“…all things are possible with God!”

We have been having a busy time at Gahini recently with several sets of visitors, and ongoing clinical work. There have also been a significant number of changes in the hospital, many of which we just couldn’t see happening even a year ago!

When we started looking for where Church Mission Society (CMS) and God wanted to place us back in 2016, we had in mind that it would be somewhere that we could use our Surgical and Anaesthetic skills to benefit people who wouldn’t otherwise be able to access such healthcare, but also where we could be involved in teaching and training with a view to leaving behind a sustainable service staffed by locals after a five year period.

Gahini Hospital in Rwanda was the place that we felt called to be, but the situation when we arrived seemed to be less on developing a service and training local staff, and more on setting up a service and running it ourselves. The idea that we might be able to do any more than this seemed quite fanciful.

Over the last two years we have tried to be involved with training Rwandan doctors, but despite gaining contacts in the Kigali training schools of Surgery and Anaesthesia, there has been little progress. Catriona was asked to teach in Kigali on Paediatric Anaesthesia, but here sessions were then cancelled in favour of some visiting Canadian Anaesthetists. Steve has taught on a UK-credentialled Surgical Skills course for the last three years, but has not been able to progress further than this. We have been teaching our own hospital staff, but this has been basic surgery to generalist doctors and anaesthetics for non-medical anaesthetists, which has been thoroughly worthwhile, but not really helpful in terms of sustainability.

We were discouraged by the fact that the Government seemed to be developing a different hospital in the East of Rwanda to become the specialist centre, and did not seem to be supportive of having specialists in their other District Hospitals. However, Rwanda produced a National Surgical Plan in December 2018, which had the aim of each District Hospital having a Surgeon, Anaesthetist and Obstetrician by 2030. We have therefore been continuing to explore teaching opportunities, meanwhile trying to help develop the hospital facilities so that Gahini becomes a very easy place to send specialists in future as the infrastructure will already be in place.

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Since the beginning of December, three very big developments have taken place, which has amazed us.

Firstly, the Government has sent two Orthopaedic Surgeons to Gahini, and plans to send an Anaesthesiologist next year. They actually appointed one Orthopaedic Surgeon to the specialist hospital an hour away from us, but then discovered that they had no facilities to allow him to work – no operating theatre capacity, no orthopaedic operating instruments, etc. At Gahini, Christian Blind Mission (CBM) have recently built and furnished a complete Orthopaedic operating suite, which is in use by a visiting Orthopaedic Surgeon who they employ to operate on children with disabilities one day each week. It’s probably one of the best Orthopaedic facilities in the country. After some discussion between the newly appointed Surgeon, Gahini Hospital, and the Ministry of Health, that Surgeon has been moved to Gahini, and joined by a colleague to form what will soon become the Orthopaedic Referral Centre for the whole of Eastern Rwanda. From my point of view, this means that I am no longer the only Surgeon here, and am able to let others look after the Orthopaedic patients (for whom I did my best as needed, but for whom my surgical skills were limited).

Secondly, and at less than 24 hours notice, I received four recently-graduated Rwandan doctors attached to my Surgical Service. The only students we usually get are from overseas, but Rwanda has decided that each of their newly qualified doctors need a five-month intensive preparation for practice course, and Gahini will receive four doctors in Surgery for a month each over the next five months. The main aim is to get them clinical experience as preparation for being doctors in potentially isolated settings, as their medical course is great on theory, but not quite as good as they would like on practical experience. This means that I am getting to teach some of the newest doctors in the country, which is really quite exciting!

Thirdly, a week ago I was asked by the University of Rwanda to become an Associate Dean of Hospital-based Medical Education. I found out more about the role at a meeting yesterday. It is linked with the placement of the newly qualified doctors at Gahini, which is likely to happen for five months each year, but is likely to be developed with more under- and post-graduate medics being placed at district hospitals. I am to be what in the UK might be called the hospital Director of Medical Education, basically overseeing all aspects of Medical Education at Gahini. Several other hospitals are having one of their specialists appointed to the role too, but it appears that I am the only non-Rwandan to be asked – something which is rather special to me. I only hope that I am able to fulfil the brief well over the next couple of years.

