Penn Medical Student Participants in ID Clinical Elective in Gaborone, Botswana

Penn Medical Student Participants in ID

Clinical Elective in Gaborone, Botswana

Entries:

Carolyn Miller, MS4, 2015

Nicole Herbst, MS4, 2015

Gabriel Heiderich, MS4, 2015

Kenji Taylor, MS4, 2015

David Sterken, MS4, 2015

Andrea Barberio, MS4, 2015

Caitlin Colling, MS4, 2015

Frederick Lin, MS4, 2015

Geoffrey Rodriguez, MS4, 2015

Hugues Yver, MS3, 2015

Joanna Stephens, MS4, 2015

Kendra Moore, MS4, 2015

Kendra Wulczyn, MS4. 2015

Miranda Farmer, MS4,2015

Robert Bonacci, MS4, 2015

Sarah Hepenbecker, MS4, 2015

William Kamens,MS3, 2015

Carolyn Miller, MS4, March 30

– May 8, 2015 camill@mail.med.upenn.edu

Description of the program:

I participated in the Botswana UPenn Partnership clinical elective for 4 th year medical students. I spent 3 weeks at Princess Marina Hospital as a medical student on the wards, participating in daily rounds and helping to care for patients. I then spent 2.5 weeks at Bamalete Lutheran Hospital in Ramotswa working with a phenomenal medical officer on the Female Ward, in a role comparable to a sub-internship. I wrote notes, saw patients independently (with subsequent supervision from the MO), and completed all ward work alongside the nurses. The program also included a lecture series and occasional conferences.

Personal accomplishments:

My situation was unique because I spent 6 months living with families in Botswana in

2007, and still remembered enough about the culture, geography, and language to communicate fairly easily with patients and staff. It was pretty amazing to be able to combine those memories and inklings of language skills with medical training. In terms of personal accomplishments, I am proud of the days in Ramotswa when the medical officer hadn't yet arrived and I felt comfortable rounding on the patients we had seen the previous day and thinking about a reasonable plan for them myself. Of course, I would wait until the MO arrived before any of the decisions were put into action, but the fact that I felt ok seeing and evaluating the patients independently, in a different language was exciting. I am also happy that I was able to find a team at Princess Marina that was welcoming and functional, with a resident and occasional attending who loved to teach. I

am happy that I was able to work as a medical student on a similar level as the local medical students - drawing bloods for the day, speaking to nurses, and locating charts for prerounding. With regard to direct patient care, the last patient that I helped take care of was a lady from zimbabwe with a meningitis/encephalitis of unknown etiology who had a twin sister. The sister was so invested in making sure she had everything necessary to make her twin better, even though the family had very few resources. She asked me to travel with her to the large pharmacy in Gaborone to ask about an IV medication that was not available at Ramotswa (IV Acyclovir). I stayed with her at the pharmacy and helped her figure out how to try to get the medication. Unfortunately the med wasn't available in the public sector, and cost $15,000 pula in the private sector, so it was not a medicine they could afford. This realization was the first time I saw a emotion from a patient's family throughout my time here; she burst into tears. At this point, her twin sister isn't doing well, and I'm not sure what the outcome witll be. And I'm honestly not sure how this is a personal accomplishment, but I suppose I am thankful that I was able to form a brief relationship with this family and that they were willing to work together to try to find a solution. Otherwise, on a personal note, I am also very

(very!) happy that I was able to reconnect with the family I lived with for several months in 2007 here in Gaborone, and spend a considerable amount of time with them during my stay. I learned so much from a medical standpoint here, but I am just so thankful that

I was able to see them, too.

Critique of the experience:

Overall this was a fabulous experience. I came during a relatively slow time in the

UPenn schedule of sending folks over (it was just 4-5 of us throughout the 6 weeks of being here), and I really enjoyed how calm and peaceful life became between interesting work in the hospital and generally relaxing life at Pilane Court. Though, some days at the hospital were really tough. It was hard to participate in rounds, discussing fairly esoteric concepts relevant to pathophysiology and such when patients were in need of immediate medical attention nearby. It was also challenging to interact with some specialists/attendings who tried to teach me concepts that I knew were incorrect; I had to politely nod and try not to remember what they were teaching. I definitely relied on tips and knowledge from overlapping students before me for some of the logistial information, including how to get around, where to go at the hospital, where to buy food and how to call a cab. Near the end of my time here, many new people arrived to Pilane and nobody had put the sheet on the fridge to update us, so it was a bit of a surprise. It would be nice to be consistent with those sheets of paper. I can also imagine it would be challenging to come here and do this program without a bit of overlap with other students. I very, very much appreciated all that Miriam did to make us comfortable and supported during this time, including taking us to lunch on our last day to get feedback on the experience. So in general, this was well organized and well supported experience. I had a great time.

Tips for future program participants:

I would say my tips for future students would be to take advantage of your time here.

Seek out experiences in specialties that are interesting to you. The majority of services are happy to have a visitor for a day or two, and it's so interesting to see what that is like in this context. Also, make an effort to learn setswana; folks here instantly warm up to you and it shows respect - at least learn the basic greetings. Try to keep an open mind and not let the differences between healthcare in Botswana and America make you angry or disheartened or frustrated. We are here to learn from a different system so we

should embrace the positives and learn from the negatives. Finally, keep saying yes to new experiences, even with people you just met at Pilane!

Nicole Herbst, MS4, March 30 – May 8, 2015 nherbst@mail.med.upenn.edu


We began our rotation with 1 week of orientation, which consisted of some lectures and getting oriented to the various hospitals by the previous group of students. After orientation, I spent 3 weeks at Bamalete Lutheran Hospital (BLH), a district hospital in

Ramotswa and 2 weeks at Princess Marina Hospital (PMH). They were both rewarding experiences in different ways.

I enjoyed my 3 weeks at BLH for many reasons. Because it isn't a teaching hospital, the role that I played was very different from what was used to. I spent most of my time oneon-one with a medical officer, rounding on medical patients in the ward. By the end of my three weeks, I was comfortable seeing most patients on my own. It was interesting to see how healthcare is delivered in more of a community setting in Botswana, and I enjoyed the autonomy I had there.

