Ariana Hoffman, MD completed a four-week rotation in Dodoma, Tanzania. Ariana left for Africa on Saturday, May 5th and returned to Minneapolis on Friday, June 8th. Below are some of her reactions to her time spent abroad.
Prior to my trip, I was running around like crazy. I was finishing my Gynecologic Oncology block and the weekend prior to leaving for Dodoma I traveled to Austin, Texas for the ACOG 2018 National Meeting. I arrived back in Minneapolis on Monday and had an afternoon to run errands and pack for the trip, all while preparing my Gynecologic Oncology M&M to be presented the next day at Education Day. The rest of the week my stress levels were at an all-time high. I continued to prep for cases and clinic while running errands and packing for the trip. I sprayed all of my clothes with Permetherin to help avoid mosquito bites. Finally, by Friday night I was all packed, organized, and ready to go!
My journey to Dodoma was quite long. I was able to get a reasonably priced ticket, but that required an overnight stay in Doha, Qatar. I tried to make the most of it by doing some sightseeing with the few hours of daylight I had after my 24-hour journey from Minneapolis to Chicago to Qatar. I enjoyed views of the Persian Gulf and seeing artifacts housed at the Museum of Islamic Art. The next day I flew to Dar es Salaam, which was Monday afternoon. Because there are only Monday, Wednesday, and Friday flights on Air Tanzania between Dar and Dodoma I had one day and two nights to rest in Dar es Salaam. One of my co-residents suggested a hotel on the Indian Ocean and it did not disappoint. Although the day was relaxing, there was still some anxiety present until I would arrive at my final destination in Dodoma. When my gate was called to board at 0530 in Dar es Salaam we walked to the tarmac and it began to pour rain. Everyone getting on the flight was wet by the time they sat down. When we were above the clouds the sunrise was gorgeous. This will be a theme for all of my writing I suspect. Everywhere I’ve seen so far in Tanzania is incredibly beautiful.
Once I got my bag I met the resident coordinator, Rogers. He is the most kind and welcoming person I have ever met. I was riding to DCMC with one of the board members who had just arrived for Ministry of Health meetings at the capital. Dodoma is the functioning capital, but many people still live in Dar es Salaam and commute as needed to Dodoma.
Throughout my first day, I got settled in House number 8, my home for the next month, was taken to the market to buy groceries, and given an orientation and tour of the hospital. During the tour, I met many of the staff that I would be working within all the departments of the hospital.
I began working on Thursday. That day was spent in a combination of urgent cases and clinic which lasted until 2130. The next day we did 13 cases. And then on Saturday, we had another full day of clinic lasting until 1900. The three things I can say that have consistently been demonstrated by all of the members of the DCMC staff are their incredible ability to make a visitor feel welcome, their dedication to their patients, and their admirable work ethic. This was exemplified in their annual dinner party that I was invited to even though I had only been here a few short days. At the party, there were speeches, gift exchanges between ‘friend of the year’ whose identities are kept secret until tonight, and wonderful traditional Tanzanian food.
My first impression of DCMC and the community is very positive and I look forward to continuing to work and learn over the next month.
Wow. I cannot believe how quickly four weeks goes by. It feels like just yesterday I arrived in Tanzania. Right now I am in Dar es Salaam waiting for my next flights on my way home to Minnesota (Wednesday Dodoma to Dar es Salaam, Thursday Dar to Doha, Qatar, and Friday Qatar to Chicago to MSP). I have such conflicting emotions. I feel very excited to come home because I miss my husband, family, friends, and co-residents, but I also do not want to leave Africa. I am going to miss the people, my co-workers, and the atmosphere of the country in general. This has been such an amazing experience that it is hard to do it justice in just a few short paragraphs.
First I want to describe a little more about the types of patients I saw throughout my stay here. There is a huge range of patients that come from varying distances and socioeconomic classes. We saw a patient who lives in Dodoma and works for the government as well as a patient who work on farms and travel hours by bus from the remote villages to seek care. The overarching concern for the majority of the patients that we saw was regarding fertility. Even when we saw patients who were young, not married, and not actively attempting to become pregnant they still wanted reassurance about their fertility. We also saw many women with primary as well as secondary infertility.
