Survey of surgical training and experience of associate clinicians compared with medical officers to understand task-shifting in a low-income country.

Background: A workforce crisis exists in global surgery. One solution is task-shifting, the delegation of surgical tasks to non-physician clinicians or associate clinicians (ACs). Although several studies have shown that ACs have similar postoperative outcomes compared with physicians, little is known about their surgical training. This study aimed to characterize the surgical training and experience of ACs compared with medical officers (MOs) in Tanzania. Methods: All surgical care providers in Pwani Region, Tanzania, were surveyed. Participants reported demographic data, years of training, and procedures assisted and performed during training. They answered open-ended questions about training and post-training surgical experience. The median number of training cases for commonly performed procedures was compared by cadre using Wilcoxon rank sum and Student's t tests. The researchers performed modified content analysis of participants' answers to open-ended questions on training needs and experiences. Results: A total of 21 ACs and 12 MOs participated. ACs reported higher exposure than MOs to similar procedures before their first independent operation (median 40 versus 17 cases respectively; P = 0·031). There was no difference between ACs and MOs in total training surgical volume across common procedures (median 150 versus 171 cases; P = 0·995). Both groups reflected similarly upon their training. Each cadre relied on the other for support and teaching, but noted insufficient specialist supervision during training and independent practice. Conclusions: ACs report similar training and operative experience compared with their physician colleagues in Tanzania.

Antecedentes: La falta de cirujanos en determinadas áreas geográficas es flagrante. Una posible solución es el intercambio de tareas, es decir, la delegación de tareas quirúrgicas en personal sanitario no médico o en clínicos asociados (associate clinicians, AC). Si bien varios estudios han demostrado que los AC obtienen resultados postoperatorios similares a los de los médicos, hay poco información acerca de su entrenamiento quirúrgico. Este estudio tuvo como objetivo caracterizar la capacitación quirúrgica y la experiencia de los AC en comparación con los médicos titulados (medical officer, MO) en Tanzania. Métodos: En este estudio, se encuestaron todos los proveedores de atención quirúrgica de la Región de Pwani, Tanzania. Los participantes proporcionaron datos demográficos, años de entrenamiento y número y tipo de procedimientos realizados y a los que se había asistido durante el periodo de capacitación. Además, respondieron a preguntas abiertas sobre el entrenamiento y su experiencia quirúrgica posterior al entrenamiento. Se comparó la mediana del número de procedimientos más realizados por cada grupo mediante la suma de rangos de Wilcoxon y la prueba de la t de Student. Los investigadores realizaron un análisis del contenido de las respuestas a las preguntas abiertas sobre las necesidades y la experiencia durante la etapa de entrenamiento. Resultados: En el estudio participaron 21 ACs y 12 MOs. Los CA estuvieron expuestos a un mayor número procedimientos del mismo tipo antes de efectuar su primera operación de forma independiente en comparación con los OM (40 versus 17 casos, P = 0,031). No hubo diferencias en el volumen operatorio total de los procedimientos comunes entre los AC y los MO (150 versus 171 casos, P = 0,995). Las opiniones de los dos grupos sobre el entrenamiento fueron similares. Los dos grupos se dieron soporte entre ellos, pero quedó patente que la supervisión por parte de un especialista durante el entrenamiento y la práctica independiente era insuficiente. Conclusiones: En Tanzania, los asociados clínicos tienen entrenamientos y experiencias quirúrgicas similares a las de sus colegas médicos.

Career intentions of medical students trained in six sub-Saharan African countries.

