Professional Placement 2014
I participated with Work the World as a senior radiology resident from America. I was placed at a private teaching hospital about 4 miles north of the Work the World house in Damside.
The hospital I was based at has a radiology residency program with the standard Nepali 3 year program. This is completed after medical school (M.D. in America, MBBS in Nepal), a year of internship and some serving an additional 2 year medical officer appointment at a remote health care facility. The hospital only has one radiology resident per year and nationwide there are approximately 20 residents planning on taking the final exam as a third year. It is regarded as a highly sought after specialty and traditionally the top scoring interns are selected to participate. This placement is worthwhile for medical students or residents.This is in addition to the program they have for technologists.
Ultrasonography is the primary cross sectional imaging modality, as it is readily available and relatively affordable to the patients.
As an example, a patient presents to general practice or emergency department, with abdominal pain. After consultation with the provider, leading to imaging being deemed appropriate, the patient is first referred to administration to pay the fee (500 rupees/$5 for abdomen and pelvis ultrasound, 3000 rupees/$30 for a CT Scan) and then move on to radiology. The nurse checks the patient in to 'USG', confirms payment by appropriate stamp on the back of the request and assigns their place in the cue by writing the number on the request form.
Sonographers do not exist in Nepal, so by design all sonography is completed by the first year resident, 6 days per week for the entire first year. They generate a Microsoft Word report, print and sign it as final and after the nurse documents the exam as final in the logbook, the report is given to the patient, thus completing their visit with their provider. (There is a similar system for laboratory exams).
The second year performs complex vascular sonography, fluoroscopic exams, mammography, and ultrasound guided procedures while the third year focuses on CT, MRI and preparing for the exam.
After plain radiographs are printed, they are given to the patient to bring to their provider. Very rarely the provider asks the radiologist for a final report. Duty is divided weekly and only ultrasound reports are given overnight by the duty resident. If a CT is performed (fairly rare), the images are printed and given to the provider and a report will be generated in the morning. Since there are 3 residents, they stand duty once every 3 weeks unless the third year is studying for exams, then it would be once every other week. Since the residents sign the final report only an exceptional circumstance would require a staff (consultant) to participate in a duty case. Subjectively it seems the duty resident is usually called a few times before 11 pm and sometimes a few times after midnight. I don't think there is a system in place per se if a resident is awake all night with cases, but I'm certain the other residents and staff would assist as needed.
Given the volume of sonography, 30 to 60 per day, and the technical expertise of the first year resident, Dr. Mahesh, I spent the majority of my time with him. It should be noted that an abdomen and pelvis exam includes right upper quadrant, left upper quadrants, bladder and a transabdominal pelvic exam of prostate or uterus/ovaries. Additionally, if the patient complains of a hernia or superficial lesion, the resident will obtain additional images and report as such.
First, second and third trimester obstetric, as well as scrotum and thyroid, were additionally performed common examinations. As time and workload permitted I would perform the exam and as it became busier I would complete the reports. We had an efficient system in place after a few days.
Other cases came through intermittently: IVP with obstructing stone, esophagram with web, post mastectomy mammogram and ultrasound, a few FNA's and taps.
Diagnostic imaging equipment includes:
- 2 ultrasound (one GE and one Acuson),
- Mammography unit
- Single slice CT
- 0.35 T open MRI and CR radiography suite, which doubles as a blind fluoroscopy unit as the current one is awaiting repair.
- All modalities are printed and there is no PACS system.
- Reconstructions and window and level manipulation occur on the modality QC quality control station as needed.
Nuclear medicine and digital subtraction angiography are not readily available in Pokhara.
There are conferences a few times per month presented by the residents to the consultants (staff) and other residents in PowerPoint format on a computer in the teaching library. There are 30 or so CT and MRI cases on light box display in the library as well.
Appropriateness of imaging exams is an interest of mine in America. There is wide variation in ordering practices and whether or not a patient gets imaging depends on the provider’s training and experience. Given the amount of abdominal/pelvis ultrasound exams I have seen, I suspect increased use of medical imaging is independent of culture.
Abdominal pain is a difficult presentation and it seems, in America, that prompts a CT, while in Nepal, it prompts an ultrasound. Similarly the request states abdominal pain, if anything at all.
The Experience
This was an amazing placement with professional, friendly and very intelligent staff. In addition to the professional experience, my cultural experience in Nepal was unbelievable. Having the local Nepali staff at the Work the World house, I felt like I had an immediate connection with the city of Pokhara. Navigating the bus system, finding the best “momos” (Nepali delicacy), hiking to the Peace Pagoda and cooling off out on a spot by the lake were some of the things we enjoyed with Work the World team.
The house is very well run. It’s super clean, the food is great and the top floor chill out room is a place for an amazing view of the mountains, most notably “Fishtail”. We would read, nap, or study there a few times per week. This is also the place where we had twice weekly Nepali language lessons with Prem.
He was such a great addition to the experience, particularly since I went on the Village Healthcare Experience. Knowing some key Nepali phrases went a long way in having fun with my host. Prem is a creative, professional and experienced teacher. Each week we had a cooking class and while cooking is by far not my forte, it was great to hang with the other students and learn about making “momos” and “dahl baht”.
The Work the World placement in Pokhara exceeded my expectations. The professional and friendly staff at the house was perfect and the people, food and culture of Nepal should be experienced by everyone. I give this placement my highest recommendation.
