Residents who participate in the Resident International Grant spend four to six weeks living and working in Gaborone, Botswana. Approximately three days a week, 20 to 40 patients are scheduled in the outpatient “Skin Clinic” on the Princess Marina Hospital campus. The resident often sees patients independently but also works together with the other public sector dermatologist. Each weekday, the resident is responsible for seeing the clinic patients, working with the pathologist and microbiologist at the neighboring National Laboratory to follow up on the clinic’s pathology and laboratory results, and providing pediatric and adult inpatient consultations at Princess Marina Hospital. Residents are expected to keep a basic log and when appropriate photographic record of patients that they have seen. The common diagnoses include much of what is seen in a general dermatology clinic in North America, such as acne and atopic dermatitis, with an emphasis on photodermatoses, including discoid lupus and phototoxic and photoallergic medication reactions; pigmentation abnormalities; oculocutaneous albinism; and infectious disease, including superficial fungal and bacterial infections. Also seen are many manifestations of HIV, such as papular pruritic eruption, herpes virus infections, human papilloma virus infections, molluscum contagiosum, deep fungal infections, atypical mycobacterial infections, and Kaposi sarcoma (). The hospital pharmacy stocks a very basic formulary and medication is provided to the patients at low or no cost through the public health care program.
(A) Clinical image of a patient at Princess Marina Skin Clinic with Kaposi sarcoma. (B) Photomicrograph taken using remote microscope. (Courtesy of Dr Saurabh Singh, MD, Washington, DC).
Capacity-building in the form of dermatology education to local health care workers is a crucial component of the program. Over the course of the rotation, the resident gives several didactic presentations to groups of health care providers associated with Princess Marina Hospital, surrounding district hospitals, the BIPAI, and/or community organizations. Often, other opportunities to teach arise; the community living situation lends itself to the development of friendships and collaborative relationships, and dermatology residents are often shadowed by medical students or other residents living with them. The University of Botswana internal medicine and pediatrics residents formally complete a one-month rotation on the dermatology service, and the dermatology resident has the opportunity for hands-on teaching, while learning more about general medicine in Botswana from the local physicians. About once a week, the resident has the opportunity to travel by bus, taxi, or with other health care workers to one of four neighboring clinics and hospitals in the rural areas outside Gaborone. At these clinics, the resident sees out- and inpatients and lectures on helpful dermatology topics to local care providers. A one-week overlap between the residents ensures continuity in the service and gives residents a chance to interact with and learn from their peers.
Although running the dermatology service fairly autonomously is a valuable part of the experience, several programs are in place to ensure that residents have sufficient support to provide excellent care. The residents work closely with the public sector dermatologist in Princess Marina Hospital, Dr Gilberto Lopez, a Cuban physician who is currently living and working in Botswana. Another service that provides support is teledermatology, and one of the goals of the Resident International Grant is to educate the residents in using teledermatology services effectively. The resident can submit consultations on an Internet-based store-and-forward system (http://africa.telederm.org
) or by mobile (cellular) teledermatology; the resident is provided with a cellular phone equipped with a 5. 0-megapixel camera and ClickDoc (Click Diagnostics, Boston, MA, USA) software, which allows for submission of cases without an Internet connection. The consultations are answered by a group of dermatologists organized by Dr Kovarik, who is always available for clinical or social support during a resident’s time in Botswana. The residents are expected to submit a certain number of teledermatology consultations during their rotation to provide high-quality care, get feedback on their diagnoses and management plans, and have enough experience with the technology to teach the next resident.
Histopathology interpretation support is another important component of the residents’ experience. Dr Scott Binder at the University of California, Los Angeles (UCLA) Department of Pathology generously facilitated the donation of a live telepathology system (Zeiss Mirax Live RT system, Carl Zeiss MicroImaging GmbH, Jena, Germany) for interpretation of skin biopsies and teaching local pathologists in Botswana (see ). Along with Dr Kovarik, members of the UCLA dermatopathology faculty regularly volunteer and provide interpretations of cutaneous histopathology to assist and educate the dermatology residents and the busy pathology department at the National Laboratory of Botswana. Generally residents work as a team with the local pathologist, Dr M Kayembe, to determine which slides to load on the microscope, and the team discusses the case with the consulting dermatopathologists through teledermatology.
As the program has evolved and become better defined, there have been several opportunities for residents to participate in and conduct clinical research while in Botswana. Residents have assisted with local clinical trials, with research on teledermatology and teledermatopathology services, with human-papillomavirus-related malignancies, and with various case reports based on their experiences.