Just as background information, in Uganda, to become a doctor resembles the European system where you can apply to medical school after high school. Their medical school is considered undergraduate level and after completion of a five year program, will earn a Bachelor of Medicine and Bachelor of Surgery (MBChB). Then they start their internship which lasts one year and are then able to practice medicine independently as a “Chief Medical Officer”. Alternatively, graduates can pursue postgraduate training to specialize and earn a Master of Medicine (MMed) similar to our residency training. In regards to payment, very few utilize health insurance, and the large majority (98% of Ugandans); source was potentially questionable but it was the first site to spit out a number!) pay out of pocket.
During my first week, I got a little taste of inpatient and outpatient medicine. My first day, I worked with Dr. Timothy who completed training in internal medicine. We saw patients in clinic that were all pretty similar to what I would see back in the US. We saw some diabetes, hypothyroidism, hypertension and heart failure management. I’d like to spend some time just sharing my thoughts on one visit which was for hypothyroidism. She supposedly had a large goiter that had some airway compromise and was surgically removed, subsequently developing symptoms of hypothyroidism and then put on thyroid replacement therapy. The patient begins by making payment for the visit. Now every visit was conducted in Lugandan and I could comprehend nothing, but I was able to review chart notes which were all written in English and Dr. Timothy would graciously discuss his findings with me intermittently during the visit. In Kiwoko, this is a limited-resource medical setting and so there are many barriers for patients to receive optimal medical care. It quickly became very apparent how spoiled it was to practice medicine back in Bremerton.
As background, managing hypothyroidism is fairly straightforward, you place the patient on a dose of thyroid hormone based on their weight and make adjustments to the dose based on their thyroid-stimulating hormone (TSH) level. It is much more challenging to do manage this here. Ordering a thyroid function test had to be done in Kampala which is about 50 km (~30 mi) away. Now this may not sound terrible,but the roads leading into Kiwoko are pothole-laden, dirt roads. In my experience, a trip from Kampala to Kiwoko takes about 2-3 hours. People generally do not own cars and travel by taxi or “boda-boda” (motorcycle). And when I say “taxi”, Ijust want to make it clear that these aren’t the luxurious yellow sedans with a single passenger, this is a van that squeezes 10-15 passengers and makes stops on the way. There’s no Uber or Lyft that will come to you at the press of a button. So, whereas in the states, I would recheck thyroid labs fairly often, this not as routinely done here due to inconvenience.
Now what if the thyroid test was slightly abnormal? Typically we type in another dose of medication (typically in increments of 12.5 – 25 mcg) into our electronic medical record and our pharmacy will take care of the rest. Here, they only carry 100 mcg tablets and so as you can imagine, it can be very challenging to make small adjustments. Her most recent TSH levels had been elevated, indicating inadequate thyroid replacement and this patient should have an increased dose. Our solution for this patient was having her cut a pill in half and taking 150 mcg daily. Another alternative plan was to take this new dose only 5 or 6 days of the week for a lower effective dosing increase. At the end of the visit, the doctor will write out a prescription and then the patient will walk it over to the nearby pharmacy to fill it. The doctor then scribbles some notes down into the paper chart which the patient will keep and is expected to bring this to every visit. (If only our patients could be that responsible!)
But generally, I was impressed with the medical practice here in the outpatient setting. It was more sophisticated than I thought it would be. There were still several things that I would have approached differently back in the States that I’ll write about later, but having a better understanding of how life worked in this specific area helped put me at ease.