OOPE/T in Developing Countries: Benefits for Trainee
This paper outlines the benefits experienced firsthand from a trainee who had completed their foundation training and took the opportunity to work for 8 months in Juba, Southern Sudan. This experience has been mapped onto curricular targets laid out in the Foundation Programme Curriculum http://www.foundationprogramme.nhs.uk/pages/home/key-documents#foundation-programme-curriculum
Placements in the developing world may have many benefits for the trainee, which are outlined in this paper. These include:
Direct Clinical Benefits:
- Development of history taking and examination skills
- Appreciation and rationalisation of investigations and treatments
- Developing communication skills
- Encountering and managing new pathologies (e.g. tropical medicine, major trauma/war surgery)
- Increased clinical responsibility
- New perspectives on acute and critical care, infection risk and control, malnutrition and public health
- Cultural insight
- Experience in leadership, management and clinical governance
- Opportunities for useful and important clinical audit
- Research opportunities
- Teaching opportunities
- Insights into healthcare systems and policy
- Increases in personal maturity, motivation, reflection and career perspective.
Personal forward by James Ayrton:
"Below are listed some of the benefits I personally experienced from my time working as a medical and surgical SHO in Juba Teaching Hospital. This took place over a total period of 8 months in two trips during 2008-9. I have categorised them into direct clinical benefits by which I mean those skills that have helped me to improve my clinical care as a junior doctor, and secondly generic benefits which have helped me to become a 'better doctor' in the more rounded sense.
My focus has been on the range of benefits that a trainee may receive working within a developing country in a way that that they may not necessarily experience to the same extent (if at all) in the UK."
Direct Clinical Benefits:
1. History Taking and Clinical Examination
Investigations are often severely limited, therefore history taking and clinical examination form the mainstay in formulating a differential diagnosis. Practicing medicine in this context focuses the mind on these vital core skills since there may be little else to go on in the first instance. This is invaluable in counterbalancing reliance on laboratory and imaging results. Clinical examination skills should improve due to the abundance of clearly elicitable clinical signs present on a general tropical medical ward - the trainee may only see these rarely in the UK. The end result is an increased confidence and competence in history taking and clinical examination, together with a good appreciation of their centrality to the medical process.
2. Use of Investigations
In many cases, the availability of laboratory investigations and diagnostic imaging are very limited. Whilst this can be challenging, practicing medicine in such a context can help to develop critical reasoning for the trainee. Reliance upon, and therefore development of history and examination skills are improved (see above.) Furthermore, the resource implications are seen much more acutely than in the NHS. If certain blood results (particularly less routine ones) are requested this cost will need to be met by the patient or their family, many of who are very poor. In this situation the doctor has to seriously weigh up the need for a given investigation at all, how often (if at all) it needs repeating, the treatment implications (or lack of) in the light of the results etc. In other words, the doctor develops the ability to rationalise the use of investigations rather than use them as blanket screens "just in case".
3. Communication Skills
The experience of working in a situation where many of the patients (or colleagues) do not speak English as a first language, is an excellent platform for the trainee to give serious thought and reflection to the nature of communication as well as the opportunity to improve such skills. The trainee will often need to communicate via translators - this requires concise and effective language on behalf of the clinician. There is little role for jargon or euphemism. In addition there is the need to pick up non-verbal clues indicating how much (or little) the patient understands the situation. This is of particular relevance in the UK when looking after non English-speaking patients.
4. New Pathologies
An understanding and increasing confidence in tropical medicine is clearly a benefit for the trainee, and will improve the quality of their clinical care when working in the NHS - for example in assessing and treating patients in the UK who have recently been travelling in regions of endemic tropical diseases. Malaria is the most common reason for medical admissions in Juba but is becoming of increasing incidence in the UK due to rising travel.
Whilst working in surgery the higher prevalence of major trauma was notable. Whilst it is unlikely that working routinely in the NHS will include victims of high-velocity assault rifles and landmines, the principles of trauma care are applicable to UK caseload.
Acute Medical Conditions with varying aetiology
A further related issue is treating more familiar pathologies presenting in a different context.
(a) For example heart failure in the UK typically occurs in older people secondary to ischaemic heart disease but in this environment it may well be seen in a younger patient secondary to mitral stenosis resulting from rheumatic fever.
(b) Sepsis as a clinical entity is also very common in the UK often affecting older patients or those immunocompromised - in Southern Sudan it is more common in younger patients and arises from malaria, typhoid, meningitis or the viral haemorrhagic fevers.
(c) Another feature commonly encountered is the typically late presentation of patients. Whilst regrettable it does provide insight into the natural history of diseases and with this exposes the clinician to different patterns for diagnosis and management.
