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Reflection

1.6.1 Approach to the Elective

I approached this elective with the goal of challenging myself medically in a new setting, exploring and immersing myself in a different culture, and learning more about Rwanda’s innovative public health and governance systems. The single insight that had the most impact on me was seeing firsthand that it truly is possible—with minimal resources and limited medical expertise on hand—to run a thriving hospital, and indeed, an entire country’s healthcare system. Rwanda’s collective hope, discipline, resourcefulness, refusal to accept mediocrity, and openness to innovation were astounding.

In contrast to environments where inefficiency is often tolerated, I found the Rwandan mindset refreshing: they embrace new technologies or approaches that help them serve patients better. This unwavering commitment to improvement—be it through daily chapel gatherings, integrated EMR systems, or welcoming foreign specialists—puts them on a trajectory to continually strengthen their healthcare sector. It’s a powerful model of what can be achieved through optimism, communal dedication, and an all-hands-on-deck approach.

How This Aligns with the Profile of the Stellenbosch Doctor

I aimed to grow in the following domains of the Stellenbosch doctor profile, integrating knowledge, skills, and attitudes to develop as a competent, empathetic, and resourceful future physician.

Knowledge:

Medically applicable scientific concepts: I applied my foundational knowledge of anatomy, physiology, and pathology in real-world scenarios, such as diagnosing and managing diseases like malaria, pneumonia, and hypertension.

Normal and abnormal human function: The clinical setting required me to identify normal and pathological findings, honing my diagnostic acumen.

Maintenance of health and disease prevention: I observed Rwanda’s public health policies, such as community engagement in healthcare costs and their effect on disease prevention and resource stewardship.

Recognition and diagnosis of common diseases: I worked on over 50 patient cases, encountering a spectrum of diseases, including some rarely seen in South Africa, such as vivax malaria.

Use and limitations of diagnostic methods: Limited resources, such as basic imaging and lab tests, highlighted the need to prioritize clinical skills and judicious use of investigations.

Factors in the community environment: Rwanda’s family-centric approach to patient care emphasized the importance of community in health outcomes.

Ethics and legal aspects: I learned to navigate ethical dilemmas in a different healthcare system, particularly around resource allocation.

Interdisciplinary approaches: I collaborated with doctors, nurses, and allied professionals, witnessing the value of teamwork in holistic patient care.

Skills:

Integrating, interpreting, and applying knowledge: I utilized clinical reasoning to manage complex cases with limited diagnostics.

Problem-solving: Managing emergencies, such as a patient with atrial fibrillation and rapid ventricular response, tested my ability to think critically under pressure.

Communication with patients from different cultural groups: I bridged the language gap through learning Kinyarwanda and engaging empathetically with patients and their families.

Diagnostic and therapeutic procedures: Performing bedside ultrasounds and blood draws helped me refine these essential skills.

Holistic care within family and community contexts: Observing family involvement in patient care deepened my understanding of treating not just the patient, but their support system.

Stress management: Limited resources and language barriers were constant challenges that required adaptability and resilience.

Effective teamwork: Collaborating with local healthcare providers and adapting to their systems highlighted the importance of interdisciplinary cooperation.

Attitudes/Views:

Respect for life and diversity: Experiencing Rwandan culture broadened my perspective on healthcare delivery in different social contexts.

Accountability: Resource limitations heightened my sense of responsibility for every decision, knowing the impact on patients and their families.

Acknowledging limitations: I recognized gaps in my knowledge, such as understanding the local healthcare system, and took proactive steps to address them.

Empathy: Seeing the familial role in patient care reinforced the importance of empathy toward patients and their loved ones.

Professional development: Engaging with innovative public health approaches, like Zipline, inspired me to integrate technology into my future practice.

Interdisciplinary respect: Working with professionals from diverse disciplines emphasized the collective effort required for comprehensive patient care.

