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DULLIE, Dr Luckson

Malawi: my family medicine story

When I graduated from the College of Medicine of the University of Malawi, in 2001, I was certain I wanted to specialize in internal medicine though my mind would wander towards obstetrics and gynecology sometimes. However, after the grueling five years of Medical school, I decided instead of going into a residency program straight on, I would work at a mission hospital for a while to recuperate. That took me, after completing my internship, in 2003, to the Malamulo Mission hospital, a rural 300+ bed hospital in Thyolo district, 50km from Blantyre, and run by the Seventh-Day Adventist church.

A beautiful facility, with bustling community outreach programs, Malamulo was a pioneer in prevention of mother and child transmission of HIV in Malawi. I joined a medical team of one pediatrician, one general practitioner, a dentist, six clinical officers and three medical assistants. Soon afterwards however, the delusion of ‘I know-it-all post internship’ fervor evaporated against the harsh reality of facing a myriad of conditions, across all disciplines, in all ages of patients. This was coupled with the expectation that I was now, for the most part, the “consultant” among the clinical officers, while I was looking for one myself. I realized I liked the idea of dealing with all types of patients, but also that I needed to upgrade my skills in surgery, and obstetrics to function optimally in such situations, where I had no immediate consultant to turn to.

I need to point out that the College of Medicine is the only medical school in Malawi and the curriculum did not have family medicine, or concepts of the undifferentiated patient at all, until 2011.

Becoming a family physician

As the idea of becoming an all-round medical officer for the rural practice was taking some shape in my mind, I contacted Dr Wilbert Hurlow, Medical Superintendent of Maluti Adventist Hospital, in Lesotho. Dr Hurlow is a South African general practitioner, with extensive experience in surgery, and who had worked at Maluti hospital for over 20 years.

I was aware that Maluti had a large volume of obstetric and surgical patients and senior doctors in those fields. They also had started a wellness center for HIV/TB care, with community outreach programs. I decided that was enough to learn from and it would help me to come back to Malamulo a better doctor.

January 3, 2006 saw my wife, our three year old daughter and myself on a 36 hour bus trip to Johannesburg, where we would connect with another bus for six more hours to get to the mountain kingdom of Lesotho. For the next several weeks, I worked with Dr Hurlow to develop what we termed my learning outcomes towards my “general and rural medicine” training program. We later learnt that what I had set out in search of and the wheel we were trying to invent already existed and was called ‘Family Medicine’.

In the meantime, Dr Brian Jack, of Boston University, working with Lesotho-Boston Health Alliance (LeBoHa) was exploring the possibility of working with University of the Free State (UFS), in South Africa (250km away from Lesotho), to establish a family medicine specialty training program, in Lesotho. The aim was to attract back doctors and medical students who went to South Africa for training. He and LeBoHa were the first to introduce the idea of using the UFS Family Med department for family medicine training, in Lesotho. This idea was picked up by the Adventist church to set up the Maluti-UFS program. That resulted into two distinct family medicine programs – LeBoHa Family Medicine Specialty Training Program (FMSTP) and the MAluti-UFS program. Maluti was also used by LeBoHA as a training site and this was an opportunity for the two programs to interface.

The beginning of a family medicine faculty in Malawi

I graduated from the Maluti-UFS , in 2008, and worked as faculty in the LeBoHA FMSTP, in 2009, before returning to Malawi, in September 2009. I subsequently joined the College of Medicine, in 2011, as the first full time faculty in family medicine, in order to initiate the development of family medicine clerkship and residency programs.

In March 2011, the College of Medicine piloted its family medicine module, which is taught in the fourth year of the five-year medical training program, as part of the core curriculum for fourth-year students. This introductory training in family medicine is a critical platform for the effective integration of primary care services that encompass a wide spectrum of priority diseases including: HIV, TB, malaria, and maternal, neonatal and child health conditions. The six weeks’ module focuses on comprehensive care and includes a week (approximately 35 contact hours) of classroom lectures, a four-week preceptorship, at four rural hospitals, and is completed with a week of assessments.

The preceptorship introduces students to the challenges and rewards of primary care medicine, in rural or underserved settings or at sites where they are exposed to different patient profiles that they do not experience at the central teaching hospital. It is thus anticipated, that the family medicine module and rotation will help students develop a culture of working in rural and resource-constrained settings. The ultimate goals of the family medicine module is: to develop into a stand alone department that will be able to deliver academic programs at both undergraduate and postgraduate levels; to participate in service delivery; and to be able to conduct research that can guide clinical practice and policy making in family medicine and primary health care.

The family medicine program, in Malawi, has links with Witswatersrand University in South Africa through a twinning project; has received support from the I-TECH program implemented by University of Washington Global Health Department; and is actively pursuing possible collaboration through Michigan State University, and the Global Health Service Corps in the US. Dr Brian Jack facilitated my attendance to the AAFP Global Health conference, in Minneapolis, in September 2012, where I made an oral presentation on the development of family medicine in Malawi. It was also an opportunity to network and create possible collaborations.

The family medicine clerkship is now in its third academic year and will be evaluated on the impact on students as well as preceptor sites. A four year postgraduate training curriculum towards Masters of Medicine in Family Medicine is being finalised and training is planned to start in 2014. Currently we also have a US Fullbright scholar attached to the program and another part time faculty.

Our current challenges are human resources and financial constraints. We need to develop faculty in order to grow into a robust academic department as well as develop rural sites for training. However, the program is looking at the possibility of developing a model site at which the integration of family medicine into the health system as well as its benefits can be demonstrated. The family medicine program, in Malawi, also envisages advocating for changes in curricula for other health care providers to reflect efforts to depart from disease oriented primary care to people-centered and community oriented primary care. This may also involve development of multidisciplinary teaching approaches in order to mold cohesive primary health care teams. Training sites for family medicine would therefore create an environment where the different cadres of the PHC team interact and learn together.

Dr Luckson Dullie
Family Medicine Coordinator
College of Medicine
University of Malawi.