all new admissions and critically ill patients stay – often 2-3 children to a bed and the acute malnutrition ward. 
  • Afternoons spend teaching medical students and assisting interns with new pediatric admissions – trying to focus on key principles in pediatric diagnositics and stabilization for a new group of interns rotating on pediatrics.
  • Attendance and participation in all departmental conferences including resident reports, daily intake rounds, and training for interns in pediatric and neonatal resucitation.

Investment in Medical Student Education: 

Rebecca Cook, Uganda - Medical StudentsIn this busy hospital, the greatest resource limitation is time for teaching. Thus I tried to invest as much as possible medical students. In the afternoons we gather at the bedside of patients as students develop their skills giving full presentations and demonstrating physical exam skills. Beyond the bedside teaching, I also review their formal write-ups -- evaluating their ability to effectively summarize the history but also develop a good differential diagnosis, apply concepts of pathophysiology, epidemiology and demonstrate knowledge of the treatment plan, including how medications work and what their side-effects are. Knowing that in 1-2 years these students will be medical officers providing direct care with minimal supervision, it’s an exciting time to work with them in developing their knowledge and clinical skills.

Weekly sessions in the pediatric HIV clinic.

In clinic spend time applying what I’ve learned in prior research and clinical experience seeing HIV-exposed infants. I am happy to share that in general the story of pediatric HIV in Uganda is a much happier one than it was a decade ago. The Ugandan government has implemented a policy of “virtual elimination” of mother-to-child transmission of HIV and to a vast extent is succeeding – with HIV-positive women receiving HAART during pregnancy most of the children I saw were happy, healthy babies with negative HIV PCR tests. Our main job is anticipatory guidance regarding transmission during breastfeeding and we also have the luxury of conducting general well child visits that focus on child development a service that most Ugandan families will not receive, since aside from visits with the nurse for vaccinations and weights, anticipatory guidance and assessment of well children is not routinely offered.

Weekly visits to a home for abandoned babies and children:

Rebecca Cook, Uganda - Home for abandoned babies and childrenAlong with my pediatric supervisor and another visiting pediatric resident we make weekly visits in order to provide general health assessments and evaluate infants who the staff were worried were sick. The reasons for abandonment are as complicated and numerous as the children themselves – now around 70. Many are developmentally delayed and starved for attention, a few struggling with malnutrition, although this is generally improving, and fewer ill with significant diseases. Entering the home we are overwhelmed with babies and young toddlers eager for attention – some of them are outgoing and will immediately make their way to you to be held, others are listless in their beds, but once touched and held they come to life – smiling and cooing, crying whenever you try to put them down. The dedicated Ugandans who founded and run the home are constantly struggling to meet the children’s basic needs for food, clean clothes and diapers and adequate staff to care for and stimulate the development of these precious children.

Visit to Bugoye Health Center:

Rebecca Cook, Uganda - Bugoye Health CenterMy own understand of health care delivery in southwest Uganda would not have been complete with time spent at the level three health center, three hours from Mbarara staffed by a mid-level provider, nurse, midwife, pharmacy and lab tech and many volunteers. Here I am able to witness to power of community health work as I go with village health workers on home visits to assess individual community health workers knowledge and implementation of integrated community-based management of childhood illnesses. This program is putting the first layer of health care in the neighborhood where village health teams elected by their community are equipped with skills to evaluate children in the community – perform rapid diagnostic tests for malaria and give the first dose of antimalarials or antibiotics prior to transfer to the nearest health center. I also spend time in the outpatient clinic working seeing adults and children, as I work alongside a clinic staff member with tremendous dedication and practical experience but very limited formal teaching I try to explain my approach to diagnosis and treatment of each patient we see. 

Strengthening partnerships for tele-education/medicine:

One of my main goals during this visit was to continue to build relationships with the MUST residents in order to understand their goals and current gaps in their post-graduate training opportunities that we might be able to address through telecommunication. Six months prior to my visit we had already started teleconferencing with the MUST pediatrics residents. By participating in these teleconferences from the Uganda side I was not only able to better appreciate and troubleshoot some of the technologic barriers, but also better understand from the MUST residents what is most useful and interesting for them. In addition, Meredith Eicken, a co-resident from MGH and myself initiated e-mail case write-ups in collaboration with MUST residents for some of the most diagnostically challenging cases on the wards – accessing subspecialist including radiologist and pathologist at MGH to help apply their expertise. We are hoping that the MUST residents will be able to continue to use this avenue of communication. In addition, as visiting residents, we have been working on handbook for visiting clinicians to help prepare them with an adequate knowledge base in the most prevalent conditions and the local options for diagnostics and management so that future visitors can be as prepared as possible to serve. 

