Elective Report 2019
I undertook my elective placement in Mufulira, Zambia. Mufulira is a small town situated in the Northern part of Zambia with a population of 125,336(2007). It is situated in the Copperbelt region of Zambia. Mufulira is known for its copper mine owned by Mopani mines. Being a mining town made Mufulira an interesting town to undertake a medical elective in as most of the population knew of someone who worked in the copper mines. I undertook my placement in two hospitals; Ronald Ross General (RRGH) (primarily) and Kamuchanga District hospital (KDH). Ronald Ross General was previously owned by the copper mines but is now a Government funded state hospital like Kamuchanga. Ronald Ross is a state-owned hospital; however, it is considered a hospital for wealthier patients as patients are charged for investigations. Kamuchanga district hospital is situated further out in the outskirts of Mufulira; therefore, it has a poorer patient population. For this reason, all consultations, investigations, and treatment are free of charge. There were clear disparities between the two hospitals; KDH suffers from a greater shortage of resources, an example of this is that whilst I was on placement they had been unable to carry out X-rays due to a shortage of films for over two weeks.
Being from a neighbouring Southern African country myself, I had my own expectations on how I imagined the cultural differences would impact healthcare. These expectations soon became a reality when I was faced with patients delaying seeking healthcare due to cultural beliefs in the powers of traditional healers. I feel that I was able to treat patients in a non-judgemental fashion as I had a prior understanding of this. I feel as a healthcare professional it is important to be aware of and open to understanding other people’s cultures and beliefs, I feel my experience in Zambia has helped me develop this further.
During my elective placement I undertook a number of roles that I would not ordinarily be responsible for whilst on placement in the UK. As my interests lie in Paediatrics and General Medicine; it was decided that I split my time at Ronald Ross between the female medical ward and Obstetrics and Gynaecology. These two wards were some of the busiest in the hospital and working on them proved to be a challenging yet thrilling experience. The female medical ward was mainly situated by female patients that had been admitted via A&E or that had been referred from clinics or district hospitals. Therefore, I was faced with a great number of acutely ill patients daily. I was under the supervision of Dr Tumba who was the only physician in charge of the medical wards. My roles included:
- The initial Clerking of acutely ill patients on female medical ward
- Taking histories and examining all of the patients as part of the ward round
- Formulating an impression and initial management plan
- Implementing the initial management
- Review of patients
- Occasionally screening patients in the outpatients’ department
I was supported in my role on the ward by the Clinical officers and nurses based on the ward. Initially I was overwhelmed by the level of responsibility I had whilst on the female medical ward however I soon adapted and became comfortable in this challenging environment. My most notable memories were being part of the initial team managing several patients presenting in a DKA/HHS coma. In my first week there were two patients who arrived in this state on the same day. This was a shock to me as it was my first time seeing DKA patients in a coma who were presenting with textbook clinical signs and symptoms. I assisted in completing an A-E assessment on these patients. The patients were treated with fluid rehydration and IM insulin injections. This is one example of the level of complexity we were dealing with, the main challenges I faced were struggling to implement the appropriate management plan due to lack of resources; most notably medication and certain investigative tests.
Whilst on my placement, it was also my first time dealing with death of patients I had directly been involved in the treatment of. I had my first experience of assisting in examining deceased patients in order to confirm death. This was an invaluable experience. However, the frequency of death on the female medical ward was unsettling as some of the deaths seemed preventable. The stark reality of high death rates from preventable illness proved to be a huge ethical dilemma for myself. I found it especially difficult to handle at first as patients died due to ill education of their health conditions. I found it disturbing that patients suffering from conditions such as hypertension and diabetes mellitus frequently came in in emergency situations due to medication non-compliance. I believe this could have been improved by patients receiving adequate education on their health conditions. I found out that patients did not take medication for a number of reasons such as – not understanding the health condition and why they need to take medication, cultural and religious beliefs that discouraged them to take medication and poverty leading to inability to afford medication and consultations. The responsibility of informing the patient on their health condition lies with health professionals, but I feel whilst in Zambia this was not always well exercised. Patients were often left with very little understanding of their health condition after being diagnosed; I tried to alleviate this by taking time to explain to patients. Furthermore, I took the initiative to attend placement on Saturday 13th July to educate patients on hypertension and its potential fatal complications. I feel this was a successful event as I was able to take the blood pressures of all of the relatives on the female medical ward visiting their loved ones. The relatives welcomed having their blood pressures checked and they were keen to learn about hypertension. From this I was able to identify a 70-year-old woman with a blood pressure reading of 180/110. She had previously been with hypertension but had never taken medication due to miseducation. With the assistance of the nurse in charge we were able to start her on an antihypertensive and to signpost her to receive more treatment and further investigations from her doctor.
Another ethical dilemma I faced whilst on placement was the attitude towards doctors and other healthcare professionals. Doctors are highly respected individuals in African society, whilst on placement I found that this attitude towards doctors sometimes encroaches upon patient autonomy and can lead to healthcare professionals abusing their power. I feel that in Zambia, a more patient centred approach needs to be adopted however this is a cultural issue that needs to be addressed.
