Dr. Andrew Wei’s Blog from Rotation at Mangochi November 2018
As part of our 2nd or 3rd year, family medicine residents at the Swedish First Hill Family Medicine Residency (SFMR) have an opportunity to do a month long elective rotation at the Mangochi District Hospital (MDH) in Malawi.
Malawi is a country in southeast Africa and is the third poorest country in the world, with a nominal GDP of approximately $331 USD per capita. Their health system is split into primary (local health center), secondary (district hospital), and tertiary care centers (central hospitals). Beginning in 2014, SFMR, SEED Global Health and the College of Medicine in Malawi partnered up to increase the presence of academic family medicine in Malawi.
The hope is to train family medicine physicians with broad, comprehensive, and community-oriented clinical skills who can help support the developing health systems in Malawi, especially at the district hospital level. In our third year of residency, my co- resident, Nathan and I had the privilege of joining Anna, one of our faculty who has been at MDH for many years and Jacob Nettleton, a SEED Global Health clinical educator, in their goal of promoting family medicine and health systems strengthening at the district level.
Mangochi District Hospital is situated towards the center of Malawi, between Lake Malawi to the North and Lake Malombe to the South. Mangochi is a beautiful, busy, hot, dusty (currently dry season) transportation & trading hub reflecting the rural flavor of most of Malawi. I felt extremely privileged to be staying in a beautiful home next to the Shire River, which connects the two lakes. The home, while simple by US standards, had hot water for showers and a washing machine, two luxuries that few if any of the 1,000,000+ people who live in the district have.
It was a short walk, about 5 turns and 10 minutes walking through parts of the main market, from the hospital. The main part of the hospital is a long hallway with different wards (male, female, pediatric, maternity, theatre or operating room, etc.) connected to the main hallway. Nathan was assigned to work in the pediatric ward with Anna while I worked with Jacob, predominantly in the female ward. The medical students were yet to arrive for their rural Family Medicine rotation when we arrived, but there were many clinical officer students who were eager to learn from us.
In Malawi, there are medical assistants (who primarily work at the community health centers), clinical officers (who primarily work at the district hospitals and are kind of equivalent to physician assistants here in the US), and medical doctors (who primarily work in the central hospitals and sometimes as leadership in the district hospitals).
Each day started with morning handoff, which involves the nurses reading the overnight events, the on-call clinician discussing cases that happened overnight, and sometimes a didactic presentation. Afterwards, we break off to our respective wards to see patients. Although I spent some brief time in other wards, I worked predominantly in the female ward so will mostly speak about that experience.
The ward itself is just one large room with an admitting/procedure room, nursing station and gynecology clinic in the hallway leading to the ward. It is organized into five bays that are separated by a short concrete slab. Each bay is then separated into two halves with six beds on each side for a total of sixty beds. Stanley, one of the Malawian family medicine interns also worked with me in the female wards, seeing patients predominantly in Bay 1, the highest acuity bay.
As a visiting medical resident, who was only staying for 1 month, my role was not to provide direct patient care, but to serve as a consultant to the clinical officers and to teach the clinical officer students. The rotating cast of clinicians changed every day, which made for new dynamics and problem solving. And given limitations in human and technological resources, it was a challenge to help advance even small systems changes.
I have worked in global health in a quality improvement context, but this was my first clinical experience and it demanded a healthy amount of flexibility and understanding. I was often not the expert in clinical knowledge and definitely not the expert in local culture, language, health literary, health beliefs/traditions and health systems in Malawi.
The role we serve is a delicate balance of coaching our Western style of medical inquiry and assessment without fully understanding all of the above contexts and the downstream consequences of our decisions. This was challenging and difficult work. And as Nathan and Anna, both physicians who have spent several years in developing countries, said, it takes at least a year to build important connections to the community and to start feeling like one is beginning to understand the health system and cultural context. This experience reaffirmed the importance of long-term commitment in global health. However, that is not to say that I did not come away with a personally meaningful experience.
Patients who present to MDH unfortunately often present at late stages of their disease; for example, I saw many patients with AIDS-related illnesses, end-stage tuberculosis, metastatic cancer, decompensated heart failure and liver failure, and late-to-present strokes. We can speculate that this is due to financial constraints, poor health literacy, and/or poor access to care but I imagine the actual reason is multifactorial and not as simple. Families and patients seemed grateful for the care of a clinician and their assessments and plans were rarely if ever questioned.
The primary languages spoken by patients are Chichewa, the national language alongside English, and Chiyao, a language spoken by the Yao tribe. Every visit encounter was translated by the clinician, which made my medical judgment based on history difficult. Clinical officers and students would present patients to me and I would use this time to give them thoughts on their medical reasoning and provide relevant teaching topics, which ranged from reminders to check the vitals on every patient to developing a differential diagnosis for proximal muscle weakness.
All of the patients and their plans were then either discussed with a senior clinical officer and/or Jacob. Stanley would round on his patients more formally with Jacob, and often I would round with them, giving them my thoughts on his patients as well. Although only an intern, I was impressed with Stanley’s comprehensiveness and medical knowledge. He has had extensive clinical experience prior to starting his family medicine training in Malawi. He is going to be an amazing family medicine doctor.
After seeing patients for most of the morning, lunch occurs between 12-2, a time when families bring and feed their loved ones lunch in the hospital. If you’re caught in the wards at this time, it can be chaotic trying to get out. The afternoons were mostly spent teaching the clinical officer students. Nathan and I led most of these teachings with Jacob and Anna’s help. We discussed topics such as the neurological exam, diabetes, hypertension, anemia, and stroke, trying our best to make the teaching relevant to their clinical and resource context. For example, we made it a priority to focus teaching on pharmaceuticals and diagnostic tests available to them at the district hospital levels.
This was an enjoyable part of the experience and it was nice getting to work with the same students over several weeks. Some afternoons, we would also connect with the other family medicine residents in Blantyre, and discuss teaching modules as resident colleagues on topics such as endocrinology, diabetes and prostate disorders. This was a nice way to review the evidence on a certain topic and discuss its relevance/implementation in the setting of a district hospital and the broader Malawi community.
On my last day in Mangochi, I gave a morning handoff presentation on interpretation of liver function tests. Nathan earlier in the week discussed thrombocytopenia in the newborn and using vitamin K in the neonate. It was important that we made these presentations after spending several weeks in the wards to better understand their clinical context in order to adapt our presentations accordingly. I thought these presentations were a great way to identify a care gap and provide useful teaching, which has the potential to change clinical behavior and/or health systems.
For our last two days in Malawi, we traveled up to Blantyre to help teach the fourth year medical students orienting to their family medicine rotation. Each of us played a standardized patient and then summarized reflections and teaching points at the end. It was inspiring working with the talented students and hearing which specialty they were thinking about. Some are leaning towards family medicine!
And as quickly as it started, it ended. The month was both physically and emotionally challenging. I am still reflecting on my time there but initial thoughts include the following. 1) I am incredibly privileged and will never truly understand what life is like for most people who live in Malawi or other resource-limited settings. 2) I am humbled by the challenging work of global health and the Malawian community of healthcare workers who are doing their best to build a better healthcare system. 3) I left with a deeper appreciation of the complexity of delivering community-oriented and culturally appropriate care. 4) To truly make a large impact, I believe that a sustained partnership, with dedicated folks who have integrated into the community, is key. 5) My hope is that I left some lasting impact, even if just for one person, through the morning handoff didactic and the daily teachings with clinical officer students. However, I suspect that I benefited most from the experience through my own personal growth, both as a clinician and as a person.