International exposure for residents in clinical rotation

Partnership provides staffing, experience in Botswana

Residents in Botswana on clinical rotation

March 28, 2018

"Prepare to be unprepared!"

This is the advice from Kathy Wunderle, M.D., a third-year resident in internal medicine. In July 2017, she participated in OHSU's Global Health Scholars Program on a clinical rotation in Botswana.

The mission of the Global Health Scholars Program is to "provide a pathway of clinical and didactic experiences to develop physicians who will care for vulnerable, underserved communities with a view toward alleviating health disparities." As Associate Program Director Claire Zeigler, M.D. R '14, M.P.H., pointed out, "Residents make career choices based on what they're exposed to. Residents who are exposed to these communities will provide care to people who need it."

And so the scholars program, looking for opportunities to provide this exposure, found its answer in an email from Beth Israel Deaconess Medical Center, based in Boston, Mass., seeking a partner at the Scottish Livingstone Hospital in Botswana. Sima Desai, M.D. R '98, associate professor of medicine, OHSU School of Medicine, and internal medicine residency program director, saw the message and set the wheels in motion for OHSU to become a partner in 2014.

Coordinated efforts to ensure coverage

Residents from OHSU, Beth Israel Deaconess Medical Center and other institutions rotate through the hospital under faculty supervision in four-week increments, carefully coordinating efforts to provide a continuous presence focused on capacity building.

Botswana was facing a "brain drain," with its medical students seeking residencies and employment in other countries – whether to pursue better paying opportunities or simply because their personal lives took them elsewhere.

The presence of residency partners at Scottish Livingstone provides continuity of care and "helps teach and model clinical practices from the basis of how we train U.S. residents," said Dr. Zeigler, who is also assistant professor of medicine, OHSU School of Medicine.

OHSU has sent more than 35 residents to Scottish Livingstone so far. While the majority of residents have been in internal medicine, neurology and emergency medicine residents have also been on rotation. Obstetrics and gynecology is performing a site visit this year to explore involvement, and there is interest from fellows in infectious disease and cardiology.

Enhancing skills, avoiding burnout

"They try to orient us before we leave, and I spoke to residents who had gone, but I really think it's something that you can't quite prepare for until you're there and experiencing it yourself," said Dr. Wunderle. "I had heard that the hospital ran out of supplies and medications at times and didn't have the sort of imaging or diagnostic capabilities that we have here, but it doesn't really hit home until you're in the hospital and really want the immediate head CT or even STAT X-ray and you can't get it."

"It is an intellectually challenging experience – invigorating in a lot of ways – and it does influence career choices," said Dr. Zeigler. Residents participate in procedural learning as they immerse themselves in a different health care system. They have to be diagnosticians without relying on the tools they have in the U.S. There are fewer labs and imaging resources, and no access to specialists, therefore residents' "clinical reasoning skills are tested and improved."

Dr. Zeigler is continuing to explore how the global experience benefits residents, from impacts on career choice to reducing burnout and improving resilience. And so far, feedback from participants is overwhelmingly positive, she reports, with responses such as "reinvigorating," "life-changing" and "most valuable thing I did in residency."

Photo courtesy of Teena Xu. From left to right: Abe Aron, IM PGY-3 Beth Israel; Ritik Tiwari, IM PGY-3 UT San Antonio; Neha Patel, Global Health Fellow, Beth Israel; Teena Xu, IM PGY-3 OHSU; Jess Dreicer, IM PGY-3 OHSU; Ihsan Yassine, IM PGY-3 UT San Antonio; Nipps the dog, SLH mascot.