Another real issue faced by Zambian patients was the inability to pay for medication. Although some medications are government funded such as HIV ARVs, anti-hypertensives, and diabetic medications. However, other, more socialist medications require payment. in obstetrics Rhesus negative patients are required to pay for their own Anti – D prophylaxis. Anti-D was extremely expensive at over 1000kwacha (over £60). The majority of patients living in Mufulira are unable to afford this. This left several women without and thus continuing the pregnancy despite the risks of isomerisation. Such inadequacies were a daily occurrence and led to many preventable deaths.
Being unable to treat patients was also very frustrating; an example of this was a 40-year-old woman who collapsed and subsequently entered into a coma following a suspected intracranial bleed. This woman passed away; she was unable to receive a CT scan as the hospital did not have this facility; furthermore, we were unable to intubate her despite her having a GCS of 3 as the equipment was not available. She was also suffering from refractory malignant hypertension however there was only one antihypertensive available. There was very little we could do to help the patient which was difficult to come to terms with. With death being a common daily occurrence, I feel a lot of the health professionals became desensitised to it. Palliative care was also a foreign concept to the majority of healthcare professionals working at Ronald Ross. I took the initiative to explain to the student clinical officers (nurse practitioners) what palliative care is and the benefits it has, I emphasised the importance of adequate communication about death and dying to the patient and the relatives for this was rarely done. I found that talking about death was not something done regularly despite it being so frequent.
My main learning objectives were:
- To understand the common conditions seen in Zambia and how they are managed.
- To become more competent in clinical skills and examination (particularly in paediatrics) and diagnostic skills
- To learn to work under pressure and adapt my practice depending on what resources are available
The main conditions faced by Zambians include malaria and complications of ill-treated chronic health conditions such as HIV, diabetes, and hypertension. I was able to fulfil my first learning objective as I was faced with all of these conditions day to day; I was also given teaching by the clinicians on malaria and HIV
I was also able to achieve the second learning objective; whilst on placement at Ronald Ross we were far less dependent on diagnostic tests. I feel that my placement helped me become a better diagnostician as my main tools were history taking and examination. Whilst on placement I undertook half of my placement in obstetrics and gynaecology. I attended several clinics where I was able to become confident in obstetric palpation and in using a pinard stethoscope as the CTG machine was not readily available.
Lastly, my ability to work under pressure was certainly tested in my first week of placement as I was encouraged to help assist in emergencies. I feel as a result I have become more comfortable performing an A-E assessment.
Another personal learning objective I had was to be able to become more confident in my own ability whilst on placement. I feel I was able to achieve this whilst on placement in Zambia as I was encouraged to participate, and I was trusted by the clinicians. Being of African descent myself, it was a privilege to work with other healthcare professionals of a similar cultural background to myself.
Future learning needs
Whilst on placement the opportunity arose to undertake advanced procedures such as pleural taps, spinal anaesthesia and assist in Caesarean sections and hysterectomies, as these procedures were above the limits of my competency I expressed my inability to undertake them. My goal is to gain training in these procedures whilst in the United Kingdom as I do plan on returning to work in southern Africa to gain more experience once qualified. I would also like to undertake training in teaching and/or medical education as I discovered my passion in it whilst on my elective placement.
I feel that I have had a positive impact on my elective host as I was willing to learn and welcomed any teaching offered by the clinicians. I also actively asked many questions as I was keen to learn how doctors manage conditions in Zambia as compared to the UK. We also discussed the different practice in the UK, this way the clinicians were also able to learn from me. I feel another pair of hands on the ward was also beneficial as there is a national shortage of doctors in Zambia. I feel I demonstrated this when I correctly diagnosed a patient with a missed deep vein thrombosis. I was able to commence this patient on anticoagulant therapy. Furthermore, as explained before; taking on the initiative to educate patient’s relatives on hypertension immediately benefited the individuals involved however I feel this may have also benefited the wider community. My colleagues and I were also able to donate essential medical equipment such as gloves, aprons, scrubs, surgical hats, toys and arts and crafts equipment which the hospitals were very grateful to receive.
My elective experience helped me put all of the theory I had learnt over the past four years into practice. I was able to exercise my knowledge of the theme structure and function whilst on placement, there were many conditions I had not been exposed to on placement whilst in UK such as malaria, HIV related disease such as Kaposi sarcoma. I feel this has had a great impact on my future practice as it has helped consolidate my knowledge of these health conditions. Furthermore, visiting a country with such a different demographic of people was very beneficial on highlighting the importance of the population perspective theme. An example of this is the importance of disease reporting and vaccination. I have seen in practice how a lack of these provisions can lead to disease outbreak. Lastly, whilst on placement I exercised the GMC’s good medical practice particularly in terms of maintaining patient dignity and confidentiality which were not always adhered to by other medical professionals. Overall, I am extremely grateful to have been given the opportunity to undertake my elective in Zambia and I feel it was an extremely invaluable experience.