Penn’s Pathology Residency Program Reaches Botswana

Published by Steve Graff, on December 04, 2018

When Tom Hu, MD (PGY-3), was creating his rank list for pathology residency programs in 2015, he dug through his options to see what global health opportunities they offered.

“You don’t have to go far to find underserved populations,” said Hu, who volunteered in Nicaragua and Peru during college and medical school. “But I had a particular interest in global traveling and working within a resource-deficit area that needed help.”

At the time, only a few institutions boasted overseas experiences for pathologists in training, and like many other academic medical centers, the Perelman School of Medicine had no such opportunity. Nonetheless, Penn sat at the top of his list, so he applied and ultimately matched. It was a minor sacrifice he would have to make – or so he thought.

His first year in, he overheard Kumarasen Cooper, MBChB, DPhil, a professor in the department of Pathology and Laboratory Medicine at Penn, and Daniel Lubin, MD, a fellow resident at the time, discussing a new program in Botswana, Africa. Under the umbrella of the Botswana-University of Pennsylvania Partnership (BUP), Cooper would take residents over to the Sub-Saharan country for one month twice a year to shadow him, help process (“gross”) specimens, and teach the pathology residents at the University of Botswana (UB) School of Medicine.

“As soon as I heard of the opportunity, I immediately jumped at it,” Hu recalled.

It came to fruition in late 2016 after Cooper learned about BUP from Harvey Friedman, MD, its founding director, and the lack of a pathology presence within it. At the same time, officials from UB and the Botswana Ministries of Health and Education were eager to get their first native-born graduates board certified and working as pathologists in the country, which currently faces a critical shortage, along with the rest of the continent.

Less than 10 pathologists work in Botswana’s public sector, and they all originate from other places: China, India, the Congo, Cuba. None are Batswana, as the citizens of Botswana are called.

Penn’s department of Pathology and Laboratory Medicine Residency Program is helping to change that, while giving its own residents a taste of pathology in a developing nation.

“The experience not only gives them exposure to pathology, but it broadens their horizons. They see patients, the facilities, the hospitals, the city, all sort of things,” said Cooper, a South African native who came to Penn in 2014. “Living there for a month leaves an impression that gives them a deep appreciation into what they have at Penn.”

Good Mornings

Cooper first went to Botswana in October 2016 and has taken a resident on each of his subsequent visits. Four have joined him so far, and two are expected to go with him on his next trip in April 2019.

They fly to Johannesburg, South Africa, and then up to Gaborone, Botswana, the capital city that houses the UB medical school facilities and Princess Marina Hospital (PMH). Both stand blocks from the BUP living complex where residents and medical students from different departments at Penn and the Children’s Hospital of Philadelphia stay during their time in Botswana, a country of over 2 million people – most of whom utilize the public health care services.

It’s a system with its hands full.

The country remains burdened with high rates of HIV/AIDS. Nearly 20 percent of the population is infected with the virus, and 75 percent of that group is coinfected with tuberculosis (TB). Later-stage cancers, particularly cervical and breast, are common, too, because many never reach a health worker or receive appropriate cancer screening and end up only discovering their tumor when it’s in an advanced stage.

When they are seen at the hospital or clinic, specimens are obtained and sent to the pathologists, whose job is to diagnose disease, so that appropriate treatment can be instituted.

This is where the residents’ days start, helping Cooper sign out cases – anywhere from 25 to 30 per day, predominantly from the patients being treated at PMH. Penn residents and Cooper also assist the Batswana residents gross some of the more complex specimens that come their way in a laboratory set up in the UB medical school facilities.

There are teaching moments all around.

In many centers in the United States, having access to state-of-the-art technologies – ancillary studies, for example, such as immunohistochemical stains or genetic testing – and facilities greatly assists the pathologists in making diagnoses. In Botswana, however, resources are much more limited. Basic supplies run out, and so typically one-time-use disposable blades or protective equipment are sterilized and re-used. The power occasionally goes off. They’re very short staffed.

“For me, it felt like going back to the roots of pathology,” said Hu, who spent the month of October 2017 in Botswana. “You are practicing pathology devoid of things that have now made modern pathology more convenient.”

Taylor Jenkins, MD (PGY-4), who went to Botswana with Cooper in August 2018, added: “It was nice to really learn more about the morphology and distinguish tumors that way. It was about what the cells look like, their architecture, and pattern recognition, to make a diagnosis.”

Jenkins also had the opportunity to see patients in the Fine Needle Aspiration (FNA) clinic, a small trailer set apart from the hospital. Her job was to collect biopsies on the spot and determine if they were adequate enough to make a diagnosis later in the UB lab or send off to a lab in South Africa.

Because of a shortage of staff and the complicated cases requiring advanced testing, some samples need to be sent out of the country. That can take weeks, though, maybe even longer if a specimen is deemed inadequate and needs to be resampled. That’s one of the goals of the FNA clinic – to avoid inadequate samples and save time.