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New Associate Deans meet the Vice Chancellor of the University of Rwanda

In essence God has been able to do something which we saw as being beyond possible for us here in Rwanda: We have local Rwandan Specialist Surgeons working at Gahini (which makes it extremely likely that a General Surgeon will come in the next couple of years); We have student doctors placed at Gahini, and I have a role within the University of Rwanda, and so should be able to further develop training opportunities. It’s all rather humbling, and is a good reminder to me that God works through our weaknesses and limitations, rather than through what we are able to do ourselves. As God said to Joshua thousands of years ago, “Be strong and courageous. Do not be afraid; do not be discouraged, for the Lord your God will be with you wherever you go.”

Embarrassed by Riches…

We had an interesting request from one of our neighbouring District Hospitals recently: Could we lend them an Anaesthetic machine? We do have a number of anaesthetic machines at Gahini, but each of them is actually in regular use. Our problem is that the hospital has developed rapidly over the last few years with multiple new facilities in separate buildings.

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We have our new government-provided Maternity building which opened almost two years ago. This has two Maternity Operating theatres, which are not infrequently in use at the same time. Each has a modern anaesthetic machine which uses pressurised oxygen from a cylinder and pressurised air from an air compressor. They’re not used often as most Caesarean Sections are done under Spinal Anaesthesia, but are essential for some cases not suitable for spinal, and others where the spinal fails.

We have new Orthopaedic Theatres which opened six months ago, funded by Christian Blind Mission (CBM). This has two main theatres, for purely orthopaedic operating (for infection-control reasons), and a smaller third theatre for infected orthopaedic cases such as osteomyelitis. The two main theatres have new anaesthetic machines which run off an integral oxygen concentrator, which makes them very simple to operate. Our Orthopaedic Surgeon visits to operate one day a week, but uses both theatres simultaneously. The smaller theatre has an older anaesthetic machine running off pressurised oxygen/air, and unfortunately is waiting repair of a sensor.

Finally we have the old theatres which is where I operate on General Surgical cases. We have one anesthetic machine there (again running off an integral oxygen concentrator) which is in use most days as I do as many operations under general anaesthesia as I do under spinal.  This anaesthetic machine was kindly donated by one of our supporting churches here, and allowed us to start doing general anaesthesia when we arrived here over two years ago.

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So despite having six functioning or nearly functioning machines, they are all actually in regular use. Catriona decided that the best way to try to assist our nearby hospital was to go and visit to see what problems they were having, so she went this morning. It turns out that this hospital has two operating theatres which do mostly Caesarean Sections under Spinal anaesthetic. They don’t have a surgeon, so general doctors do infrequent basic surgical procedures. They needed an anaesthetic machine in order to gain accreditation (the government process for assessing healthcare facilities to allocate financial reward), so they had been given an old machine through the government supply process. This machine was old and required pressurised oxygen – unfortunately the connection for this was for a piped oxygen wall outlet, which the hospital did not have, and could not be connected to an oxygen cylinder, which the hospital did have. There seemed to be potential other issues within, but these could not be confirmed without oxygen, so Catriona has asked them to bring the machine here to Gahini for her to check further.

In discussing these problems, it became apparent that not only did their anaesthetic machine not work, but the anaesthetists had no form of patient monitoring other than an automatic blood pressure machine. At the absolute minimum for safety they should be able to measure oxygen saturation throughout an anaesthetic. Catriona suggested to me that we might be able to give them an oxygen saturation monitor from Gahini, and in fact we have a small unused saturation monitor sitting in a box in theatre in case one of our own fails.

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I’m embarrassed to say that my first reaction was rather negative. We have managed to facilitate various donations of equipment to Gahini over the last couple of years, and although we have provided some of it ourselves, I do tend to think of this equipment as owned by us, for use at our hospital. A reasonable amount of effort goes into securing funds or donations, and my first thought was that our neighbouring hospital should source their own equipment rather than gaining from our efforts to improve Gahini’s equipment.

