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Monday, August 19, 2013

Teaching ultrasound in Tanzania

I have just pretty much recovered from jet lag and my anti-malarial-drug-induced dysphoria (I will attest to the fact that Mefloquine does have side effects) and am excited to tell the story of a project that I got to be part of.

In mid-July I got on a plane and flew to Kilimanjaro airport in Tanzania with seven medical students from the University of California, Irvine. UC Irvine's medical school is small and encourages its students, after their first year of training, to do interesting projects in the summer, before returning to immerse themselves in massive absorption of data and passing of standardized tests. I met some of these students while doing my mini-bedside ultrasound fellowship, when I acted as preceptor to a group who staffs a regular rural health clinic in Mexico. A project to teach ultrasound in Tanzania was in the planning and not-quite-sure-if-it-would-happen stage, and I signed on, in a not-quite-sure-I-was-coming kind of way. Five months later I got off of a plane with medical students, took a very large and unreliable bus west to the shores of Lake Victoria and dismounted in Mwanza.

Tanzania is a mostly politically stable East African country with the worst doctor to patient ratio in the world. It provides for basic medical care of children, old people, pregnant ladies and patients with HIV and tuberculosis. Medical care outside of cities is very sparse, and in cities down to the bare bones of adequacy, or not quite. Into this setting we placed myself and seven medical students keen to teach ultrasound.

UC Irvine is on the leading edge of medical schools in teaching all students basic bedside ultrasound, first as a sort of living anatomy class and then gradually adding in understanding of pathology and diagnosis. All medical students become adept at using an ultrasound machine to visualize the human body, from the eyes to the internal organs to muscles, joints and bones. An emergency room physician and well-loved clinical teacher, Dr. Chris Fox, has been a champion of this cause and it is now well established as part of the curriculum. There are other medical schools which do this, but perhaps not as well as UC Irvine. It was there that I did my ultrasound mini-fellowship at the beginning of this year which has made me basically competent in bedside ultrasound. Teaching medical students was part of the fellowship and so I met some of them who decided that they wanted to go to Tanzania to teach people what they had learned about ultrasound in their first year.

This was an ambitious project, bound to fail on some level, and yet it didn't. It also seems to me that it is an example of exactly what we should be doing in the developing world. Its goal was to teach a technology which was appropriate for its target audience and provide materials so that the teaching could be ongoing after we left. The tricky parts involved developing a curriculum that could be learned by people of unknown educational capacity who were primarily Swahili speakers. They did get most of their post primary education in English, but not the English that we Americans speak. We also needed to make sure that ultrasound machines would be available to the students after we left and we had to find the students and a setting in which to teach.

Much of this ground work was done before I even joined the project. The students sent out e-mails to various contacts who had connection to medical education in Mwanza, the second largest city in Tanzania. Many were dead ends, but through a Nazarene preacher who had been a host to one of the students on a previous trip, we were introduced to a doctor and businessman who worked at several hospitals and also owned one. He had also, as part of a nongovernmental organization, recently opened a medical school for clinical officers, like a physician's assistant training program. In addition to providing access for the UC Irvine medical students to observe medical care in the city, he also provided us with students and a place to teach them.

I came in handy on several levels. The first was that I had just recently bought an ultrasound machine from China, in order to see what Chinese technology, which is much cheaper than U.S. technology, was like. I had thought that the machine should probably be donated to some place where it could serve patients, but since it was not FDA approved, that place was not going to be in the U.S. The students had been unable to convince anybody to donate a used U.S. ultrasound machine for their project, so clearly my machine had found its home. The students had done a huge amount of work developing the curriculum, but the power point presentations needed adjustment to our students' level of understanding, and my clinical input was helpful, both in the content of the lectures and in learning better how to do and teach actual hands-on ultrasound skills. It also turned out to be nice to have an actual medical doctor along to establish legitimacy.

The students gave four classes a week for 3 weeks, with two additional days for hands on practice and one day for examinations each week, a 7-day a week commitment. Each student learned and taught a specific subject area, determined what defined competence in that area and taught the other students to be teachers in the hands on part of each class. The classes started at 5:30 every evening and lasted 3 hours, with 1 hour of lecture followed by 2 hours of ultrasound practice. They expected to be teaching maybe 20 students, but ended up with about 140, which required having two sections to reduce crowding. UC Irvine and Dr. Fox allowed the students to bring five Sonosite Nano ultrasound machines with them, and with my Chinese machine, that made six learning stations. The remaining student and I acted either as models or floated to answer questions. Our students and friends also played model after some wheedling and cajoling.

