Fig. 27.1
Queen Elizabeth Hospital. (a) Queen Elizabeth Hospital in Blantyre, Malawi, is the largest referral hospital in the country, with about 1,000 beds. (b) Teaching anesthesia clinical officers in training in pediatric advanced life support at Queen Elizabeth Hospital. Photographs M.E. Durieux
Pennsylvania, 2013: This state of 46,000 square miles has more than 250 hospitals, serving a population of about 15 million. There are 1,900 anesthesiologists and 3,600 nurse anesthetists. There are eight accredited residency programs that graduate more than 50 residents per year.
Malawi has approximately one tenth of the number of hospitals, and approximately 1/50th of the number of anesthesia providers as does a US state of similar size and population. In addition, Malawian anesthesia clinical officers train for fewer years and with less clinical apprenticeship than anesthesiologists or nurse anesthetists in high income countries (HICs). The training of Malawian anesthesia clinical officers and residents is largely self-directed and infrequently supervised. Although mid-level providers often have a wealth of clinical experience and are technically skilled, their limited training in physiology, pharmacology, and the principles behind anesthesia practice place severe constraints on their capabilities, and this likely contributes to the high perioperative mortality—approaching 5 % in low- and middle-income countries (LMIC).
With the hospitals overloaded, the providers overworked, those few who are involved in teaching have most of their time taken up by administrative and clinical issues. Compare the Malawian residency program, which has two physicians and no administrative support, to a US residency program with hundreds of clinical faculty and dozens of support staff. As a result, even if qualified students, adequate facilities and appropriate materials are present, training still may not occur simply because there are no teachers available.
In addition, this vicious circle is a critical factor holding back the development of many specialties, including anesthesiology, in many countries. The USA has about 25 physicians per 10,000 population; Malawi, Rwanda, and Tanzania, and about 20 or so other nations make do with less than 1 per 10,000 [1]. The countries with this excessively low ratio are largely in sub-Saharan Africa (Fig. 27.2). In such countries, a critical mass of teachers will have to be established before the cycle can be broken, and this can be done only with outside teaching support. This disparity, the resulting impact on the health of the population, and the clear need for educators demonstrate why anesthesiologists from HICs should become engaged in teaching in LMIC.
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Fig. 27.2
Physicians working around the world. Territory size shows the proportion of all physicians that work in that territory. In 2004 there were 7.7 million physicians working around the world. If physicians were distributed according to population, there would be 12.4 physicians to every 10,000 people. The most concentrated 50 % of physicians live in territories with less than a fifth of the world population. The worst off fifth are served by only 2 % of the world’s physicians. Note the disproportionately low number of physicians in Africa (red). © Copyright Sasi Group (University of Sheffield) and Mark Newman (University of Michigan). Reproduced under Creative Commons license
In this chapter we provide practical information for anesthesia providers who want to play a role in improving anesthesia education opportunities by volunteering their time to teach overseas. First, we discuss some important practical considerations for volunteers considering teaching work beginning with the difference between service and education focused work and continuing with some considerations for pre-trip planning. This section expands on some material published recently [2]. The subsequent sections focus on pre-departure preparation and practicalities of in-country teaching.
A Comparison of the Teaching and Service Volunteer Experience
The primary goal of service-based global health work is to provide medical or surgical care to the local population, while the goal of education-based global health work is to build capacity and train a workforce. When a volunteer commits to service or education, these goals will impact not only the enjoyment of the experience, but the outcome of the work. There are many models of providing service and education, or a mix of the two, but here they are contrasted in their most basic forms.
Facilities, Equipment, and Techniques
Service work focuses on treating the maximum number of patients in the limited available time. For this reason, practitioners will often bring their own equipment and drugs, so as not to be dependent on the local supply. In teaching settings, the trainees will need to be trained on their own equipment with drugs that will be available after the teachers leave. Hence, the visitors will have to make themselves familiar with anesthetic drugs, equipment, and techniques that they may not be used to, or, in fact, may never have seen or heard of before (Fig. 27.3). The volunteer may need to dedicate substantial preparation prior to the teaching trip to familiarize and train her- or himself in the methods and tools used by the students.
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Fig. 27.3
Unfamiliar anesthesia equipment. Material in use at Haydom Lutheran Hospital in Haydom, Tanzania, a large district hospital covering an extensive capture area. An Oxford miniature draw-over vaporizer is used to deliver halothane; Oxford Inflating Bellows are used to ventilate the patient. The pulse oximeter was brought by one of the authors (MED), who was teaching anesthesia medical officers in the hospital. Photograph M.E. Durieux
The practice setting is likely to be quite different as well. For example, it is not uncommon in some countries to have several operating tables in one room, so that multiple surgeries take place in parallel. Many locations will not have a preoperative area for evaluating the patient or a post-anesthesia care unit.