However, our neighbouring hospital is half the size of Gahini, is purely part of the government health system (with no church or other charitable input), and has no ex-pat/volunteer doctors who are able to use their contacts to source equipment and donated money. Clearly our hospital needs to be careful about stewarding the gifts we are given ourselves, but most donors want to see their donations being used to benefit healthcare in the area, and if we have an abundance of one item of equipment, it makes sense for something spare to be given or leant to somewhere that has none.

It took me a while to sort my thoughts out about all of this, and also to realise that any decision on lending or giving spare equipment wasn’t really up to me anyway, but would be the responsibility of our hospital director (although we could influence the decision). Shortly after deciding that I should really be trying to help our less fortunate neighbour (remembering the Parable of the Good Samaritan!), I received the news that I had been successful in gaining another large donation in the form of a grant from the UK to facilitate access to safe surgery. We have been really blessed recently by donations totalling many thousands of pounds that will go towards refurbishing our Surgical and Medical wards, equipping a High Dependency area in the Surgical Ward, and improving hygiene by adding running water to the ward and operating theatre. In the context of being given so much ourselves, how can it not be right to support our neighbour with a small piece of surplus equipment?

 

Engaging young people in church

We have an English Service at our Cathedral here at Gahini. We usually meet between 07:30-09:00 on Sunday mornings, prior to the 10:00 Kinyarwanda service. It’s probably not like any church service you may have attended elsewhere, even in Rwanda.

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When we arrived at Gahini over two years ago, we were told that the English Service happened weekly at 7am. This was a little early for us, but we made the effort to attend only to find that the service only happened during school term, and really didn’t start until sometime between 7.30 and 8.00am. The congregation is essentially made up of the pupils from the local Secondary and Primary schools, with occasional visitors. This makes it a bit like a school assembly, and is an interesting mix of teenagers who love worshipping God, and those who attend because they have too – I believe this includes those pupils of other faiths and none.

Few people in our part of Rwanda have particularly good English language skills, but education is supposed to be delivered in English and the Cathedral wants to have an English Service, so I guess having children who should be able to understand English attend isn’t necessarily a bad idea.

Two years ago, it was hard to see how the children attending could follow the service. The leader tended to mumble his way through a full Anglican English Liturgy from a book which only he had. The same four songs were sung every week, usually with a good rendition of the first verse, with fewer people knowing the words to subsequent verses. Bible readings were from a King James Bible (which isn’t particularly easy to follow if English isn’t your first language). It was fairly dull, and this was born out by large numbers of the children sitting and chatting among themselves through the service.

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As a native English speaker, I was asked to preach and lead from time to time, and to take a leadership role for the service along with others from the church. We bought a projector and started putting Powerpoint slides onto the wall at the front, with the liturgy, bible readings and song words clearly visible. We bought a couple of International Children’s Bibles, and started using these as the language is easy to understand. I started introducing some new songs, and soon found that most weeks that I was in Gahini I was leading the sung worship from my guitar at the front, and either leading the service or preaching (and sometimes all three!). We started introducing some multimedia in the form of short videos linked to the service theme, which have been well received.

Although the Cathedral wants an English Service, I think most of the children would prefer to attend a service in Kinyarwanda. , Despite this, I hope that we have helped to make our English service more accessible to those attending. I have preached my way through Philippians over the last year, which is a little unusual as there wasn’t a structure to the themes or readings previously, but which seems to have been appreciated. The younger children especially have enjoyed learning some songs with actions, and join in enthusiastically.

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However we have many challenges to continuing to deliver a church service to which those attending can engage. Language remains a major issue – there are very few people who have good enough English for them to feel able to preach. The Bishop is probably the only ordained member of the Cathedral Staff who preaches, and he is only able to come occasionally, so the service is lead by lay-people. The Anglican church in Rwanda is characterised by much more formality than I am used to (the UK Anglican church is much more varied and I have generally attended churches with a much more informal service). I am not sure whether the formality of robes, leaders processing in and out of the church, and wordy liturgy is a help or a hindrance to worship for these children, but I am usually less formal when I am leading.