INTRODUCTION: Sub-Saharan Africa(SSA) is the world region worst affected by physician migration. Identifying reasons why medical students wish to stay or leave Africa could assist in developing strategies which favour retention of these graduates. This study investigated the career intentions of graduating students attending medical schools in SSA to identify interventions which may improve retention of African physicians in their country of training or origin. METHODS: Final year medical students attending nine medical schools in SSA were surveyed--students from four schools in South Africa and one school each in the Democratic Republic of Congo, Kenya, Nigeria, Tanzania and Uganda. The response rate was 78.5% (990 of 1260 students); data from the 984 students who indicated they were remaining in medicine were entered into a database, and descriptive statistics were obtained. RESULTS: Most (97.4%) of the 984 responding students were African by birth. The majority (91.2%) intended to undertake postgraduate training; the top three specialty choices were surgery (20%), internal medicine (16.7%), and paediatrics (9%). Few were interested in family medicine (4.5%) or public health (2.6%) or intended to practice in rural areas (4.8%). Many students (40%) planned to train abroad. About one fifth (21%) intended to relocate outside sub-Saharan Africa. These were about equally divided between South Africans (48%) and those from the other five countries (52%). The top perceived career-related factors favouring retention in Africa were career options and quality and availability of training opportunities. Several factors were reported significantly more by South African than the other students. The top personal factors for staying in Africa were a desire to improve medicine in Africa, personal safety, social conditions and family issues. The top career-related factors favouring relocation outside Africa were remuneration, access to equipment and advanced technology, career and training opportunities, regulated work environment and politics of health care in Africa. Several of these were reported significantly more by students from the other countries as compared with South Africans. The top personal factors favouring relocation outside Africa were personal safety, opportunity for experience in a different environment, social conditions and greater personal freedom. DISCUSSION: The career intentions of African medical students are not aligned with the continent's health workforce needs. A number of interventions that warrant further attention were identified in this study.

University partnership to address the shortage of healthcare professionals in Africa.

The shortage of qualified health professionals is a major obstacle to achieving better health outcomes in many parts of the world, particularly in Africa. The role of health science universities in addressing this shortage is to provide quality education and continuing professional development opportunities for the healthcare workforce. Academic institutions in Africa, however, are also short of faculty and especially under-resourced. We describe the initial phase of an institutional partnership between the Muhimbili University of Health and Allied Sciences (MUHAS) and the University of California San Francisco (UCSF) centred on promoting medical education at MUHAS. The challenges facing the development of the partnership include the need: (1) for new funding mechanisms to provide long-term support for institutional partnerships, and (2) for institutional change at UCSF and MUHAS to recognize and support faculty activities that are important to the partnership. The growing interest in global health worldwide offers opportunities to explore new academic partnerships. It is important that their development and implementation be documented and evaluated as well as for lessons to be shared.

Introduction of regular formative assessment to enhance learning for clinical students at Muhimbili University College, Tanzania.

OBJECTIVE: To determine if undertaking regular Formative Assessment (FA) in the setting of our medical school enhanced the students' learning experience. METHODS: An FA intervention was designed and implemented with clinical students during their clerkship in the academic year 2003/04. FA was administered as structured verbal comments on daily clinical case presentations. Evaluation of the intervention included pre- and post-surveys exploring the perceptions of students and teachers on the quality of the learning experience. Focus group discussions with students and with teachers were held at the start and conclusion of the intervention to identify strengths and weaknesses of FA. FINDINGS: All participating teachers perceived that students were interested in learning before the intervention. Teachers who perceived that students achieved the set learning objectives increased from 0% before to 28% after the intervention. Most teachers (71%) and students (86%) perceived FA to enrich students' learning experience. Students appreciated the positive change in teachers' attitudes during the FA intervention. Both students and teachers recommended that FA become a regular and routine activity. CONCLUSIONS: Students and teachers viewed FA as a positive, feasible intervention. They thought it enriched the learning process and recommended it be a routine learning activity.

Research on medical migration from sub-Saharan medical schools: usefulness of a feasibility process to define barriers to data collection and develop a practical study.