“But they ran out of stains, so they weren’t able to do onsite evaluations,” Jenkins said. “So I am sure that a lot of the patients ended up getting called back. It’s unfortunate.”

They’re also seeing diseases they would rarely, if ever, see back at Penn, such as Kaposi sarcoma, a relatively rare skin cancer more frequently found in immune-suppressed patients, such as those patients with HIV/AIDS.

“I certainly learned a lot. There are cases there, for better or for worse, that I just don’t see in the U.S. anymore,” said Salvatore Priore, MD, PhD, a molecular genetic pathology fellow at Penn who traveled to Botswana as a resident in April 2017. “I don’t know that I’ve ever seen a real TB case, but we would always get one or two cases there.”

One case involved a woman with cervical cancer treated by surgeons at PMH and a Penn obstetrics and gynecology resident. They opened her abdomen to operate and found it studded with nodules, the resident told Priore one night back in the BUP living complex.

“In the U.S., you would think this was cancer all over somebody’s abdomen. But the Botswana physician she was operating with said, ‘No, that’s not cancer. That’s TB’,” Priore said. “So it’s just a very different experience in a different situation.”

“I was able to see the bacteria later and show that it was in fact TB,” he added. “She had seen it in the clinic, and I had seen the specimen later on in pathology. It was a nice teaching moment.”

Educational Afternoons

After cases are signed out for the day, Cooper lectures the current six residents, who are all at different stages of their training. As the UB residents see a relatively low volume of cases, Cooper reviews additional cases from his own collection from Penn for a few hours in the early afternoon at the multi-headed microscope.

“My role as I see it is to help them in their interpretation of slides, give them more expertise, and broaden their knowledge with respect to surgical pathology,” Cooper said. “Not only for their patients, but also for the purposes of them taking the examinations, so that they could attempt them with confidence.”

Penn residents then take over later in the day, giving hour-long lectures to the residents. Priore, who taught molecular pathology, called the group “incredibly hardworking and diligent.” Jenkins, who handled gynecological pathology, said they never missed her class, no matter what else they had going on. Hu covered breast pathology.

“I was teaching this really eager-to-learn, sponge-like group, taking in everything,” he said. “They were phenomenal.”

The board exams – administered in South Africa, where the residents do the second round of their residency training – come in two parts and have been described as very challenging. Many residents don’t pass the first round and have to retake it, so they’re often glued to text books, putting in that extra effort to master the field. Angela Maotoa, a Batswana resident who had the opportunity to come to Penn for a month last year, even bought her own microscope so she could study cases at home.

“What I really learned from them,” Hu said, “was there is an extremely high ceiling to how hard one can work to perfect their craft in pathology. Their work ethic was truly inspiring.”

That hard work may soon pay off. A senior resident is set to the take the second part of the exams in January 2019. If he passes, he will become the first Botswana-trained pathologist in the country.

“We are lucky enough to be able to have an impact, even with such a large distance and pretty complicated problem,” said David Roth, MD, PhD, the chair of the department of Pathology and Laboratory Medicine. “Arguably, coming from the first medical school in the United States, to be able to contribute to the first class of residency graduates in Botswana is poetic.”

Down Times

Outside of their duties, the Penn residents also have time to explore. Beyond the restaurants, shops, and bars that line the streets of Gaborone lie landmarks and experiences to take in.

Victoria Falls, the world’s largest sheet of falling water situated at the northern tip of Botswana, along with Madikwe, a game reserve an hour from Gaborone, are popular spots to witness some of Africa’s wildlife and natural beauty. Before heading to Botswana, Jenkins joined a tour group for a trip to the red dunes in Namibia.

Hu had the honor of attending a wedding, a two-day celebration that began with food preparation. When he arrived, Angela’s husband, Jason, handed him a knife and put him to work. Help carve up the cow carcasses, the elders told him, to make the traditional Botswana stew known as seswaa for the guests.

“In my mind, I thought, ‘This is crazy,’ and the other part of my mind was saying, ‘This is exactly what I wanted,’ to participate in the festivities, and not just be a bystander,” Hu said. “That cultural experience will never leave me.”

The time spent in Botswana affected everyone differently, but the residents all agreed the experience solidified their interest in global health and outreach, and that they’d go back in some fashion if the opportunity arose.

Going into year three, Roth and Cooper look forward to continuing the program with residents from Penn, as well as bringing more Batswana residents back to Philadelphia for a rotation to help them on their journey.

“It reminded me about why I got excited and interested in medicine, so it was really like a revitalizing trip in a lot of ways,” Priore said. “The fact that I was able to connect with the Batswana residents, and hopefully provide them with some valuable information so that they can continue the boards process and get certified and provide expertise for their growing health care system is wonderful.”

     --- Steve Graff