Global Health Electives & Rotations

This course is a four-week clinical elective at the Nicaragua Medical Center in El-Viejo, Nicaragua sponsored by OneWorld Health. The course will involve Monday through Friday clinical shifts of 8 hours (9 am-5 pm) in the outpatient, urgent care, and emergency medicine settings in El-Viejo, Nicaragua, as well as the Emergency Department of the University Medical Center in Leon, Nicaragua. Students will also have the opportunity to shadow physicians in Chinandega, Nicaragua. http://academicdepartments.musc.edu/com/education/UME/yr4/Catalog_Year4/courses/MDCOR846.pdf

The course consists of 18 eight-hour shifts at the One World Health Masindi-Kitara Medical Center (MKMC) in Masindi, Uganda. During each shift, the student will interact with patients and learn how to perform a focused H&P. The student will focus on how to order appropriate diagnostic tests and formulate a differential diagnosis while focusing on the many limitations of medical care in the developing world. The student will work closely with the attending on duty and learn how to treat and manage many various illnesses and injuries including tropical diseases. The MKMC Medical Center in Uganda operates 24 hours a day, 7 days a week and sees over 2,000 patients a month on average. The student will have the opportunity to work in Emergency and Urgent care, inpatient care, outpatient clinical care, OB/GYN care, and surgical care. Furthermore, the student will have the opportunity to participate in laboratory diagnostics as well as ultrasound performance and interpretation. If the rotation falls during one of four PMI short-term mission teams to Uganda, the student will have the opportunity to join the team in remote mobile clinic locations. For more information, http://academicdepartments.musc.edu/com/education/UME/yr4/Catalog_Year4/...

Course Description
This course is a four-week clinical elective in Dar es Salaam, Tanzania and designed for fourth-year medical students with a genuine interest in global health and in caring for underserved populations.  This rotation will expose the student to 1) medical care at a national hospital (Muhimbili National Hospital) in a developing country which has recently invested in an advanced cardiac center and 2) participation in a rural outreach clinic where MUSC and Muhimbili University of Health and Allied Sciences (the national university) have an active, NIH-funded field research site focused on large-scale community-based prevention and care programs, including integration of screening for non-communicable diseases such as diabetes and hypertension with HIV testing, coupled-based HIV treatment, HIV pre-exposure prophylaxis for HIV-uninfected clients coupled with HIV-infected partners, home-based monitoring for diabetes and hypertension, development of a low-cost locally produced glucometer, studies of the prevalence and predictors of non-communicable diseases (diabetes, hypertension, CKD), tailored counseling and testing for HIV based on risk profile, home-based HIV self-testing, and an incentive-based program to encourage sexual partners of HIV-infected and high risk patients to seek HIV testing. 

The primary focus will be on teaching the student to rely on clinical skills and judgment in addition to technology available in that setting. Students will participate in all aspects of care of medical patients at Muhimbili National Hospital. This will include daily inpatient ward rounds, outpatient clinics, ICU, and emergency room management of medical patients.  There will be hospital-wide didactic teaching sessions involving attendings and students, didactic conferences, case presentations and interactive sessions with attendings.  Students will be exposed to a wide spectrum of heart diseases in addition to problems not commonly seen in the US such as malaria, typhoid and rheumatic heart disease.

Maximum number of students per block:  2
Block 8:  February 1 - 26, 2016

Learning Goals and Objectives:
Patient Care
·         Teach students to gather accurate and essential information in a system without modern technological equipment and use that information to provide best possible care
·         Teach students to diagnose and manage illnesses which are common worldwide but that are rare in the U.S
·         Assist with diagnostic evaluation and provision of care to patients on the MNH medical ward under the supervision of attending physicians.
·         Participate in the diagnosis and treatment of a wide spectrum of heart diseases and other prevalent health conditions.

Medical Knowledge
·         Teach students about diseases in low-income countries and enhance students’ ability to integrate and apply their basic and clinical science knowledge to these diseases
·         Examine the role of community-based interventions in providing health care in rural communities with relatively limited resources  to ensure proper treatment in patients with chronic health issues
·         Expand medical knowledge of heart disease and treatment in poor socioeconomic conditions by assisting with histories, physicals and assessments (rheumatic heart disease, etc)

Practice-Based Learning
·         Expose students to local patient population, helping them to observe how local health practices and local culture and beliefs affect the patient.
·         Gain insight into health care disparities and social determinants of health
·         Demonstrate the ability to adapt clinical skills and practice in a resource-constrained environment

Interpersonal and Communications Skills
·         Expose the student to the challenges of cross-cultural communication in a multilingual context
·         Exemplify an awareness of and respect for cultural differences unique to their experience and self-evaluate during difficult interactions
·         Demonstrate sensitivity and openly discuss ethical decision-making in treatment of patients as well as in teaching situations

Professionalism
·         Expose the students to the ethical dilemmas posed in an developing country hospital such as limited resources, needs of poor patients
·         Demonstrate humility, flexibility, professionalism, and cultural sensitivity when working within a different healthcare context.
·         Demonstrate an understanding of cultural and ethical issues working with underserved populations

Systems-based Practice
·         Expose students to various health care systems available in Tanzania and how this hospital fits into that system
·         Identify barriers to health and health care in low-resource settings
·         Develop an understanding of the need for feasible interventions targeted to the local health system realities that maximize positive health outcomes at a low cost
·         Gain an appreciation of the need for continuity of interventions at the community-level, and the risks and perils of sporadic provision of services in low-income settings