CONTEXT: The maldistribution of physicians in sub-Saharan Africa is having serious impacts on population health. Understanding the effect requires investigation from both donor and recipient countries. However, investigation from the perspective of donor countries has been lacking. METHODS: This brief communication describes a model process for the design of a research project that addresses medical migration issues from the perspective of eight African medical schools. During an international meeting, the participants designed an initial "ideal" study, and then rapidly tested its feasibility through a brief survey, and group discussion through a listserv, teleconferences and one face-to-face meeting. FINDINGS AND PRACTICAL IMPLICATIONS: Innovative research ideas can be followed-up with surveys to test the feasibility of an "ideal" research design, modifying the design accordingly. This is currently occurring with our medical migration survey study.

Atraumatic intracutaneous skin closure with self-made fishing line suture compared to commercial thread.

OBJECTIVE: The aim of this study was to prove, whether the intracutaneous skin closure with self made fishing line suture is equivalent to commercial sutures. DESIGN: It was a randomised blinded animal study. SETTING: The study was performed in December 2002 at the Muhimbili University College of Health Sciences in Dar-es-salaam. SUBJECTS: Both German surgeons from Mannheim, and Tanzanian surgeons from Dar es salaam operated on nine one year old Tanzanian domestic sheep. INTERVENTIONS: 108 standardised cutaneous wounds on the backs of the animals were closed by intracutaneous sutures either with self produced fishing line suture or a commercial nylon suture (Ethilon). MAIN OUTCOME MEASURES: The clinical and histological outcomes, as well as the costs of this self-made fishing line suture, with a commercial nylon thread were evaluated and compared. RESULTS: There are no significant differences between the two sutures in histological or clinical findings, or in the reported ease of use by the surgeons. The cost of a self-produced atraumatic thread is US$ 0.12, less than one-twentieth of the cost of the commercial thread. CONCLUSION: Self-made fishing nylon suture has characteristics and properties in sheep skin wounds comparable to commercial nylon suture. The advantage of the commercial thread is the guaranteed quality assurance. It is discussed whether this quality assurance justifies the large price difference, and whether the self-produced thread should be recommended to surgeons in countries where the costs of surgical material often remains an obstacle for life saving operations.

Small volume resuscitation with 7.5% hypertonic saline solution--treatment of haemorrhagic shock in the tropics.

Rapid intravenous injection of 4 mL/kg body weight of a 7.5% hypertonic sodium chloride solution immediately increases intravascular osmotic pressure and intravascular volume after haemorrhage. This 'small volume resuscitation' rapidly improves blood pressure and microcirculatory perfusion in patients with hypovolaemic shock after large blood losses. Pathophysiological findings as well as practical application approaches are described. Small volume resuscitation is an effective and economic method in the first-line treatment of acute haemorrhagic shock.

Prevalence and clinical presentation of HIV infection among newly hospitalised surgical patients at Muhimbili National Hospital, Dar es Salaam, Tanzania.

BACKGROUND: In Tanzania information is lacking on the prevalence of HIV infection in surgical patients in tertiary care facilities, in whom there are many points of special interest. OBJECTIVE: To determine the prevalence of HIV infection and associated clinical and demographic features among hospitalised surgical patients at Muhimbili National Hospital (MNH). SETTING: Muhimbili National Hospital. MATERIALS AND METHODS: Consecutive newly admitted patients were tested for HIV antibodies after pre-test counselling. Sera were tested using a dual ELISA algorithm. The data were analysed to determine the prevalence of HIV infection and relationships of serostatus with clinical and socio-demographic characteristics. RESULTS: Of 1,534 patients admitted during the study, 1,031(67.2%) consented to HIV testing following pre-test counselling. The prevalence of AIDS-related clinical features in patients who declined to be HIV tested was similar to that of seronegative patients, but significantly lower than that of seropositive patients. The overall age-adjusted HIV prevalence was 10.5% (95% CI = 9.9-14.0). The highest age-specific HIV prevalence was in the age group 35-44 years at 27.9%. No one was infected in the age group 0-4 years (n = 111). Differences in prevalence between age groups were statistically significant (p < 0.0001). Patients with granulomatous and suppurative infections had HIV prevalence of 28.3%. Twenty of 124 seropositive patients (16.1%) died in hospital compared to 58 of 907(6.4%) of seronegative patients (p = 0.0001). CONCLUSION: At Muhumbili National Hospital overall HIV prevalence in hospitalised surgical patients were 10.5%, compared to an overall national prevalence of 6.7%. Patients in the age groups 25 to 34 and 35 to 44 years had HIV seroprevalence of 26.8% and 27.9% respectively. Patients with infective conditions had the highest HIV prevalence. HIV seropositive patients were associated with higher hospital mortality than seronegative patients.