From a teaching perspective, infrastructure and facilities may be scant or absent. There may be very little in the way of educational facilities or classroom space, and frequently there will be no defined curriculum from which to work.
Workload
The pace of work can be quite different between service and education trips. Again, during service missions, the team attempts to maximize the number of cases done, and that means starting early and often working in the operating room until late at night. Usually, little else is done during the trip. During education work, the volunteer has to adapt to local customary start and end times, which are generally quite different from those in academic medical centers. Even though the hours are different, volunteer educators will work hard. The non-clinical time at the beginning and end of the day is packed with lecture preparation, test writing and grading, and meeting with students. In addition, it is not uncommon to become involved—whether planned or unplanned—in other educational activities such as medical school curriculum development, outside lectures, or teaching for practitioners outside the specialty.
Cultural Considerations
Language barriers can be a major problem during both service and teaching work. For teaching, a good understanding of the level of education of the trainees, and of their background knowledge and clinical experience is required. This information can be difficult to obtain, and at times the teacher may not have worked previously with trainees with this mix of knowledge. For example, as mentioned above, it is not uncommon to work with people who have quite extensive clinical skill, but only a rudimentary understanding of physiology and pharmacology. Even a concept such as “tidal volume” may be unknown to the students, making effective teaching very challenging. The best approach is to be aware of and continuously challenge one’s assumptions about the learners’ knowledge by obtaining immediate feedback. Frequent questions on the degree of understanding of material just taught can provide this information. For example, including multiple-choice questions in presentations can quickly check understanding of material presented a few slides earlier.
Cultural mores and norms run deep and can challenge and surprise even the most effective teacher. An educator needs to be mentally prepared to find one morning that all of the students are absent because someone’s distant relative has died and they all needed to be at the funeral as a sign of respect. A visiting teacher needs to be ready for unexpected pushback during a discussion of ventricular fibrillation, because the students know from experience that none of those patients survive in their hospital, so it is not worth instituting treatment. While it is helpful to prepare by reading on the culture and religion of the area where the teaching will be done, the reality is that the visiting educator will be confronted with unexpected responses and behaviors. The ability to adapt and improvise is an important trait for both the service-based volunteer and teacher; however, a longer duration of a teaching trip means there will be more surprises.
Program Duration
Short- versus long-term involvement will be discussed in more detail later in this chapter, but in the context of a comparison between service and education, it is important to realize that education work will require more time in-country than does a service mission. Unless one commits to a long-term in-country stay, this means that the individual educator will only see a small slice of the whole job. After a service mission of 2 weeks, the volunteer anesthesiologist knows exactly how many patients were operated on and helped; after 2 weeks educating local anesthesia providers, progress may not be quite so visible, and it is easy to become discouraged about long-term prospects. The volunteer can mitigate the natural tendency to become discouraged by understanding the totality of the group’s mission, being mentally prepared not to see immediate results, and maintaining contact with people who have previously worked on the same project. On the other hand, educational work often affords practitioners more opportunity and more time for close personal contact and for developing friendships with the local teams, which can be professionally and personally satisfying. Also, educational activities come with the realization that one is adding to capacity, and not in any way taking away from or displacing local professionals.
Program Planning
It is unfortunately only too easy to come into a developing country with the best of intentions yet unprepared to really effectively help with an educational program. For each program, some important considerations need to be addressed. Below we discuss how to define the organizational structure, tailor the message and methods to the intended audience, incorporate technology, and be sensitive to the history of medical education in the country. Incorporating this level of understanding into teaching activities will increase the probability of implementing a successful medical education program.
Program Organization
In-country education programs that are driven by the local clinicians and administration—who are the only people who really understand the local needs and limitations—are more likely to accomplish their goals. Not even the most intense and frequent “scouting trips” and “evaluation visits” can match local knowledge. A formal needs assessment is important and very useful for planning the program, but it cannot replace direct input from local people. Local practitioners are also the people who know if other outside groups are involved in local teaching and can keep well-intentioned organizations with similar goals from duplicating each other’s work. In-depth interaction with the local stakeholders will assure that the program is unified and comprehensive, that separate efforts directed at a residency or mid-level training program are aligned, and that all visiting faculty teach according to a defined curriculum. Ideally the local faculty members are in charge of the entire process.