There is a lack of regularity about the service too. Not only is there no service when the children are on holiday (and often the start and end of term is not known until the week beforehand when it is announced on the radio), but there are some Sundays when the Secondary School decides that it’s pupils are doing something else, and there are some Sundays when the Cathedral brings forward it’s Kinyarwanda service for a special occasion, and the English Service doesn’t happen. Unfortunately this is often not communicated in advance. I sometimes find that the person preaching doesn’t turn up, and I have had to deliver some sort of message with no preparation, and also have spent time preparing a message only to find out on the Sunday morning that someone else important has decided that they are preaching that day!

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Our latest challenge has been within the building itself. The church was decorated internally with drapes for the installation of our new Bishop in May this year, which unfortunately covered up most of the wall we used to project our slides onto. Since June we’ve had to use a small portable screen from the school, which means that many of those attending can no longer follow what is happening easily. I am in on-going discussions with the cathedral about whether the appearance of the inside of the building is of more importance than the ability to let all those attending see the words we are using for liturgy and songs, etc, but I am not sure we share the same priorities!

For the time being I will continue to try to assist when I am in Gahini on a Sunday, although as a family we do try to get to a church in Kigali which has a Sunday School when we are able. Meanwhile we continue to trust and pray that God will speak to people despite our efforts as well as because of them!

 

 

 

 

Super-spiritual or lack of forward-thinking?

We gave one of the hospital Security Guards a lift to Kigali yesterday, or at least half of the way there. He had got some time off to go and visit a doctor there, and pounced on the chance of some free transport, to the extent that he was sitting ready and waiting for us when we left at 8.30am. We weren’t sure exactly where in Kigali we were taking him (due to the limitations of combined English and Kinyarwanda communication), but we were surprised when he asked us to stop and let him out at a small town a little over halfway there. Apparently he had relatives living on an overlooking hill and had to go to them to try to get some money to pay for his visit to the doctor.

As we left him at the roadside, cheerfully preparing the next stage of his journey, we considered this significant cultural difference between Mzungu and Rwandan – we would never have set out without having the money to complete the task. One could argue strongly and biblically that he was living out his Christian faith – Paul declares in Philippians 4 that, “God will meet all your needs according to the riches of his glory in Christ Jesus,” in the context of Paul describing being content in all situations whether of plenty or poverty. This man had managed to get a couple of days off work and was setting out on a long journey without the means to pay to get there, or pay for what he needed when he got there, but he trusted that he would be able to acquire the money he needed on the way, and complete his journey in time to be back for his next work shift.

However, Jesus says in Luke 14, that if you want to build a tower, “Won’t you first sit down and estimate the cost to see if you have enough money to complete it? For if you lay the foundation and are not able to finish it, everyone who sees it will ridicule you, saying, ‘This person began to build and wasn’t able to finish.’” – within the context of the cost of the cost of choosing to follow Him. So had our guard prayed and trusted God to meet his needs, or had he failed to estimate the costs in advance?

In our area of Rwanda there are many partially completed buildings. It would seem to be fairly standard practice to start a building when you have enough money for foundations, and then continue building the next year when you have a little more money. Many buildings show little or no progress, but others do move forward a little each year. The cultural expectation that if you are someone who has money, you will help out your (potentially quite distant) family member who is in urgent need of money, probably doesn’t help this situation. Our former Nanny had failed to complete college due to a lack of money, but once she was earning money by working for us, she was expected to contribute to the cost of school fees for a younger sibling, meaning she was unable to save up to pay for returning to education herself.

I am also reminded of a story I heard in Uganda of a man who told his friends that he had almost been given a brand new car that day. Apparently he had met someone with a really nice new car, and had asked if he could have it. The answer was unsurprisingly no, “but he might have said yes!!!”