PMH was a very different experience from BLH, although the role I played as a medical student was more similar to rotations in the U.S. I was on a team with several medical students from University of Botswana, 2 medical officers, an intern, and a specialist.

Because the teams are so large, it is more difficult to take ownership of patients and do procedures. However, there is more structured teaching at PMH because it is a teaching hospital.


I think that during the rotation I became more confident in the knowledge and skills that I have gained in medical school, as I forced to be a little more independent at times at

BLH. By working with the unique patient population in Botswana, I learned a lot about the management of various opportunistic infections, as well as the complications of AIDS and TB.


There were definitely many times throughout the rotation that I was frustrated with the care patients were receiving. However, I think this is more a part of the learning experience of the rotation as opposed to a weakness. It was a valuable experience to see how healthcare is practiced in different settings, and to try and understand different points of view in the context of an unfamiliar system and culture.


There were definitely many times throughout the rotation that I was frustrated with the care patients were receiving. However, I think this is more a part of the learning experience of the rotation as opposed to a weakness. It was a valuable experience to see how healthcare is practiced in different settings, and to try and understand different points of view in the context of an unfamiliar system and culture.

Gabriel Heiderich, MS4, February 16 – April 3, 2015

gheid@mail.med.upenn.edu


I participated in the internal medicine clinical elective in Botswana. I spent three weeks rotating through Princess Marina Hospital, in the capital, Gaborone, and three weeks rotating through BLH, in Ramotswa, a smaller town about one hour away. The initial week was spent as orientation, during which we shadowed in various outpatient clinics.

This was an internal medicine elective, and as such consisted primarily of rounding on inpatient medical floors and completing daily tasks related to patient care. At PMH, in

Gaborone, you are part of a much larger medical team consisting of an attending, an intern, a resident or medical officer (someone who has completed 1 year of internship only), and several local Batswana students. At BLH, in Ramotswa, you are working together with only one other person, a medical officer, and as such are given more responsibility and autonomy. The clinical experience was very different from what we experience at HUP. In terms of patients and cases, your patients are predominantly

Batswana, with some Zimbabwean immigrants, and you see much more infectious disease and AIDS-related opportunistic infections than in the states. For example, cryptococcal meningitis was an almost daily diagnosis. Additionally, you are providing care in an environment with lower resources and a much lower level of organization and administration, which can be frustrating at first in terms of learning how to navigate the hospital and professional culture.

During the course of your rotation, you live in a housing complex with several other Penn students, residents, and attendings. This provides a collegial environment in which you can seek help from the residents and run things by them from cases you had that day.

Additionally, it provides a good social structure, and you quickly become friends with your housemates as you eat, drink, and travel together. You get all your weekends off which allows for awesome weekend trips.


I gained a lot of practical experience drawing blood and putting in IVs. Some other students got a lot of lumbar punctures as well, so there are a lot of clinically-related accomplishments that you may not have as much opportunity for at HUP. I learned a lot about myself in terms of how I deal with certain types of adversity or frustration, and I grew a lot through my experiences in Botswana.


At Princess Marina, the teams are quite large, so I often felt like an odd appendage that was struggling to participate in patients care or get procedures. This was not the case in

Ramotswa, where I felt valued and helpful.


Bring sunscreen and Purel- both are essentially non-existent in Botswana and the hospital often runs out of the latter so it ’s nice to have your own supply. It is an incredibly exciting, eye opening, and thought-provoking experience, but it does not come with its own set of unique frustrations. People often expect the frustrations that may come with working in a resouces limited environment. What I did not expect, however, was the frustrations stemming from differences in professional culture, work ethic, and general attitude towards medical care. Some people may seem lazy or callous at first, but remember that this is a reality that they deal with every day, and you are a visitor, so do

your best to try to understand where certain behaviors or attitudes are coming from and accept the for what they are.

Kenji Taylor, MS4, February 16 – April 3, 2015 taylorni@mail.med.upenn.edu


The Botswana-UPENN Partnership (BUP) is a long-standing partnership between the

University of Botswana, University of Pennsylvania and Governemnt of Botswana. Their three aims are clinical care, education and research. Fourth-year Penn medical students can do a 7-week medicine sub-internship through BUP that consists of clinical care at two different sites: Princess Marina Hospital (PMH) - an urban tertiary referral center - and Ramotse District Hospital - a smaller community hospital in rural Botswana. Clinical duties at these sites span adult male and female, maternity, pediatric and TB wards.


I spent 4 weeks at the district hospital and 2 weeks at PMH, both very different clinical experiences. The four weeks at the district hospital were more rewarding personally and educationally because I worked one-on-one with a medical officer caring for patients with common illnesses affecting the people of Botswana. My time at PMH was spent on a large team of medical students, interns, residents and attendings. The organizational structure was similar to that of a team in the United States, but rounds were still quite different and attending-dependent. While I had less patient interaction on the PMH teams, I did have more exposure to more complicated disease processes and got a better understanding for medical student education in the country.


The experience overall was incredible and eye-opening in many ways, not so much about the issues of resource-limited settings but how I would cope with being a provider in a resource-limited settings. I think the orientation could have been more "orienting" and provided a clearer sense for what our role would be in the different hospitals. I didn't feel prepared once I came in and it was ultimately up to me to carve out some role on the different teams. I also think more language training, other than one afternoon session during the first week, would have been helpful. People in Botswana really expect you to start picking up the language and more than just appreciate the effort - it’s an implicit expectation for foreigners. I felt grossly incapable of even basic Setswana and I think that deficiency could have been addressed through regular language class.


Brush up on Setswana or get a good resource for the language. You may not be fluent or conversational or even able to elicit any meaningul patient history, but you'll build bridges with local staff if you show an aptitude for their language. Be prepared for downtime. The clinical day is much shorter than in the United States and unless you have weekend trips planned (which you should!), you will have time to workout, cook, read and do those things you've denied yourself for large chunks of medical school.

Finally, be patient! Everything takes more time in Botswana and no amount of pushing makes things move any faster.

David Sterken, MS4, January 5 – February 20, 2015

sterken@mail.med.upenn.edu


I went for a 7-week rotation. The first week was shadowing in clinics and a rural hospital in Mochudi to get accustomed to medical care there, then I spent 3 weeks doing clinical work at Princess Marina Hospital (public referral hospital) in Gaborone and 3 weeks at

Bamalete Lutheran Hospital (another rural hospital) in Ramotswa. At Princess Marina, the work consisted of being part of a typical medical team, whereas at Bamalete

Lutheran it was just me and a medical officer rounding on patients.


