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TIPS abroad: Bangladesh

TIPS (Teaching Improvement Project System) has been delivered at ACME for several years since it was adapted by Deborah Gill and Jane Richardson. Doctors throughout London and the UK have benefited from the opportunity to critique and improve their own teaching, with support from skilled educators. But TIPS’ impact is not confined to the UK: it has previously been delivered by ACME educators as far afield as Libya!

Recently Caroline Fertleman (Consultant Paediatrician and UCL Medical School site lead at The Whittington Hospital) and Chloe Macaulay (Paediatric Registrar and Fellow in Medical Education at The Whittington Hospital and ICH) worked with Louise Day (Consultant Paediatrician and Head of Paediatrics, Lamb) to adapt the TIPS course for a Bangladeshi audience.

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Lamb: an integrated health care project in Northern Bangladesh

Lamb began as a community project in the 1950s and has expanded to include a hospital and 30 satellite medical centres and safe delivery units. It provides health care for a population of about 2 million people. This is a challenge as the organisation receives no governmental funding and is entirely dependent on donations, grants and fees. It was originally a mission hospital and still has a strong Christian ethos. However, many staff are Bangladeshi, and many of these are Muslim. Lamb welcomes those of any faith as long as they are sympathetic to the ethos of Lamb.

Screen Shot 2013-01-21 at 13.45.36Babies born in this region in Bangladesh have the odds stacked against them and perinatal mortality is high (6/100). The hospital has few of the interventions that are considered routine in the UK and for a premature or low birth weight baby, a woolen hat and careful “KMC” (kangaroo mother care) provide the best chance of survival. The hospital tailor makes bags which mothers tie around themselves, attaching the babies to their front: the mother’s body heat keeps the baby warm, the mother’s movements stimulate the baby to breathe, and the baby has direct access to breast milk. It is a very practical and natural solution to the absence of incubators, medication and monitoring. However, KMC is a crude intervention, and many babies still get cold, septic and die. Despite the lack of resources the staff are absolutely committed to providing the best care they can, and training the community in health behaviours and more advanced medical care.

Lamb: a provider of high quality education for community staff

Lamb has a significant educational role and trains many different levels of staff. These include community health volunteers who actively seek out pregnant women and encourage them to attend community health clinics for monthly antenatal care and birth planning. Skilled birth attendants and community midwives are trained for between 6 months and 3 years to work in the community safe delivery units. All complicated labours are referred to hospital, but these community sites manage approximately 200 deliveries a year each. Lamb has just started running a three year nurse training programme in an attempt to provide its own nurses as recruiting rurally is not easy.

Adapting a short course for a resource poor setting

Screen Shot 2013-01-21 at 13.46.21Given that education makes up such a large part of daily activity at Lamb, the Clinical Lead for Paediatrics who is a British trained doctor and knew Caroline from the UK, invited the UCL ACME team to deliver a bespoke TIPS course to a variety of local faculty. Planning of the content and organisation began several months in advance. The content was simplified to take account of varying levels of English language skills, and the examples were changed, making them more culturally appropriate. A Bengali film (“The Clay Bird”) was used to illustrate how not to give feedback, although the participants actually derived more pleasure from the clip of “Ferris Bueller’s Day Off”!

Screen Shot 2013-01-21 at 13.46.42There were 17 participants on the course – made up of doctors (three Paediatricians, one Obstetric surgeon and a General Practitioner), one physiotherapist (who trains several physiotherapy assistants), two medical assistants, several senior nurses and nurse trainers, and staff from the training centre. As is usual during TIPS the groups were frequently mixed to promote skill-sharing and integration between different clinical groups.

The programme was adapted to suit the needs of learners.

Day 1 (full day):

  • Introduction and Theory
  • Lesson Planning
  • Objectives – RUMBA
  • Questioning – principles, techniques, different levels
  • Evaluation – student/self/peer

Day 2 (full day):

  • Review of Day 1
  • Microteaches
  • Teaching clinical skills – 4 stage technique and practice

Day 3 (half day):

  • Bedside teaching
  • Clinical reasoning
  • Opportunistic teaching
  • Review
  • Closing ceremony (!)

Rather unusually for the team, every day started with a short “devotion” – a religious discussion which is the routine way to start the day at Lamb.

“The daily devotional reading was unusual for TIPS. Each day I put up a sentence from the Old Testament in Hebrew and English” Caroline

Screen Shot 2013-01-21 at 13.47.25Traditional Bangladeshi dress – shalwar khameez – a long shirt-like dress, baggy trousers and a scarf – or “orna” is insisted upon, even for Western visitors, which was also a new experience for the team. Despite being warned that they would be reticent, and reluctant to participate, there was good engagement from everyone, with lots of laughter at attempts to join in with traditional Bengali songs which they use to break up long sessions.

“I was pleased that they engaged so fully from the beginning. I felt that we got something right in the mood so they felt comfortable to participate.” Chloe

The hard work in preparing the materials and considering the teaching approaches prior to delivering the course, ensuring the material was culturally sensitive, also paid off.

“I felt that despite being 2 assertive white British women we could engage the Muslim, Hindu and Christian men and women on the course.” Caroline

The language barrier was more significant than anticipated and the fact that the course was simultaneously translated into Bengali was essential.

“It absolutely needed to be translated as there were often two rounds of laughing – first when we said something funny and then after it was translated.” Caroline

Microteaches were done in a mixture of English and Bengali and included a broad range of topics such as diagnosing dehydration, wrapping a baby, and giving breast feeding advice. The examples used for clinical skills training were setting up KMC, drying and wrapping newborns, taking blood pressure in a pregnant mother, and counseling mothers on future birth planning.

“There were lots of experiences about teaching this course which were similar to teaching it in the UK but also some subtle differences. Participants enjoyed all the different ways we taught but often needed to have this signposted. If traditional questioning did not receive any responses putting people in buzz groups got the answers flowing. They were adaptable to try new teaching methods and get away from traditional rote learning as is common in Bangladesh. ” Caroline

“I realised that we make certain assumptions about knowledge: it was a very mixed group. Several seemed to really rise to the challenge and be very advanced while others took a while to get it.” Chloe

Caroline and Chloe enjoyed the process of planning and delivering the course, and learnt a lot that they will integrate into their personal educational practice. They are grateful to their hosts at Lamb who were extremely welcoming, and hope that the news skills their participants gained are effective in supporting the development of essential local healthcare providers.

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So, where next for TIPS abroad? We have our sights set on Burma so watch this space!

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