In our own circumstances of working as missionary doctors, I think we have a lot to learn from those around us. On the one hand, in order to move forward, sometimes you have to trust that God will supply your needs, and guide your steps. “If you want to walk on water, you have to get out of the boat.” At the same time, you have to consider the potential cost, and while it’s all very well to say that God will provide, sometimes his means of providing involves you doing the work to gain that provision. For us, that has meant stepping out of the boat that is the NHS, and moving to work for Church Mission Society in a Rwandan hospital. At the same time, we had to ensure that enough funding was in place, and pledged for the future, in advance of us leaving – and we are incredibly grateful to all of the churches and individuals who continue to support us financially.

I suspect for many of us, we need to have a little more faith and trust in God, so that we do keep trying to walk on water…

 

Taking Stock

Life at Gahini has many frustrations and difficulties, and sometimes it’s can feel very difficult to see where we are making a positive difference by being here. While too much pride in what we have achieved isn’t necessarily a good thing, it can be helpful to look back and see what God has done through us in the hospital. I recently put together a list for a grant application, and perhaps it is worth sharing to encourage those who support us that their efforts are going a long way.

 

Patient Care – in the two years we have been in Gahini, Steve has operated on over 1100 patients, and looked after many more who did not need operations. Catriona has provided anaesthesia for many of these patients, and in addition has anesthetised many children (often with significant abnormalities) for our visiting Orthopaedic Surgeon to operate on. Many of the patients we have helped would not have been able to access surgical care elsewhere, either due to the urgency of the need for treatment or the lack of finance with or without insurance to allow them to go to Kigali.

Anaesthetist training – Gahini has five non-medical anaesthetists who previously were limited to spinal anaesthesia only. All have now been trained to safely deliver General Anaesthetic to patients aged 1 year and above. Two of the five are currently undergoing official teaching in Kigali to allow them to receive the appropriate qualification commensurate with their skills. This was funded by a partner organisation, and includes a commitment to remain at Gahini Hospital for the next seven years.

Anaesthetic equipment – we now have suitable anaesthetic machines and patient monitoring in all of the general surgery and maternity theatres thanks to a kind donation from churches in the UK.

Theatre equipment – We raised £17000 last year from various individuals and organisations in the UK to pay for a new operating table, operating light and ancillary equipment for the General Surgery theatre. Further donations have paid for consumables not available through the government supply system such as small calibre sutures for operating on children.

Orthopaedic Theatres – as part of the CBM Rehabilitation project, CBM have built and equipped new orthopaedic operating theatres. They fund a visiting Rwandan Orthopaedic Specialist Surgeon who operates on children with disabilities one day each week, and we are able to use these facilities for trauma orthopaedic operating when he is not present. Catriona was particularly involved in guiding the decisions about what equipment was best suited for the new theatres.

Hospital Water Supply – we helped facilitate the financing of a new borehole and pipeline to provide a reliable source of water for the hospital, through funding from CMS and CBM, which has revolutionised the hygiene of the hospital especially through the dry seasons.

Paediatric Ward Refurbishment – our paediatric ward has been completely refurbished thanks to the kind donation of the Lyndhurst Deanery’s Lent Appeal from the UK. This has provided a much cleaner, brighter, safer environment for paediatric patient care.

Surgeon Training – Steve has been training local Generalist doctors in general surgery, increasing the capabilities of these young doctors providing basic emergency surgical care, and also teaches the Surgical Residents in Kigali intermittently, with the aim of bringing specialist trainees to Gahini in due course. In the meantime, trainees from Scotland have visited to gain experience of global surgery and assist with the generalist doctors’ training.

 

Our next hospital project is to refurbish the surgical ward and create a high-dependency care area, so that we can offer better post-operative care to our patients, improve patient dignity by having single-sex ward areas, and have a brighter, cleaner environment to help reduce the risk of infection.

What does Rwanda’s newest Scottish Three-year-old get up to on her birthday?