I had the opportunity to care for patients with conditions I had never seen before, manifestations of conditions I had never seen before, and in a context that was vastly different from the US. I also got to perform a number of procedures, see how the medical system is constructed in Botswana, and gain a general sense of the culture there.


Everything you do there has an educational value, but there are definitely things that can be frustrating. Poor patient outcomes are often a result of limited resources and public health shortcomings, but are sometimes simply due to inappropriate care, administrative problems, or negligence on the part of medical or nursing staff, which is much more difficult to accept. Still, this added to my understanding of the problems that need to be addressed in global health, so it was beneficial for me to have that exposure, even if it was disheartening.


Go in without any specific expectations but do go in ready to be as engaged as possible.

There is a lot that you can learn and you can be very helpful as well, but not if you are essentially just shadowing. That said, there will be times when your suggestions are not taken even though you may know they are the medically correct cour se of action. In these situations, just try to constructively and politely explain your point, but be prepared to accept their decision and work from that even if you disagree.

Andrea Barberio, MS4, January 5 – February 20, 2015 landre@mail.med.upenn.edu


I participated in the Botswana clinical elective through the Botswana UPenn Partnership.

I spent the first week in various clinics at Princess Marina Hospital, including a day at the cervical cancer screening clinic. Then the following three weeks I was a part of one of the general medical teams at Princess Marina. The remaining three weeks I spent at a district hospital in Ramotswa, where I had more freedom to round with and help out on any of the wards there.


Through this experience, I was able to gain a very unique perspective on medicine through global health. It was eye opening to be able to observe medicine in an underdeveloped country. It was especially interesting to see the extent of disease the human body can withstand and recover from. It was also eye opening to see the ways in

which the availability and extent of healthcare changed cultural perspectives on disease and death.


Overall it was an amazing experience. There is little I would change about the clinical aspects of the program. My biggest critique is that the start date for the

January/February rotation should ideally be moved back by a week. In Botswana, everyone is away on holiday until about the middle of January so arriving and starting on

Jan 5 was problematic. My flight arrived on Jan 2, which I had gotten approval for beforehand, but when I arrived no one was there to pick me up from the airport and no one was available to come pick me up. There was no one living in the apartments and no one with keys to the apartment. Then when starting the rotation on Jan 5, little was planned for that first week, because no one was in clinic and we often did not know what we were supposed to be doing the next day until about 10 PM the night before.


Have fun and enjoy Gabs! Keep an open mind and observe as much as you can while you are there!

Caitlin Colling, MS4, June 21 st –August 7 th , 2015 ccolling@mail.med.upenn.edu


I took part in the Botswana clinical elective and rotated through the inpatient medical ward at Princess Marina Hospital for 2 weeks and BLH, a smaller hospital in Ramotswa, for 4 weeks. The first week of the elective was orientation. The orientation week was interesting and a helpful way to orient to Bostwana. I spent one day at a smaller hospital outside Gaborone and one day in cardiology clinic. Each Wednesday for the seven weeks are spent at HIV failure clinic with one of the ID specialists. It is shadowing, but it is incredibly useful to become familiar with HIV medications, the first, second and third line treatments in Botswana and more complicated management decisions like side effect profiles and number of pills. The inpatient time at Princess Marina was my first two weeks and was very much like an inpatient elective in the US, except there was no prerounding and I spent a lot of time running around looking for charts, lab results and xrays. It took a while to adjust to the system -paper charts and Xrays, handwritten notes during rounds, etc., but it was nice to sit back and take in medicine in another environment. I saw a good number of cases many similar disease processes as in the

U.S., but also some more advanced cancers and advanced HIV. While at Princess

Marina, I attended morning conference on Monday, Wednesday and Friday. The last four weeks were at BLH where I rotated on the male medical ward. I really enjoyed my time at BLH as I felt like I contributed significantly to patient care and saw cases more thoroughly than I was able to at Princess Marina. I rounded on the whole ward with the attending and wrote notes and developed plans. Many patients here spoke only

Setswana so often it was necessary for the nursing staff to translate. For me, it was difficult to adjust to the limited use of labs and not infrequent patient death from an unknown cause.


I have never done a clinical elective outside the US, so I was grateful for the opportunity to learn in a new environment and see patient care in a different setting. It was nice to be

able to teach residents and attendings at BLH about differences in how we provide care and apply what I learned in my clinical electives at Penn to patients in Botswana. I felt much more like I was contributing that I ever have at Penn.


None

Tips for future program participants: Like many other people have written - it is important to download apps on your phone that you can use without internet. I used Micromedex and the Hopkins Antibiotic Guide often. Since the internet is slow, I would recommend downloading these while still in the US. Also, I bought data for my phone so I was able to look things up in the hospital which I found very helpful. Enjoy the opportunity to travel on weekends. Bring books because Gaborone isn't the most hopping of cities!

Frederick Lin, MS4, May 18- June 26, 2015 fredlin@mail.med.upenn.edu


Medicine rotation under the UPenn-Botswana partnership.


To experience and practice medicine globally in a resource-poor area. To interact with physicians and residents of different training.


This was an amazing experience that I would recommend to anyone who is interested in global health. You will gain firsthand experience as to what medicine entails in a resource-poor environment. It is a well-run program and there was a lot of flexibility in being able to pursue whatever interests you have. The faculty working for the partnership are amazing people and very helpful in getting you into whatever interests or goals you have in the rotation. It was also fantastic to have housing set up already and be able to live with students and residents from all over the US who have come to rotate at the BUP program.


There is no question that the rotation will be frustrating at times due to the very different culture of medicine and availability of resources there. It is always important to be understanding of this difference in the culture of practice.

As far as tips go, packing light is helpful. The only piece of equipment you might need is your stethoscope and maybe some edition of Pocket Medicine. There is zero need for a white coat, or any of your reflex hammers/tuning forks. As far as clothes to pack, it is a pretty dress down environment, so if you are a guy, some dress shirts and slacks are fine, no need for ties. It does get pretty chilly in Botswana during the winter, so definitely bring a jacket and a fleece/sweater of some sort. You will have time during the weekend to travel, so definitely take advantage of those. There is a rhino reserve several hours away, as well as the salt pans, Chobe national part and Victoria Falls as well. Some are accessible by bus, while others you would need a car.