Critical Care in a Primary Setting
Related to the common issue in the developing world of late presentation to hospital (usually due to decreased access to healthcare services) is the issue of acute care. As a general observation, patients needing admission are often extremely sick and frequently haemodynamically unstable. There are therefore significant opportunities for trainees to gain experience in managing sick patients in the acute setting. This is true across the disciplines (medicine, surgery and trauma, obstetrics and gynaecology and paediatrics).
(a) Sepsis: Managing these cases increases confidence of the trainee in handling acutely unwell patients firstly because of the numbers treated, and secondly because of the general population demographic. Common causes include malaria, meningitis and typhoid.
(b) Hypovolaemic shock: This often follows acute watery diarrhoea or cholera and typically affects the young who have been relatively fit beforehand. Simple treatment modalities such as appropriate fluid therapy, oxygen and antibiotics/anti-malarials can be life saving.
(c) Deep coma or Convulsions: This is another common condition and often arises from cerebral malaria. Once more basic skills of acute care together with appropriate antibiotic therapy is all that may be needed to save a life. Care can include good airway management (due to the coma), monitoring and assessment of breathing (including instructions to relatives not to attempt to feed the patient and risk aspiration) oxygen therapy if available, monitoring and assessment of circulation and appropriate fluid therapy, good glycaemic control with neurological assessment and anti-convulsant therapy, monitoring of the pyrexia and sepsis with appropriate treatments and investigation for the underlying cause, regular turning to avoid pressure sores, nutritional needs etc. If done well the dramatic recovery patients can make in just a few days can be astounding, reinforcing the importance of the underlying principles of acute care.
The issue of patient nutrition and implications for medical management is often more clearly brought into focus when working in the developing world. This is unfortunately due to the much higher prevalence of chronic malnutrition amongst the general population. This can be exacerbated by hospital admission - typically in many hospitals including Juba Teaching Hospital, there is no hospital provision of food for inpatients - their relatives provide and cook the food for them. In some cases, a patient may have no relatives and in those circumstances patients may starve whilst in hospital.
Infection Risk and Control
To a visitor in the developing world issues of risk and appropriate management are more often consciously (rightly or wrongly) considered than they would be back in the UK.
Clinical risk of blood-borne infections such as HIV and viral haemorrhagic fevers needs to be carefully considered and evaluated when dealing with the indigenous of sub-Sarahan Africa. After working in such a high-risk area engenders a more prudent approach to cross infection once back in the UK. This is currently very topical with the drive to reduce MRCA and C Difficile within secondary care.
Non-clinically, issues of risk need to be carefully considered in daily life and activities inside and outside the hospital. Such risks range from the relatively minor (safe consumption of clean water and food hygiene) to the more serious (possible political instability, violence, security threats, curfews, target attacks on the apparently 'wealthy westerner'). These all need careful and systematic planning, strategies and vigilance, all of which are highly transferable skills the trainee can benefit from throughout their career.
In my experience, there is often a higher degree of clinical responsibility working in the developing world, due to their limitations in human resources. In an African hospital there is unlikely to be any registrar grade between medical officers (SHO equivalent) and consultant. Furthermore the general consultants /senior clinician has less of a visible presence on the wards during the acute take or to review emergency admissions. The resulting increase in clinical responsibility of the trainee provides a valuable opportunity for that individual to develop maturity and also to appreciate his or her own limitations.
Rationalisation of Treatments & Creative Problem-Solving
Limited resources necessitate the trainee to consider carefully the costs and benefits of different investigations and rationalise their use. The same principle applies to medical interventions and treatments prescribed. In an environment where people may be too poor to afford, (or certain treatments are unavailable) these implications have to be considered and treatments rationalised accordingly.
Although best practice should be aspired to, the trainee will need to be able to think pragmatically as well, otherwise the risk is the patient may get no treatment at all. For example, in treating peptic ulcer disease in Juba, ideally one would prescribe proton-pump inhibitors. These are only available at cost to the patient from private pharmacies. Ranitidine is usually provided free from the hospital pharmacy - therefore pragmatic practice will result in the latter being prescribed. These principles and skills are useful to the trainee in the UK where compliance issues are just as real (perhaps also related to polypharmacy) although less obvious.
Working in such an environment can also help to foster skills in creative problem solving, both in the clinical context and management/hospital systems work. Examples have included the need to improvise the delivery of nebulized salbutamol by using a plastic water bottle and micro-pore tape. This is not a situation one would ever expect to encounter in the NHS!
Public Health and Preventive Medicine
Public health may be more appreciated by its absence than its presence. Simple measures such as effective sanitation and clean water would do much to reduce disease. This also extends to viral infections including HIV. Having said this the picture is slowly changing through Global Health initiatives and this can be experienced first hand by working in an environment hit by poor public health infrastructure.
