I have always been passionate about teaching and mentorship of the next generation of doctors and have been active in these areas since the time I qualified.
Dr Yohane Gadama -YG (MMJ Intern) talks to Dr Mulinda Nyirenda (MN), Emergency Medicine/Internal Medicine Specialist at Queen Elizabeth Central Hospital (QECH) to share her role in the shaping of the country's Acute (Emergency and Trauma) Care services, training of health workers and her research interests.
YG: Tell us about your personal and academic background?
MN: I am Mulinda Nyirenda and was born at QECH and raised in Blantyre. I did my primary school education at South End School and secondary school education at Our Lady of Wisdom. My university education started with Chancellor College where I studied Bachelor of Science for two years before moving to College of Medicine to complete my medical degree. I got my internal medicine specialisation from University of Malawi and University of Witwatersrand. I am excited to say that I was part of the first clinical postgraduate programs at University of Malawi. Since 2010, I have been working in emergency medicine - a young medical specialty that is still defining itself in Africa and probably most of the developing world. So here I am now as a tri-faceted doctor — clinician, lecturer and researcher.
YG: Why did you choose to study medicine and later specialize in Internal Medicine and Emergency Medicine?
MN: As a child, I enjoyed and performed well in both arts and sciences subjects. But sciences always held the most appeal and challenge for me, so a career in medicine seemed automatic as it also gave the opportunity to contribute to the wellness of others.
After medical internship, my decision on which specialization to choose was based on finding a speciality that would offer holistic care to patients and also recognised as a specialist area by the locally developing medical establishment. At that time, few medical specialties were fully recognised. With the counsel and guidance of the then Dean of Post Graduate studies - Professor Eric Borgstein — I was advised to consider Internal Medicine thus I became one of the three pioneering trainees in Internal Medicine at College of Medicine, University of Malawi.
During my internal medicine training, I was always concerned with the state of acute or emergency care being offered at QECH. It was therefore easy to be convinced by senior specialists and mentors that I could lead the initiative to harmonise adult emergency and trauma care pathways to improve medical, surgical/trauma and gynaecological services at Queen Elizabeth Central Hospital. In August 2010, I was also assigned to develop an undergraduate emergency medicine module in the then revised MBBS curriculum at College of Medicine. It has been wonderful to be part of the team that collaboratively developed and established Emergency Medicine as a recognised specialty for Malawi.
In a nutshell, career progression and choice of specialisation has been facilitated by my passion to make a difference that was wisely directed by mentors and educators who recognised my abilities more than I would say I had defined personally.
YG: Your name stands out when one wants to talk about Acute Adult Care/Emergency Medicine in Malawi. You have been pivotal in the genesis of the QECH Adult Emergency and Trauma Centre; tell us more about this facility and the contribution it is making to patients' care?
MN: I am part of the story because of a number of visionary specialists in public and academic medicine who entrusted this young specialist with the opportunity to facilitate the improvement of the adult acute care services at Queen Elizabeth Central Hospital as the new Adult Emergency and Trauma Centre (AETC) was being opened. The Ministry of Health and the College of Medicine were entrusted in operationalising acute care services in the AETC.
With the help of a wise team of medical specialists, nursing specialists, laboratory and other allied health professionals, we began with the formulation of adult acute care pathways, developing standard operational procedures, alongside the training and development of emergency department staff team who were responsible for delivering day to day care on the ground. The goal was to provide more time-sensitive clinical care that was conscious of the severity of the patient's illness or injury to reduce the morbidity, length of hospitalisation and mortality associated with sudden illnesses or injuries.
Since October 2011, the AETC has an adult triage system at the point of entry in order to facilitate an appropriate immediate response based on patient need. The aim of this is to facilitate prompt clinical care decision processes that reduce unnecessary hospital admissions and the length of hospital stay when a patient is admitted. The AETC's existence has also improved in the efficiency and effectiveness of health service delivery in which tertiary hospital expertise for rare specialised medical problems can be seen and dealt with appropriately.
The genesis of AETC is a very good example of how collaboration between private, public and academic institutions can benefit Malawi Health Care Services. The AETC was built with funds from the Anadkat Family, Malawi Liverpool-Welcome Trust and other private partners.
YG: Since 2011, you have seen AETC in operation. What would you say are the key deliverables and positive things that the facility has brought to patients' care?
MN: The key deliverable that AETC has contributed is providing evidence that our health system can offer better emergency and trauma care services relevant in addressing the wide spectrum of communicable and non-communicable diseases in our population. It has highlighted the need to invest and strengthen health workers' knowledge, skills and practice towards delivery of acute care in our health system. The value of interdisciplinary health care delivery and teamwork ethos in delivering patient centred health care is showcased in this facility. It has contributed to insights on how to streamline primary health care for sudden illnesses and injuries in Blantyre district health system while increasing access for patients requiring specialised acute care at QECH. Adult triage in AETC has helped identify very sick people early on arrival, have them directed to the most appropriately skilled personnel who institute appropriate treatment and interventions; reducing the occurrence of unnecessary and preventable health consequences of sudden illness or injuries. This has demonstrated the value of having senior, experienced and highly skilled health workers working alongside junior and less experienced health workers in the acute setting — a rare citing in Malawian health care facilities.
YG: Talking of injuries, Malawi continues to be burdened by an increased rate of road traffic accidents. What are you doing to respond to this burden as far as improving trauma care is concerned?