Geoffrey Rodriguez, MS4, September 14- October 23, 2015

rodg@mail.med.upenn.edu

Description of Program:

I spent the majority of my time on the Botswana - UPenn clinical elective at the district hospital in Ramotswa. I split my time between male medical ward and female medical ward, seeing a variety of both infectious disease and non-infectious disease pathologies.

I worked directly with the medical officer in charge of each ward. We would round on all of our patients every morning, talking to them, performing the physical exam, and discussing the plan. I was responsible for writing the progress note for each patient, as well as the discharge summaries. I also spent time at Princess Marina Hospital in

Gaborone, where I worked on a team of one specialist, two residents, one intern, and 5 other medical students. I was assigned my own patients, following them from admission through to discharge, and would present them on rounds each day. Additionally, I spent one day a week in infectious disease clinic, seeing patients who were failing their HIV therapy. I would see patients on my own and then present them to the specialist, who would then come see the patient.


I was able to perform many procedures during the clinical elective, becoming comfortable with phlebotomy, lumbar puncture, and thoracentesis. I also learned how to manage patients in the setting of limited resources, and how to recognize disease processes that I had not previously seen in the US, such as abdominal tuberculosis and cryptococcal meningitis. I also developed confidence in coming up with a plan for the patients, as the medical officers would sometimes look to us for more nuanced patient management questions. Working in the infectious disease clinic also gave me a stronger understanding of different anti-retroviral drugs, their side effects, how often to check viral loads, etc.


Not speaking any Setswana made the experience a little more difficult than I was anticipating. Most of the patients in the district hospital and some in Princess Marina did not speak any English. This definitely limited my ability to connect with many of the patients or provide any counseling for their families. At the district hospital some of the medical officers spoke Setswana, while others didn't, so we would need to find a nurse to translate when I was working with the medical officers who didn't speak Setswana.

While at Princess Marina Hospital, I found it difficult to learn the system and paperwork, and had to be constantly asking questions to get my work done (which tube should I use to run a lab test, what form do I need for a dietition consult, etc). Consequently, I felt pretty inefficient and spent a lot of my time looking for someone to help me. It was also difficult to see patients have poor outcomes because of limited resources, and resource mismanagement at the administration level.


I would try to learn as much Setswana as possible to make the most of patient interactions. Obviously it is a difficult language to learn quickly, but having a few more phrases than the basic greeting would definitely be useful. Bring pocket medicine. I used it every day and it helped to resolve many of our questions about patient management.

Make sure to keep reading about patient's pathologies outside of the hospital as well, as you won't always have a consultant for every condition. For example, we had a patient with cryptococcal meningitis, who we read should have been getting more frequent lumbar punctures than she was getting.

Hugues Yver, MS3, May 18-June 26, 2015 hyver@mail.med.upenn.edu

Description of Program:

I participated in the MS3-MS4 7-week clinical medicine program based out of Gaborone in Botswana. There, I lived at the Penn residence named Pilane Court, along with 2 MS4 classmates, several Penn residents as well as a few medical students from other schools that joined us near the end of our experience. As a start, the location of Pilane

Court is ideal, with groceries at "Main Mall" a short walk away, a gym available ("Jack's

Gym") a short bus ride away, and, importantly, the main hospital Princess Marina is only a 10 minute walk. When we first arrived in Botswana, we had a week of orientation where we rotated through several different services and had some lectures as well to better acclimate us to our new environment. Two of us then spent the next several weeks at a rural smaller community hospital BLH, about an hour drive away. I spent 4 weeks at BLH before finishing up my last 2 weeks at PMH. At BLH, I mainly worked on the Male Ward with the Medical Officer (MO) in charge. The two of us would go through rounds together every morning, one patient at a time. We would get an update on the patient from nursing, speak with the patient, examine him to see how their physical findings were progressing and review any labs that might have returned. With supervision from the MO, I was in charge of deciding the plan for the day, writing the note, and ordering any medications/tests that needed to be coordinated with nursing. It took several weeks to really get used to the increased responsibility of doing all these new tasks that are directly supervised by an intern or a senior resident back at our home hospitals in Philadelphia. Many times, the MO would simply agree with my plan without much discussion, even when I wasn't very sure of myself. It helped to have a classmate at BLH with me working in the Female Ward who I could easily call over for help, and vice versa. I think a very big help for us was having the Pocket Medicine tool as well as the Sanford Antibiotics guide to help us through the more difficult cases we encountered, and in particular for medication dosages, and oftentimes it was patients with conditions that are not as common back at Penn. But after a few weeks, you do gain a certain level of confidence in your plans - it really felt like what I imagine new interns go through at the beginning of residency! The afternoons were typically reserved for the actual work to be done on all the patients you rounded on in the morning - tasks such as blood draws,

LPs, thoras, paras etc… Most of those tasks were performed by us, which was great experience! Before leaving for the day, we would write up discharge summaries and update the MO on the patients' progress that day/sign out any remaining work to be done. It’s a good tip to know that not much gets done in the afternoons, so it’s important to prioritize your work to make sure what needs to get done that day is accomplished by the time you leave! We typically would get back to Pilane Court around 3-4pm, and did different things at night - e.g. exploring the city, hitting up the gym, going to Zumba right next to Pilane (!!).

My 2-week experience at Princess Marina Hospital was a lot different. I spent the majority of my time on the pediatric ward, working on a team with a CHOP attending who worked in Botswana full-time as well as a visiting CHOP resident. In those circumstances, I learned a whole lot and had a lot of guidance, and overall it was a very pleasant experience, albeit with a lot less to do and much less autonomy.

Nice perks of going to Botswana too is the traveling you can do on weekends. We took weekend trips to Madikwe and Cape Town in South Africa, to Serowe Rhino Sanctuary,

to Chobe and Victoria Falls and much more. That was really great, and it truly is a beautiful part of this world I had never been to before!


Overall I think I contributed to patient care on a daily basis at a level I had not before. It meant a great deal of responsibility, but we really enjoyed working in that environment.