General Cultural Insights
Many of the benefits described below have underpinning them the general benefits of a genuine and meaningful cross-cultural experience. Whilst a comprehensive analysis of the nature of culture is beyond the scope of this document, suffice it to say that the very act of leaving one's own culture and integrating into another, together with its corresponding underlying world-view and value systems, has immense potential to stimulate personal growth and development for the trainee. This is of course true at a broad personal level, as well as specifics related to perceptions of health in society, patient expectations, hospital values and management systems etc.
For one thing, as an outsider the visiting doctor is in a valuable position to evaluate and question aspects of the host culture that are regarded as normal in that context. For example, Juba generally demonstrates a higher tolerance towards patient mortality rates, especially amongst paediatric and young adult patients than it would be in the UK. By and large, parents in Southern Sudan expect some of their children to have died before reaching adulthood. This is almost certainly due to the collective experience of almost half a century of civil war, where death becomes part of normal existence, together with disease burdens and under-developed public health and primary healthcare systems and under-resourced hospitals. This is an underlying attitude that it may be appropriate to sensitively question and until it is highlighted and addressed, teaching on emergency or acute care is likely to stall or fail to be well integrated into practice. ("Why bother?" may be the response…). Indeed a parallel experience can be seen in the UK where, until recently, hospital-acquired infections were expected as a norm. Now there is a national drive to reduce rates to an absolute minimum.
As a note of caution, trainees need to be very aware that the western way of doing things is not necessarily the best way, or the best way in this context. Ideas about changing or "fixing" things (which can end up being synonymous for 'westernising') in a hospital or indeed anywhere need to be firmly underpinned by an attitude of cultural and general humility and open-mindedness. It can be argued that changes should only be lead by senior clinicians within the hospital with input, ideas or supervised implementation from visiting trainees. Any attitude (explicit or covert) of 'western superiority' is a recipe for disaster.
Further advantages to the trainee of cross-cultural experience come later on. As one becomes more naturally integrated into host culture and leave their own, this in turn provides a good platform to look back and critically evaluate many aspects of their own situation that they may previously have been blind to or just accepted as 'normal'. This phenomenon can not only strengthen a trainee's personal development and maturity, but also help to develop skills in thinking creatively about solutions to problems. It certainly provides excellent hard-experience in dealing and empathising with patients in the UK of different cultural values and backgrounds or perhaps feelings of vulnerability about being an 'outsider'. These will all help to improve general professionalism and communication when working in the NHS.
One final general observation is that working in a hospital with severe limitations or a country rife with poverty can very much help any trainee in appreciating the system in which they work in the UK. It adds a certain degree of perspective to criticisms of the NHS which is no bad thing.
Management, Leadership & Clinical Governance
Following on from the chance to provide an outsider's perspective or evaluation of a system (if invited by local staff) trainees may also be given opportunities to suggest improvements and assist or lead on their implementation. (This also may arise as part of the audit cycle - see below.) In Juba, there have been a number of discussions that led to restructuring the emergency ward system and staffing levels to improve the quality of acute care service delivery. All of these tasks have been invaluable in developing management, project and leadership skills, as well as effective team working.
In attempting to solve seemingly simple problems that the clinician faces on the ground, new insights and appreciations for the running of a hospital and healthcare system may be developed. For example, one may ask the question "Why is there no Ringer's Lactate available to give to this patient?" In attempting to answer and solve the problem, one would have to consider numerous elements related to this restructure. For example an analysis of need within the hospital pharmacy would include hospital logistics and warehouse systems for storage, local hospital policy for procurement of drugs and fluids, how they're budgeted for, systems for ensuring orders are made to keep stocks adequate, efficacy of the supply chains and transport infrastructure etc. In this scenario the trainee will have to take into account both local hospital and national policies for state hospitals in their evaluation. The role and relevance of good hospital management and clinical governance in improving clinical effectiveness and patient care are seen in context in a clinical environment such as Juba Teaching Hospital. This is largely because the opportunity to work in and experience a system where they are not functioning well has far more power to underline their importance to the trainee than merely explaining their benefits
Although most trainees in the UK would concede that clinical audit is essentially a good way of improving clinical care sometimes the full impact and potential power of the audit cycle can be underestimated in the UK. This is essentially because, relative to developing countries, the UK health system generally performs well - audit in the UK can sometimes seem obscure or pedantic. A placement in the developing world, where healthcare delivery is often not as developed as here, can offer real opportunities for the audit process to measure and quantify deficits and implement changes to make significant improvements to patient care.
