Effect on knowledge.

There was universal agreement amongst interviewees that the greatest impact of the MUYU program was on the fund of general and specialized medical knowledge of participants. Half of respondents specifically mentioned improved ability to interpret medical literature or practice evidence-based medicine (EBM), and several mentioned improved ability to read and interpret various imaging modalities. Interviewees overall expressed great satisfaction with the knowledge they gained. For example, one participant stated:

“…I learned how to do dialysis—peritoneal dialysis from there [Yale]. I learned how to manage patients with peritoneal dialysis from there. Management of patients with acute kidney [injury]– got it from there. Interpretation of results like radiology co-investigations, ultrasounds, CT scans, and all of that. Also the methodology of teaching… even professionalism in patient care – all those things I learned from Yale and I’m practicing them.” Interviewee number withheld for confidentiality

Effect on clinical practice.

All respondents indicated that the exchange had a considerable effect on their role and practice as a clinician. Half noted that an increased use of EBM had affected their clinical practice. One interviewee noted:

“I still do read a lot of journal articles, and I do fortunately now understand and interpret them accordingly. I put some of the clinical information accrued from these journals to real practice… if the evidence is sound, it is worth practicing it.” Interviewee 4

Most respondents also described a significant effect on their doctor-patient and doctor-family relationships as a result of the exchange, which they characterized as including increased communication, and increased valuation of patient autonomy and independence. One interviewee described his post-exchange practice as follows:

“I give patients time. … I take time to speak to the patient about the disease. Maybe not so much how the disease comes but how we are going to manage and what options we have available. But I also tell them what options they would get if they went elsewhere… And I found that it gives the patients—they feel a lot of relief and they've been respected.” Interviewee 3

Effect on medical education.

All interview respondents cited some positive effects of the exchange on medical education at M-MakCHS, generally via its effect on their skills as teachers. Most interviewees referred to an increase in their own knowledge base, while several also mentioned changes to their teaching methods (such as increased teaching of EBM and use of journal articles as teaching sources). Several also described alterations to the attending-student relationship, leading to a more Socratic, less didactic approach to teaching. One interviewee noted:

“A good teacher should be very knowledgeable. The knowledge I acquired has helped me to be able to speak confidently learning to question the evidence… As a teacher I know that I have a good knowledge base. But also being compassionate. I’m no longer your boss when I’m on the ward. I take all the ideas from the students and then we discuss them.” Interviewee 1

Interviewees also referred to the recent establishment of an office of resident medical education and a chief resident position at Mulago. These innovations were the result of a project created by a MUYU alumnus, with financial and logistical support from the MUYU program. These developments were felt to reflect an increased interest in education within the department of medicine as a whole, and to have been beneficial to resident education.

Effect on research.

MUYU participants reported mixed effects of the exchange on their roles as researchers. Some interviewees noted no significant effect of the exchange on their research careers, though others credited the exchange with increasing their publications (via Yale collaborations), creating mentor-mentee relationships leading to current research, and providing the knowledge base that allowed current research pursuits to progress. Amongst interviewees, there was general agreement that the exchange was not structured primarily to support research skills or projects, and a few suggested that more specific programming should be incorporated to this end.

Effect on leadership.

Interview respondents reported that the program did not have a significant direct effect on their skills as leaders, although several noted that their leadership roles increased as an effect of program participation. Interviewees explained that promotion to positions of departmental leadership or oversight, as well as informal leadership in the larger Ugandan medical community, were the result of the sought-after specialty skills that they had acquired through the MUYU program.

Applicability of skills.

While interviewees were not directly asked to comment on the applicability of training in a resource-rich environment upon return to a resource-poor environment, they often commented on this issue. Although some interviewees commented that not all of the knowledge they had gained was immediately applicable in Uganda, none felt that the time spent attaining the knowledge and skills was wasted. Rather, several interviewees specifically noted that the knowledge they gained anticipated technology that soon became available in Uganda, making their knowledge especially valuable. For example, one interviewee noted:

“As you know, they have opened a [cardiac] catheterization laboratory [at Mulago Hospital] … [While at Yale] I managed to see how people do catheterizations and now they’re being done here. So things are, like I told you, two years ago, three years ago, they didn’t look like they would be useful, but right now you can see that the training was really appropriate.” Interviewee 2

Other interviewees noted that the knowledge of what is unavailable at M-MakCHS is key for motivating improvements in the medical system, regardless of whether the capacity currently exists for the implementation of these improvements.

Effects on professional interpersonal relationships.