Through this elective, I sought not only to strengthen my clinical knowledge and skills but also to grow in my understanding of the human aspects of healthcare. This approach has brought me closer to embodying the ideals of the Stellenbosch doctor—a knowledgeable, skilled, empathetic, and community-oriented practitioner who contributes meaningfully to the healthcare landscape.

One additional observation I made early on was how Kibogora’s operational routines (like the 7am chapel service) and robust EMR system underscore Rwanda’s strength in doing “the simple things” exceptionally well. The daily chapel gatherings unified everyone—physicians, nurses, admin, and social workers—in a shared spirit of caring and purpose, setting a collective tone of commitment for the day’s work. Meanwhile, the existing digital infrastructure allowed us to experiment with AI-powered note-taking solutions, illustrating the country’s openness to innovation and efficient processes. Both elements—spiritual unity and technological readiness—gave me new insight into how a resource-limited setting can thrive when everyone pulls in the same direction.

1.6.2 Summary of the Elective

The elective at Kibogora Hospital provided an array of transformative experiences that significantly shaped my understanding of medicine, public health, and cultural integration. These key moments illustrate the achievement of outcomes and highlight the profound impact of this opportunity.

1. Finding a Liver Abscess through Abdominal Ultrasound In one particularly memorable case, I performed an abdominal ultrasound on a patient presenting with fever, jaundice, and abdominal pain. As I moved the probe across his abdomen, the grainy black-and-white images revealed a shadowed, fluid-filled cavity in the liver. It was a visceral moment, the kind that crystallizes the intersection of science and newly learned skills. The abscess, likely due to an untreated infection, required immediate intervention, and I felt a profound sense of purpose in being able to identify and address it in such a resource constrained environment.

2. Communicating with an ICU Patient In the ICU, I encountered an elderly woman who was disoriented and struggling to communicate. With the assistance of a nursing translator, I was able to bridge the gap, addressing her concerns and ensuring she felt heard. This interaction underscored the universal importance of empathy and the ability to connect with patients, regardless of language barriers.

3. Learning Kinyarwanda from a Unique Tutor A highlight of my time in the wards was learning Kinyarwanda from a patient initially diagnosed with psychosis. On risperidone and under monitoring, she transformed into our enthusiastic tutor, teaching me basic conversational phrases and medical terms. This unexpected dynamic deepened my connection to the community and made every interaction in the hospital more meaningful.

4. Witnessing the Innovation of Zipline Visiting the Zipline site was nothing short of awe-inspiring. Standing amidst the buzzing activity, I watched as drones, known as "Zips," were meticulously prepared for their missions. Each drone, lightweight yet robust, was packed with life-saving supplies, from blood units to emergency medications. Seeing them catapulted into the air and later retrieved with precision highlighted Rwanda’s commitment to innovation and efficiency in healthcare delivery. This experience was a testament to the potential of technology to transform patient outcomes in resource-limited settings.

5. Running Our Own OPD Room In the outpatient department (OPD), Nellie and I set up our own consultation bench in a back corner, with bilingual nursing students facilitating communication. Our makeshift room quickly became a hub for ultrasound referrals and patient consultations. The experience of independently managing patients, with the support of the local team, was both empowering and humbling, showcasing the value of collaboration and adaptability in clinical practice.

6. Another memorable instance was exploring the local cuisine—where I discovered, quite humorously, that Shambaza fish must never be eaten undercooked. Though it’s a small anecdote, it reflects how cultural immersion isn’t just about medical practice; it’s also about learning local norms and daily habits. Whether diagnosing an abscess on ultrasound or being reminded to double-check my dinner’s doneness, each experience highlighted the profound interplay between clinical work, community life, and practical adaptation in a new environment.

These experiences not only enhanced my clinical competencies but also provided invaluable insights into the integration of cultural, technological, and human elements in healthcare. They have left an indelible mark on my journey to becoming a holistic and innovative doctor.

1.6.3 Reflection on, and Evaluation of, the Elective

Did you achieve the intended outcomes?

Yes, I achieved most of the intended outcomes I had set for this elective.