We were exposed to patients and diseases that we had never treated before, so it was a great learning experience at the same time. Unfortunately, patients also come to the hospital a lot sicker, and death is much more of a common occurrence than we are used to in Philadelphia. Given the amount of death, we really tried to treat every day as a new start, as we had no idea what to expect once we reached BLH in the morning - whether the ward was emptied because several patients died the night prior or if there was an overflow of patients etc. What was really tough at first was the feeling of not being able to help as much as we could due to not only the lack of resources we are accustomed to

(getting labs quickly, imaging equipment often down for maintenance…), but especially the lack of good management in general. It was very hard to get the right people on the phone to transfer a patient, or to obtain a lab result only to be told that they ran the wrong one and we had to wait till the following day, or that a head CT for a possible stroke was not possible for another week, or that essential medications were out of stock due to faulty paperwork. For the first few weeks while you learn the ways around the hospital, it gets to be overwhelmingly frustrating at times, in particular when patients' lives are literally in the balance, but once you realize that you cannot possibly win many of these battles, it becomes a lot easier to handle. It's just something I wasn't prepared for, and would have been useful to know.


It was an overwhelmingly positive experience, and I think it's hard to be fully prepared for what you'll see, do and accomplish once there. Preparing students with testimonials from peers of exactly what they might face - the burden of disease, the amount of death and the frustrations that are inevitable with the system - might be beneficial. Also having a little leeway in being able to rotate in different departments that students might be interested in could be useful - e.g. if interest in EM, allowing that student to take shifts in the ED (or "A&E" there) would be helpful.


1. Bring Pocket Medicine and your Sanford Guide if you have one. 2. Don't hesitate to take charge on rounds if you have an idea or thought on patient care - more likely than not, you'll be right and the plan will be better for it. You'll quickly realize you're a valuable asset to the team, and it's important to speak up and ask questions. 3. Take advantage of the traveling opportunities!!

Joanna Stephens, MS4, 6 weeks stejoa@mail.med.upenn.edu


BUP program through Penn: I spent 6 weeks as a medical student at two different hospitals in Botswana. I spent 4 weeks at Bamalete Lutheran Hospital in Ramotswa and

1 week at Princess Marina Hospital in Gaborone. I also participated in the HIV

Resistance clinic each Wednesday at Princess Marina.

The experiences at BLH and PMH were very different. At BLH, i enjoyed being on a smaller team and working one-on-one with the medical officer, although the learning experience depended on the officer. Dr. Khothlane was really excellent and taught me a lot during my time with him. He was also very knowledgeable. Dr. Mwanza was more difficult to work with, mostly because he wanted me to lead rounds and to take on more responsibility than I felt comfortable with. He reluctantly took a more active role in rounds when I explained why I needed him, but it was a somewhat uncomfortable situation.

Another frustrating aspect of our time at BLH was the lack of a functioning lab. For 4 weeks at BLH, we had no basic metabolic panel and only coagulation panels once a week —if we were lucky. That was a good learning experience in how to make clinical decisions without the resources we are accustomed to in the US.

The time at Princess Marina also very dependent on which doctor was supervising the team. Working with Dr. Haverkamp was the best learning experience, as she has a phenomenal knowledge base and is an excellent clinician. I enjoyed working on a team with multiple med students —- they were very friendly and helped to show me the ropes in the hospital. The hardest part of Marina was dealing with acutely ill patients who would have been transferred to the ICU in the US, but who simply suffocated to death on the general wards because the ICU space is limited in Botswana. During my last week, I worked with a young woman who came to the emergency room 7 months pregnant with symptoms of pneumonia. She had been waiting 12 hours by the time I took her history, at which point she was really struggling to breathe. She should have been intubated and sent to the ICU. But she was HIV+, and they generally don ’t send HIV+ patients to the

ICU. I told her we were going to start her on intensive antibiotics and fluids and that the obstetrician would come and examine her. As I was leaving, she took my arm and said

“I’m dying, you’ve got to help me.” I reiterated all the things were were going to do for her to take care of her. But she died several hours later because nobody would intubate her or send her to the ICU. Her death was very hard to accept because I know that she and her baby would have probably survived in the US. I think these kinds of experiences were the hardest part of working at PMH. Perhaps the most frustrating thing is that

Botswana is a relatively wealthy country and could afford more ICU beds and better access to primary care if they invested more in their health system.


I felt that I built good relationships with my patients and the staff at both hospitals. I also significantly improved my skills in phlebotomy .


One aspect of the rotation at Marina that I found somewhat awkward was the different expectations of shift length for Penn students and the Motswana med students. They essentially have to stay around until 8 or 9 pm on call days, and typically 5 on non call days. I finished admitting my patient at 6pm on one call day and was told by my Penn resident to come home with her. It felt uncomfortable. On the one hand, I would have just been sitting around without anything specific to do in the hospital and the resident was telling me to come with her. On the other, explaining to the Motswana med students that I was going home while they had to stick around felt like I was getting special treatment as a foreigner. I almost wished the requirements were more stringent for us as

Penn Med students —-that we needed to stay on the same schedule as the local students to avoid giving the appearance that we can just pop in and out of the hospital when we want.


I wish I had learned more Setswana before going. I think it would have helped me interact more with the patients. Phrases that were especially useful were those for phlebotomy: “I’m going to take a sample of your blood.” “Make a fist.” “This will hurt a little ”. Also introductions: “I’m a medical student. My name is ___” There is an iPhone app you can download for medical Setswana that would have been super useful.

Unfortunately, my phone wouldn ’t let me download it while i was there, which i found very frustrating. I would recommend downloading it before you leave the US.

I also REALLY recommend downloading the Medscape app to your phone before you leave. There is no internet in the hospital and you don ’t want to use your roaming. I didn ’t download it before leaving, so I had to read up on diseases at home and then return the next day with my plan. One of the other students had the app on her phone and was much more useful in the hospital as a result.

Kendra Moore, MS4, August 3- September 18, 2016 mooreken@mail.med.upenn.edu


While in Botswana, I rotated on the general medicine wards in two hospitals. I spent the first four weeks at Bamalete Lutheran Hospital in Ramotswa (~45 outside Gaborone).

