Not at all jealous really...

...of my friend Charlotte who is about to head off to Kiwoko Hospital in Uganda for a couple of months on her medical elective (http://charlottegunner.blogspot.com). From what she tells me, she was completely inspired by a talk I gave about working in Kiwoko to a group of medical students two years ago who were exploring options about how to go about sorting their elective. The elective is a period of time most medical students get at some point in their final two years of university which they can use to go and work/study anywhere in the world. My own elective was in the summer of 1996 and I spent July and August in The Nazareth Hospital in Israel, and then September and October in... Kiwoko Hospital in Uganda! I’d been trying to get back for over ten years when I finally managed it by working there for the whole of 2007.

I remember some aspects of my time there as a medical student very well. I hadn’t done that much travelling before, and had absolutely no idea what to expect from Africa before I went. I think a cousin’s friend had been to Kiwoko Hospital a couple of years earlier and that’s how came to know of it. I do remember finding it very isolated for the first couple of weeks. There was one other medical student there with me from Leeds, who I fortunately got on with well. He appeared back to the house we lived in one afternoon with a bag of aubergines, very excited about finding them in the local village. “I hate aubergines!” I remember saying, much to his dismay. That comment found its way into his diary, I found later, with the comment: “I wonder if we’re going to get along!”

Kiwoko Hospital Main Building in 1996 and 2007

In those days, the postal service was the best method of communicating – mail from the UK took about a week to arrive. I did manage one phone call home, after about a month, from a call box in the main post-office in Kampala. Nowadays, with mobile phones, communication is much easier, and mobile phone reception is excellent and pretty cheap. Kiwoko also has a functioning internet connection via a satellite receiver at the nearby New Hope Orphanage. That allowed me to maintain email and blog communication when I was there, and was great at helping to source equipment and resources for the hospital.

Kiwoko Hospital Entrance 1996 and 2007

Other memories include the food – we had pretty much the same each day: rice and beans, sometimes with gravy, sometimes matoke (savory steamed banana). You had to be careful with the rice, as it had many small stone in it! At one point we had some Ugandan medical students there who shared our meals, and after one such lunchtime I found one of them, Diana, sitting beside me stroking my arm... “Hello!” I thought, but it was just that Ugandans have smooth arms, and my arm hair was amusing her greatly!

Of course the hospital has moved on since those days, and is now about twice the size. But the thing I appreciated most when there 12 years ago, and also when working there in 2007 was the ethos of the place, which hadn’t changed. Kiwoko Hospital is still an oasis of God’s love in the midst of a poor developing country – aiming to reach out in His strength to make a difference in people’s lives, physically, socially, and spiritually. The vast majority of staff are there serving God, and relying on Him day-to-day to provide all that the hospital needs. I certainly witnessed many miracles of healing (see earlier blog posts) and of finance at just the right time during my stay there.

Of course, I shouldn’t be jealous at all. I’ve had three opportunities to return for brief visits over the last two years. I have a good job here that gives me the money to support the hospital in many ways, and to sponsor several students there, as well as paying for airfares and associated costs of trips back to Uganda. I’m also just back from a superb skiing holiday in Austria, which gave me a much needed break from work as well as great exercise and intoxicating amounts of fresh air!

Schladming 2010

I'm also planning a further visit to Kiwoko later this year, perhaps at the time of the Nursing School Graduation, when I’ll be able to support the students who I’ve sponsored over the last couple of years. But I am excited for Charlotte, heading off into the unknown, and hopefully about to have a life-changing experience. Who knows, she may end up working there again at some point in the future – both myself and the current Medical Superintendent at Kiwoko Hospital were once elective medical students there in our time!

Steve

Relief And Exhaustion...

...is turning to joy and self-satisfaction! I’m pleased to report success in what will hopefully be my last exams ever. Many would say that I’m far too old to still be sitting exams, but the profession of surgery in the UK requires me to pass an ‘Exit’ exam before completing my training. Having passed, I can now add the letters ‘FRCS(Gen Surg)’ to my name in place of the basic MRCS qualification, but more importantly it means I can become a Consultant Surgeon when I finish in October later this year.