Clinical Skills Development: I conducted over 50 patient examinations, spanning a wide range of medical conditions, including malaria, hypertension, and pneumonia. Additionally, I performed diagnostic ultrasounds and blood draws, which significantly refined my procedural skills. Facilitators: Access to patients and collaboration with bilingual nursing staff helped overcome language barriers and allowed me to operate more independently. Barriers: Limited diagnostic resources meant that I had to rely heavily on clinical reasoning, which, while challenging, honed my diagnostic acumen.

Diagnostic Proficiency: I interpreted diagnostics for over 30 cases and performed bedside ultrasounds, which enabled me to make accurate clinical decisions in resource-limited settings. Facilitators: My portable ultrasound device significantly expanded the scope of diagnostics we could offer. Barriers: The lack of advanced imaging and laboratory tests highlighted the gaps in diagnostic capabilities but reinforced the importance of clinical judgment.

Knowledge Expansion: I gained a deeper understanding of diseases like malaria, which are uncommon in South Africa, and learned about Rwanda's healthcare system, including its emphasis on patient and family participation in care. Facilitators: Exposure to different diseases, cultural practices, and public health systems broadened my perspective. Barriers: The language barrier initially hindered communication, but learning Kinyarwanda mitigated this over time.

Did you experience things that impressed and motivated you or were there matters of concern?

Impressive and Motivating Experiences:

Witnessing the efficiency of the Zipline system for delivering life-saving medical supplies was incredibly inspiring. It demonstrated how innovation and technology can revolutionize healthcare, even in resource-limited settings.

The family-centric approach to care was profoundly moving. Seeing family members take active roles in caring for patients reminded me of the communal aspect of health and reinforced the importance of empathy in medical practice.

Rwandan hospitality and resilience—from nursing staff to patients—motivated me to strive for excellence in my interactions and practice.

Personal Growth

My optimism, discipline, and cross-cultural empathy deepened significantly. Experiencing how Rwandans tackle challenges reinvigorated my drive to look for creative, tech-forward, yet compassionate solutions in my future practice.

I began rethinking how to best prepare for my next clinical placements—whether in family medicine in Worcester or future specialties—by leveraging AI tools (like Perplexity) to explore relevant treatment algorithms for resource-constrained settings.

Beyond the Hospital Walls On one Sunday, I joined a local church gathering where men had traveled up to seven hours to study scripture and disciple each other. Among them was Emmanuel, my internal supervisor, who was just as invested in the spiritual and communal well-being of these men as he was in his hospital duties. This glimpse into Rwanda’s communal fabric reminded me how deeply healthcare professionals can embed themselves in the lives of the people they serve.

Later, I bumped into Samuel, one of the men from that gathering, outside the hospital. He had come to care for his grandmother in the internal medicine ward. His trust in me—strengthened by our conversation a few weeks prior—highlighted the power of personal connection. This has reshaped my vision for internship and community service, underscoring the value of truly belonging where I work, rather than being a transient sojourner.

Matters of Concern:

Underutilized Equipment and Skills: The donated ECG machine and defibrillator were underused due to a lack of training. This became glaringly apparent during an emergency resuscitation, where gaps in knowledge led to delayed intervention. Action Taken: Nellie and I initiated a conversation with the clinical manager that got the ball rolling for training of the nursing and medical staff on ECG use and emergency protocols, advocating for continued skills development.

Overprescription of medications: Many patients were prescribed unnecessary drugs like omeprazole and cetirizine for minor illnesses. Action Taken: I raised this concern during clinical discussions, emphasizing evidence-based medicine to guide prescribing practices.

Opportunities I Would Have Liked to Utilize Differently

I would have liked to receive more formal teaching sessions from the nursing and medical teams on specific topics, but didn’t get around to asking.

I would have preferred more structured time for cultural immersion and language learning, as these significantly enhanced patient interactions.

Preparation for the “Real World” of Medicine

This elective prepared me to navigate the complexities of healthcare in resource-limited settings and adapt to challenges beyond my control. It underscored the need for resilience, collaboration, and proactive problem-solving in the face of systemic limitations.