BLH is a mission hospital that is staffed almost entirely by medical officers. There are no other students there and available diagnostics are limited. When rotating at Ramotswa, I had the responsibilities of a resident- rounding on all of the patients, setting the plan for the day, writing notes and performing procedures, under the supervision of the ward's medical officer.

After working at BLH, I spent 2 weeks rotating at Princess Marina Hospital, which is

Botswana's main public referral center. This was a very different experience, as I was on a team with four Batswana medical students, two interns, a resident, and two specialists.

Here my role was largely observational and the medicine was quite different. Doctors at

PMH have access to many more diagnostics and have a more academic environment in which to gain input from others on the management of patients.

Throughout the rotation, I spent Wednesdays at the Infectious Disease Care Clinic

(IDCC), working with Dr. Haverkamp, the clinical director of the rotation and Botswana's leading HIV expert. These clinics were primarily devoted to treating patients with virologic or immunologic failure of HIV treatment, however at times I would join Dr.

Haverkamp to see complex medical patients on the wards on which she had been consulted.


My primary goal and accomplishment of the rotation was gaining an understanding of how medicine is practiced in Botswana, and the unique challenges that are present in a low resource setting. Additionally, my time at BLH allowed me to function at a higher level of responsibility than I am used to in the Penn hospitals, which allowed me to grow in my ability to manage a large number of patients. My teaching skills also improved, as there were a number of topics about which I was able to share information/guidelines/tools with the medical officers. Lastly, I was able to improve my procedural skills.


This is a wonderful opportunity that I highly recommend to any student interested in global health who is able to "go with the flow". Given that the program has been functioning for years, the infrastructure is well-developed and things generally run fairly smoothly. While the barriers to the highest standard of care are at times overwhelming, there is ample opportunity to make an impact here and educate while learning. There is also a ton of opportunity to read about conditions that you see in your patients, and then translate that reading immediately into treatment decisions.

I would not recommend this opportunity to students who struggle without creature comforts, or who have a difficult time letting go of organization and routine. Conditions in

Gaborone are not bad, but they are not what we are used to in Philly. A water shortage was a key issue while I was there; we had running water at home approximately 60% of the time. Things don't run efficiently here, and those who are bothered by wasted time will find themselves with a constantly high level of anxiety. Finally, students should be prepared to see patients die of illnesses they would not die of in the United States.


Before leaving the US, I recommend downloading Micromedex and Medscape to your phone. Also definitely bring your Green/Purple book- you will refer to it constantly! I also recommend downloading some entertainment materials (think, TV seasons to iTunes! and many, many ebooks) because you will have a lot of free time without access to fast internet!

While you're there, definitely go to Tau at Madikwe, and consider a trip to the Salt Pans if they aren't flooded. No. 1 Ladies Café will improve your day when you're about to go insane without good internet and good coffee.

Kendra Wulczyn, MS4, October 29- November 27, 2015 kwulczyn@mail.med.upenn.edu


I participated in the 6 week-long clinical elective for medical students in Gaborone,

Botswana, as a part of the UPenn-Botswana Partnership.


This was a difficult, yet invaluable, experience characterized by much personal growth and a greater understanding for the culture of Botswana and the challenges facing healthcare on a global scale. In my role as a medical student, I had the opportunity to both observe and assist with the care of complex medical patients. I was helping to take care of patients with advanced stages of diseases that I had frequently studied in medical school but never experienced first-hand. This was, at times, both frustrating and rewarding. In my time at Princess Marina Hospital, I felt that I was able to integrate myself well into the care team and carry out responsibilities expected of me in my role as a student. I enjoyed getting to know and work with the University of Botswana medical students as well as the other members of my team. I was also able to follow the course of numerous patients on our service and enjoyed getting to know them and to participate in their care during their stay. During my time there I also became proficient at blood draws and IV insertions. My fellow medical students and I also enjoyed our time in highresistance HIV clinic every Wednesday morning. At this clinic I was able to see patients

on my own and then precept with one of the local physicians. I learned much about the approach to treatment of HIV and was able to have some longitudinal relationships with patients in the clinic over the course of my time there. My role during the weeks at BLH, however, was slightly less structured as compared to Princess Marina. At BLH I spent time on both the male and female medical wards rounding with a local medical officer. In some instances, I was able to take the lead in the counseling and education of patients.

For example, I helped to diagnose a woman with migraines and then played a role in the decision of choosing her medication regimen and explaining the source of the symptoms to the patient. For another patient, I was successful at advocating for the start of empiric tuberculosis treatment. However, these small personal successes occurred alongside very challenging and disappointing cases. We had a patient on our ward with suspected esophageal cancer who was unable to eat or drink anything for days. Because of the structure of the health care system, difficulties with access to care, and limited resources in terms of enteral nutrition, I watched as the patient wasted away and eventually passed away, feeling that I should have done more to help her but not understanding how best to make a difference. Though sad, experiences such as these also served to teach me about the way in which the people of Botswana think about death and dying and the role of medical interventions. Despite the somewhat challenging and frustrating nature of patient care in Bostwana, I feel that the experience as a whole was quite rewarding and beneficial and I feel lucky to have had this opportunity.


I alluded to the negative aspects of my experience in the paragraph above. I think the most difficult part was being involved in the care of patients in situations where I had concerns about the standard of medicine being practiced but felt that I did not have enough knowledge or experience to make a change. This was not wholly unexpected and though it was difficult I still felt supported by Dr. Haverkamp and my other colleagues in Botswana. I have one suggestion for improvement. I think that orientation in Philadelphia should include more specific details about what to expect in the hospitals

- preferably from a medical student who has already made the trip. It would be helpful to hear what the experiences of former students have been and how best to approach this rotation, where healthcare is delivered in a manner much different than in the US.


Try to decide early on what you'd like to get out of the experience and what you want your role to be in the hospital. Unlike at Penn, the learning environment is much less structured so I found it helpful to have a plan in my mind of what I wanted to get out of each day. If you want to get involved with procedures, there are a lot of opportunities but you need to be proactive early on. Or, maybe you decide to pick one patient every day and research one aspect of their care plan that you'd like to discuss with the team the next day on rounds. In general, people are very willing to listen to your ideas on patient management and make changes based on your suggestions, but for me that meant that

I needed to do a lot of reading on my patients before I was comfortable making such suggestions. No one is telling you what you should be doing on a daily basis, so I thought it was a good idea to try and make goals for myself.