The Intercollegiate Specialty Examination in General Surgery has left me rather more stressed over the last few months than I would have admitted to myself. There are two parts – the first written part was in June 2009, consisting of a two hour multiple choice exam and a two and a half hour Extended Matching Questions exam. Having passed that, I was allowed to progress to the second Clinical exam.

I’m very much a General Surgeon. When I was in Uganda, that obviously encompassed every possible type of surgery. Here in the UK, most people choose to sub-specialise into Colorectal, Oesophagogastric, Hepatobiliary, Endocrine, Vascular, Breast, or Transplant Surgery. The exam tests both General Surgical knowledge (encompassing all of these sub-specialities) and sub-specialist knowledge. For me, sitting as a Generalist, I had to know all of the specialities to a higher level (!), although not to the full sub-specialist level.

The clinical exam itself was in Newcastle, held over two days. The Thursday afternoon had two exams – both half an hour long with two examiners, seeing actual patients. I had quite a mixed bag of conditions to discuss – a thyroid lump, a breast cancer, an incisional hernia, an abdominal aortic aneurysm, a large retroperitoneal tumour, and a post-op short bowel with ileostomy in the first part; obstructive jaundice due to retained gallstones, an incisional and an inguinal hernia, a male breast lump, an enterocutaneous fistula, a post thyroid cancer with an odd neurological syndrome, and some varicose veins in the second. You’re expected to be able to adequately speak to and examine patients, and then discuss the case in question in some detail.

The Friday exams were oral exams – an academic viva, a general surgical viva, and an emergency surgery and critical care viva. The academic exam requires an hour to read two published papers, before getting questioned for ten minutes per paper on your understanding of what the paper is trying to say. It’s all about the study design, appropriate methods, statistical tests, interpreting results and assessing whether the paper is worth taking notice of in clinical practice. The General exam was half an hour discussing Investigating anaemia, consent for hernia repair, pyloric stenosis in children and adults, bile leak after laparoscopic cholecystectomy, and clostridium difficile infection. The Emergency/Critical Care exam was a further half an hour discussing inflamed small bowel found at laparoscopy for suspected appendicitis, rectal bleeding and its investigation and emergency management, chest trauma with investigation and analgesia for flail segments, correction of coagulation after massive blood transfusion, and brainstem death.

I came away thinking I’d done well in the Academic and the Emergency/Critical Care vivas, but with no idea about the others. It’s an exam in which only about half of the candidates pass, so I was fairly concerned. Fortunately it doesn’t take them long to produce the results, and I had an email waiting for me when I got home on Monday. I can only say that I was relieved and exhausted. There was very little sense of achievement or joy at having passed, but that has developed through the rest of this week. Four of my colleagues in Edinburgh also sat the exam at the same time, and we all passed, which is a fantastic result. Another former colleague from another area of the country was unsuccessful on this occasion, but he’ll be able to sit it again.

Surgical Exams are an expensive business – the exam itself costs £1700; I went on a pre-exam course costing £1100; then there was travel and accommodation in London for the written, and in Newcastle for the clinical; Finally there’ll be an “election fee” to the Royal College of Surgeons to allow me to become a Fellow (FRCS stands for Fellowship of the Royal College of Surgeons) rather than a member (the basic surgical exam I passed ten years ago was the Membership exam). Still, it’s a hurdle that has been jumped, and I can now enjoy my last few months of training.

Of course, next up will be finding an appropriate Consultant job. There have been advertisements for posts in Elgin and Fort William, but both are a little too far away from the Central Belt of Scotland for me at the moment. I’m hoping that there may be jobs in Perth, Dumfries, Dumfermline or Forth Valley – a lot depends on other surgeons retiring. If nothing appropriate comes up, I may yet find myself back in Uganda!

48 Hours...

... is the maximum number of hours per week that I am legally allowed to work here in the UK. The European Union have produced a European Working Time Directive (EWTD) to which all employees have to adhere, or sign an opt-out. In its infinite wisdom, the NHS has decided that although doctors-in-training were initially exempt from this rule, as of August last year, we’ve all had to comply both with average hours worked per week and with various rest requirements.

