Residents’ Section
Career Path
Enhancing the Resident Experience With Global Health Electives
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Keywords: global health, international health, radiology, Tanzania
Have you ever wondered how you would do your job if the power went out for several hours each day? How would you work up an abdominal mass without access to CT, MRI, or pathology? What kinds of diseases occur in places without vaccination programs, access to clean water, prenatal care, or antibiotics? As radiology residents in the United States, we have the opportunity to use the most advanced diagnostic and interventional tools and make important contributions to patient care. However, we may become quite reliant on these advanced imaging modalities to make simple diagnoses. Global health electives can provide the trainee with a broader vision of health care, while bringing much-needed medical imaging services to patients with limited access.
During my fourth year of radiology residency, I arranged a 4-week radiology rotation at Kilimanjaro Christian Medical Center (KCMC), a 500-bed tertiary hospital at the base of Mt. Kilimanjaro in Tanzania (Fig. 1). After an Internet search of available programs, I chose KCMC to work with Dr. Helmut Diefenthal, a retired radiologist who has been running a rigorous radiology training program in Tanzania for the past 20 years. Dr. Diefenthal spent his early life as a medical missionary, working as a general practitioner in rural clinics in Malaysia and Tanzania. After teaching himself how to obtain and develop radiographs to diagnose patients with tuberculosis, he developed a passion for imaging and decided to pursue a radiology residency in the United States, with the aim of someday returning to Tanzania. At the age of 65 years, he retired from his practice at the University of Minnesota and moved back to Tanzania to establish the radiology department at KCMC, now a highly functional department performing 70–80 radiographs, 50–70 sonograms, 10–20 CT scans (using a single-detector CT scanner), and several fluoroscopy studies daily. Dr. Diefenthal’s efforts have greatly increased radiologic expertise in East Africa. He has trained more than 15 radiologists in a 4-year training program and 65 assistant medical officers (AMOs) in a 2-year training program.
The workdays at KCMC were long, usually running from 7:30 a.m. to 8 p.m. The day began with visits from orthopedics, surgery, medicine, and pediatrics services to review all of the abnormal imaging results from the prior day. These daily multidisciplinary sessions were incredibly useful for patient care and teaching. We also visited the patient floors often to perform ultrasound or deliver abnormal results because there was no paging system. I felt as though we were practicing in a different era, one before high volume and digital imaging isolated us from our patients and colleagues.
After the morning conferences, we covered the various services (radiography, ultrasound, echocardiography, CT, and fluoroscopy), breaking for lunch and lectures from 3:30 p.m. to 6 p.m. and returning to the hospital for more film reading from 6 p.m. to 8 p.m. (Fig. 2). As a visiting resident, I taught informally throughout the day and gave a series of lectures to the residents. Many of my cases, such as diagnosis of hepatocellular carcinoma or acute aortic syndrome, were based on multiplanar and multiphasic CT and MRI, modalities not available at KCMC. At times, I thought that these cases were impractical. However, the residents were eager to learn these concepts, knowing that it was only a matter of time before more advanced imaging became available to them. In return, they taught me ultrasound and echocardiography and shared with me their personal stories. Many residents had struggled and left their families behind to pursue their training in radiology.
The experience of working side-by-side with Dr. Diefenthal, a knowledgeable and hard-working 85-year-old, was very memorable (Fig. 3). I learned about diseases that we rarely see, such as rheumatic heart disease, chronic osteomyelitis, disseminated tuberculosis, and AIDS-related Kaposi sarcoma, in addition to ubiquitous diseases, such as heart failure, pneumonia, cancer, and trauma. Our imaging services, particularly obstetrical ultrasound, abdominal ultrasound, and chest radiography, had great impact on clinical care. The experience was transformative for me on many levels. I learned to adapt to a new culture, see how medical care was practiced in a different country, and investigate disease processes with far fewer resources than I was accustomed to using back home.
 View larger version (128K) | Fig. 1 —Photograph of Mt. Kilimanjaro in Tanzania. Kilimanjaro Christian Medical Center, a 500-bed tertiary hospital, is at the base. |
 View larger version (136K) | Fig. 2 —Radiology reading room at Kilimanjaro Christian Medical Center. |
As my rotation progressed, I became increasingly aware of the substantial obstacles for radiology in resource-poor settings. In addition to the dearth of training programs in Africa, the few trained radiologists prefer to work at better-paying private practice centers in the big cities (leading to an internal “brain drain”) rather than in public hospitals or rural areas. One way to combat this is through “task-shifting” to midlevel providers, such as KCMC’s 2-year AMO program. Having a reliable supply of electricity and an equipment maintenance plan are also essential. At KCMC, as with many places in the developing world, there were frequent power outages and an entire fleet of unusable ultrasound machines because of lack of maintenance (Fig. 4).
