Wednesday, July 27, 2011

Tour of Student Field Placements- II

For the students the field placements are a challenge. They have to work as a team to ensure their accommodation is clean, adequate and protected from mosquitoes. They need to organize for meals to be prepared and water provided as it is not always nearby. Often they have to clear and clean the rooms they will use. Ways to visit schools and homes in the neighbourhood need to be planned carefully as often the students do not speak the local language.
As I am leaving Uganda in a week a quick visit has been arranged for me to the student placement sites a week after they have settled in. I will travel with Clotilda, a skilled community facilitator whom I work with in training health workers. She also works for the university assisting in the field placements and is a skilled linguist. For the last month we have been launching our initial training on community facilitation. None of the facilitators have university education, while the participants do, yet they have managed to pull this off with aplomb, earning gratitude and praise from the participants.

We are taking with us on our tour, four hour-long sessions I have prepared for the students that are based on the interactive training we have done with health workers. We will have 1- 2 hours at each site as the sites are widely scattered on a route that takes us beyond Kabale on the road to Rwanda from our base in Mbarara. We hope to visit three sites each day and overnight in a hotel in Kabale, the Switzerland of Uganda.
As the site supervisors have little time to spend with the students, my hope is to package the material so someone like Clotilda can facilitate them. Clotilda trained a long time ago in a three month course as a nursing assistant but she is very bright and has great depth and breadth of practical PHC experience from her years as a university facilitator.
Clotilda and I take turns being the lead facilitator. We use the same training techniques and tools as we have used for our health workers. We ask somewhat different questions and we respond with connections to examples related to the student's clinical work.. Clotilda easily picks up the additional material I am adding for the students, only occasionally referring questions to me to respond or give an example. We try all four of the sessions, mix and match them after asking the students what they would like to do. Originally we planned to leave out teamwork but as one of the groups identified that they were having trouble, we felt it was a teachable moment.
The only thing limiting us at each site is the time. The enthusiasm of the students prompts us to overstay at every site. We are able to do two full hours in all but one site. We leave additional handouts for them from all the modules at their request. Clearly we have sparked their interest.

Our first stop is Kinoni, about an hour from Mbarara, where there is a large group of students including four German medical students. It takes a while for them to gather as they have to turn their clinical duties over. It would be better if Clotilda and I arrived in the afternoon as patients would have returned home by then, but we have little control over this on our short tour. We then head on to Rubanda where the students are waiting in their lab coats for us. Although all groups have not received their kerosene for cooking, both the first groups are settled in and close to water and markets.
Our next stop is Rubaare, a faith-based health unit. The grounds are well kept, the equipment is rudimentary but available. As it is Uganda Martyrs Day and a national holiday, their preceptor joins us for our session. We spend some time at each site listening to their problems and helping them to solve some of them. From here we head directly south to Kabale. Just before reaching we drop in on the group at Bukindi. It is late in the day and they are far from the market so after our session, several of them grab a lift to the market. We find a hotel in Kabale and have a late supper. The next day we visit a small but dedicated group at Humurwa.
We arrive first thing in the morning so are able to have a short chat with their preceptor. An experienced rural clinician, he is enthusiastic and has helped the students to settle in and get organized, but outside his door ranges a long line of patients. We do get to talk about record keeping and he shows us the largest register I have ever set eyes on. This is surely a place for computerized records! We head south of Kabale to reach the farthest site at Muko. Here the students have no electricity and some of the windows are broken so it is cold at night. Clotilda negotiates with the administrators for them and we get promises to make needed improvements to their accommodation. As we leave, four of them jump into our vehicle so they can recharge their computers about 10 km. down the road.

On our way back to Mbarara we pick up the DVD Outbreak that I left overnight with one group. We had hoped to discuss it with them, but they have copied it but not viewed it yet. We arrive back in Mbarara at 11 pm after two full days on the road. We make a final stop just outside Mbarara to drop off some onions, carrots, and potatoes we purchased at greatly reduced prices by the roadside in Kabale. The project secretary meets us on the road after a short cell phone call. We need to haul out the flashlight to separate the various bundles of vegetables. A couple more phone calls and a detour down a side road to a deserted building, locates a bunch of matooke set aside for Clotilda to take home.
Even the short time with the students has been useful. they tell us. Their written evaluations of the sessions are very positive. Mainly, our visits serve as a reminder that they and their education are important to all of us. At each site they have requested a photo of the group and our visit.
Clotilda and I discuss the possibility of spending a week based in Kabale and going out to visit a couple of different groups each day. We think it would work and give us more time at each site. I am convinced a set of reading materials for each session could be arranged using print and internet material if we could solve the problem of electricity. We need to continue to work out ways to make it happen.
Photos: Kinoni students; Rubanda students, Aids Register; Muko students


Tuesday, July 26, 2011

Tour of Student Field Placements- I

Some of my best times in Uganda have been with medical students during their rural field placements. They spend about 6 weeks in remote health centers following a short orientation. Over the years the program has grown and improved. Recently field supervisors drawn from the health centers were recruited and attended a week-long leadership training workshop. I attended for one day and found the facilitators excellent and the group energetic. Although as busy managers and clinicians in rural centers they have little time to spend with the students, they were interested and committed. Involving them as field preceptors seems a great way to strengthen the service in rural centers.