It’s a far cry from working in the un-restricted world of Kiwoko Hospital in Africa, although I actually believe I had a better work-life balance there and was generally less tired. I guess a lot of that depends on how busy the night-time workload is. Two years ago in Uganda, we generally worked 7.30am-5.30pm Monday to Friday. Then one week in three I covered surgical emergency operating outside of those hours Mon-Sun. I got a night off on Thursday, but had to work until 5pm on Saturday and covered the whole hospital overnight Sunday rather than just the surgery. The next two weeks were standard Mon-Fri only, with one extra Thursday night on call for the whole hospital.

That sounds a lot, but in general I wasn’t often called out overnight – there were occasionally emergencies before midnight, and a couple of 6.30 calls to theatre to help with a difficult Caesarean Section being performed by one of the other doctors who was struggling a bit, but in the main these weeks involved a decent amount of sleep except for the Sunday night which could end up being 4-5hrs only.

Now I’m back in the UK, the amalgamation of hospitals into larger centres, the transformation of out-of-hours healthcare to nurses answering telephones and seeing patients rather than the old model of General Practitioner doctor consultations, the reduction in training hours and therefore less experienced junior staff, as well as an aging population more prone to ill-health and with much greater 24hr expectations, has resulted in a much heavier overnight workload than was the case when I started work as a doctor over twelve years ago. The lack of expectation of sleep overnight combined with the EWTD means that I’m on shift work, and I hate it!!!! Unfortunately I’m one of those people who find it very hard to sleep during the day between night shifts, and so I get progressively more tired as my night-shifts go on.

Over the last three weeks I have worked: Friday, Saturday, Sunday nights; Monday to Friday daytime on a course 8.30-5.00; Saturday & Sunday off; Monday to Sunday Emergency Surgery shifts 8.00am-9.00pm; Monday off; Tuesday-Thursday nights. Admittedly my week’s course in the middle should have been a fourth night and then the rest of that week off, but it’s still a fairly punishing schedule. Fortunately before nights come round again I get five weeks of normal 8am-6pm Monday-Friday working. On paper it does eventually average out at 48hrs over the course of the rota, but of course in practice events require you to start earlier and finish later regularly. Life was definitely better with the old on-call one night a week and one weekend a month...

The best thing about this year is that in theory I finish my training at the end of October 2010 getting my Certificate of Completion of Specialist Training, and enabling me to register as a Specialist Surgeon and get a Consultant job. There’s the small matter of passing exams in a couple of weeks time, and then the need to find that new job. There are potentially a couple of jobs coming up in some of the medium-sized hospitals in Scotland – As a generalist with a laparoscopic surgery interest, I’m not specialised enough to go for jobs in the big city hospitals, which does limit the type of jobs available. I guess I’ll have to see what comes up, pray hard, and trust that I’ll end up somewhere I can be useful. Various things in life are suggesting to me that staying in this country initially would be better than heading immediately back out to Uganda... which is possibly what I would actually really like to do... but I’ll wait and see where God is guiding me.

One thing I am able to do much more easily from Scotland is head to the Alps to go skiing which is my next break at the end of February and hopefully a reward for getting through the exams. Anyone for Gluhwein?

Steve

P.S. The snow in Edinburgh (pictured above from Arthur’s Seat) has now all gone again. I hope spring comes soon!

A very un-African New Year

I still find myself thinking of Kiwoko Hospital in Uganda frequently, recalling the life that I lived there over two years ago with fondness. One obvious and major difference between Edinburgh and Uganda this New Year has been the weather – for once the UK has had a proper cold spell with winter weather that has now lasted over two weeks! I suspect my friends at the Equator have been suffering with the beginning of the dry season, temperatures of 28-30 degrees (Celcius), and a distinct lack of water. Here we’ve had more snow than I’ve seen in Edinburgh in over 15 years, repeated snow-falls, temperatures dropping to -14, and plenty of ice. It makes a nice change from the usual dark, wet, windy pseudo-winter that we usually suffer each year, and I’m all in favour of it, especially as it happened over Christmas.