MN: I continue to contribute to the improvement of knowledge, attitude and practice of health workers in delivering care to injured people in road traffic accidents in Malawi. I coordinate a nationwide multi-specialty faculty of Primary Trauma Care (PTC) trainers who offer a course on trauma care to doctors, clinical officers and nurses in Malawian health care facilities. We do this in partnership with the Primary Trauma Care Foundation in collaboration with the COSECSA Oxford Orthropaedic Link (COOL).
I am a supporter of good injury data collection that generates information to facilitate effective and efficient prevention and management practices that will reduce disability and death associated with injuries. So establishing a QECH trauma registry in the AETC was fundamental in taking steps to improve trauma care at QECH. Some key insights should be available in publications soon.
YG: It seems the subject of injury care has caught the attention of policy-makers at the government level. Recently, Malawi instituted a special commission on Non-Communicable Diseases and Injury (NCDI) of which you are in the technical working group. Can you tell us about the role you played and why you think that launching this special commission was very important for health service and care delivery?
MN: I was privileged to be part of the Technical working group for Non-Communicable Diseases and Injury (NCDI) from 2012 to 2015. Our role was to facilitate the development of a framework for improving injury care in Malawi and also facilitate efforts to revive injury prevention and management systems in our country. This revived collaboration between those in the health, police, education, and legislative sector. One key outcome was the recognition of the need to provide pre-hospital care for the injured patient on the accident scene that has led to the current training of emergency medical service providers in the past year. An emphasis was also made on the need for the development of national/local injury (trauma) registries in Malawi and work towards improvement in injury care systems nationwide. We have seen positive progress in injury care systems and research within the country through this special commission.
YG: Training remains a critical component in offering medical care today and tomorrow. What has been your contribution to clinical training of medical students in Malawi?
MN: I have always been passionate about teaching and mentorship of the next generation of doctors and have been active in these areas since the time I qualified. My clinical teaching engagement was formalised in 2011 when I started coordinating and delivering the undergraduate emergency medicine module to fourth year medical students at the College of Medicine, alongside other colleagues who were interested in acute care. This has been exciting, as we have seen medical graduates who have been exposed to this module become more confident in delivering acute care services in the facilities they work in. More recently, clinical interns have begun rotating in AETC at QECH. Another major milestone was the addition of the 2 Malawian Emergency Medicine specialists who are pioneers of our own EM specialist-training program — Dr Grace Katha and Dr Grace Chatsika.
Clinical training in acute care knowledge and skills is also offered formally to clinical officers who are enrolled on the Bachelor of Science degree programs at College of Medicine as well as the Malawi College of Health Science clinical officer students during their clinical attachments in the AETC. We also contribute to acute/emergency care nursing training as nursing school students rotate in AETC.
In postgraduate medical training, we offer emergency medicine attachments for family medicine registrars conducted at Central and District level, acute medicine attachments for internal medicine registrars, and acute surgery experiences to surgical/orthopaedic registrars.
YG: As a clinical lecturer at CoM, what is your opinion on the sentiments from people that quality of doctors being produced in recent years is going down?
MN: These sentiments need to be defined and contextualised to the uniqueness of medical practice now and then. It is evident that training in current years is less personalised as the lecturer to student ratio has increased over time. Different training approaches and methods are needed to facilitate engaged learning for students nowadays. I also think the average entry age to medical school has become younger, requiring more coaching and training for the responsibilities expected from medical graduates in our environment. Advances in medicine globally are also changing medical career pathways and the organisation of health service provision. It is now more attractive to have specialised medical personnel, however this simultaneously creates a gap in the number of general medical doctors who are expected to meet the health needs of the general population. This calls for a 360-degrees reflection that focuses on medical training designs and expertise required in the health system with the aim of retaining good quality medical graduates who contribute effectively and efficiently to Malawi health system that wants to achieve defined sustainable development goals.
YG: Apart from clinical practice, I have seen a number of publications from your research works. What are your current research interests?
MN: I have been an active clinical researcher throughout my career as I value the need for us to provide locally relevant evidence based improvements for the people we serve in our country. I have been active in infectious diseases research addressing HIV prevention and treatment, tuberculosis, Hepatitis B and other co-infections and malignancies associated with HIV infection. Within emergency medicine, my research interests include the evaluation of acute presentations of illnesses and injuries, triage, disease acuity scores, medical education, medical Informatics and technology, and health care systems.
YG: You have repeatedly mentioned of the role of collaboration and working together between departments and organisations. How have you seen this working and what can you say to all health workers out there?
MN: Collaboration and working together is the key element of providing equitable, accessible and affordable healthcare services. Effective and efficient health care delivery can only happen if human and financial resources are aligned to offer acceptable and appropriate care to the population it exists to serve. Teamwork presents its own challenges as we all have our own ways of looking at things, but, properly harnessed, these differences lead towards providing the solutions for some of the complex health care challenges in our country today. Everyone — at all levels and from all backgrounds — working within the health service needs to be acknowledged for the vital role they play to ensure smooth delivery of services. This is particularly true in Emergency Medicine where the response of everyone — from the guard at the point of entry to the consultant in the resuscitation area-can make the difference between life and death.
YG: Outside your profession life, what do you like doing?
MN: I love art, music, appreciation of nature and having stimulating inspiring conversations with people (young and old). My main goal outside my profession life is learn and experience more of the wonders of this beautiful world we live in. In order to contribute to the next generation of medical professionals, I engage in Christian medical mentoring activities to stimulate young minds to find and live out fulfilling God-given purposes for existence on earth!