Can you tell us a little bit about yourself?
My name is Dr. Peter Smith from York, England and I have just returned from my 8th visit to the FIMRC site in Bududa District, Eastern Uganda. Like many physicians, I have always wanted to work in the developing world but found difficulty in finding work where my skills could complement and add to a situation. When I decided to travel to the developing world I was concerned about working within my capabilities and I contacted numerous NGOs. Surprisingly, few were able to reassure me sufficiently. When I contacted FIMRC I actually expressed an interest in their project in India, however they took a very careful note of my CV and suggested Uganda!
The clinic in Bushika is what we call in England a primary care clinic so family medicine is the order of the day. I have spent all my career as a General Practitioner in the UK and when I arrived at Project Bumwalukani (now Bududa) 4 years ago, I immediately felt that I had something to offer. The clinic had always been run by nurse practitioners who are eager to learn from US/UK physicians, PAs etc. Many medical students visit and they have great skills to offer but an experienced primary care physician has much more, and not enough visit this clinic which is now housed in a beautiful brand new medical facility.
How did your relationship with fimrc evolve?
I set off on my first trip with a mixture of excitement and apprehension but from day one of my first visit, I realised that this clinic was well managed and had the potential to achieve great things in an area where infant mortality was needlessly high due to treatable diseases. So what started off as a one off visit has carried on because of a number of factors.
Firstly FIMRC is a very professional, committed organisation and staff are not afraid to push the boundaries. Working with successive managers, we have been encouraged to pass on skills to staff, and I have been so impressed at the professional attitude of the team as well as the professional respect that we receive when we parachute in and out each time. The most rewarding aspect is that when we return most of what we suggest has been carried out and retained by everyone! Staff in this clinic also have great respect for each other and are not afraid to say “ I dont know, “ which is so important and often lacking in clinical situations. All of this makes me want to come back again and again.
how is the fimrc clinic set up?
Stations are a way of the patient passing through a clinic in an orderly fashion. Each station has its own computer and they are on a network together.
Station 1- Registration and check-in
Station 2- Observations or vitals (Weight, height, temperature, BP and mid-upper arm circumference are measured where appropriate.)
Station 3- Clinicians room or consultations (Where details of the clinical condition as clinicians notes, prescription and diagnoses are entered and coded.)
Station 4- Pharmacy (Where the pharmacist looks at what is prescribed and the drugs are dispensed.)
Station 5- Review of the consultation (where a health worker checks that the patient understands all that the clinician has said and that he or she knows how to take their medicine. Very important in communities of high illiteracy.)
what does your typical day look like?
A typical day will be sitting in with Station 3 where the nurses see patients; there are often 90 per day so you are never bored. I sit in and watch consultations and advise on examination. Our philosophy is to pass on knowledge not to be doing the work on our own which adds little. The staff have a very professional approach and I never feel that I am intimidating when I offer advice. Conversely I learn from them as they can diagnose malaria and other conditions much more effectively than me. They also understand the cultural attitudes of patients much better than me.
I will also spend time in the lab, Station 2, where observations are taken and Station 4, the pharmacy. Each day I return feeling that I have made a difference, often by giving simple advice. I also offer CPD talks after the patients have been seen which helps my understanding of people’s knowledge base. Recent topics included infection control, the importance of accurate measuring and discussions about appropriate prescribing. We have created a culture in this clinic that not all patients need medicines and staff are very good at safety netting patients now so they are given a time after which they should return if they're not better. This level of consultation is rare in Africa
The job is never done and we are working on simple clinical governance, such as keeping sharps boxes off the floor, along with the start of a staff handbook and the concept of empowering staff to have ownership of this. All these practices seem to be basic practices in our world, but are new concepts and greatly impact the efficiency and effectiveness of the FIMRC clinic.
what are some unique diagnoses you see in the field?
We have 200 diagnoses to chose from on the computer. These are coded by clinicians so we can search on any one of them and measure prevalence over time. Important diagnoses with high rates that are responsible for most of the infant mortality in Africa are malaria, pneumonia and diarrhea . We also diagnose many cases of viral cough, skin infections, ENT conditions, eye conditions, urinary tract infections, sexually transmitted diseases and gastrointestinal conditions to name but a few!
could you explain the database?
Project Bududa has 29,000 patients on an electronic medical records (EMR) database. Every station has a computer which enables chronological clinical records, pharmacy history and there are over 200 WHO coded diseases with a reporting system enabling you to study disease prevalence along with geographical prevalence. I should add that this is one of the few clinics in Africa with an EMR. You can find out more at https://www.emr4dw.org/.
FIMRC now uses our EMR system in Costa Rica and Nicaragua as well (the Dominincan Republic soon to be added), and we now have 40,000 patients in the databases; I suspect that this alone will give me and my charity a lifetime commitment! This is another example of FIMRCs vision.
what have you enjoyed most about working with FIMRC?
Two of us physicians, Dr. Bill Tams and I, visit quite regularly from the UK, and another colleague just made her first visit to Project Bududa recently. This clinic has so much potential and is blessed with some amazing staff, but would also benefit from additional clinical input. It would be so wonderful to team up with other like minded experienced clinicians- even 4 weeks can make a real difference! The experience of working with such wonderful people in a beautiful, safe part of Africa is a privilege. If anyone wants to know more, please feel free to contact me via FIMRC, I am more than happy to share additional details and advice on establishing a long-term relationship with FIMRC and its project sites.