The topics chosen may be very simple but extremely important. For example, as part of evaluating acute care services in Juba, an audit was carried out looking at the number of patients on whom vital signs were being taken and recorded on admission, and also what basic interventions were performed when the patient was identified as haemodynamically unstable. Findings from this simple audit illustrated to the staff at JTH the need and method of changing practice. Interventions were introduced which included nurse education and training. Also staff was encouraged to contribute directly to the development of new admission protocols. A repeat audit demonstrated measurable improvement in patient care and staff engagement. This particular audit was presented several times at Ministry of Health level, including to the Minister of Health himself.
In 2008 a simple retrospective analysis was carried out looking at hospital mortality (this particular data was unknown at that stage). The particular focus was on the chronological distribution of mortality. Analysis indicated a large peak in mortality within the first 24 hours of admission. This evidence was sufficient to strengthen the case for improved acute care services. Later this was presented to the annual Government of Southern Sudan Health Assembly, to the Ministry of Health, WHO, UN and other health policy makers in Southern Sudan. In 2009 at the requests of the local consultants another analysis was conducted looking at caesarean sections performed over the previous 12 months. This was then compared with WHO targets. A further audit looked at war surgery (gun shots, landmines, grenades) conducted in Juba Teaching Hospital dating back to 2006. This data was presented at the International Committee of the Red Cross (ICRC) war surgery conference in Juba.
Surprisingly perhaps there is scope for useful research projects in the developing world although without the support of an academic institution they will typically be relatively simple. For example data exists on basic hospital operating systems, including patient data. This can be used in simple but relevant clinical research questions (defined by local senior clinicians) and can be of significant benefit to the local hospital and beyond.
Evidence Based Medicine & Clinical Effectiveness
Evidence based practice in the UK is the ruling paradigm for health care. However this is not automatically the case in other parts of the world. Its absence ironically can help the trainee to appreciate its value in clinical decision making and improving clinical effectiveness. In general differing viewpoints are also an excellent means for the trainee to develop independent analysis and the need to explain or justify ideas is also an excellent means of stimulating thought, understanding and reflection on the subject.
Healthcare Systems & Policy Making
Trainees working in the frontline of secondary healthcare in a government-run hospital such as Juba, often stimulates the individual to consider and reflect upon the influence of government on practice. It also provides an opportunity to evaluate the degree of success (or otherwise) in relation to the healthcare needs of that community.
In some, but not all, cases there may be opportunities to offer contributions. Examples have been outlined above where presentations have been made to the Government of Southern Sudan Health Assembly.
There are many opportunities to participate in teaching in Juba. As a guest of the hospital, particularly one associated with a hospital-hospital training link, the atmosphere tends to be one of openness and enthusiasm for any teaching. Opportunities include the setting up of inter-departmental educational meetings. Subject areas have included basic knowledge such as the ABCDE approach to initial assessment of the unstable patient.
Reflective practice has been recognised for a while now as being an important component to active learning in the UK. However it is not necessarily exercised regularly by UK healthcare staff, its value often being questioned by trainees. In the midst of a sometimes dramatic cross-cultural experience, everything is so different, new, exciting, sometimes shocking or upsetting, it is virtually impossible not to take a reflective attitude as a means to processing it all: cultural differences, hospital differences, difficult or exciting clinical scenarios, implications of resource limitations to health, evidence based medicine, the role of public health and preventative medicine, global inequalities and justice issues, the role of humanitarian aid to name but a few.
Such reflection is a natural response and can take many forms from informal debriefing with friends after work to communications back home updating families or formal communications to senior colleagues/mentors back home to publishing a weblog. (See for example http://stmarysjubalink.blogspot.com as an example.)
The benefits of this reflective approach are then more likely to be embedded in practice once the trainee returns home.
Personal Maturity & Self Motivation
Planning and undertaking a placement in the developing world can increase personal maturity mainly due to the increased levels of general responsibility - both clinically and as a guest of the hospital. Also the responsibility for personal safety and respect and vigilance regarding general living in a sometimes difficult environment, respect for cultural sensitivity and so on can all promote maturity in a trainee.
Fun, Personal Satisfaction, Career Perspective
Finally, it should not be overlooked that, for much of the time, working in the developing world can be immensely satisfying and often great fun. Most doctors have gone into medicine for altruistic reasons. Sometimes this focus or drive can be lost under pressure of complex organisations such as the NHS. Shift patterns and increasing intensity of work can leave the trainee feeling alienated, even anonymous and sometimes undervalued. Feedback from healthcare workers returning from a developing country would indicate a significant increase in self-worth, drive and ability having worked in a new culture with different challenges. This can only be for the good towards healthcare delivery in the home country.
Last, but not least such opportunities provide a valuable career taster should the individual be considering overseas work as one of their long-term career aims.
Dr. James Ayrton - CT1 Anaesthetics
Dr. Malvena Stuart Taylor - Consultant Anaesthetist
25th February 2010