Shifting Forms

What is it about teaching that is so irresistible?
One of the reasons I was recruited to the Lubutu project is that I have experience with teaching medical professionals. When I lived in New Orleans, I taught pediatric residents from Tulane University. I found the experience rewarding but exhausting. The fatigue was primarily my fault, as I taught a one month course over and over. By the time I got good and burned out, I had taught the same two dozen lessons about sixty times. Not smart.
I took a few years off from teaching but was eventually ready to dive back in. In 2007 I taught a one month course in pediatric neurology at Queen Elizabeth Central Hospital in Blantyre, Malawi. I took my old Tulane lesson plans and changed them to fit the context. With the topic of Acute Flaccid Paralysis, I added a large section on polio, something not needed when I discussed the topic in New Orleans. Malawi was my introduction to tropical medicine. Photo below, Doug with residents in Malawi in 2007.

When I sent my resumé to MSF, I emphasized my teaching experiences. The recruiter told me that this was one reason I was placed in Lubutu. There is a log of formation going on here. Formation (fohr-mah-syohn, accent on the final syllable) can be loosely translated as "teaching" but involves much more. It means to mold or form someone into someone else by imparting knowledge.
The goal of many non-governmental organization projects is to teach local (in this case, Congolese) staff. In Lubutu we are teaching them the work necessary to run both primary care (the Centres de Santé) and referral health facilities (the hospital). We do this through a series of formations and working side by side. I have three main targets of my teaching- the Consultants, a mid-wife, and a supervisor-trainee.
The Consultants have attended a four year course in the diagnosis and treatment of disease. There are six of them- two at Mungele and four at Kalibatete.
When my ex-pat predecessor was here, only Mungele was open, so he concentrated all his efforts there. In general, the results have been good. The Mungele Consultants are both intelligent and can follow the MSF primary care protocols.
At Kalibatete, three of the four consultants are ex-hospital employees. They have worked for MSF for years. I enjoy spending time with the three of them. We share interesting cases and discuss treatment options. They have all the protocols memorized. The fourth consultant was recruited from outside the MSF system. She worked for many years in government-run Centres de Santé before getting the job with MSF in Lubutu.

When I arrived, Soki(photo:above) was challenging. Her book knowledge was excellent. When I asked her the signs of tuberculosis, she could recite all eight. But she was terribly disorganized. In English-speaking medicine, we write SOAP notes. This stands for Subjective (what the patient tells you, the history), Objective (the physical exam and any laboratory tests), Assessment (the differential diagnosis- what are the possibilities here?) and Plan (therapy, including prescriptions). One learns to write SOAP notes early in medical school. Soki never learned this organization. Her physical exam skills were excellent in some areas (abdomen, pelvic exam) and poor in others. Her biggest challenge was thinking about the history and physical examination together and coming up with possible diagnoses. Initially , diagnosis and treatment were reflexive. Patients who complained of pain in the upper abdomen immediately received a prescription for antacids. No further questions ("what makes it worse?") and no physical exam. Chief complaint led to prescription.
I have spent dozens of hours working with Soki and she has dramatically improved. Patients now get a complete history and physical examination. She can follow the protocols we use in the Centres de Santé—everything from a cold to measles to whopping cough. She knows when she is beyond her limits of knowledge and needs help some someone with more experience.

Aside from the six Consultants, I also teach Kenimbe, the mid-wife at Mungele(photo). My predecessor in this position made sure that Kenimbe received lots of instruction in the MSF systems of prenatal and postnatal care as well as childbirth. Kenimbe is thrilled to have an ambulance to summon in case of a difficult delivery. Most of my formation with Kenimbe has been on family planning and care of pregnant women.
Of all the formations with which I am charged that of my assistant, the supervisor-trainee, has been the least successful. Part of this is structural. There are two Centres de Santé for the two of us to supervise. We are rarely in the same physical space. Joseph is being groomed to take my position when I leave. We have a lot of work to do.
Today, a new phase of my formation of the staff began. Every other week I am doing formal presentations on a selected clinical topic. This week schistosomiasis, next is family planning, after that typhoid fever. Preparing the lectures is a huge amount of work. I have to make a PowerPoint presentation (printed out as there is no electricity at the Centres de Santé), handouts, and a pre-test and post-test. Three weeks ago I sent all of this off to Kinshasa for approval, received their suggestions two days ago(!), and did the first presentation today. It went great. As usual, part was through I ran into a verbal wall. I did not know the verb "to hatch." We had a momentary diversion while I described chicks leaving eggs. I was rewarded with "éclore", the answer to my word search.
The educational level of my audience was a change for me. In the past I have usually taught physicians. The original PowerPoint presentation I created was inappropriately technical. Fortunately, the people in Kinshasa reformatted my slides. They added graphics and eliminated some complex wording. All the participants succeeded, with scores on the post-test perfect or nearly so. Afterwards we had a long discussion about schistosomiasis and public health, out of the boundaries of the lecture. They learned and then thought about the implications of this new information for their patients.
So why do I think that teaching is wonderful? Personally I love the moment when a student has an imaginary light bulb illuminated above their head. They've had information crammed into their brain. At an AH HA! moment it all comes together. They can think.