Interviewees were asked to compare the character of staff relationships (e.g., between physicians and students, residents, or nurses) at Yale and M-MakCHS, as well as comment on any effect that the exchange may have had on those relationships at M-MakCHS. The most notable differences were identified in physician-medical student and physician-nurse relations. Both relationships were routinely characterized as being more distant and involving less bidirectional flow of information at M-MakCHS compared to Yale. Interviewees often described a “gap” between physician teacher and medical student at M-MakCHS, and interactions that were confrontational and tended to use fear as a significant motivator. Most interviewees felt that the closer physician-student relationship at Yale improved teaching productivity relative to M-MakCHS. In contrast, one respondent felt that a kinder, less confrontational relationship led to less motivation amongst the students, and thereby less uniform achievement of expectations. Most interview respondents described a significant change in their relationships with students after exchange participation, which was usually characterized by increased rapport and communication. One stated:

“[At Mulago] I don’t know whether it’s a combination of respect and fear but the professor I mean is held in awe… But that is changing with our program… [The faculty] have actually greatly changed. Now they allow the students to email them, they can even phone them and ask them for a session. Probably that was not there before but after these interventions things have changed a little bit.” Interviewee 1

Physician-nurse relations at M-MakCHS were uniformly described as problematic, with no routine communication other than via physician orders, and no structured mechanisms for feedback. Interviewees acknowledged the benefit of more open communication, and a more bidirectional flow of information, but also noted contextual factors limiting the improvement of physician-nurse relations, including the severe nursing shortage in Uganda, and a relatively greater knowledge gap between the physician and nursing groups, which most attributed to the different educational requirements for nurses within the Ugandan and US systems. While a few interviewees did not see a clear effect of the MUYU exchange on their relationship with nurses, the majority of those who commented on the issue described improvements, including increased respect for nurses, increased appreciation of nursing contributions, and increased desire for communication. One interviewee described the changes as follows:

“My relationship with nurses is—I revere nurses a lot more now. I feel that they are more a part of the team than I actually thought they were. I know now that the nurses play and should play and should be allowed to play a much bigger role than we allow them to play in Uganda.” Interviewee 4

Institutional effects of the Yale to M-MakCHS exchange.

As the MUYU Collaboration involves a bidirectional exchange, interviewees were asked to compare the impacts of the Yale to M-MakCHS and the M-MakCHS to Yale exchanges on M-MakCHS as an institution. All interviewees cited some beneficial effects of the Yale to Mulago exchange, though they were mostly described as modest in scale, with some potential to have neutral or even negative effects, depending on the circumstances. The most commonly cited benefit of the Yale to M-MakCHS exchange was the visiting residents’ and faculty’s role in providing on-site teaching, and several noted that visiting residents provided good modeling of patient advocacy skills. A few respondents noted that this exchange also had some positive effect on supporting research collaborations between faculty at the two institutions. The effect of visiting medical students was felt to be relatively neutral: while their insightful questions may benefit ward-based clinical teaching, on balance it was felt that “they learn more than what they bring” (Interviewee 1). The potentially negative effects of the Yale to M-MakCHS exchange were mentioned only abstractly. One respondent noted that the ability of visiting residents and students to adapt to the novel environment is highly variable; while most visitors maintain a positive, flexible attitude and are therefore successful, those individuals who have more difficulty adjusting to the novel environment may become withdrawn, negative or condescending, which may have adverse effects on interpersonal and team dynamics.

Institutional effects of the M-MakCHS to Yale exchange.

There was widespread agreement that the ongoing M-MakCHS to Yale exchange has had positive effects at a wider departmental, if not institutional level. The exchange was seen to have beneficial effects on patient care, student and resident education, staff relations, and potentially research, mostly via the alterations to individual knowledge, skills, and practices that are described above. There was considerable variation, however, in the interviewees’ assessments of the degree of this larger effect. Amongst respondents who provided specific estimates, two-thirds characterized the effects of the exchange as moderate to large, while the remaining third characterized the effects as small or minimal. Those who described more modest effects of the exchange routinely described the main barriers to achieving a more significant effect as either 1) the small total number of MUYU participants in the wider faculty pool (i.e., the program had not yet reached “critical mass”), or 2) the systems and resource limitations that have been unaffected by the collaboration. Only one respondent expressed pessimism about the capability of the program to have more widespread effects, which he attributed to perceived insurmountable financial and systems issues at play in the larger medical system. The remainder, including those who felt that the effects of the exchange were modest to date, encouraged continuation, if not expansion of the program, to allow benefits to continue to accrue. One interviewee described the slowly accumulating effects of the program as follows:

“Initially it was hard to see the outcomes of this collaboration because we are few. You could not easily tell from the whole pool of many people around our influence—the influence of how Yale has impacted on us. But as we get more and more people from here going to Yale and coming back to practice here… everything is adapting to that American way of doing things, Yale standards.” Interviewee 7

Barriers to participation—Financial.