Miranda Farmer, MS4, October 3-November 29, 2015 mfarm@mail.med.upenn.edu


Botswana medical student internal medicine elective.


I gained a lot of confidence in my clinical skills and got a lot of exposure to fascinating medicine (particularly infectious disease) that I wouldn't ordinarily encounter in the US. I also gained a much better understanding of the medical management of HIV.


Overall, I loved this experience. It was easy to arrange, which was a huge factor in making it possible for me. I also really appreciated the split where some of my time was spent at Marina and some at BLH, as the experiences were fairly complimentary.

While I had a few bad experiences, particularly with one attending at Marina, the good moments were more than enough to make up for the frustrations. I particularly loved the patient population. It's hard to put into words what made Batswana so wonderful to work with, but it is definitely a big part of what made this experience so rewarding. It was also fascinating to see the similarities and differences between the common medical problems here and there. For example, metabolic syndrome was still a major issue, so a lot of my patient visits felt surprisingly similar to Philadelphia, except that our discussions of diet, etc. had a few substitutions. Dialysis was approached quite differently - there is one doctor in the whole country who does dialysis, so instead of doing lots of labs and individualizing the formula for every patient, everyone gets the same basic formula. Yet despite this, the outcomes seemed quite similar. I also really appreciated getting to know some of the MOs and residents there. They had some amazing experiences and a lot to teach.

I was emotionally prepared for the challenges of bad outcomes because of limited resources, but I wasn't prepared for some other elements of this experience. There is a different style of practicing medicine that is common there which I had a hard time adjusting to. Vitals were rarely mentioned on rounds. In one instance, the emergency department was telling us about a patient they had successfully coded and when I asked what his blood pressure was, they said "oh good question - we should check that."

Instead of having a problem list where the main problems have a differential diagnosis, patient assessment and plans would be much shorter and to the point, both in notes and in presentations. At Penn, I am used to the evidence-based, academic approach to medicine, and it was a bit shocking to transition to this more haphazard, flying by the seat of our pants approach.

Here is a list of changes I think might make the program better:

-Email the students who are going in advance to put them in touch. It would also be nice to give them a list of others who will be in Botswana at the same time. It would also be nice to email the group in Botswana when someone new is about to arrive so that they are ready to welcome the new arrivals and can plan accordingly. We tried several times to get this list from the staff in Botswana but were unsuccessful.

-If possible, it would be wonderful to have weekly didactics for the medical students on rotation there. The attendings there (e.g. Miriam Haverkamp) could take the lead on this but I'm sure the fellows and residents who rotate there and do research would gladly help teach these.

Tips for the future participants:

Take the preparation seriously! The more you can learn about relevant topics before you get there, the more comfortable you will be. You will often feel like you aren't supervised as carefully there compared to Penn - it is rare for anyone but you to look something up instead of just guessing when a clinical question comes up on rounds, so what you say is usually trusted and can have huge impacts on your patients. So, the more you can be prepared and knowledgeable, the more you will be able to take good care of your patients.

Robert Bonacci, MS4, August 3-September 18, 2015 rbonacci@mail.med.upenn.edu


As part of the 4th year general medicine elective, I spent 3 weeks at Princess Marina

Hospital in the capital and 4 weeks at BLH, a district hospital in Ramotswa. As part of the medical team, I attended morning meeting each day followed by rounding on the male and female medical wards of each hospital, caring for the patients alongside local

Medical Officers. After rounds were complete, we would carry out any procedures or tasks needed to complete the plan of care for the patients. I was able to do many procedures with oversight and then independently including thoracentesis, LP, paracentesis, blood draws, and IV insertion. On Wednesdays, I'd go to HIV treatment failure clinic, where we would see patients with BUP physicians who were on 2nd and

3rd line ART. You may also have a chance to attend specialty outpatient clinics if you mention specific interests. On a larger scale, the program is designed to introduce you to medical care in a lower resource environment (though notably, this is a relatively resource rich country in Southern Africa). You learn about the public health challenges posed by HIV and TB, about how the rise of non-communicable diseases is altering the disease burden of the population, about how to care for patients when our traditional diagnostic methods aren't necessarily available. Throughout the rotation, you have a few check-in meetings w/ Dr. Miriam Haverkamp, who is the medical coordinator of the rotation.


I think what I'm most happy to have achieved here is to gain a broad picture of the provision of healthcare and the public health challenges involved in treating the HIV and

TB epidemics here. The burden of HIV and TB are so high that you can't help but be learning about these diseases constantly, both in terms of how to diagnose and manage the conditions as well as the overall implications to the country. I was also happy to gain additional procedural experience, to learn how to care for patients in a diagnosticslimited setting, and to build meaningful relationships with medicine colleagues here who shared so much about medicine and life in Botswana.


I don't have any major program critique. However, I will note that Princess Marina can be a challenging place to work due to the large nature of the medical teams. For example, a usual medical team there is composed of 1-2 attending physicians, 1-2 residents/medical officers; 0-1 interns, and 3-4 University of Botswana medical students.

Because there are so many individuals, it means that you often lack a real role on the team and have trouble finding out how/where to contribute to patient care. It certainly takes more effort to speak up and be willing to take on work, since it will easily be distributed without you having to do much if you're not proactive.


My first tip to future program participants would be to understand fundamentally that you are here to learn and that this experience is a privilege that is provided by the Batswana and the medical professionals with whom you work. Specifically, you are there to learn about the public health and clinical challenges facing Botswana, the resources available to address those challenges, how you care for a patient in a lower-resource setting, and in general how their lives, culture, and care interact. If you remember that you're a guest, an observer, and when able, an enthusiastic contributor to your medical team, you will not bear as much frustration at the many difficulties, management decisions, and delays you might encounter on the wards. Certainly, you should strive to provide the highest level of care possible to your patients and to support your team members in any way you can. But try to keep in context your frustrations about the care you might witness, that not everything is done the same way as at HUP, Presby, etc. If you do this, you will learn a great deal about global health, HIV, TB, and medicine in general. You may also just be able to contribute back a bit to the country, which is giving you this rich opportunity.