Instructional Methodologies and Rotation Activities
Students on this rotation will be expected to learn and achieve the educational goals and objectives through the following methodologies and activities:
1.       Participating in daily rounds and conferences on the Cardiology services of the Muhimbili National Hospital
2.       Participating in the evaluation and management of patients undergoing routine and advanced cardiac procedures and the evaluation and care of patients presenting to the Emergency Department at Muhimbili National Hospital
3.       Participation in a rural outreach clinic where MUSC and Muhimbili University of Health and Allied Sciences (MUHAS) have an active, rural field site focused on large-scale community-based programs addressing HIV testing, linkage and retention to care, couples-based interventions, and non-communicable diseases.  Students will participate in the diagnosis, education and management of patients.
4.       Students will be expected to spend one day in the MUSC Ashley River Tower Heart And Vascular Center prior to departure in order to observe advanced cardiac procedures in the US to gain an understanding of the differences in health care systems.

Patient Encounters
Students will be expected to work up patients with a wide spectrum of heart disease and heart-related diseases, as well as chronic communicable diseases common to the area (TB, Malaria, HIV/AIDS), and non-communicable diseases such as diabetes and hypertension

Evaluation/Feedback Methods:
1.       Exit interviews with MUSC supervising faculty upon return to the US  (MK, PC, PR, CS, SL, PL)
2.       E*Value Clinical Performance Evaluation conducted by supervising faculty at Muhimbili (MK, PC, PR, CS, SL, PL)
3.       Presentation and discussion of patients with the consult attending (MK, PR, CS, PL, SL)
4.       Direct observation of clinical patient care skills verbally evaluated by the attending physician. (PC, PR, CS, MK)
5.       Student will be required to present a 45-minute case-based presentation from a clinical experience seen at MNH or field site.  Students will meet with Course Director to discuss case details and presentation forum.   (MK, PC, PR, CS, SL, PL)

Instructors/Staff:
Faculty and staff may change depending on Attending Rotation Schedule and assignments
Course Coordinator: Karen Turpin

Faculty:
·         Eric Powers, MD:  Course Director
·         Peter Zwerner, MD
·         Mohamed Janabi, MD (Dr. Janabi is the Chair of Cardiovascular Medicine at Muhimbili National Hospital and an adjunct faculty member in the College of Medicine at MUSC.)
·         Others:  TBD

Additional Information:

1.       This course requires the following:
a.       Approval by the COM Associate Dean for Curriculum - Clinical Sciences and the COM Selectives and Electives Committee.  Permission to participate in this elective may be denied or revoked after original permission is granted if for any reason concerns arise regarding safety or quality of the educational experience.
b.       Coordination of travel with the MUSC Center for Global Health and adherence to the MUSC International Travel Policy and restrictions, which includes

                                                   i.      Registration of travel with International SOS, the university international travel assistance provider
                                                 ii.      Completed Health and Safety Plan
                                               iii.      Completed International Travel Waiver

c.       Vaccines are required for travel into Tanzania; please see the CDC website on travelers’ health and/or visit the MUSC Travel Medicine Clinic for more details
2.       Scholarship money may be available to cover costs associated with this elective, please contact Kathleen Ellis in the Center for Global Health at ellisk@musc.edu for details.

Location:  Muhimbili National Hospital (MNH), Dar es Salaam, Tanzania

Tanzania is home to one of MUSC’s established global health partnerships for research, training, and education. Over the last two decades, MUSC has established strong partnerships with colleagues in Tanzania to develop and implement research and clinical programs to address HIV/AIDS prevention and care, and scaling up the prevention and treatment of non-communicable diseases such as heart disease, chronic kidney disease, hypertension and diabetes.  

MUSC has an active collaboration with Muhimbili National Hospital (MNH) the national referral hospital and the teaching hospital for Muhimbili University of Health and Allied Sciences (MUHAS), the oldest and largest university in Dar es Salaam, Tanzania.  MNH is a 1500-bed facility, with 1,000 to 1,200 outpatients encounters per week and admitting 1,000 to 1,200 inpatients per day.  MNH has 300 doctors and specialists and 900 registered & enrolled nurses.

Dar es Salaam, with approximately 4 million inhabitants, is the economic center of Tanzania (about 49 millions inhabitants). The United Republic of Tanzania is situated on the East Coast of Africa, south of Kenya and north of Mozambique. According to the World Bank, the GDP for Tanzania was among the lowest worldwide (744 international dollars – purchasing power parity- in 2006) and total health expenditure amounted to only US$ 11.3 per capita per year

Tanzania has a high burden of communicable diseases such as HIV/AIDS and malaria. At the same time, chronic non-communicable diseases such as cardiovascular diseases are becoming more common and are projected to be the highest contributors to disease burden in Africa by 2030.  The effects of increasing risk factors, including unhealthy lifestyles, have led to rapid increase of diabetes mellitus, hypertension, and ischaemic heart diseases. Increased use of Highly-Active Antiretrovirals (HAART) is also contributing to an increase in non-communicable diseases.

Recognizing that cardiovascular disease is a national concern, the Government of Tanzania committed to opening the country’s first advanced cardiac center at MNH, which includes a 96-bed facility equipped for procedures and diagnostic heart catheterizations.