I thought I’d hack Daddy’s blog and share some of my day…

Life in Rwanda tends to start a little earlier in the day than it did when we lived in Scotland. It gets light at about 6am, and often I am woken by our gate-guard who tends to move around on the verandah outside my bedroom from around that time. However, my parents bribe me with sweeties and a star-chart to get me to stay in bed until “Yellow Time” on my Glo-clock, which seems to be a little before 7am. I often sing to and chat with some of my soft toys until then, and then with a big shout of “Daddyyyyy!” it’s time to start the day properly!

This morning was different – I usually get to watch some Cbeebies TV shows while Daddy gets breakfast ready and Mummy gets my little sister up, but this morning I arrived in our living room to find a stack of wrapped presents and cards waiting for me. I really enjoy opening envelopes and presents, and today they were actually for me, although it didn’t stop my little sister trying to eat all the wrapping paper. My uncle had given me a Barbie Doll, which was new to me, but she had pink hair, so she has quickly become a favourite toy. I’m completely obsessed by Ben & Holly, so Grandma & Grandpa’s present of a Ben & Holly T-shirt and storybook was wonderful. I’ve worn the T-shirt all day, and plan to do the same tomorrow. Another present was a Disney Princess’ dress, which I wore on-top of my new T-shirt all day too. I love dressing up, and my previous favourite was a Mermaid, although I think I like the Princess even more.

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After breakfast, my new Nanny, Kellen, comes to play with me. She’s supposed to look after both my sister and me, but as Mummy is often feeding Rachel and is otherwise still on maternity leave I often insist that Kellen plays with me in my room on our own. Fortunately Kellen is very short, as one of my favourite games at the moment is to sit and have tea parties with her and all of my soft toys in my small play tent.

It was good to get to speak to both of my sets of Grandparents too – they miss me terribly, but I can see them on Daddy’s phone. This morning they were a bit static, which Mummy says was due to a poor internet connection. I do miss them as well. For the first six weeks after we came back here, I was determined to go back to Kigali and find a blue plane to fly to see them. I would pack a small bag with all of my essential toys and leave it by the front door, and mention it several times a day, but my parents didn’t take the hint. Apparently I’m going to have to wait for them to come and visit me, which I’m told will be fairly soon… I’ve heard that before from my parents, but I do expect some of them to visit before Christmas.

Mummy made me a fantastic cake at lunchtime. It was a chocolate cake in the shape of a monkey (my favourite animal, and also soft toy) and had a candle in the shape of a number 3 on top. I was so excited by the candle that I blew it out before Mummy & Daddy had finished singing “Happy Birthday” to me, and almost didn’t notice that the cake was a monkey! It was covered in buttercream icing, which is my favourite bit of the cake, so much so that I often leave the cake bit until later in the afternoon, or forget about it completely!

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This afternoon we had an outing to one of our local towns (about half an hour towards Kigali). Mummy had found out about a hotel there that has a swimming pool, and we went to try it out. I love swimming, and am getting pretty good at it these days. It helps to have a lovely pink swimming wetsuit, and armbands to keep me up, but I am happy now to kick my way around a pool without holding onto Daddy all the time! None of the pools in Rwanda are heated, but today’s was pretty warm. These days I enjoy the swimming so much that I don’t get out until Mummy tells me I’m looking blue instead of pink!

Once we’d done all that, we got home just in time for my normal evening routine – dinner, bath, stories and bedtime. Mummy says that it’ll not be my birthday tomorrow, so I won’t get as many treats, but Daddy says that we’re going to visit the animals at our local National Park at the weekend as another part of my birthday present, so I’m sure I’ll get some more treats then.

Daddy says he’ll see me later when he goes to bed himself. Just now I have to take some medicine for a spot that has become infected. Mummy and Daddy tried to give me some really yucky stuff out of a syringe, but it tasted horrible and I kept spitting it out. Daddy cleverly thought that now I was three I might manage a tablet instead, and that has been much more acceptable. I haven’t yet decided if the problem was the taste of the yucky stuff, or the fact that I’m now a big girl who doesn’t need baby medicine, but I do like that nice pink “Calpol” stuff so for now I think the problem has to be the taste.

Good night, and do come and visit me in Rwanda!!!

