Sharing Knowledge. Strengthening Health Systems. Saving Lives – Kiran’s Story

Daisy WinnerBlog, Uganda

…showing them that by analyzing the information we had available and empirically treating for the most likely condition, we were able to successfully help this child survive.Dr. Kiran Mitha, Pediatric Volunteer – Uganda

The educational system in Uganda is based on the British system, and medical school here begins right after high school (your “O and A” levels) and lasts for 5 years. During this time, you learn both your basic sciences, like biochemistry, as well as your clinical skills rotating in the hospitals. Students rotate through pediatrics during their 3rd and 5th years of medical school for 8 weeks at a time.

13_12_11 KMitha(seeingpatientsoutdoors.onpediatric ward.b-c.hosp.doingmalariaspray.1)

The medical school at Gulu University started quite recently, in 2004, and there are only about 60 students per class. More strikingly, there are very few faculty members as part of the University. Only about 35% of the faculty spots have been filled. Part of the reason is that Gulu is not a big city and cannot attract faculty the way Kampala can. There are also few high quality primary and secondary schools in Gulu so faculty members do not want to move here if they have children. Lastly, the population here is quite poor so there are not many private medical clinics, which is where many of the faculty members are able to make extra income to supplement their low government salaries.

The medical school (or as its called here the Faculty of Medicine) is trying to expand its student body on a yearly basis. However, they are having a difficult time expanding their faculty positions, and this creates a dynamic where there are far too few teachers for the number of students. There are lectures scheduled for the students on a daily basis, in the morning and afternoon, and there have been countless times I’ve walked by the lecture hall to see students just sitting there teaching themselves because the assigned faculty member did not turn up for lecture. One student even told me that for the 8 weeks she was on her pediatrics rotation as a third year student, she did not see even one pediatrician. Rather, she spent all her time working with interns and trying to teach herself pediatrics.  After completing medical school, these students become interns at local hospitals and then are the primary physicians responsible for patient care. In many hospitals, interns do not have adequate supervision or backup in case they have questions or if a patient is becoming very sick. Some hospitals will have medical officers (MO’s) who have graduated their internship and serve as supervisors to the interns. Finally, in the highest level hospitals, there may be some specialists (i.e. attending physicians) who help supervise and manage the sickest patients. Pediatricians are considered specialists here since the system is based on all physicians initially being general practitioners, then a select few specializing afterwards. To be a pediatrician, you have to go for your masters in pediatrics which is only offered in 2 places in the country.

The focus of the Global Health Service Partnership is to help fill this vacancy in faculty positions while local universities are trying to recruit and train future teachers. This is one of the primary reasons I chose this program – the focus on education, capacity building, and sustainability of the work, is rare to find in programs for physicians abroad. Training the medical students, interns, and medical officers has definitely been one of the most rewarding parts of my work here. Everyone is so hungry for knowledge – they appreciate any little clinical pearl you can pass onto them. Initially I was quite worried about what I would actually be able to teach them. I mean, how much do I really know about malaria and HIV? These are obviously conditions we rarely see at home and are abundant here.

However, I have realized that there are definitely critical thinking skills I have learned during my medical training that I can pass on. Because there are certain diseases that are so prevalent, and the focus for public health programs is to standardize care, the way students are taught is often through algorithms rather than through critically assessing clinical scenarios. Algorithms are essential for health care workers who need to recognize common conditions without having a lot of formal medical training. However, physicians who are working at higher levels should have critical thinking skills to be able to analyze a case that did not improve with the algorithmic treatment. Or to recognize a patient with a rarer medical condition that may present similarly to a condition that is more common. Simply by being present during rounds and questioning the typical management of cases, I feel like I’ve imparted some intellectual curiosity about patient management. Often when we are discussing a patient and I ask, “Ok, what is the differential diagnosis for this patient?” I will get a list of common infectious conditions – pneumonia, meningitis, sepsis (or septicemia as its called here – the favorite grab-bag diagnosis for someone with a fever and no other signs).

I have been constantly challenging the students here to think outside infectious disease – like helping them recognize that cancer is actually a common condition here or to recognize congenital anomalies that present in pediatrics. At first the students didn’t understand why I was making them think about diagnoses that were not as common, and some probably still feel that way, but I think some have recognized the value in thinking about patients in a broader sense. We have had patients that didn’t fit any one diagnosis (as often happens in medicine) and by critically analyzing the case together, we have been able to successfully treat patients who may have been mismanaged otherwise. Obviously, many of the cases here improve with algorithmic treatment because certain diseases are so common, but when I’m able to demonstrate to the students that critical thinking can help save a patient’s life, I think the message really comes across.

I think my biggest success with this was when the medical students tried to organize a pediatric grand rounds, where they planned to discuss a very complicated case of TB meningitis. The diagnosis was not clear-cut and we had no clear confirmation that this was actually TB (since TB is a very hard organism to isolate in general and our laboratories here are not so reliable). Many of the students really were hard to convince since this patient didn’t follow the typical presentation of TB meningitis and it didn’t fit our general algorithm for TB. However, showing to them that by analyzing the information we had available and empirically treating for the most likely condition, we were able to successfully help this child survive. Many of the students present, especially those who have been on other rotations and have not worked with me, commented that this was one of the best grand rounds they’ve had because the discussion was so passionate and the case really made them think outside the box about how to diagnose and manage patients. Personal victory!

My first batch of medical students are finishing their pediatric rotation in just a few short days, and honestly I’ve gotten quite attached to them so it will be hard for me to see them go. I spend 5 days a week with them here and they are wonderful. In the mornings, I have a small group of them with me during inpatient rounds where I will challenge them to present cases and get pimped about patient care (in a nice way of course) and then in the afternoons I do directed teaching and bedside rounds with larger groups of them. We have become quite comfortable with one another over the last 2 months. Students who were really shy to speak up and answer questions have now gotten used to me and my funny American accent and teaching style, and I am able to see how much the students have actually learned. I really hope that they take some of these skills with them through their future rotations and continue to question and probe about the uncommon and peculiar.

– Dr. Kiran Mitha, Volunteer – Uganda

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