The next topic I want to share is about the number of cesarean sections. Professor Majenge mentioned that the rate has been approaching 50%. This may seem extremely high, but I think there are a few factors at play that I did not immediately understand. The first is that many of these patients have had myomectomies due to infertility that then require a cesarean section for delivery. The next is that the monitoring during labor of the fetal heart rate is very minimal. The next is related to the importance of fertility and many patient’s prior struggles with infertility. The patients, as well as their doctors, feel that the risk of fetal distress in labor outweighs the risk of a cesarean section and will either do an elective cesarean section or have a very low threshold to call a cesarean section. The final factor I noted was the ability to urgently/emergently deliver a patient. If the OR staff and anesthesia team is in the hospital a cesarean section can happen quite quickly, within 30 minutes. If the OR staff and anesthesia are not present it would take at least an hour to have them arrive, prepare, and then start the cesarean section.
The work days at DCMC are very long. It was quite common to be there from 7 am to 8 or 10 pm. Professor Majenge was kind enough to allow me to miss a Friday and Saturday of the clinic so that I could visit Ruaha National Park. This was a bit intimidating because I was going all by myself. I took the bus from Dodoma to Iringa (4.5 hours) and then my safari camp guide picked me up from Iringa and we drove an additional 2.5 hours to the camp. The next day was my game drive and it was truly incredible to see the animals that I had only seen in small zoo cages out in their wild habitat. I thought this trip would just be a fun adventure to see animals, but that was not my only take away. I also was able to see and experience the journey that some patients take to get care at DCMC. We traveled extremely rough roads through tiny villages with mud huts and saw farmers harvesting rice in the fields. After this side trip, I had a better understanding of where some of our patients live and come from.
My final day at DCMC was an OR day with Professor Majenge. After our last case, the OR staff had a small party for me with soda, coffee, tea, and snacks. Their kindness and welcoming were never-ending. DCMC is a very special place and I truly hope I am able to come back sometime in the future. I would like to thank the administration of The University of Minnesota OBGYN Residency Department for making this rotation a reality. Thank you Lydia, Justin, and Pamela for your encouragement and tips for the trip. I do not know if I would have been brave enough to go on this adventure without your reassurance. And finally, I would like to thank all the staff at DCMC for their kindness, hospitality, and giving me the opportunity to learn with them. Asante sana!
Lydia Staples, MD, MPH completed a four-week rotation in Dodoma, Tanzania. Lydia left for Africa on Sunday, March 4th and returned to Minneapolis on Saturday, March 31st. Below are some of Lydia's reactions to her time spent abroad.
March 8th, 2018
I arrived a few days ago. I'm back in Dodoma after not having been here for over three years. What a difference time can make! This place has changed so much! When I left last there were around 20 beds, now there are over 50 beds and a brand new ward. There is still one operating room, of which a second is desperately needed, but the number of surgeries each week has increased from around 5-6 to now typically more than 30. There are several cesarean sections each day and multiple births. Last time I was lucky if I participated in one of the few births. There were near 40 employees when I left and now there are over 90. I did not recognize most when I toured the hospital for the first time, however of the employees that were there last time, the majority of them are still present at DCMC. This tells me a lot about the work environment of this place—many stay. It is a very welcoming environment and I typically see many of the employees joke and laugh all while working hard and long hours to provide above average care for patients in Tanzania.
The other positive part of this rotation was the very vibrant and active community health department that participated in various types of women’s health outreach in the villages.