Each UC Irvine student giving a lecture first delivered the lecture to the rest, with each word examined and critiqued. They then spent the day of their first lecture polishing their slides and practicing speaking much more slowly and clearly. The results were beautiful lectures, at a level the students could understand which covered the most important points. They skillfully incorporated repetition and simple questions for the audience to make sure that at least a good number of the students understood the material. The same material was presented again during the practical sessions.

With regard to our audience, there were excellent students and not so excellent students, but the majority of them became competent in the subject areas that they were taught. Some of our audience had MD and RN degrees and worked in the community. Most were students at the school for clinical officers. They all learned to ultrasound the heart, abdomen, lungs, pelvis, the shoulder and hand and learned the very basic physics of ultrasound. They learned to turn the machines on and off, change the transducers, adjust the various knobs to get the best pictures and to store patient information. They learned that the anatomy they saw in books was really, truly present inside real human bodies. They will never be afraid of ultrasound technology.

Our doctor host has bought ultrasound machines both for his classes and for a couple of the district health centers in Mwanza, which will be used by those of our students who practice in those centers and also by part time radiologists, if they are available. Although our brief course did not cover enough pathology to make the students capable of diagnosing diseases in all of their subtleties, the plan is to have a radiologist who works with our doctor host continue to teach. The ultrasound machines in the district health centers will primarily be used for basic obstetrics, identifying fetal hearts, measuring fetal heart rates, evaluating the position of the baby to identify high risk presentations. The MD students will improve at this with practice and will need to use local as well as online resources to develop competency.

In a year, barring mishap, we will go back and see what the project has unleashed, if anything. Our impression was that the Tanzanian students took to ultrasound like fish to water, and I suspect their abilities to use the technology to the advantage of their patients will progress faster than mine did. East Africa already uses ultrasound far more effectively than most of us do in the U.S., due to lack of other affordable technology, and it seems likely that our introductory class will feed into a knowledge base that is already becoming well-established in that area of the world. One of the directions that I think we should go before returning to Tanzania is to find out where the centers of excellence are in East Africa so that our piece can be incorporated into care improvements that will develop organically.

A question that arises in connection with this project and also with the increasing use of ultrasound at the bedside in the U.S., by non-radiologists, falls in the category of, "Is a little knowledge a dangerous thing?" Radiology technicians spend thousands of hours learning how to image the human body, and radiologists then interpret the images that the technicians record. Radiologists are MDs, with 4 years of medical school and often a rotating internship year prior to spending years in dark rooms peering at images of human anatomy in health and disease while being mentored by teaching radiologists in their residency programs. Cardiologists read echocardiograms obtained by echo technicians and look at these images with eyes that are informed by years of familiarity with the human heart. The three dimensional knowledge of anatomy that my colleagues the radiologists and radiology technicians have is truly inspiring. They are able to see things in images that I can't and interpret them in the light of years of experience. Still, when I can see inside a person with an ultrasound as part of my examination, that is extremely powerful, and improves my ability to make a diagnosis and to choose which official imaging tests will be most useful.

In Tanzania, the medical students, with only one year of training, were able to help the Tanzanian doctors identify a pregnant woman whose baby was in distress and a few women who, at term, had babies in the breach position, which were not identified on physical exam. These women did not have the advantage of a fully trained radiologist to evaluate their pregnancies, and the limited information we were able to give them was profoundly helpful. In the U.S. and Europe there is active research about how bedside ultrasound can be useful. A few studies have shown that it can diagnose small bowel obstruction when used by resident physicians in emergency medicine, with a few hours of training. Despite the difference in backgrounds, radiology residents were no better at it than ER residents.

Medical students with handheld ultrasounds were significantly better at making cardiac diagnoses than cardiologists with stethoscopes, in one study at the Cedars-Sinai School of medicine. Ultrasound is much more sensitive for pneumothorax than X-ray, which is the present standard of care, and requires very little training to perform accurately. There are lots of other examples.

My experience has been that it is very possible to miss important diagnoses with ultrasound as a beginner and to over-interpret findings, and that learning to be more accurate is a constant part of the process of using it as a tool. I think the little knowledge that the Tanzanian students got as part of our course will probably be very helpful, and more so if their training with ultrasound is ongoing and supervised by a radiologist at their school. Ultrasound is a natural extension of the physical exam in this setting and can cost nothing after the purchase of a machine. As more medical professionals become comfortable with the technology, they will be likely to use an ultrasound for answers to clinical questions, just as they might pick up an otoscope to look in an ear, or a pair of glasses to more accurately see a skin lesion. This will never replace the skill of an official radiologist, but in most of Tanzania these are few and far between.

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.

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Anonymous Sharri Gouzy said...

My goodness, the things we take for granted in the western world. Ultrasound has been a standard procedure in the U.S. since the mid-1970's. Since about the same time VCRs came about.

December 30, 2013 at 7:54 PM  

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Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

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Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

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Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

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