New Year was spent in the middle of Edinburgh’s Hogmanay Street Party for the first time this century! We wrapped up well, took a hip flask of a rather nice Tobermory 10 year old, and joined the crowd for some live music, dance and banter. In fact midnight itself was seen in with a rather flamboyant Cuban band and some Latino music. And the fireworks were magnificent. It turned into a late night as we went on to another friend’s party, very handy at a flat overlooking Edinburgh Castle. I’ve had much quieter New Years in the recent past, so it’s good to remind myself that I can still enjoy myself even as I get older!!!

My friend Mark from Uganda wouldn’t have coped with the cold. I Kiwoko hospital again in October, and brought him back for a few weeks to the UK, which was a fantastic experience for both of us. It’s surprising how much you can squeeze into a short space of time. I had only ten days in Uganda on this occasion, but found myself working (Dr Peter tends to take some time off if he knows I’m visiting!), and it was good to find a couple of patients specifically attending to see me. One was a lady with intermittent jaundice due to gallstones and I was able to unblock her bile duct and remove her gallbladder – an operation the local surgeons wouldn’t have been comfortable doing. The other was a patient with swallowing difficulties. I was able to use the Endoscopy facilities that were still working well (see previous notes for details of setting up an Endoscopy Unit in 2007), and unfortunately found he had a large obstructing oesophageal tumour. Here in the UK we would have seen if the tumour had spread by means of a CT scan before deciding on surgical or oncological treatment. However, this man couldn’t afford the cost of a bus to Kampala, let alone the CT scan (albeit only costing £15), and I didn’t think that taking on such a major operation as an oesophagectomy without the back-up of an intensive care bed was very sensible. The best I could offer was a plastic stent to allow him to swallow food again – fortunately I had brought one of these out with me previously, and this was successfully put in place. It’s certainly not a cure, but hopefully he’ll at least have some quality of life over the next six months before the tumour spreads further.

Back in the UK with Mark, we found all sorts of things to amaze a person from Uganda who’s never travelled outside of his country before! I think the whole experience was a little overwhelming, but he went home with lots of photographs and a better understanding of our part of the world – people in Uganda get many visitors from the West, but have a number of inaccurate preconceptions of how life is here. Hopefully Mark will be able to address this. He was particularly impressed at our street-lighting and the orderly nature of the traffic on our roads, and amazed at the cost of living.

We managed a few days sightseeing in Edinburgh and nearby Scotland, a few days in London, a week at my UK hospital, and finally meeting up with several UK friends who managed to visit while he was here. Particular highlights included staying next-door to the Queen (a hotel near Buckingham Palace), taking in a show (Grease seemed to be fairly straightforward to follow), and of course tube and train travel. The main reason for his visit was to get some experience of Theatre Nursing in a UK hospital, and my colleagues at Edinburgh Royal Infirmary were very friendly and willing to show him how we do things here – hopefully he’ll have several thoughts that may be helpful back at Kiwoko. The main surgical difference he noticed – laparoscopic (or keyhole) surgery, which he found very exciting as its not seen in the hospitals he’s been in in Uganda.

But here I am at the beginning of 2010, with my final Surgical Exams in less than six weeks. After that I plan to get out and enjoy myself a bit more with skiing trips, mountaineering trips and social outings planned! I’ll need to focus then on what I do when my contract here ends in October – the options probably being to find a Consultant Surgeon job here in Scotland, or to head back out to work in Uganda again... not an easy decision – I’ll let you know how it works out!

Steve

I left my heart in Uganda...

It’s been far too long since I last posted, but this blog was really supposed to be a record of what I was up to in 2007 when I was working as a Surgeon in Kiwoko Hospital, Uganda. I returned for a visit recently, and realised just how much I missed working there, and just how unsatisfying I am finding my current UK life. I think there are a number of reasons for this, and I probably need to sort out a few of my issues here in Scotland before making definite plans to return long-term – although this is a definite possibility!

Living in community is a big feature of Ugandan life, and something we don’t do particularly well in this country. There’s something very wonderful about living as part of a Mission Hospital community. Although living in my own small house, my immediate neighbours included several other ex-pats, and most of the Ugandan staff lived on site too. There’s always other people around, and Ugandan’s are the most friendly, genuine, respectful and welcoming people I’ve met. Starting each day with your colleagues in a short service of worship, teaching and prayer before heading off to live out your faith together in all that you do at work is an amazing and energising way of life!

