Our visiting doctor, Kathleen Mcgeough, who had been with us at Cairdeas for six months this year, shares some thoughts on the routine they built while volunteering in Uganda. To hear more about our visiting doctors and their time in Uganda, visit the complete blogs at Kate Howorth and Kathleen Mcgeough.
The time my day starts depends on whether I am at Mulago Hospital (leave the house at 7:05) or Kiruddu Hospital (leave at 7:35). We generally start the day by meeting with the clinical team in the morning to go through our list of patients and decide who needs seen. These patients are then divided between us (with a translator for Kate and I) and we start our reviews. A large part of the job is assessing and trying to treat symptoms, but a large part is also discussing (sometimes more debating) with other doctors what our treatment priorities should be. An example of this is on the renal wards. We get a lot of referrals of patients who cannot afford dialysis; either they cannot afford to start it or it has been started but they can no longer afford to continue.
The cost of initiating dialysis is over £200 as patients have to pay for central line insertion, blood tests, medications and the actual dialysis. This is more than the annual salary for many patients and many families face choosing between financial ruin and starting treatment. We spend a lot of time on the renal unit discussing with the ward doctors what our treatment goals are; it is painful to hear that families have sold their homes and everything they own for 2 weeks- worth of dialysis before having to stop treatment and facing the inevitable deterioration from renal failure. Instead we try to ensure that the ward doctors have frank and honest conversations with their patients and consider the benefits and risks on an individual basis.
We tend to finish our reviews and clerking new patients by the afternoon and try to beat the traffic on the way home. Alongside the ward reviews we have been doing a lot of teaching. This has ranged from undergraduate to postgraduate teaching. Thanks to zoom, we can often do these from home as most teaching has remained virtual. As well as delivering lots of teaching there has been plenty opportunity for me to attend teaching. This has been either “mini rounds” where an interesting case is presented followed by teaching and discussion as well as journal club.
The main week to week variation has been medical students. We teach students from 2 different universities- one university sends a large group of students (currently 32!) to the unit for a block of 4 weeks while the other university sends a smaller group (8 students) on alternate weeks. This makes a massive difference to the workload for the week; the weeks we have medical students involve a lot more bedside teaching and therefore slower ward reviews. There is also the Friday PBL session which takes a good few hours going through 3 different cases- wish me luck doing that with a class of 40! We have been lucky to have post-graduates rotate through the department, once they have been with us for a week or so they are able to work more independently and help share the work load.
The weekly routine generally involves 3 days at Mulago and 2 days at Kiruddu- though this can change with public holidays, staff absences or when the case load is much greater in one hospital. We have also managed some routine in our personal life. Tuesday evening is yoga, Wednesday is Quiz night and we have tried to stick to a “Fun Friday” where we treat ourselves to a milkshake, cake or even a cocktail seeing as its Friday! We try and go to the gym regularly, luckily it is walking distance so we tend to manage at least 3 times a week.
Generally the variation month to month has been dependent on medical students. March was an overwhelming month as we had a large group of students, GP trainees and internal medicine trainees whilst Kate and I where trying to find our feet with how things are done. There was also loads of teaching that we delivered and attended. April was slightly different, we did not have many medical students which made it easier to get stuck into clinical work and get to know our colleagues in both hospitals better. In May we where lucky enough to travel to the North of Uganda to participate in some research, though I’ve already bored you with this in another post.
We have tried to make the most of being here and filled our weekends with adventures and activities. Being away in Uganda for a longer period has meant we have been able to build up a network of friends outside of work and have started to feel like we have managed to build a bit of a life here. Our colleagues have expressed how grateful they are for the extra woman-power but have also been keen for us to explore the Pearl of Africa and enjoy everything Uganda has to offer. I have just had some annual leave travelling around Uganda, and it truly was amazing. 3 days back at work now and it’s like I’ve never been away… though there is something comforting about a routine.
Our visiting doctor, Kate Howorth, who had been with us at Cairdeas for six months this year, shares some thoughts on a typical week while volunteering in Uganda. To hear more about our visiting doctors and their time in Uganda, visit the complete blogs at Kate Howorth and Kathleen Mcgeough.
I thought it would be a good idea to share a bit more about what day to day life looks like for me here. In the first few weeks, we were trying to gather as much information as possible about the team and it’s responsibilities, what tests and treatments were available, paperwork and the different training pathways for students and healthcare professionals, all while learning lots of names and avoiding getting lost! Two weeks in I was heard talking about what “normally” happens on a particular day and soon realised there may not always be as much of a predictable structure and schedule to the week as I was searching for, so keeping a level of flexibility to our days and weeks was going to be necessary. Having said that, I’ll try to share a flavour of the different things we’ve been involved in.
We are working as part of the Makerere Palliative Care Unit. This is a great Ugandan team including specialist palliative care nurses, a social worker, admin staff and some great volunteers. The team is supported by Mhoira and has two Ugandan doctors who have spent a number of years working in palliative care and help with the work for three days a week at the moment. Most of this team is very experienced having worked in the team for a long time and we have learnt a lot from working with them already. We work in two hospitals: Mulago and Kirrudu. These are both government-run hospitals and the referral centres for the country. Mulago also has the Ugandan Cancer Institute (UCI) on site so we visit there too. The team is a liaison service meaning we go and review hospital inpatients on the wards who are referred to us (which is often via word of mouth of Whatsapp!). The team is referred large numbers of patients and have been stretched in what they are able to do especially with the challenges of Covid, so we have bolstered numbers, been able to provide extra senior medical cover and hopefully free some of the nurses up to do other managerial, research and leadership tasks they have needed to.