Although the MUYU program sponsors travel to and from Yale, housing, and provides a small stipend to support basic necessities, all participants stated that making ends meet was difficult. For many, participation in the program required significant financial sacrifice. The most significant financial concern for most participants was not related to personal expenses, but to the ongoing support of both immediate and extended family, which is common in Ugandan culture. While participants who already held junior faculty positions at M-MakCHS continued to receive their base salary, these participants often still complained of loss of income, as it is common for a significant proportion, if not a majority, of a physician’s gross income to come from private clinical work or other outside activities. The two interviewees who provided numerical estimates noted that their family’s income during participation became roughly one-quarter (20–30%) of what it was prior to participation. All respondents suggested increasing the amount of the stipend or offered other suggestions on methods to decrease the financial burden of participation, such as cost-sharing amongst alumni to support current participants, or pursuing additional sources of support outside the program.

Barriers to participation—Licensing, procedural and practical clinical limitations.

Due to US licensing and insurance issues, Ugandan participants are generally not permitted to perform any patient procedures and some hands-on examinations; they act as observers under most circumstances. Although interviewees routinely expressed overall satisfaction with their educational achievements during the exchange, many also noted that the inability to perform hands-on clinical procedures was a limiting factor. A few interviewees stated that due to the close, trusting relationship they developed with their mentors or supervisors, they were still able to participate in some procedures. Another noted that although opportunities were not available to perform a certain procedure at Yale (kidney biopsy), it was possible to arrange hands-on supervision for this procedure upon returning to Uganda, and thereby incorporate the procedure into regular practice. Nonetheless, this restriction remained significant for many participants.

Barriers to participation—Institutional attitudes regarding participation.

Some participants described initially skeptical institutional attitudes at M-MakCHS regarding participation in the exchange. One early participant summarized his experience as follows:

“The administration [was] usually skeptical. They say: are you going to learn very much from Yale? Are you sure you want to go to Yale? Why don’t you go to India and all those things because of the limitations of the hands-on, but of course when you come back they begin to appreciate the knowledge you have and every day I get five consults from the different departments because they know I’m the expert in the field.” Interviewee 1

These attitudes among the administration appear to have changed considerably over time, however, as earlier participants were more likely to describe resistance, whereas later participants described strong support from the administration.

Barriers to the application of new skills—Resource limitation after participation.

Interviewees universally cited resource limitations after their return to Uganda as a significant barrier to the application of new skills and to programmatic success. The most commonly cited resource limitation was a lack of both durable and disposable medical equipment necessary for clinical care. Interview respondents discussed limited or absent equipment to support diagnostic procedures (such as kidney biopsy or specific laboratory testing), diagnostic imaging modalities, dialysis, surgical capabilities, and other basic patient care requirements. Although interviewees referred to some helpful contributions that had been made by the MUYU program (such as an ultrasound for echocardiogram, and CPAP machines), there was also agreement that, given their modest scale, these donations had little effect on the overall resource limitation. Other resource limitations that were discussed included staffing limitations, both amongst physicians (limiting interviewees’ ability to pursue additional projects) and nurses (limiting interviewees’ ability to foster an improved physician-nurse relationship), as well as a lack of intellectual resources (such as a relatively limited medical library, and access to online medical information content), and technological resources (such as computers and handheld devices). Respondents also cited resource limitations in larger local and national systems as significant problems. Interviewees described barriers including poorly functioning governmental and institutional bureaucracies, lack of easily available financial support for research in general, and non-communicable diseases specifically, and even lack of national infrastructure, such as reliable roads and transportation systems, to allow consistent access to care.

Barriers to the application of new skills—Cultural barriers to change.

Although the increasing pool of MUYU participants has provided an impetus for increased institutional support for the exchange, participants still described confronting habitual cultural standards that sometimes make alteration of practice patterns difficult. One respondent described the manner in which his efforts to improve his own relations with students were impaired by other faculty working with different (perhaps older) standards:

“With the students, it's nothing that I can do necessarily, because I become just a drop in the ocean. If they are free with me, then we rarely do rounds in solitude. Just as I am creating a rapport with them, my other friend or senior colleague walks in. They quickly build the barrier up again because the relationship with this other colleague is not the same as mine. “Interviewee 4

Another noted that while some students took readily to changes in teaching style that incorporated more journal article use and case-based learning, others were more hesitant because of their long experience in a lecture-based system. One interviewee discussed potential drawbacks to changes in the physician-resident relationship as well, voicing doubt as to whether residents at M-MakCHS were sufficiently self-motivated to continue to fulfill their responsibilities without what is currently the habitual threat of a more antagonistic relationship with their superiors.