At present I’m working a couple of hours away from home, so I live in the hospital during the week and only get back at weekends, so I’m completely missing any sense of community at present. It’s difficult not to feel very isolated, and it’s hard to meet up with friends when you only have limited time in the same city. I’m also studying for more professional exams, further keeping me away from being sociable! Hopefully these things will improve when I move back to my local hospital in August, and get the exam out of the way.

Working as a doctor in Uganda is also incredibly rewarding. If you read some of the other posts below, you’ll realise just how obviously worthwhile is everything you do there. Patients only come to hospital when they have something reasonably seriously wrong, and often they can’t afford to go anywhere else for help. The buck stops with you, and you do the best you can to help, knowing that there’s no alternative. The vast majority of patients recover well from their operations or other treatment, and are very grateful for all you have done (and I must give a lot of credit to God for many miraculous events I’ve seen along the way!). The work is hard, time consuming, and thoroughly satisfying!

A lot of the time work in the UK seems much less satisfying. Patients are much more demanding, they expect to have perfect health and often blame the doctor when this isn’t the case. Work time is limited by European Working Time, and so work-patterns involve a series of shifts and handovers of patients – there is less of a relationship with patients and less continuity of care, which ends up being demoralising. The emphasis is on patient throughput, and often you don’t again get to see patients you’ve admitted or even operated on! I’m envious of the surgeons of 30 years ago who enjoyed much more autonomy, and were able to practise in a more holistic way. Perhaps this side of things will improve once I complete my specialist training and become a consultant next year.

Spiritually things are harder here in the UK too – it somehow seems easier to totally depend on God for everything when you’re in an environment where there is little else. As one Ugandan said to me, “In the West you have God and things, here we just have God!” There is a definite tendency when one has much to depend more on yourself and what you have rather than surrendering everything to God’s care. That’s another challenge for me here in the UK.

Meanwhile I continue to enjoy great friendships with many Ugandans who stay in touch through the occasional email or phone call. It was fantastic on my recent visit to be welcomed back in such a loving way, and it’s very encouraging to feel so obviously wanted and loved. I’m surprised I’ve still not settled back into the UK after well over a year... perhaps Developing World medicine really is my calling!

Steve

Do you want to make God laugh?

Tell Him your plans! At least that was what my former minister said (Rev Dennis Lennon, who sadly died recently). I sometimes feel that God’s been able to laugh at me a lot. It’s now over three months since I returned to Scotland from Uganda, and I’m still finding it difficult to settle, workwise. Surgery at the Royal Infirmary Of Edinburgh is a very different work environment from surgery at Kiwoko Hospital in Uganda, but I think it’s more the type of surgery that I’m doing that is causing me difficulties.

I still have two and a half years of specialist surgical training to complete before I become a consultant. My plans had always been to specialise within General Surgery and become a Vascular Surgeon (arteries and veins outside of the heart) – the fine, technical nature of the operations was stimulating; the patients were generally in hospital for slightly longer than a lot of surgical patients, allowing for a better doctor-patient relationship; and the out of hours work is usually limited to exciting emergencies!

However, over the last two months I’ve come to realise that this doesn’t stimulate or interest me any longer. I crave the variety of operations the Generalist Surgeon is able to perform; I enjoy keyhole surgery which isn’t a feature of vascular surgery; I’m already bored of varicose veins; and there is much less of a sense of admitting a patient, diagnosing them, operating on them, getting them better, and discharging them – all too often our vascular patients have multiple medical problems that are difficult if not impossible to sort out, and frequently there is no treatment option other than amputation of a limb, often resulting in a patient who never recovers to get out of hospital.

Fortunately my director of training is very understanding, and has agreed without any problems to enable me to change the direction of my training. I’ll stay where I am for a total of six months, as there’s lots to learn here that will be useful for any type of surgery, but then I’ll continue training in a more General, Gastrointestinal Surgery. The choice then will become where to work as a consultant, and I’ve been finding out a bit about Remote and Rural Surgery in Scotland, which sounds very similar to what I was doing last year in Uganda.