The last thing that immediately stuck out to me while navigating my first few days in Tanzania was the language barrier. While I learned Swahili over the years, I have not used it in years. I forgot how many patients do not speak English and it was typically 1 in 10 that did speak English that I saw in clinic. On my second day in Dodoma, I joined Prof. Majinge for clinic. As I was still practicing my Swahili and remembered little about GYN Swahili, I asked him if I could have an interpreter. In his Prof Majinge sort-of-way, he smiled kindly and said, “You will learn.” That was not the response I wanted at the time, but I sat next to him at my desk while he saw patients at his desk and horribly stumbled through my first day in clinic learning how to take a complete history in Swahili. By Saturday in clinic, I improved significantly and only had to ask him to help translate a few things here and there.
March 31st, 2018
In clinic, you get to see so many different types of patients. In Professor Majinge's clinic we saw patients who were from high-ranking government offices or family members of those individuals and individuals who identified as 'kulima' which means villager or subsistence farmer.
There is also a wide range of medical concerns too. Patients have similar complaints to the patients that we see in the United States, but it can be fun to do the full scale of services yourself. I got to see patients in clinic, take them over to the ultrasound room to image them, then schedule for surgery, and then actually do the surgery myself. I had more continuity of care in my clinic in Dodoma where half my patients traveled over 20-30 miles to see me, than in my clinic at HCMC.
Pamela Mills, MD, MPH completed a 4-week rotation in Dodoma, Tanzania. Pamela left for Africa on Monday, November 28th and returned to Minneapolis on Saturday, December 24th. Below are some of Pamela's reactions to her time spent abroad.
Today was my first day working at DCMC. The schedule and style are very different than what I am accustomed to in the United States. The pace is more laid back and the schedule is much more fluid. We started the day at 0700 hours with a group devotion/signing service which is designed for staff and patients at DCMC. This is followed by a morning report where all of our patients are discussed. This is tricky to follow sometimes as it is mostly in Swahili with some English and rapid changes between the languages.
I went on rounds with one of the house officers. There were 10 patients and it took about 2 hours to see them all. Many of the discussions were in Swahili, so I read the patient charts while the officer spoke with the patients. Luckily all of the charts are in English!
Following rounds we had a break for tea and breakfast followed by seeing clinic patients with Dr. Majinge. There are a wide variety of clinic patients and there isn't really a labor and delivery triage like we have in the United States.
One thing I've found really nice is that patients sent to lab and ultrasound early in the day return later in the day to discuss results. It is really nice to have this continuity of care.
Our day wrapped up around 1800 hours. Tomorrow will be my first day operating. Typically patients arrive at the hospital a day prior to a major surgery in order to prepare.
The last few days have been pretty busy. Sunday was my day off and I spent it with some of the locals. Everyone here is so generous and not only did they have me over for a meal, they gave me a wrap and showed me how to wear it depending on the weather! They also gave me fabric to take to the tailor to have my own dress made. The fabrics are beautiful and I am so grateful for the kind gifts.
On Monday I had an 18+ hour day because I was called in for a c-section at 0430 hours. On this day, Dr. Majinge made an observation that really stuck with me. He noted that at DCMC you have to constantly plan ahead. When something happens and we need to call in the anesthesia team, it can take up to an hour for the DCMC driver to pick them up from their houses and have everyone in place for a procedure. It made me think that in the United States, we have people available at a moments notice, so we have the luxury of waiting and delaying procedures that you don't have while working in Africa. I appreciate this type of insight. Sometimes it is easy to just default to what you know in medicine, but context is key.
The DCMC team works so hard to see everyone that comes here. On Saturday, I was at clinic until nearly 2100 hours when the last patient was seen. In the first part of the day, we see patients and make a plan, similar to investigations in the United States. The patient then undergoes testing and returns later on that day to discuss the results and make additional plans. I really like the continuity, but combining that with paperwork all being handwritten and it makes for a long day. I asked one of the house officers about the schedule and essentially everyone just keeps seeing patients until there are no more patients to be seen. I am humbled by the dedication here and the patience/gratitude of the patients. There is never a complaint about waiting and schedules are very fluid, so some people wait all day to be seen.