Many interviewees noted changes in their clinical practice that have improved their physician-patient relationships. However, one respondent noted that while patients clearly respond to the sense of respect implicit in a patient-oriented approach to clinical care, many are not accustomed to, and therefore are hesitant to participate in, shared decision-making:

“The patients tell me that ‘Doctor, you make the decision. I'm just a layperson.’ And I'm trying to tell them we are now emphasizing patient-led care. I give you the information. You make the decision. But they are not forthcoming. It's a new concept. They don't know that they have that ability to make a decision.” Interviewee 3

Increase project scale and scope.

Given that a number of the challenges to programmatic success are related to the relatively modest number of program participants operating in a larger health system and cultural context, it was common for interviewees to suggest expansion of the program. Interviewees suggested allowing more M-MakCHS faculty from internal medicine to participate, as well as expansion to other M-MakCHS faculty and staff. The most common suggestion was expansion to other physician groups, including pediatrics, OB/Gyn, neurology, radiology, and pathology. Several interviewees suggested including nursing in the exchange, as well as other clinical and support staff, including laboratory and radiology technicians, biotechnologists, and social workers. The inclusion of public health practitioners was suggested as well, specifically in relation to increasing the community impact of the program, and one respondent suggested the inclusion of clinical officers (a group of clinicians similar to Physician Assistants). Ultimately, these suggestions seemed to reflect a belief that programmatic participation was likely to benefit practitioners with various backgrounds, and that the health system as a whole was more likely to improve if efforts to build capacity were present across departments and cadres.

Improve programmatic mentoring systems.

Discussions of the MUYU program mentoring systems revealed a nuanced situation in which some participants described productive relationships, while others cited sub-optimal mentorship as a barrier within the program and also as a major opportunity for improvement. All but one of the interviewees were at least "satisfied," and most were quite positive about their overall mentorship experiences. One respondent, however, described difficulty arranging specialty-specific mentorship (i.e., a mentor who practiced the same specialty), and another reported inconsistent quality of mentoring—with a very positive mentorship experience at one US hospital site but a poor experience at another.

Discussions supported the idea that a close, supportive mentor-mentee relationship could be vital for navigating difficulties, and ensuring achievement of educational goals during the exchange. Characteristics identified as important for a productive mentor-mentee relationship included a mentor with previous experience at M-MakCHS or another resource-poor environment; mentee involvement in mentor selection (ideally with the mentee having met the mentor prior to the exchange); a mentor who is specialty-specific; communication between the mentor and mentee to guide preparation prior to the mentee’s departure from Uganda; and a mentor who is present at, or can arrange appropriate supervision at, all clinical sites (if a single mentor who works at all sites is unavailable). As the pool of Yale faculty who have traveled to Uganda is limited, related suggestions were also made that the program arrange more regular visits by Yale faculty to M-MakCHS, both for teaching and to allow formation of mentor-mentee relationships.

Manage pre-departure expectations.

Despite the difficulties that interviewees described related to financial issues, and limitations to hands-on experiences, the majority also stated that appropriate disclosure and discussion prior to participation made these issues easier to handle and would be unlikely to discourage participation among potential future participants. One respondent suggested that as part of this preparation, the program should support the pursuit of additional outside funding for all participants (such as Fulbright Scholarships, or funding from other medical specialty groups). Another interviewee suggested that perhaps some form of structured procedural documentation could allow participants further latitude in hands-on participation during their exchange. Establishment of specific educational objectives, or use of a pre-departure educational curriculum, ideally guided by a specialty-specific mentor, was also mentioned as likely to increase the educational achievements of participants. One interviewee commented on the selection process, and proposed that, to avoid imbalances as participants accrue in different areas of specialization, the selection of participants and their subspecialties should be made based on an assessment of need within the department and the hospital, rather than on participant preference.

Target resource support to ensure use of new capacity.

While the MUYU program has been able to provide some durable medical equipment to returning program participants, such support has not been universally available. A majority of respondents suggested that the program focus further on the provision of medical resources specific to the new skills or capabilities of returning participants. Half of interview respondents also suggested increased support for research pursuits or the pursuit of research grants, and several participants also emphasized the importance of supporting an ongoing mentor-mentee relationship after participation, often as a means of supporting research and other projects.

Provide programming to ensure the maintenance of capacity.

Suggestions for programming to ensure the maintenance of new capacity were common. Half of participants suggested arranging more regular visitation of Yale faculty to M-MakCHS. Most of these respondents recommended that faculty provide short courses on specific topics and make themselves available as future mentors, although some suggested that their visits be arranged to specifically support the specialty skills of returning MUYU participants, such as by providing post-exchange procedural training that participants were unable to garner in the US. Several respondents suggested that the program arrange CME activities for program alumni (independent of Yale faculty presence), and an equal number suggested that the program arrange semi-annual or annual alumni meetings to discuss and continue to amplify the effects of the program. A few participants suggested that return trips to the US were desirable or should be made available to program alumni, noting that these visits could be of shorter duration, as little time would be needed for reorientation prior to pursuing specific educational goals.