Additional suggestions include to take your weekends to explore the different parts of this beautiful country. There is a lot worth seeing, things you can't see anywhere else in the world. Take time to explore your home, Gaborone as well, which incidentally will make you feel less like a stranger.

You should also know to expect occasional to frequent water shortages, power outages, and other frustration that you might not be used to back home. Be flexible and maintain a bit more carefree attitude than you would otherwise.

Sarah Huepenbecker, MS4, August 3-September 18, 2015 hueps@mail.med.upenn.edu


The program is a 7 week clinical elective. Week 1 is an orientation week, with a meeting with the program director in Botswana. I then spent 4 weeks at Bamalete Lutheran

Hospital, a small district hospital in Ramotswa, Botswana, as well as 2 weeks at the major tertiary care center in the capital city of Gaborone, Botswana. Each morning began with a morning meeting, where the hospital doctors discussed new admissions from the previous night and then discussed an interesting clinical case or gave a topic presentation or talked about an ethical dilemma they had faced. After that was rounds, which is organized just like in an American hospital, except the patient charts are all paper, orders are handwritten, and labs are drawn as you go from bed to bed. In addition, the cases are often very different than what you would see in an American hospital. For one thing, HIV and TB are extremely prevalent in Botswana, and many patients present with diseases from one or both of these entities. In addition, basic screening tests are seldom implemented in Botswana, so many patients present very late in the disease process, especially cancer cases. Another difference is the lack of resources that the hospitals have. There is a dearth of diagnostic instruments, so more often than not; we were using our best clinical judgement to treat what we thought the most likely diagnosis was, instead of using confirmatory tests to be sure. For example, there is one CT scanner available to the public hospitals in the whole country. The one x-ray machine at BLH hospital was broken the entire time I was there. And the lab simply doesn't have a lot of the necessary reagents to run the full gamut of tests, even when

labs are drawn, which they often are not. As far as treatments go, there is a very limited selection of medications, especially antibiotics, to choose from. Despite these limitations, the physicians at the hospitals were generally very dedicated, and they taught me a lot as we went on rounds and then completed patient tasks when rounds were finished. The days were much shorter at the hospitals than at Penn, and that went for the doctors as well as the students. So by the time I got home, I had plenty of time to look up clinical information and standard of care medicine, as well as relax by reading, cooking, and hearing about the experiences of my fellow medical student rotators.


Because there are few specialists in the country, and most physicians are generalists who are responsible for knowing every discipline of medicine, they are extremely versatile and must know how to read their own imaging, interpret their own labs, and treat every condition imaginable. I think I got much better at these skills myself. I feel much more comfortable reading CT scans, x-rays, ultrasounds, and EKGs without consulting radiology reads than before I arrived, and this skill will be hugely useful when

I am a resident next year. I also improved my phlebotomy skills, since the doctors usually draw labs on their own patients. My most proud accomplishment, however, was diagnosing a patient with third-degree heart block during rounds one day. The physicians I was working with had missed it, so I felt like I made a big difference in the patient's prognosis. This also inspired me to give a topic presentation on heart block one day during the morning meeting, which I think went over really well and was a useful review for all of the doctors who were present. From a personal perspective, I became much more flexible and adaptable in my living conditions, such as learning to live with unreliable power, water, and internet. I also learned how to navigate the city very comfortably, and really enjoyed exploring the city and country. By the end of the 7 weeks, it really felt like home.


Although I am sure there are reasons to make the rotation 7 weeks, the first "orientation" week was not really necessary, in my opinion. It is helpful to have one day to get over jet lag and meet with the administrator to get your cell phone and learn where to get groceries, etc., but after that I think it would be fine to jump right into the clinical experience. In addition, it would be great if the program could be expanded to include the option to rotate on non-medical services, such as surgery, OB/GYN, pediatrics, etc.

Global health is not just a medicine endeavor, and I think that the program could attract some really great students who are interested in global health but not necessarily in HIV and TB care, and this is a prime opportunity to allow them to explore their own field and broaden their clinical experience.


There is a lot of flexibility for what your experience can look like, based on your clinical interests. I would definitely express your interests to Miriam, the in-country program coordinator, early on and she will connect you to the right people to make your time in

Botswana more relevant and helpful to you. In addition, make sure to use your fellow housemates as resources! There is always a derm resident at Pilane Court, and we often took pictures of our own patients with dermatologic complaints to show to the derm residents later in the day, and this often helped with patient diagnosis and treatment. In addition, your fellow MS4's can often help you work out a tricky diagnosis or provide information that you may have missed, especially because it is very difficult to access resources that are readily available at Penn, such as UpToDate and PubMed (and even

just basic Internet sites sometimes!). I would even consider bringing hard copy books to use.

William Kamens, MS3, May 18-June 26, 2015 wkamens@mail.med.upenn.edu


Clinical rotation in Botswana. This is an internal medicine rotation run by the Botswana-

UPenn Partnership. It takes place primarily at Princess Marina Hospital and Bamalete

Lutheran Hospital.


Independently managed patient care in a developing country with different disease prevalence and resource availability.


This is an excellent experience and would gladly participate again. I would highly recommend it. It is easy to be frustrated by the experience initially, as one may perceive that patients are receiving substandard care, but there is great potential for contributions by medical students at this level of training, and I found the experience highly rewarding.

I would highly recommend it to my peers. There are many opportunities to develop clinical skills including radiology, physical exam, and differential diagnosis.

The living situation at Pilane Court is excellent.

The supervision by Miriam Haverkamp is great.

Participation in HIV clinic weekly was also very helpful; I quickly learned all the major antiretrovirals.


This is an excellent experience and would gladly participate again. I would highly recommend it. It is easy to be frustrated by the experience initially, as one may perceive that patients are receiving substandard care, but there is great potential for contributions by medical students at this level of training, and I found the experience highly rewarding.

I would highly recommend it to my peers. Don't bring your white coat, and bring a copy of "Pocket Medicine."

Penn Medical Student Participants in ID Clinical Elective in Gaborone, Botswana

Penn Medical Student Participants in ID

Clinical Elective in Gaborone, Botswana

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Penn Medical Student Participants in ID Clinical Elective in Gaborone, Botswana

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