Advancing Global Pediatric Oncology in Sub-Saharan Africa: One CHOP David N. Pincus Global Health Fellow's Journey

Dr. Westmoreland with her CHOP fellowship mentors: Loeto Mazhani, MD, Andrew Steenhoff, MBBCh, DCH, and Jeremy Slone, MD, MPH After participating in monthlong rotations in Nicaragua (2006), Brazil (2008), South Africa (2008) and Swaziland (2011), and implementing a maternal-child health program in Nepal (2011-12), Kate Westmoreland, MD, knew she wanted to pursue a long-term career in global health. She applied to all three of the global health fellowship programs that were available at the time, but the David N. Pincus Global Health Fellowship offered by Children’s Hospital of Philadelphia (CHOP) stood out the most: It offered a fully immersive two-year program with a focus on research and clinical work that aligned with her career goals.

In 2013, Dr. Westmoreland joined CHOP, becoming the third Botswana-based David N. Pincus Global Health Fellow. She spent the first few months of her fellowship learning about the Botswana health system and about the processes and procedures at Princess Marina Hospital, the country’s primary teaching hospital, where she would spend much of her time during the fellowship. As a newcomer to Princess Marina Hospital, she had a different perspective that helped inform the three research areas she eventually focused on during her time there.

Seizing the opportunity

The hospital faced a number of challenges: Botswana had opened its first medical school just four years before, in 2009, its residency training programs were relatively new, and the country was working to address a high prevalence of HIV. Given all of these challenges, Dr. Westmoreland was not surprised to observe considerable burnout among residents at the hospital. In addition to the toll that burnout takes on individual providers, it also negatively influences patient care in many ways, including increased medical errors and provider turnover.

After sharing these observations with her in-country mentors, including Loeto Mazhani, MD, then the Assistant Programme Director in the Department of Paediatric and Adolescent Health, Faculty of Medicine at the University of Botswana (UB), Dr. Westmoreland designed a research study to measure burnout among UB residents. She also used the validated Maslach Burnout Inventory in a two-part questionnaire to identify possible factors associated with and protected against burnout. She found that 75 percent of residents reported a high degree of burnout in one or more of the burnout domains, including emotional exhaustion, depersonalization, and diminished feelings of personal accomplishment. To reduce burnout, respondents suggested wellness lectures, career development lectures, and mentorship and resident social events.

As a result of Dr. Westmoreland’s study, the UB Faculty of Medicine introduced wellness activities for residents and began providing free psychotherapy services through the University’s Department of Psychology. The findings were published in the African Journal of Health Professions Education in 2017.

Dr. Westmoreland says, “It is important for medical schools and hospitals across Africa to prioritize implementing programs that improve the well-being of their doctors and nurses who are working in challenging resource-limited environments. This will improve the quality of care they provide and also ultimately improve their job satisfaction and retention in the public sector.”

Teaching compassion

Dr. Westmoreland also led a teaching team comprising residents and medical students. She wanted to help them learn strategies for delivering unwelcome news to parents and caregivers. It is something they had to do regularly. Unlike in the United States, in-hospital pediatric and neonatal mortality rates in Botswana are incredibly high. The team at Princess Marina Hospital reported that from 2011 to 2013, the neonatal unit had a mortality rate approaching 20 percent, and the pediatric medical ward had a mortality rate of around 6 percent.

This led Dr. Westmoreland to her second project during her fellowship: developing a three-hour peer role-playing workshop to train medical students — many of whom had very little communications training — to deliver bad news. The workshop incorporated the validated SPIKES protocol, which gives providers a step-by-step guide to delivering bad news to a patient and their caregiver. Peer role-playing provided a more cost-effective training approach than hiring the standardized actors often used in high-resource settings. Following the workshop, medical students reported increased skill and self-confidence in delivering bad news.

The manuscript for this project was published in October 2018 in the journal Palliative & Supportive Care. “This is exciting for me because to my knowledge, this is the first published report describing a peer role-playing workshop for teaching communication to medical students in sub-Saharan Africa. Hopefully more medical schools across Africa will be inspired to adopt this as part of their curriculum,” says Dr. Westmoreland.

Answering the calling

Dr. Westmoreland also regularly volunteered to provide staffing support on the pediatric oncology ward when she was not on the general pediatric service or doing research. This changed the trajectory of her career, as it inspired her to specialize in global pediatric oncology.

After Dr. Westmoreland completed her Pincus Global Health Fellowship, she was awarded a Fogarty Global Health Fellowship with the University of North Carolina (UNC), and spent a year in Malawi under the mentorship of Satish Gopal, MD, MPH. During this time, her research focused on pediatric Burkitt lymphoma, Hodgkin lymphoma and quality of life for patients with pediatric lymphoma. 

Recognizing that she needed more training to have the impact she envisioned, Dr. Westmoreland returned to UNC-Chapel Hill to complete a Pediatric Hematology Oncology (Hem-Onc) Fellowship. She is currently pursuing expertise in clinical pharmacology through the UNC-Duke Collaborative Clinical Pharmacology T32 Fellowship. Dr. Westmoreland will continue her research to understand how chemotherapy drugs act and are metabolized, in hopes of optimizing chemotherapy dosing for children and adolescents in sub-Saharan Africa. She is also completing additional work in the field of patient-reported outcomes to better understand the quality of life of Malawian children with Burkitt lymphoma.

Dr. Westmoreland credits the CHOP David N. Pincus Global Health Fellowship with helping her find her true calling in global pediatric oncology. “I saw many pediatric oncology patients die during my time in Botswana due to limited resources and lack of knowledge on how to best adapt treatment protocols for the region. This made me passionate about devoting my career to learn how to better treat and improve survival rates for children with cancer in sub-Saharan Africa, while at the same time focusing on their quality of life. The flexibility and mentorship I received during the CHOP David N. Pincus Global Health Fellowship allowed me to explore my academic and clinical interests and led me to pediatric oncology.”

How you can become a Pincus Fellow

If you are an early-career pediatrician or pediatric subspecialist seeking the skills to become a leader in pediatric global health, this is the fellowship for you. It is an expertly mentored and fully funded (now) three-year experience in global health practice. If you are interested in becoming a CHOP David N. Pincus Global Health Fellow like Dr. Westmoreland, email the CHOP Global Health Center at globalhealthcenter@email.chop.edu to request an application.