Dan Bourque, Class of 2007, Uganda, Spring 2007
Attending rounds were exemplary learning experiences and I can say without hesitation that these were some of the most meaningful and best clinical learning experiences of my clinical training at Einstein.
Throughout medical school I have been fortunate enough to have a few experiences that have challenged my perspective of who I am as a person and a physician, the world we live in, and how I as a person and physician fit into that greater picture. This experience in Uganda has contributed to this process greatly and has served as further evidence of my desire (or need) to dedicate my career to global health. I see this perspective as a being shaped largely by the experiences I have had in Nepal, Guatemala, Peru and most recently Uganda. When confronted with the issues that were witnessed in Uganda, and elsewhere, is it possible for one not to be impacted?
Eleanor Chung, Class of 2008, Uganda, Fall 2006
Several key components of the 2-month Uganda experience are strikingly outstanding as a medical experience: the preceptorship with emphasis on clinical reasoning and physical exam skills, the integration into the community (both with Ugandan staff and village members), and introduction to research methodology. I strongly believe that this combines — in such a short amount of time — all the essential elements of being a physician; that understanding and managing a patient's health extends far, far beyond the textbooks and hospital walls. How can I differentiate her respiratory complaints without an X-ray? How far must the patient travel to seek medical care, and is this why s(he) waited too long before admission? What did the patient sacrifice in order to raise funds to purchase his chronic anti-HTN meds, and is this why he stopped taking the pills altogether 4 months ago?
The workload seemed necessarily 'overwhelming' — in the sense that the heavy workload was constructed by the dire facts that there are very few physicians & nurses to begin with, and a high number of ill patients. Especially after arrival, it seemed necessary for us to be available 24, or 25 hours of the day, everyday — exhausting, but very rewarding, at the end of a full day's work.
Because of the lack of laboratory/imaging services, it was necessary for us to develop PE skills. I especially thought that observation (watching the preceptor examine), repetition (preceptor watching the students examine, with feedback on skills), and reasoning (interpreting dull vs. resonant chest percussion; why use percuss on one finger vs multiple fingers; why examine some groups of muscles in the neuro exam and how, etc). In this Uganda experience, we received far more tips and explanations of subtle details in the PE that sharpened our exam exponentially than in prior rotations; we also practiced a methodical approach to any organ system of any patient, primarily with observe–palpate–listen.
"In this Uganda experience, we received far more tips and explanations of subtle details in the PE that sharpened our exam exponentially than in prior rotations; we also practiced a methodical approach to any organ system of any patient, primarily with observe–palpate–listen."
— Eleanor Chung
In other rotations, PE skills are lost in our reflex use of lab/imaging; felt that most attendings did not have enough confidence in their own PE skills to teach/emphasize importance for students. I rarely had anyone observe my PE skills, so I was simply refining bad habits on my own. Not surprisingly, continued to have a large discrepancy between reading texts and actual practice of skills.
In Kisoro, we had many teaching points in clinical reasoning, particularly in the face of no lab/imaging tests. I especially liked, that despite having no lab/imaging capacity, it was still important to compare pre-/post-test probability reasoning in Uganda just as in the U.S. The "comparison teaching points" of U.S. vs. Uganda also helped drive home the point that tests are often excessively or blindly ordered in the States.
This Uganda experience undoubtedly provided an enriched understanding of our role as health care providers — not only emphasizing that we certainly can still make a difference in low-resource settings, but also emphasizing that in low-resource settings (or perhaps any setting), we must expand our definition of "physician" to include much more advocacy for quality health care for the patient. That is, even the care offered by the best physicians within the hospital (exact diagnoses and impeccable management skills) will be ineffective if the patient decides to discharge himself prior to completion of antibiotics or clinical stability, or the patient lives hours away and does not have the resources to return for follow-up, or the patient stops taking daily/chronic meds due to inadequate education/explanation of the importance, or the patient returns home to a "nest" full of undiagnosed TB family members, and so on. The Uganda clinical experience pushes us to think beyond the conventional role of a doctor, which is an important lesson to bring home to any socioeconomic setting.
Interestingly, I think my 'sense of meaning' as a physician became more complete (complementing the ward experience) when we made home visits in the community. Understanding that health care can certainly be carried beyond the concrete walls of the clinic or hospital, that more effort should be made to allow patients/communities to demand for health in the home (family planning knowledge, fighting against domestic violence, practicing hygiene within limitations of harsh environment (i.e. no safe water, sanitation, etc), education for children, basic nutrition.
Several key components of the 2-month Uganda experience are strikingly outstanding as a medical experience: the preceptorship with emphasis on clinical reasoning and physical exam skills, the integration into the community (both with Ugandan staff and village members), and introduction to research methodology. I strongly believe that this combines — in such a short amount of time — all the essential elements of being a physician; that understanding and managing a patient's health extends far, far beyond the textbooks and hospital walls. How can I differentiate her respiratory complaints without an X-ray? How far must the patient travel to seek medical care, and is this why s(he) waited too long before admission? What did the patient sacrifice in order to raise funds to purchase his chronic anti-HTN meds, and is this why he stopped taking the pills altogether 4 months ago?
The clinical reasoning and physical exam skills emphasized during those clinical weeks are absolutely invaluable, and require time (experiences) to develop. My goal is to bring home lessons learned from this and other international health experiences, to use within the U.S. system — to develop a clinical decision-making approach that limits wasteful resources, to more completely incorporate into management plans the socioeconomic factors of a patient's health, to understand the cultural background of U.S. immigrants. My personal career plans have included (and are now further strengthened by this Uganda experience) international health projects — to establish close ties with communities in 1-2 different countries as well as a focus on immigrant health within the U.S. This Uganda experience that includes BOTH clinical and community components of health care has further defined the challenges encountered by foreign health care providers wishing to practice in developing communities, and how to address such challenges with community-specific strategies (that is, what will work in Kisoro will not work in Peru). I feel that through this Uganda experience, I've gained more specific tools in global health work that is sensitive to the communities we visit.
To put it more directly, I strongly feel that I learned tremendously more during my Uganda experience than all of my 3 years of medical school (and truly not an exaggeration). I remember thinking, this is exactly the kind of education I envisioned prior to coming to medical school, and wished I had throughout my 3rd year!