For the past several years, the university has made the field placements multidisciplinary so the medical students have been joined by laboratory science, nursing and most recently pharmacy students.

I started staying for days and even weeks at a time with students at one of the sites where the health workers for our project are also trained as there is accommodation for trainers. When we were doing interactive training in Child Health, we would include the students in some of the sessions. Three of the Level IV health centers used as field sites for students had groups of the community health workers I help to train attached, so I was able to spend some time at each of the three sites. It helped that our child health project had an interest in developing a way for students to learn about and to appreciate the work of community health workers. Some of us also felt that involvement with the student teaching at the health center was a way to improve the quality of service provided in rural health centers.

The Dean, Associate Dean and the Head of Community Medical Education have been actively involved in and committed to improving the field experience and using as a way to influence future practitioners, coming up with the idea of involving field preceptors, providing leadership training and revising the curriculum.

It isn’t always possible to combine my visits to Uganda at the same time as the field placements but when it has proved possible, it is always a highlight. Over the years I have been pulling together a number of interactive training sessions related to community health in Uganda that can be delivered on site. Topics include specific areas students request such as Community Entry as well as topics the Coordinators ask for such as Community Participation and even issues I feel need more of a community and preventive approach such as Motor Vehicle Accidents.

The response from the students has been very positive. One group said they all wanted to do community medicine after the week. I had to assure them that that wasn’t my intent and I would be happy if in whatever field they chose, they took a more preventive and community approach. Some of the success of these interactive sessions is likely due to the contrast it provides to their past exposure to rote learning and to the isolation they often feel in the field. Even a modicum of the mild amalgam of challenge and direction that is provided by participatory training seems to combine to light nascent flames of interest and excitement. But whatever the reason for their enthusiasm, it is a delight to work with them.

To be continued in the next blog.

Photos: the line up at the Rubanda water pump; student groups at Rubanda work on action steps of development; participation ladder with Bukindi students; Muko group in front of the new building.


Sunday, July 24, 2011

Open Hearts & Surgery

She is almost two years old when I finally meet her. A sturdy toddler, inquisitive and like most African children, Isabel is interested in other people. She wanders around around the Agip Motor Hotel in Mbarara where her parents and I have gone to dine out.
She plunks herself down in my lap but soon is off to explore the verandah. A Chinese business group notice her watching them and give her a cellophane-wrapped sweet which she brings back to us. Something new for her, she shows it around to us all. At first we don’t know where she got it but as they are the only Chinese group eating on the porch and the writing is in Chinese, we soon figure it out. When she sets off again, her brother, Timothy is delegated to keep an eye on her, but she is clearly a handful.

When she reached six months, she began to have difficulty breathing and took on a blue tinge. She was taken to Kampala where she was diagnosed as having a small hole in her heart. This is bad news in Uganda where the doctors may be able to diagnose it correctly but have no access to cardiac surgery, not even for fairly simple manoeuvres such as fixing a patent ductus. The news quickly spread and people offered to locate a place where surgery could be done, to review the diagnosis and to contribute air miles and cash. A search was made of sites, advice was sought, but in Uganda, time was running out.

Her parents are dear friends, among the first people I met at the university in Mbarara when I arrived in 2002. We share an interest in community health. They are hardworking and resourceful. They quickly located a surgeon and hospital in India which accepted children from Africa and they committed to making it happen. This proves difficult as time is running out. Also although colleagues were generous, the cost of sending mother and child to India and getting the operation done are nothing short of prohibitive.

Still colleagues at the university in Uganda managed to raise $1000 in cash, a phenomenal feat in such a cash-strapped economy. This nest egg and some donated air miles were not enough to ensure it will be done but it was enough for Isabel and her mother to set off on the plane before she was severely compromised.

Some of us were still trying to process the info and help to locate an appropriate place where the operation could be done, when we heard they had headed for India, one step ahead of the Grim Reaper. It was clear that at this point, cash was needed, not advice. Through donations wired to the Kampala branch of her bank account, which her mother was able to access in India,enough money was realized. The whole thing was touch and go for most of the time, but thanks to modern banking transfers, the internet and generous friends, one very sick, young gal was able to get the life-saving operation she needed.

It is such a thrill to see her clamouring over the chairs in the hotel. She is a testament to Open Hearts and Surgery in a place where one doesn't deserve to find them.

Photos: Isabel and mom, Brother Timothy


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