Lessons Learned:

With the help of faculty mentors, co-residents and the wonderful Ugandan colleagues who hosted us I think I have developed a few guiding principles I learned from the time I spent in Uganda.

You are a guest.

People in East Africa are well-known for their hospitality and my experience in Uganda this time was no exception. Yet at the same time, early in my time, I could sense some trepidation amongst the Ugandan medical staff – It was the unspoken fear that I could read in their eyes, “what are we going to do if this visitor tries to do something that is not possible, safe, or acceptable in our setting?”  Based on prior experiences working and observing others work in global health settings, I developed a “code” to help guide my interactions as a guest:

  • I will never undermine a local provider in front of a patient/peer
  • I will approach points of clinical disagreement with humility and an eagerness to learn
  • If I am concerned about the clinical judgment of another provider, I will ask a question, and only directly intervene when  there is a risk of immediate and serious harm to the patient
  • When in doubt, I will ask... and if no one at my site can provide a satisfactory answer I will seek information from outside experts
  • I will not perform procedures alone that would require supervision in my own institution
  • I will not handle medical emergencies by myself and I will not be the team leader in emergencies
  • I will defer all final decisions about referral, payment, discharge plans to local clinic leadership

While I’m sure I did not implement this code perfectly, I do find that these guiding principles have helped me to better work with colleagues in Uganda and also experience less moral distress about my role. 

It’s helpful to have a long-term perspective, even if you are there short-term.

Often when Western medical providers visit resource-limited settings, especially for brief periods, they waver between well-intentioned but often naïve ambition to “fix” things and utter disillusionment and futility. Both attitudes are often not helpful and may damage partnerships. Sitting in the quite village of Bugoye one night with one of the Ugandan Internal Medicine faculty members reflected on his perspective, “We will still be here… We will fall and then we will get up again.” This wisdom helps ground me when I walk away from the pediatric wards feeling dismayed about the level of care we are able to provide. It also helps me remember that the most important investment I make is in the people who are here – the students and residents I’ve worked with.

Systems based practice is essential.  

As one of the “core” competencies identified by the ACGME, as medical trainees we are expected to develop in our ability to approach systems based practice in medicine where we appreciate the context and system in which health care is provided and demonstrate evidence-based and cost-conscious strategies in treating patients. I know of no better learning experience to develop in systems based practice than working in the developing world. Here the resource limitations are a constant reality and integrated into the dialogue of clinical practice. Each day, assessment of resources is a formal portion of our “daily intake” report. During my month there; there were days when they were not the most common examples being blood for transfusions, oxygen supply especially when the electricity went out, very occasionally we ran out of IV ceftriaxone or IV artesunate, but even more basic things like the appropriate stationary to write admission notes or consult requests on were often missing. This systems perspective begins in medical school. The third sentence of each medical student presentations I listened to was always where the nearest health center is to the patient and how much money it cost them to travel to the hospital. Daily as we make decisions about patient care we use crude indicators such as the presence of sheets or blankets on the bed to get a sense of the families’ abilities to afford diagnostics or treatment that is not available for free. These are painful and frustrating examples of the global inequities that exist; but what I learned from practicing alongside my Uganda colleagues who deal with these realities daily is that we all need to be more aware of the context in which we practice medicine. It is almost impossible to return to practice in the US without a deeper awareness of systems and resources; I’ll  rely more on my history and exam, and will assess whether the diagnostics I’m are considering are really necessary, and when I do order tests or treatments, I will be more grateful that they are available.

Rebecca CookIn many, if not all cases, I have very little to offer more than an extra hand to help hold a patient for a procedure, extra time and energy to invest into teaching the eager young medical students, a bit of experience to talk the interns through some basic pediatric management and dosing principles, more than anything what I can offer is the company – someone to share the burden of trying to care for sick children with incredibly limited resources. This is really why I am here:

  • To learn about the daily realities of caring for patients in this setting as a contemplate my pathway in global health and medical education after residency
  • To teach and help where I can
  • To encourage the dedicated providers who work here every day and continue this partnership via the wonders of modern communication in order to help them meet their educational goals 
  • To come back to the US and tell the story of these amazing patients, families and health providers, and advocate for action to address the tremendous health inequities that exist.   

Thank you so much for allowing me to have this amazing experience and for your interest in an evolving story. 

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