Most of our days are spent on one of the hospital sites reviewing patients on the wards. Similar to the UK, we are referred any patients with life-limiting conditions who need our involvement to help manage complex physical symptoms (pain, nausea & vomiting, breathlessness), support with difficult communication issues or sharing bad news, provide psychological and social support, or family support. Different to the UK is the patients we are seeing. The age of our patients is much younger overall, we are seeing lots more infectious diseases like TB or complications of HIV, and many patients seek medical help much later so their disease is already more advanced. One of the reasons for this is the cost of healthcare, but I’ll discuss this more in another post. A particular challenge for me is that we see a lot of patients who are children here. I mostly look after adults at home, so this has meant me learning lots in terms of the different conditions children have here, how to prescribe medication safely, and supporting parents. Being in the country’s main referral hospitals means there are a lot of tests and resources available but still significantly less than in the UK particularly one that are affordable. It has been really hard caring for patients knowing the different care they would be able to access if I was caring for them back at home, particularly when this impacts on how well we are able to manage their symptoms or give them information about what is happening. It has once again made me grateful for the free healthcare accessible to all that we have in the UK and reminded me of the need to keep working towards affordable palliative care to be available worldwide.
Considering the size of the team, we do a lot of teaching which I’ve really enjoyed being part of. In our first week, we had 17 medical students and 4 junior doctors training in internal medicine or family medicine (equivalent to our GPs). It is much more common in Uganda to do big teaching ward rounds where a senior doctor takes a big crowd of students to see patients and grills them with questions standing round the patient’s bed. The first time I joined one of these to help see how this worked and contribute to the teaching made me realise that being 5 foot was going to be a significant disadvantage in this method – even on tiptoes I couldn’t see the patient we were discussing! I was surprised to see the patients and families don’t seem to mind either – it seems to be accepted as part of being in hospital and if anything, a sign that their case is being thoroughly looked at. I’ve also been doing some bedside teaching for postgraduate exams and we have weekly journal clubs and mini rounds, so there is lots to get stuck in to!
Finally, one of the other main focuses of my time here is helping to develop a Fellowship programme. I am 3/4s of my way through my specialist palliative care training in the UK but there is no equivalent training programme for doctors to specialise in palliative medicine in Sub-Saharan Africa. This means that despite the Ugandan doctors working in our team having a lot of experience, skills and knowledge in palliative care, this is not formally recognised or accredited. The team here with support from a number of UK colleagues have been wanting to set up a Fellowship programme for a while to facilitate this, so I am spending time reading curriculums, arranging meetings and making proposals to try to make this happen. Watch this space….
As you can see, work is busy, challenging and rewarding. But we are also getting lots of time to explore Uganda and meet people, but that sounds like something for a future blog post!
Hello! Allow me to introduce myself; my name is Hannah Ikong and I joined as the Education Programming Consultant in March. I have experience in both education and administration in Uganda, the UK, and the USA, and I am delighted to provide support to our most recent education programmes.
This year has been marked by growth in the educational programmes by Makerere Palliative Care Unit (MPCU) and Palliative care Education and Research Consortium (PcERC) in Kampala, Uganda. We have not only expanded our medical student resources and fellowship programme planning but have added a new member to the team. We currently are working on two projects to strengthen our educational goals in palliative care in Uganda: the MMed Family Medicine Expert Lectures and a Palliative Care Fellowship Programme in Sub-Saharan Africa (SSA).
The MMed Family Medicine Expert Lectures are a response to the learning needs of the Makerere University family medicine (general practitioner) students. Postgraduate students often have clinical instructional rotations in different specialities, including palliative care, at the end of their course. The most recent rotation during March 2022 spurred us to create an expert lecture series addressing the primary medicine approach to palliative care. Through the partnership of palliative care specialists around the globe, engaging 30-minute lectures were recorded, designed for group discussions and immediate application in clinical rounds. Topics surrounding complete healthcare worker participation and hospital-specific set up of palliative care and perspectives on palliative care in global, rural, and fragile settings were covered. The students were inspired to incorporate palliative care in their own daily practice. The expert lectures are now being organised and saved for future family medicine students.
While the expert lecture series is coming to an end, we are in the thick of building a Palliative Care Fellowship Programme, which will be the first of its kind in SSA. The Fellowship will begin in Uganda and then we hope branch to other countries under the ambit of the East, Central and Southern Africa College of Physicians (ECSACOP). The palliative care specialist training will be accredited through the Uganda Medical and Dental Partitioners Council and we are delighted to have partnerships to support this through Cairdeas IPCT, members of the Royal College of Physicians of Edinburgh and London and members of the Association for Palliative Medicine, UK. We are currently preparing the curriculum and developing the framework. This entails benchmarking other specialist curriculum in Uganda as well as international palliative care programmes. Over the next few weeks, we should finalize the structure and order of content, with the aim to prepare the curriculum for accreditation by September 2022. We must note and thank the ongoing collaboration of several palliative care specialists in and outside Uganda, including doctors Kate Howorth and Kathleen Mcgeough from the UK, volunteering with MPCU and the leadership from DR Elizabeth Namukaya, PcERC .
As we reflect on both the tasks accomplished and remaining, one word comes to mind: collaboration. Palliative care specialists across the globe have provided their expertise and time to create the MMed Family Medicine Expert Lectures, and others are continuing to support in the Fellowship’s curriculum creation and approval. We also have amazing support for the Department of Medicine and Family Medicine at Makerere. We are so grateful for the teamwork and passion being invested in palliative care education. We look forward to outcomes of improved clinical skills and research, and improved access to palliative care in communities around Uganda and beyond. We also invite further collaboration from those interested in the Palliative Care Fellowship Programme or other projects; for enquiries, please contact me, Hannah Ikong at firstname.lastname@example.org.