A comparison of topical Phenytoin with Silverex in the treatment of superficial dermal burn wounds.

OBJECTIVE: To compare topical diphenylhydantion (Phenytoin) with silver sulphadiazine/chlorhexidine (Silverex) in terms of rate of wound healing, analgesic and antibacterial properties in small to moderate-sized (< 30% TBSA) superficial dermal (second degree) burn wounds. DESIGN: A prospective randomized controlled study. SETTING: Surgical wards, Muhimbili National Hospital from July 2000 to February 2001. SUBJECTS: Sixty four patients with acute burns, 32 in each group. INTERVENTIONS: Study group treated by sprinkling Phenytoin powder and control group by sprinkling Silverex powder on the wounds for 14 days or until the wound epithelialised or was ready for skin grafting. The data collected included demographic characteristics of patients, aetiology of burn injury, circumstances of injury, site and extent of burns, pus discharge and smell from the wound, pain and discomfort from the wound, bacterial cultures of wound swabs, rate of reduction in wound size and outcome of treatment. RESULTS: The study enrolled 33 male and 31 female patients, 69% being children under five years of age. Hot liquids (80%) and open flames (20%) were the only causes of burns. In 97% of patients injury was due to domestic accidents. In half of the patients burns involved the trunk, and 52% of all patients had less than 15% total body surface burnt. Pus discharge was recorded in 59% of Phenytoin-treated and 75% in Silverex-treated patients while foul smell was noted in 19% and 31% of cases respectively. There were more negative bacterial wound cultures in Phenytoin-than Silverex-treated wounds on day five and day 10 of treatment, the difference being statistically significant (p < 0.01 and 0.001 respectively). There was also a statistically significant difference in wound pain in favour of Phenytoin (p < 0.01). There was no statistically significant difference in the rate of healing in the two groups. CONCLUSION: Phenytoin is a cheap and easy-to-use medicament, effective in suppressing burn wound bacteria and relieving pain thereby promoting healing, and may be advocated for the purpose in resource-scarce environments.

Hydraulic urethral dilatation after optical internal urethrotomy: preliminary report.

OBJECTIVES: To determine the rate of early recurrence of urethral stricture in the first six months in patients who perform hydraulic urethral dilatation(HUD) after optical internal urethrotomy (OIU) and compare the early recurrence rate in patients who perform HUD after OIU with the recurrence rates in patients reported in the literature who undergo OIU without performing HUD. DESIGN: Prospective descriptive case series. SETTINGS: Urology clinic, Muhimbili Medical Centre, Dar es Salaam, Tanzania. SUBJECTS: Patients with symptoms of urethral stricture subsequently radiologically demonstrated to have urethral stricture that was deemed treatable by OIU. INTERVENTIONS: Evaluation included urethrography, renal biochemical profile and urethroscopy at the time of OIU. Patients with strictures no longer than 50 mm, no complete block or marked tortuousness, and no paraurethral sepsis were selected for OIU, urethral catheter for seven days followed by HUD) for one month. RESULTS: During a follow up period of five to seventeen months (mean 10.1 months), only two out of twenty three patients (8.7%) showed clinical evidence of stricture recurrence. The remaining patients reported normal voiding. CONCLUSION: This report suggests that HUD, a cost-free technique, is an effective method for preventing stricture recurrence after OIU. As follow up of these and subsequent patients continue, it is hoped that this not-so-well-known technique will undergo evaluation at other centres in our region.

Pneumatosis cystoides intestinalis--in Tanzania.