The Audience
Practically, the level of instruction will differ between programs for residents and those geared for anesthesia technicians. Philosophically, many anesthesia educators in HICs feel that anesthesiologists should focus on training more physician providers. Whether efforts and resources should be spent on developing nascent residency programs or whether those efforts are better expended towards improving technician training is a heavily debated question. Physician anesthesiologist and anesthesia technician programs are sometimes at odds within the host country, and the visiting educator may need to negotiate these politics [3]. Because in over half the countries in the world technicians or nurses with an average of 1–2 years of training provide most of the anesthesia care, it is in the best interest of the local patients that technicians are optimally trained, and participation in their training is valuable [4, 5]. At the same time, the goal of having at least one anesthesiologist available in each hospital is an important one—physician anesthesiologists can advance anesthesia care with respect to other medical and surgical services, they can provide subspecialty services, and they can supervise and support technicians and mid-level practitioners. Ideally for the health of the population in LMICs, residencies will be started, and residents and technician education will have to take place simultaneously [6].
Distance Learning
Internet facilities in most parts of the world are by now capable of video uplinks of very acceptable quality, and tele-education can be immensely valuable in many ways. As one important example, it allows a variety of specialists, not all of whom would be able or willing to travel to another country, to take part in educational activities. In addition, it allows residents or other learners to see behavior modeled by their counterparts in HIC. Case teleconferences can be an excellent learning tool for residents in LMICs and remote areas of HICs; for example, the University of Virginia runs a monthly case conference with the anesthesiology residency in Rwanda (see Fig. 27.4), and these are being evaluated positively [3]. Although operating room and bedside teaching are an essential part of medical training that cannot be replaced by distance learning, teaching be enhanced through the use of technology for case-based learning or simulation. A program such as the case conferences mentioned above can maximize educational value and minimize cost for training programs in LMICs.
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Fig. 27.4
Distance learning. A case teleconference in progress between the anesthesiology departments of the University of Virginia and the University of Rwanda. Photograph C. Lewis, with permission
Beyond the Curriculum
When physician educators arrive to teach the curriculum and implement an educational program, they become ambassadors from their home country. What this means is that they are unavoidably a model for many of the trainees, and this may be one of the more important aspects of in-country teaching. A visiting physician educator walks a fine line between capacity building and recruiting anesthesia providers away from the home country.
Many developing countries suffer greatly from “brain drain”: For a variety of reasons, local physicians trained, at great difficulty and cost, are at high risk of leaving the country and finding more comfortable and lucrative employment elsewhere [7–10]. To prevent this, it is important that foreign teachers do more than train in technical and cognitive aspects. Working and teaching in the local setting can be a truly interesting job and this needs to be conveyed to the trainees. They also need to be made to feel part of the modern anesthesia world. In some ways, when one talks about techniques, drugs and approaches used in the western world, trainees in LMIC get a glimpse into their future. Our goal as anesthesia educators is for them to be part of that future—in their own country.
Before You Go: Finding a Program and Preparing for Your Experience
Somewhere in sub-Saharan Africa: A woman of 48 years needs surgery for a uterine fibroma. Her husband is a surgeon and she told him she does not want general anesthesia. The husband recommends a surgeon colleague who works in a private hospital famous for its regional anesthesia. In this hospital the surgeon is also the doctor who gives anesthesia. The husband plans to assist his friend in operating on his wife. What happens?
The day of the operation, the surgeon places the single shot epidural anesthesia. Both surgeons prepare themselves for the operation and an assistant trained by the surgeon is charged with taking the blood pressure, and monitoring pulse and oximetry parameters. Before the incision, the husband remarks that his wife is yawning. His friend tells him that she probably wants to sleep and asks his assistant to give 100 mg of propofol intravenously to help her sleep. The propofol is given and the operation begins. After a few minutes, the husband, not hearing his wife, tries to talk to her. She doesn’t answer. When the assistant attempts to measure the blood pressure, it is not recordable: the woman is in cardiac arrest. An anesthetist from another hospital is called to come and resuscitate. He arrives 30 min later, but by that time the patient is dead. On site there was equipment to ventilate but the laryngoscope didn’t work because of battery failure.
Although the details change, stories of avoidable anesthetic deaths such as the one above are shockingly common in many parts of the world. The high perioperative morbidity and mortality in many LMICs has a number of causes, but a lack of well-trained anesthesia providers is certainly an important one [6, 11]. As we have discussed, an increasing number of anesthesiologists and anesthesia trainees from high-income countries are eager to travel overseas and help. Several practical pre-trip steps can be taken before an educational visit overseas to make it a more productive, rewarding, and safe experience for the visitor, the host, and most importantly for the patients. The following section will review the most critical steps in preparing for an educational trip.