I learned the importance of advocating for systemic improvements while maintaining empathy and professionalism.

It was a stark reminder that knowledge and skills are only impactful when coupled with effective communication and teamwork.

Overall, this elective was a transformative experience, equipping me with the tools, insights, and motivation to contribute meaningfully to healthcare delivery in diverse contexts.

Utilizing Existing Knowledge and Skills

Were you able to utilize existing knowledge and/or skills? Absolutely. The foundational knowledge and skills that we garnered through internal medicine rotations at home in South Africa were crucial throughout the elective. Using the skills and resourcefulness that working in the South African circuit had taught us, Nellie and I established an efficient outpatient setup, streamlining patient flow in the clinic and ultrasound rooms, which ultimately allowed more patients to be seen each day, and allow the clinical staff to leave earlier. My portable ultrasound and POCUS training were instrumental in conducting emergency scans in the ER and performing abdominal ultrasounds and echocardiograms in the wards. This significantly reduced waiting times and ensured timely diagnoses, particularly in a resource-limited setting where efficiency and accuracy are paramount.

Beyond diagnostics, I relied on my clinical reasoning and communication skills to navigate cases ranging from common presentations like malaria and pneumonia to more complex situations like atrial fibrillation with rapid ventricular response. These moments required me to adapt my knowledge to a new healthcare system and cultural context.

Were there gaps in your knowledge or skills that you believe perhaps should have been in place before the elective? While I felt prepared for the majority of the medical challenges that we faced, there were undeniable gaps:

Language barrier: Limited proficiency in Kinyarwanda initially hindered communication, especially in building rapport with patients and understanding subtle cultural nuances.

Cultural awareness: I lacked an in-depth understanding of Rwandan healthcare structures, such as the practice of patients purchasing their own medical supplies, which differed starkly from my South African training.

Resource limitations: Adjusting to the absence of advanced diagnostics (e.g., blood cultures, CT scans) underscored gaps in my reliance on comprehensive investigations to make diagnoses, and opened up learning opportunities for me to learn more about clinical signs and typical symptom descriptions that can guide us toward a diagnosis without the need for expensive special investigations.

Emergency protocols: I encountered a steep learning curve when working with unfamiliar equipment like the defibrillators there, which highlighted my need for better preparation in equipment training.

How did you intend to address any shortcomings? To bridge these gaps, I adopted a proactive approach:

Language learning: I practiced Kinyarwanda daily using a spaced repetition system, focusing on conversational and medical vocabulary. This deliberate effort significantly improved patient communication and fostered deeper connections.

Reading: I read up on each case that I saw, aided by my AI paper finder I was able to get into the nitty gritty details of each disease - only temporarily quenching my curiosity. I used these newfound insights into each disease to augment my existing flashcards on each topic, and took the opportunity to revise the details from our previous blocks on each.

Cultural immersion: Engaging with hosts, translators, and clinical supervisors provided insights into the cultural and systemic intricacies of Rwandan healthcare. These interactions were invaluable for understanding patient expectations and community dynamics.

Equipment training: The defibrillator incident underscored the importance of familiarizing myself with medical devices. I advocated for ECG and emergency equipment training sessions for the staff, ensuring better preparedness for future emergencies.

New Knowledge and Skills Obtained

What new knowledge and/or skills have you obtained?

Kinyarwanda vocabulary: Developing conversational proficiency allowed me to connect with patients on a deeper level, enhancing their comfort and trust. I can now humbly converse in basic Kinyarwanda and extract a basic clinical history, main complaint and medical history without any outside assistance.

Resource optimization: Managing patients without extensive labs or imaging sharpened my clinical acumen and diagnostic efficiency.

Disease expertise: I gained firsthand experience diagnosing and treating diseases uncommon in South Africa, like falciparum malaria, and learned about their varied presentations, treatment protocols, and complications.