Pneumatosis cystoides intestinalis (PCI) is a rare benign condition affecting portions of the intestinal tract, characterised by: multiple subserosa and submucosal gas cysts, unknown aetiology, and non specific clinical presentation. Its diagnosis is often coincidental. Management of PCI entails that of the associated condition.

Urinary stone disease in Tanzania: an insight into the magnitude of the problem.

Urolithiasis is generally said to be rare in Africans. Detailed studies of the condition are few in our region. This 2 year prospective study at Muhimbili Medical Centre identified 77 adult patients with urinary stones. Males were affected 3 times more commonly than females and most patients were in the young productive age group. Many patients reached hospital several months or years after the onset of symptoms. However, as in industrial countries, upper urinary tract stones were predominant. Involved kidneys suffered serious damage especially in the presence of obstruction and infection. The only available treatment was outmoded surgery, and long delays were inevitable in the face of overstretched resources, resulting in the sacrifice of kidneys. Urolithiasis is probably not nearly as uncommon as we have been led to believe from impressions and retrospective studies of incomplete records. Therefore, there is a need for more research on the problem in our region.

The management of operative urethral injury an experience with ten patients at Muhimbili Medical Cenntre

10 patients were treated at Muhimbili Medical Centre (MMC) for operative injury of the ureter following gynaecologic surgery. 7 were referred from up-country while three sustained injury during operation at MMC. The age range was 27 to 52 years with a mean of 36.5 years. Abdominal hysterectomy was the operation at which the ureter was most commonly injured. Only two of the injuries were discovered interpretively; a trend common to most series. Ureteric re-implantation or end-to-end anastomosis were performed according to the circumstances; with good results in all patients. The main shortcoming was prolonged delay before treatment in the majority of patients. A ureteric catheter inserted cystoscopically before operation; avoidance of excessive dissection of the ureter; constant consciousness about the possibility of urethral injury during abdominal and pelvic surgery and an intravenous urogram (IUV) in cases where difficulties are anticipated are useful preventive measures

Guided dilatation of urethral strictures.

Ten patients with pinhole urethral strictures were treated by introducing a flexible guide wire endoscopically through the stricture then passing flexible hollow dilators over the wire across the stricture. The procedure was successful in 9 out of 10 patients. It inflicts minimal trauma to the urethra and is recommended as a practical substitute for optical urethrotomy where the latter is not available.

Urinary stone disease in Dar es Salaam.

Forty four adult patients, 34 males and 10 females, with urinary stones were seen over a six-month-period at Muhimbili Medical Centre, Dar es Salaam. Most patients were peasants and semiskilled workers. 8 of the patients were Arabs, which suggests a high predisposition for this race. 12 of the patients had a history of having suffered from bilharzia. There was a high proportion of bladder (and urethral) stones (30%) but upper urinary tract stones were still predominant (70%). Of 20 patients whose stones were available for analysis, 8 were composed of calcium oxalate, 7 of calcium phosphate and 5 of mixed composition. The ratio of stone patients to all hospital admissions of 243 per 100,000 suggests the prevalence of urinary stone disease is comparable to that found in Western countries.

Percutaneous upper urinary stone surgery.

Fifty-five patients underwent surgery for renal and upper ureteric stones in the department of urology at the Royal Infirmary in Glasgow, Scotland, during a one-year period beginning in October 1986. There were 31 males and 24 females, with a mean age of 47.7 years. The targeted stones were successfully removed in 46 (83.6%) patients. 52.7% of the patients were discharged home within 4 days of operation. Minor perforations of the renal collecting system was the commonest complication, which occurred in 6 patients. Three patients had serious haemorrhage, one of them requiring nephrectomy for bleeding from a torn renal vein. One patient had cardiac arrest on post operative day 3, suffered brain damage, and died on day 10. Percutaneous lithotomy has become a well-established, effective method of treating upper urinary stones. Costly equipment is involved, however, and critical assessment is required in deciding to introduce this technique of stone treatment in a developing country. In those circumstances a gradual assimilation is suggested.