I guess I’m waiting for God to make it clear to me that I’m to go back to Africa, something I’d love to do – but that will have to come from Him, as I’m sure I couldn’t cope if I didn’t have His complete help and support! Still, last year wasn’t my idea at all, and yet I’m sure it’s what He had in mind for me. As Proverbs 3v5 says, “Trust in the Lord with all your heart, and lean not on your own understanding. In all your ways acknowledge Him and He will direct your paths.”

Steve

Life in the UK doesn't completely suck!

I’ve been having a fairly depressing time since returning to Scotland from Uganda – the weather in January was miserable, it’s been a little overwhelming to reacquaint myself with old friends, life is very over-regulated, and returning to work in the NHS hasn’t been easy. However, on Saturday I found myself saying, for the first time in six weeks, “I’m glad to be here today!”

I was standing on top of a mountain at the time, Carn Gorm, north of Loch Tay and Ben Lawyers. The weather was fantastic – sunshine, crisp coldness, no wind – and as a bonus the only clouds were in the surrounding area, with temperature inversion causing only the tops of the other big mountains to show through. It was glorious, the early start totally worthwhile, and the prospect of three more mountains to climb during a circular walk turned the whole thing into a fantastic day out. This is definitely one of my favourite things about living in Scotland. On the right day, being able to get out of the city and up a big mountain within a couple of hours is unbeatable.

Rather than moaning about the last six weeks (which is also one reason why I haven’t posted recently), I’ll try to focus on the positives! I may have been less than enthusiastic about the weather, but the comparison between the constant dry, sunny, 28oC of the Ugandan dry season in December and early January, and the wet, cold, windy, darkness that greeted me for the whole of the rest of the month, was difficult to ignore. Fortunately February has been more than making up for it. It’s been mostly dry, cold but bright, and the days are noticeably getting longer. In fact this week I’ve been cycling to and from work in daylight.

It’s been good to get back together with friends, all of whom have been fabulously interested in what I’ve been doing over the last year. Kiwoko Hospital has been a great place to live and work, and the people there are frequently in my thoughts. It’s been superb to relive many memories of the year as I’ve had various dinner parties, short presentations and catch-up chats, often accompanied by brief photo-sessions. I hope that I’m opening people’s minds to how a good proportion of the world lives, something not often greatly realised by people in the West. I’ve also been very gratified by the number of Ugandans who have been in touch. A number of the nursing staff (male and female!) have been in touch by email and texts, and I’ve spoken with my former housekeepers several times, keeping in touch with what’s happening in their lives. I also have one former hospital staff member (currently studying in Belfast) coming to visit next month, which I’m looking forward to enormously.

Working in the NHS again hasn’t been the most pleasurable experience, although things are getting better as I settle in. From being my own boss, solely responsible for my own patients, I now have to work for five different consultant surgeons, sharing responsibility with four other middle grade doctors, and supervising a number of more junior doctors. It isn’t helped by the type of surgery I’m doing just now – there was hardly any need for vascular surgery (arteries & veins) in Uganda, and I haven’t worked in the specialty for several years. It’s an odd experience from being the most experienced General Surgeon in a hospital to being unsure of how to manage most things because my knowledge is a few years out of date and from a different hospital setting. Add to that the fact that most of my patients are old with multiple other illnesses to manage (almost none of them encountered in the last year!), and I’ve been feeling a bit like a fish out of water. Still, a fortnight in, I’m starting to understand the system, and am trying hard not to harbour thoughts of putting most of my patients out to pasture!

One thing that has been good is the amount of surplus equipment and consumables that I’ve been able to collect – things that can’t be used in the NHS for whatever reason, but that can be used time and time again in a Developing World hospital – and which I’m hoping to take out to Kiwoko when I next visit, possibly at some point in the next few months.

Anyway, if I haven’t managed to catch up with you personally yet, get in touch – what are you waiting for? If you think you might be able to help Kiwoko Hospital in any way, get in touch! If I can offer any assistance to anyone thinking of going to Uganda, get in touch! I’m told that the real depression is going to hit about three months after getting back here... that means I’ve about six weeks to go!

God bless,
Steve