The hard part about the work is the language barrier. I have an interpreter for part of the day which helps me see more patients, but Swahili is not the quickest language for me to pick up and I would say 70-80% of the patients I see do not speak enough English for me to see them independently. The other tricky part of the work is there is a very different practice style in Tanzania. I know how to treat and care for patients in the United States, but here I find myself asking a lot of questions. The standard treatments and medications used can be very different. There are some medications used that I have never heard of. I am feeling like a primary care physician at times and have learned a lot about pediatrics as well. Overall, the house officers are very kind and I appreciate how they treat their patients.
Today was the first full day in the operating room. We scheduled many of our cases just the day prior. I have had great learning experiences here, but it can be much more challenging than in the United States. I feel a little weird giving suggestions in the operating room about technique, but the officers seem really receptive when I do. They are happy to change suture and ask me what I prefer. My time in the operating room is great for learning and teaching. Everyone is taking really good care of me, making sure I eat and drink (bringing me food and drinks) and also trying to teach me Swahili. I try my best, but I am certain I have a notable American accent.
I am waiting to hear about a 6-day community trip to the villages that the community health team at DCMC is currently planning. We are just waiting for the funding to come in before we go. The hope is to go next week sometime. I will likely be away from the internet during that time, but will try to blog when I return.
Justin Boeke, MD completed a 5-week rotation in Dodoma, Tanzania. Justin left for Africa on Tuesday, September 6th and returned to Minneapolis on Tuesday, October 11th. Below are some of Justin's reactions to his time spent abroad.
Hello all, overall Tanzania has been great so far. This is one of the friendliest, most welcoming, and safest places I've ever been. Just walking down the street, I’ve experienced people willing to go out of their way to be helpful all the time.
Even though the hospital has been keeping me busy, and it feels somewhat like a normal rotation, I feel like I haven't been this relaxed in years. The first weekend I was here was a holiday, so I took the opportunity to travel south to visit Iringa and Ruaha, and see a little more of Tanzania. This trip was amazing. I was able to see tons of native wildlife including hippos, leopards, cheetahs, and rare African bird species.
DCMC itself is a bit of an anomaly. It is a small, but busy and relatively well funded and a very well run hospital. It predominantly serves a mix of poor and rural people, as well as some more economically secure families. This wealthier patient population is likely to expand as more of the government transitions to Dodoma. This is exciting as it would allow the hospital to provide more routine care in addition to emergent care. The hospital is fortunate to have an IM physician, a surgeon, and two gynecologists. The staff here is well trained, despite the diagnostic resources being very limited. Few labs are available and there’s no equipment to run cultures.
I visited a much larger nearby regional hospital which made DCMC look even more luxurious. The regional hospital has 3,000 deliveries per year (compared to about 400 here), yet no OBGYN or surgeon! The regional hospital lacks many basic medications, and is primarily funded by patient payments; many of whom are experiencing extreme poverty.
At DCMC, I have been operating frequently, mostly minor procedures and Cesareans, with a few laparotomies. There is staff in the room, but the cases are yours to do as you see fit and you have the opportunity to teach the medical officers at times. It is challenging to learn to operate with fewer instruments than I’m accustomed to. In addition to operating, I have been leading rounds with the medical officers, seeing patients in clinic, and performing ultrasounds. The language barrier can be a challenge in clinic, however, the patient's concerns are identical to what we see and know in the United States, and so the evaluations tend to run smoothly.
My experience has been generally positive and worthwhile. I even found a fetal heart tracing monitor in storage, hooked it up, and have been training the staff on it. The training of staff at DCMC is good, but I feel there is a lot of room for improvement, just like anywhere else. The medical officers present new patients to me once they've seen them which has provided a good opportunity for staff and I to discuss assessments and plans, and for me to do some teaching.
By the end of the trip, I am hoping to also do some formal teaching with the fetal well-being assessments, I am working with Professor Majinge on scheduling. It has taken a few days to get settled in and figure out my role, but I am now identifying many ways that I can be involved, gain experience working in a resource-poor setting, and have a significant impact on care and training in Tanzania.