Global health has been a long-neglected field within radiology [1]. According to the World Health Organization, up to two thirds of the world’s population lack access to medical imaging. However, with the advent of more portable and affordable technologies, such as compact ultrasound in combination with digital technology and increased Internet access, the radiology sphere can now extend to the farthest reaches of the world. Several recent initiatives show promise in improving access to radiology in resource-poor settings. Imaging the World, an organization founded by University of Vermont radiologists Kristen DeStigter and Brian Garra, has been using volumetric ultrasound images coupled with teleradiology interpretation to provide much-needed obstetric ultrasound in rural Uganda. Dr. Barry Goldberg’s Jefferson University Research and Education Institute offers 3-month “Teaching the Teachers” ultrasound immersion courses for foreign physicians, with many of these physicians establishing ultrasound training centers in their home countries. Table 1 contains additional resources.
 View larger version (132K) | Fig. 3 —Dr. Diefenthal performing ultrasound examination. |
Primary care organizations working to strengthen health care infrastructure are starting to introduce ultrasound and radiography into their health care coverage, and collaborating with them can lead to a lasting impact. For example, an initiative to introduce ultrasound services through a 9-week training program at several Partners in Health (PIH) clinics in Rwanda has been successful in training local physicians to perform and interpret ultrasound. In this study, clinical management was changed in 43% of the patients scanned [2]. PIH has also published a Manual of Ultrasound for Resource-Limited Settings, which is available free online, and they have teamed with the International Radiology Exchange, a nonprofit teleradiology organization providing interpretation of images. Nyaya Health, a nonprofit organization working in Nepal, has overcome great logistic and human resource challenges in their efforts to implement radiography and ultrasound services in an extremely rural region of western Nepal [1].
 View larger version (143K) | Fig. 4 —Ultrasound machines that are unusable because of lack of maintenance. |
Several organizations are also creating a network of individuals interested in radiology and global health. The American College of Radiology (ACR) Foundation International Volunteer System has supported many global health projects, including fundraising for Haiti, providing trainee service grants (including the ACR Goldberg-Reeder International Travel Grant, which supported my elective in Tanzania), publishing informative newsletters, and creating an online volunteer database. RAD-AID, a nonprofit organization founded by radiologists at Johns Hopkins School of Medicine, is creating an exciting entrepreneurial model for increasing imaging access in developing countries and has developed a comprehensive “Radiology-Readiness” assessment tool that has been used in China, India, and Haiti. RAD-AID has also held two conferences on international radiology, summarized in an informative white paper on the topic [3].
TABLE 1: Global Health Websites Listed in Order of Appearance in the Article
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Do as much research as possible and reach out to several possible host organizations. Identifying an organization that is working with a local government to develop sustainable and locally driven efforts will allow you to have an excellent clinical experience as well as conduct much-needed research. You may start with a needs assessment or quality improvement project. Eventually, you may be able to establish a longitudinal initiative within your department and collaboration with other departments in your hospital (such as internal medicine or surgery), allowing even more robust clinical support and outcomes-based research.
Once you have found a suitable host organization, you will want to draft a well-researched carefully written proposal and present the plan to your program director and chairman. You may encounter some initial resistance within your department because radiology rotations abroad are currently uncommon and your supervisors may not be aware of the global need for radiology. Network within your department to gain the support of influential people. Be persistent. Once people realize how passionate you are about the cause, they are much more likely to support you. You will also need to obtain the approval of the hospital graduate medical education office. Each hospital has its own policies regarding work abroad, and you will want to find out early if there are any potential barriers.
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The ideal time to do a global health project is later in residency, such as the third or fourth year, when you will have more expertise to share. In addition, it can take 1–2 years to get the necessary approval and to prepare for your trip. Now that the newly structured radiology curriculum is being implemented, there may be opportunities for residents to spend several months during their fourth year working on global health projects.
| Preparing for Your Experience | |
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Before embarking on a trip, it is critically important to understand the political situation and history of your destination. This will enable you to better understand the health care system (or lack thereof) and the factors that influence health care decisions. Talking to prior volunteers is very helpful and can give you the best idea about local politics, safety, and what to expect. Consult the Centers for Disease Control and Prevention Website and your travel clinic as soon as you decide on your destination because certain required vaccinations may be difficult to obtain. Many sites require antimalarial prophylaxis and documentation of your vaccinations, including yellow fever. I also received advice from prior volunteers on what items to bring: a Steripen (Hydro-Photon) to sterilize water, reading material, and conservative but light clothing. I brought an old laptop to prepare presentations. It is best to pack things you would not mind losing. Ask your host what donations they would find most practical. In my case, the most useful items were radiology textbooks (both in print and electronic), electronic journal subscriptions, pens, scrubs, and gloves. Advanced equipment, such as interventional supplies, is unlikely to be useful unless specifically requested. Laptop computers are useful; however, long-term security can be challenging. Imaging equipment, such as portable ultrasound machines, is very much appreciated; however, it must be accompanied by a long-term plan for maintenance.
No matter how much you prepare, there will be many surprises along the way. My rotation in Tanzania opened my eyes to the opportunities and challenges when practicing radiology in a resource-limited setting. This experience inspired me to join my hospital’s global health program, enroll in public health classes, and learn more about how to do effective long-term work abroad. Whether your elective is a once-in-a-lifetime experience or the beginning of a career in global health, you will learn a great deal about medicine and be surprised by your own and others’ resourcefulness.
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