I was a Trainee once…

As a Missionary Doctor, my over-riding priority while working in Rwanda is to share God’s love with people in their time of need. However, one of the other important things for me to be doing here is to try to work myself out of a job as a Surgeon. The old Chinese saying “give a man a fish and you feed him for a day; teach a man to fish and you feed him for a lifetime,” has always resonated with me. Although there is much to be satisfied about with each patient who has been successfully treated, I have often found that things that give me most satisfaction are the activities that I have initiated and which have been sustained once I’ve left.

Twelve years ago, as a trainee surgeon myself, I spent a year working in Uganda at a fairly well known Mission Hospital, alongside a couple of Ugandan Surgeons. With very limited experience of the Developing World at that point, my aim was to use the skills that I had to help individual patients who might not otherwise have received the medical care they needed. It was a surprise to me then to find that although I had help many people during the year, I got more satisfaction from having set up an Endoscopy service with donated equipment and personally training theatre staff and colleagues to look after and use that equipment, and subsequently even more satisfaction from seeing that equipment in use during several return visits.

While working in the UK, one of my passions is teaching and training junior surgeons, so I have been quite involved in Surgical education in my own hospital, region and even nationally. It should be no surprise then that here in Rwanda I really want to be teaching local doctors in Surgery. I have been fortunate over the last couple of years to have several of the hospital doctors working with me for a few months at a time, gaining experience, learning basic operations, and developing their medical mind-set. A couple of these doctors have expressed a desire to gain further training to become a specialist in surgery or a related field in future, and I hope that the time we have spent working together will benefit them if they are able to realise this.

Doctors here in Rwanda are a variable bunch, just as they are in the UK, and the challenge for me is to try to engage each in a way that helps them to progress. I’ve had several doctors working with me for a few days at a time recently, most of them doctors who are new to the hospital and who I haven’t worked with before. I generally try to work out what level of knowledge and skill they have early on, so I can get teach them an appropriate level of task – for example it’s not very sensible to try to teach someone how to do a complicated bowel operation when they first need to learn how to tie knots or hold a scalpel. All doctors here do Caesarean Sections, so they should have some surgical skills to start with, but even so, many have not had much teaching in the basics, such as even how to hold a pair of forceps.

Recently, one doctor did not endear himself to me when he decided to tell me that assisting me during a moderately complex operation was beneath him, and he would much prefer if I let him just operate by himself. This was despite my initial assessment that he would require quite a bit of instruction to bring his basic operating skills up to a level where I would be happy even to leave him to close a wound at the end of an operation! You do need a certain degree of confidence (if not arrogance) as a Surgeon, to have the belief that it is a reasonable plan to stick a knife into someone for their own benefit, but that should always be tempered by realism and self-awareness – one difficulty I had myself when I was training to be a surgeon was that I was often quite scared and lacked confidence in my abilities, but unfortunately I subconsciously portrayed myself as being a bit over-confident instead. I almost laughed a few days later when this same doctor told me that as he had now completed a hernia operation (which he had, albeit with my significant assistance and step-by-step instruction), I should give him a certificate to say that he could now do hernias and should be allowed to do them by himself in future. He was shocked when I said that once he had done 40-50 hernias with assistance he might be able to do straightforward hernia operations himself, but would probably still require assistance from time to time. There are no short cuts to experience in Surgery.

I have another doctor working with me now for the next few weeks. I have come to respect this doctor greatly over the last two years, during which we have worked together intermittently. We have some language difficulties (which have improved with time), and sometimes I still get a phone call from him that I just don’t quite follow. However, invariably every time he asks about a patient it is completely appropriate for me to see that patient – I just rarely work that out until I actually see them! He knows what he knows and he knows what he doesn’t know, and sensibly seeks advice. According to medical education theory, we progress from unconscious incompetence (I don’t know what I don’t know) through conscious incompetence (I know what I don’t know) to unconscious competence (I don’t know that I actually do know), and conscious competence (I know what I know). That first stage is the dangerous stage, and I am grateful this week to be working with someone who has moved well beyond it. The whole week will be more manageable as a result.