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Elective Report by Matthew Cox For my elective, I travelled to Kiwoko Hospital, a missionary hospital in rural Uganda for seven weeks. My objective was to experience a variety of specialties from the perspective of a charitable hospital in a tropical environment, both to develop and expand my clinical skills and to see if this setting is one which I would like to consider working in more long term post-qualification. My initial plan was to spend roughly a week in each of surgery, male medicine, female medicine, paediatrics, obstetrics and gynaecology and community medicine. However, due to staff shortages, my plans had to be modified such that I spent four weeks on paediatrics to provide some continuity of care during changeover of staff, one week on male medicine, two weeks on O&G and a couple of days on community medicine. Whilst this did limit my exposure to other specialities, it did mean that I was able to play a more productive in those I did, particularly paediatrics. During my time on paediatrics, I had the opportunity to see the presentation and management of a variety of tropical – and more ‘normal’ – diseases and – with appropriate supervision – take the lead in caring for half the ward. Given the complex nature of some of the cases and the very limited availability of investigations and treatments available, this presented significant problem solving tasks and made good use of Pathology teaching in order to find ways around the limited resources! My time on paediatrics allowed me to hone my history taking skills and allowed me to get involved with several resus situations and in the care of critically ill patients. On reflection, some of what I was asked to do whilst doing paediatrics exceeded my capabilities, but given the severely limited nature of healthcare provision in countries like Uganda, such situations are likely to unavoidable. Thankfully for the vast majority of this placement I did have appropriate supervision, but I know the doctors supervising me often felt – and indeed, were – out of their depth and they had only limited help to call on when needed. Working on male medical ward was another opportunity to get involved with complex medical conditions – mostly related to advanced HIV infection – and to work alongside a variety of specialist nurses and physiotherapists. Whilst there, we faced a number of ethical dilemmas – mostly relating to management of HIV related psychosis in a country where there is little, bordering on no, psychiatric services. Differing views on the ethics of treatment options arose which focused around physical/chemical restraint. This created opportunities to get involved with presenting the patient to the hospital staff and participating in ethics discussions and decision making. My time on maternity served as a good reminder of both the practical and theoretical aspects of the O&G teaching I’d received previously. It also gave me much greater scope to get involved in a variety of surgical and other hands on procedures including both elective and emergency operations and neonatal resus of which we had little opportunity to experience in the UK. During this placement the importance of cultural awareness was particularly driven home, particularly attitudes towards pain relief (both during normal birth and C.S.) and towards the community aspect of Ugandan culture. Particularly striking was how women often needed to seek permission for treatment from either their family of village elders. Initially this was alarming, but on investigation turned out to be a result of the women relying on family and/or their entire village to scrape together enough money for even basic (heavily subsidised) treatment due to the extreme poverty. In summary, I think I met my learning objectives – to experience a variety of specialities in the setting of a charitable hospital in the tropics. My final timetable resulted in a slightly less varied exposure than planned, but allowed me to get much more involved in the care of patients and gave me opportunities to safely take the lead in the care of some patients. It also gave me some experiences I wasn’t expecting, but which on reflection are a much more common part of tropical medicine than I’d anticipated. Whilst such dilemmas are thankfully less common in the UK, hopefully the experiences I received in Uganda will be of use should analogous situations arise in the future. Probably the most memorable event occurred on my second day on the paediatric ward. A very young, very sick child we had admitted earlier that day went into respiratory arrest unnoticed and rapidly progressed to cardiac arrest. Despite our best efforts, we were unable to resuscitate the child. At the time I was angry that no-one, including myself, had noticed the child deterioration in time and felt helpless at my/our inability to do anything to change the final outcome. Sadly this was the first in a string of 10 deaths during my first 2 weeks on paediatrics. This really brought home the limitations of what we as doctors – or indeed, enthusiastic young

elective students – can do. We can – and should – rightly do all we can to alleviate suffering, but it is easy to become blind to how limited our efforts are and how vast the problem. It is easy to think medicine has far more power to solve the world’s problems than it evidently does, this is sometimes apparent in the UK, but in Uganda, this truth is hammered home almost every day. This is not a nice or an easy truth to swallow, but I think once we have accepted that medicine is much more limited in what it can currently do than we, let alone patients, would like or expect, then we might be more realistic in our targets and our expectations. Throughout the trip I was made to feel very welcome by both the staff and patients at Kiwoko. Living with other students in the missionary compound was a gentle introduction to a very different culture and provided a really good support network which was needed after difficult days on the wards – as well as companions on our various weekend excursions. I would highly recommend Kiwoko to any student (or indeed doctor) who is looking for experience in tropical medicine or who is considering missionary work in the future. As a result of my experiences on my elective I think it likely that I will return to Kiwoko, or a similar hospital, in the future to serve as and where needed. Thanks to The Medical Elective Fund at Selwyn College, Addenbrooke’s Abroad and the Rhodri Wilson Memorial fund for their kind support.

Medical Elective Report: Matthew Cox  
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