Never eat Shambaza raw: This is only partly a joke. Shambaza is a local fish delicacy, made from small-fry caught in Kivu and then deep fried in a mixture of salts and spices. It was highly recommended by our ex-pat hosts in Kigali before we came to Kibogora. Let the wise learn: always, always make sure your Shambaza was cooked before eating it - otherwise you’re in for a nasty, fishy surprise ;)

Has this taken place in a context or manner that differs from the opportunities in the curriculum? Yes. The elective provided unparalleled exposure to rural healthcare systems, cultural immersion, and diseases outside the typical South African curriculum. The integration of innovative systems like Zipline offered a glimpse into scalable, tech-driven solutions that are rarely discussed in traditional medical education. Given Rwanda’s welcoming approach to innovation, and small population, they offer a unique environment in which to see growing healthcare systems flourish.

Have you identified new knowledge or skills that you would have liked to learn?

I’d love to learn more Kinyarwanda, and other regional languages to further enhance my communication abilities in similar settings, even within South Africa’s borders. (Shortly after we got back, we went on a medical mission trip to KZN, which further emphasized the benefits of being able to converse in Zulu - inspiring me to learn and practise more of it; a practice that I intend to take forward with any language that I find forming a barrier to my clinical communication in future.)

Greater understanding of healthcare logistics and public health policy to better navigate resource-limited environments. I’m fascinated by Rwanda’s approach to resource-limited healthcare and national healthcare coverage - incentivising people to take better care of themselves by involving them in the care-taking decisions, billing and nursing.

I’d also love to learn more about how South Africa uses primary healthcare workers, and whether the Rwandan model (of mobile, locally sourced primary healthcare workers who assist with screening, drug dispensing and verification of drug adherence) could be replicated in struggling South African micro-ecosystems.

What do you intend to do about this?

Continue language learning and revising using Remnote and OpenAI models to expand my vocabulary in African languages.

Pursue more electives in challenging settings to deepen my understanding of rural healthcare and public health systems.

Since returning, I’ve read up on the South African approach to primary healthcare and have found resource limitations to be the chief issue preventing such a model to be effective in our setting. This, I believe, is temporary, and that greater access to personal transport and monitoring will slowly enable our frontline workers of public healthcare to provide a greater standard of care to their neighborhoods. This is something that I’d like to incorporate into the long term vision of the a number of the organisations that I’m involved with, that have a primary healthcare focus.

Relationships and Attitudes

Have relationships with, or attitudes towards others, changed positively or negatively? Explain. My relationships and attitudes have grown positively. The warmth, resilience, and dedication of Rwandan healthcare workers, even amidst resource limitations and challenging working conditions, inspired me to be more empathetic and collaborative. Observing families actively participate in patient care reshaped my perspective on holistic treatment, teaching me to approach healthcare as a collective effort rather than an individual task.

Have any of your opinions or ideas changed? Yes. I now appreciate the critical role of cultural and familial factors in healthcare delivery. Witnessing the community-driven approach to care in Rwanda underscored the importance of integrating patients’ families into treatment plans for better outcomes. In addition, my ideas of as to how to build a thriving public healthcare system in South Africa have been augmented significantly by seeing the close-knit teams working at Kibogora and their success in empowering community healthcare workers to bolster medical campaigns and drives.

What caused the change? Explain why opinions and ideas that could have changed, remained the same. Manya was an 69 year old father with heart failure, diabetes and hypertension in our rudimentary ICU. Beside him sat Winston, his 40 year old son, a working man, sharply dressed in the same pink blazer and bowler hat each day. Through bouts of delirium, extra IVs and ultrasounds Winston was always there to help his dad by feeding him, comforting him and talking to him. Despite my inability to communicate with him in any meaningful way, beyond the standard greetings and small talk, I saw his investment in his father’s care - his sacrifice in listening to, washing and cooking for his dad really warmed my heart, and, I’m convinced, helped Manya’s heart too. Why? Because I saw the same thing happen with over 100 other families in the space of a month, all who demonstrated incredible mental tenacity in the face of infirmity, and who supported one another through trying times, most of whom made a significant enough recovery to return home with them.