Program or Project Selection
An important first step in contributing to in-country anesthesia training is to search for a reputable aid organization or program that is a good fit with the physician’s skills, interests and values. An established program has the advantages of having performed a needs assessment and having worked out relationships between key players at the overseas site. It is important that a visiting anesthesiologist not be a burden to already overworked health care providers by making demands on their time for assistance with orientation, housing and transportation needs. A good organization can help guide the educator with planning, communication, and setting reasonable expectations in order to increase the likelihood of a useful and productive trip.
If the anesthesiologist is not already aware of an educationally oriented organization, how does he/she find one? Fortunately in the past 5–10 years there has been a strong focus on workforce development and education in anesthesia and other specialties by academic institutions, the World Health Organization (WHO), and the US Government [12]. Good places to start looking are within the home institution, on websites such as the American College of Surgeons Operation Giving Back (OGB) [13], the American Society of Anesthesiologists (ASA) Global Humanitarian Outreach (GHO) [14], and subspecialty websites such as the Society for Pediatric Anesthesia [15] and the Society for Education in Anesthesia [16]. Networking with health care workers interested in global health at the home institution and at meetings can also be helpful. Other educationally oriented anesthesia organizations that are useful are the World Federation of Societies of Anaesthesiologists (WSFA) [17], Health Volunteers Overseas (HVO) [18], and Kybele [19], which are all represented in this text. An opportunity for longer involvement in teaching is the newly launched Rwanda Human Resources for Health Program [20].
Many residents are interested in global health and can contribute as well as benefit from an international teaching rotation. Residents can play a special role as peer mentors to local students who may relate better and be more comfortable asking questions of a fellow adult learner. Residents are often technically savvy and innovative which can help to bring new and exciting teaching techniques to a developing country. For example, one SEA HVO traveling fellow taught residents in Peru how to film procedures at their hospital using a cell phone and some inexpensive attachments. These filmed procedures could then be used to teach new residents how the procedure is performed at their hospital. Also, residents may at times be a better source of practical clinical information and clinical “pearls” than the academic faculty.
Some anesthesia residency programs have standing overseas teaching rotations. Residents in these programs are well advised to let their program director know early in their residency if they are interested in global health. Residents who do not find an opportunity within their own institution can apply to receive a month’s scholarship with the SEA HVO Traveling Fellowship. Applications can be found on the HVO or SEA websites on December 1st each year for the following academic year. Residents should be aware that traveling with an organization outside their own program may be considered an “out of program rotation” by the country’s accreditation body. For example, according to the American Board of Anesthesiology (ABA), international rotations have special requirements including (1) the rotation must occur during the first 9 months of the fourth postgraduate year of anesthesia training and (2) a letter requesting ABA approval must be obtained prior to departure for the rotation. Details on requirements for residents teaching abroad can be found on the SEA website [16].
Next, the anesthesiologist should evaluate his or her skills, values, interests, and needs and decide how these attributes best match with a program. To maximize the chances of a successful visit for the educator and the host, this issue should be addressed when choosing a program—not when in-country. A potential volunteer should take into consideration the following:
How much time are you willing and able to spend overseas?
Do you have special health needs or concerns that will limit where you can visit and for what amount of time?
Do you plan to bring family members with you and will it be safe for them? What will your spouse or partner do while you are working?
Do you prefer to train anesthesia providers in basic anesthesia techniques or to educate anesthesiologists with more sophisticated concepts? Some sites are more suitable for one or the other.
Is the anesthesiologist comfortable teaching in a hospital with equipment, drugs and patient conditions that he/she has only read about and is he/she willing to learn from the hosts as well as to teach?
Would you be willing to work in a country with political, social, or religious values which you don’t share? Would it be difficult to resist judging or criticizing their ways? If so, it may be best to choose another program or site.
Anesthesiologists with a flexible, patient, and nonjudgmental approach and an enthusiasm for learning as well as teaching should do well when some effort has gone into finding the most appropriate program and site.
Personal Health and Safety
The health and safety of medical professionals is too often neglected in the enthusiasm for going overseas [21]. Illnesses and injuries—often avoidable—can be a disaster for the educator but can also be a burden for the host. It is a good idea to visit a travel clinic several months before leaving the country to get advice about vaccinations, malaria prophylaxis and how to handle postexposure HIV prophylaxis. Educators who are participating in hands-on teaching in the OR or ICU should be aware that many of the protective barriers and devices used at home as part of universal precautions are in short supply or not available in many low resource countries. Bringing gloves, masks, eye protection and hats will help the visitor maintain universal precautions and will prevent the hosts institution from being further depleted of supplies.
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