As a former U.S. Army medic who had completed two tours in Baghdad, Iraq, Brandon Beattie ’15 was drawn to international medicine. When the Yale Physician Associate (PA) Program — in collaboration with the Office of Global Health, Department of Internal Medicine — gave him an opportunity to be the first PA student to do a formal clinical rotation in Kigali, Rwanda this fall he eagerly signed on.
Yale’s PA program is one of only a few in the country that have strong ties with international rotations, sending several select students abroad per year. The international rotations expose students to different cultures and allow them to sharpen their clinical skills in environments with limited resources. Students have also trained in Peru, Uganda, and Spain.
Window into history
Rwanda is known as the “land of a thousand hills” because of its many sprawling green peaks, upon which whole cities are built. It is also known for the 1994 genocide, which took the lives of an estimated 1 million of its inhabitants in as little as 100 days.
During his month-long rotation, Beattie assessed a patient who still bore scars from the tragedy in the form of several wounds across her forehead and scalp. Like many Rwandans, she had received treatment from traditional healers, but the scars appeared to have healed on their own. “The patient was quick to mention it, then move on,” he said.
The nation’s wounds from the genocide are similarly just beneath the surface, said Beattie. Early in his stay, he visited the Kigali Genocide Memorial, which he described as a moving experience. Just outside the memorial lie two large slabs of concrete, dozens of feet long and wide. “They are mass graves,” Beattie said, memorials where family members and visitors can gather and pay tribute to the fallen.
On the ward
Beattie did his training at Central Hospital-University of Kigali (CHUK), the primary teaching hospital for all Rwandan medical students. According to Beattie’s research, CHUK was built in 1918 by Belgian officials. What began as a four-room hospital with a dispensary is now a 500-bed facility offering emergency and pediatric services. It is the main public medical institution and referral center in the country.
Patients admitted to the hospital stay on the primary ward, where they are kept in close proximity to each other. Patient areas have narrow beds and IV poles as they do in the United States, but family members often bring their own bedding. Each bed also has a mosquito net overhead, which is let down at night and tied in a knot above the bed during the day.
Another contrast with Western hospitals: Much of a patient’s nonmedical care is handled by family members. “The family member takes care of bathing and feeding and also gets the medication,” said Beattie. “It’s a cultural thing — the idea that a family member is going to take better care of you than a stranger. It’s seen throughout that part of the world.”
The aforementioned patient was a 57-year-old Rwandan female. In addition to her scars, she suffered from asthma, chronic pain, chills, cough, fever, and shortness of breath. Her asthma was controlled with medication, and the pain was due to another old injury. With the help of a translator, Beattie took a complete history and conducted a physical exam. Afterward, routine labs and imaging tests were ordered by the Rwandan clinical staff who were working under the supervision of a U.S. attending physician. The initial diagnosis was pleural effusion (a buildup of fluid between the tissues that line the lungs and chest), due to either pneumonia or cancer.
Given the patient’s lack of response to antibiotics, the laboratory findings, and the overall clinical picture, the team concluded that her symptoms were likely due to a malignancy and that she would benefit from a chest CT scan and referral to a specialist. But while Rwanda’s public insurance system — which costs $5 per year in U.S. dollars — gets patients in the hospital door, it does not cover a majority of imaging and laboratory tests such as CT scans. “Almost all payment for imaging and labs is out of pocket,” said Beattie. “The family would have been unable to afford a CT scan.”
At the end of his rotation, the patient was still in the process of trying to secure funds to pay for a chest CT scan. Given her age and the cost of care, it’s unclear what the patient would do with the results even if she had been able to afford testing, noted Beattie.
Despite its limitations, the health care in Kigali was excellent, said Beattie. “What was most surprising was the quality of healthcare with such limited resources,” he said, noting that’s due in large part to the fact that clinicians have been well trained in the Western model and have access to many of the same journals and websites as U.S. providers. “They were already very knowledgeable,” said Beattie. “The deficit comes in critical thinking in using that knowledge.” In addition to his role as a student on the team, he taught classes to the medical students and resident physicians, including one on how to conduct a neurological exam on a comatose patient.
Another eye-opener was the issue of cost and how it affects care. Since patients pay for tests and imaging out of pocket, the cost of each test is factored into medical decision-making. “Rwandan clinicians have a profound working knowledge of various sensitivities and specificities of the tests they order. There you would only see a couple of tests run because patients have to pay for it,” said Beattie. This perspective has already influenced how Beattie thinks about medical management and cost-effectiveness.
Key to his experience, and that of other PAs who might consider a rotation abroad, is having an open mind, said Beattie. “I would recommend it to PA students who have an interest in international medicine but who are also willing to leave judgment at the door and take from it what they can.
“Training in Rwanda was one of the highlights of my training at Yale,” he added.