Evaluating the Elective Experience

Was this a valuable experience? Explain. Without question. This elective provided unmatched exposure to clinical, cultural, and public health dimensions of medicine. It enhanced my practical skills, broadened my worldview, and deepened my commitment to becoming a holistic and compassionate doctor.

Are they closer to attaining the “Profile of the Stellenbosch Doctor”? Yes. The elective strengthened my knowledge, skills, and attitudes in alignment with the profile. It emphasized adaptability, cultural competence, and evidence-based practice, key traits of a Stellenbosch doctor.

Have you reached new insights into your chosen career or about yourself? Absolutely. I’ve realized the importance of continuous learning, cultural sensitivity, and leveraging innovation to improve patient care. It has also posed me with a challenge; to be further involved with medicine, or with public healthcare and systems entrepreneurship. I loved being able to use my knowledge of systems architecture and coding as much as I loved using my medical knowledge to help sick patients. Regardless of which area I have the opportunity to specialise in, this elective has shown me that one thing is certain: I’ll be using the knowledge and unparalleled access to information and resources that I have to be the best clinical practitioner that I possibly can be, and, to enable other doctors across the continent to be the best clinical practitioners that they possibly can be. //

What do you now believe is important about becoming a doctor and being a doctor? Becoming a doctor requires more than just clinical competence; it demands empathy, adaptability, and a commitment to lifelong learning. While technical knowledge and skills are fundamental, a doctor must also have the ability to connect with patients on a human level, understanding their stories, cultures, and unique challenges. Effective communication is essential—not only with patients but also with colleagues across the healthcare system—to ensure coordinated and patient-centered care. Cultural awareness and sensitivity are key to building trust, particularly when working in diverse or underserved communities. Additionally, an openness to innovation is critical in today’s rapidly evolving medical landscape. Whether through adopting new technologies, refining systems for better efficiency, or rethinking care delivery models, innovation enables doctors to improve outcomes and address systemic challenges. A heart for systemic improvement—recognizing and addressing gaps in healthcare delivery—is equally vital, ensuring that care evolves alongside the needs of the community. Ultimately, being a doctor is about balancing the art and science of medicine, serving both individual patients and the broader healthcare system with compassion, curiosity, and a willingness to grow.

Has this changed from when you set out on the elective? Yes, my understanding of what it means to be a doctor has deepened and evolved during the elective. Initially, I viewed the role of a doctor primarily through the lens of clinical excellence and patient care. However, my experiences highlighted the importance of collaboration, innovation, and cultural competence. I came to appreciate that healthcare delivery is not just about addressing immediate medical needs but also about navigating systemic challenges and advocating for lasting change. This requires working closely with interdisciplinary teams, leveraging technology and data to optimize care, and understanding the unique social, cultural, and economic contexts in which patients live. Moreover, I realized that adaptability and a willingness to learn from every situation—whether through hands-on practice, feedback, or observation—are essential for growth as a doctor. My time on the elective reaffirmed the need for a mindset that prioritizes curiosity, open-mindedness, and continuous improvement, both in clinical practice and in the broader healthcare system.

Do you intend to do anything differently regarding your profession in the future?

Advocate for integrating innovative solutions like Zipline into local healthcare systems.

Prioritize cultural competence and language proficiency in patient care.

Leverage technology and public health strategies to enhance healthcare delivery in resource-limited settings.

Advocate for systemic change in healthcare funding models (Rwanda uses a mixed private-public medical aid funding model that gives every citizen the responsibility to take care of their own healthcare by contributing - even if minutely - toward their own medical aid expenditure. Every person receives the best care available, and pays for a portion of it, incentivising them to protect their own health instead of taking advantage of the resources of the public system to the detriment of their own health and limited resources that need to be shared amongst the public.) This has had a great influence on the way that I’ll be involved in commercial, private and public medical care in the future.

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