<p> Report on Postgraduate Training Programme in Anesthesia November 2006</p><p>In January 2006, the Canadian Anesthesiologists’ Society International Education Fund (CASIEF) and the American Society of Anesthesiologists Overseas Teaching Programme (ASAOTP) began sending volunteer teachers to the National University of Rwanda (NUR) to assist in the development of a postgraduate training programme in anesthesia. Since that time there have been four American and two Canadian teachers plus one senior resident in anesthesia (Canadian) who spent a total of six months in Kigali. This review was undertaken to assess the level of success of the assistance programme and to recommend any needed changes. Following two weeks spent in Rwanda, meeting with everyone involved in the programme including the Minister of Health, the Rector of the NUR, the Dean and Vice- Dean of Medicine, the Head of the Department of Anesthesia, the Kigali head of programme, the Rector of the Kigali Health Institute (KHI), the Head of the Nurse Anesthesia Programme KHI, faculty of anesthesia members NUR both in Kigali and Butare, faculty of anesthesia members at KHI, residents in anesthesia and nurse anesthetists of CHUK (Appendix A), my overwhelming impression is that the programme is successful. There were some start-up difficulties and, from time to time, logistical problems but, with the good will of all concerned, most of those were resolved.</p><p>Visiting Faculty Although the memorandum of understanding agreed on having visiting teachers for eight months of the year, the gaps between the visitors were difficult for everyone to manage. In 2007 this will be resolved by having teachers for 11 months of the year. There will be no teacher in December of 2007 since this is a major holiday period for everyone. The list of teachers for 2006 and 2007 (Appendix B) is appended. Professor Franco Carli brought with him a senior resident in anesthesia from McGill University. This turned out to be a major benefit for everybody. The residents at NUR appreciated having a resident to whom to compare themselves. They also enjoyed the discussion sessions between the residents, moderated by Dr Carli. Dr Paquet helped Dr Carli develop useful protocols for the department. Together they set up a pediatric cart and also a difficult airway cart. Considering the success of this venture, we will now encourage other faculty to take senior residents with them. These residents, when they graduate, will form the backbone of the future visiting faculty.</p><p>Academic Programme Organization of Core Curriculum: Perhaps the biggest problem was one of organization especially with reference to the teaching of the core academic programme. The NUR faculty did not know what the visiting faculty would teach and the visitors did not really know what NUR wished to be taught. This will be resolved in 2007 by sending the list of modules to be taught to the visiting faculty ahead of time. They will choose an area to teach and will devote time to doing that during their stay. The NUR faculty will know ahead of time what the visiting faculty will teach. The core programme is covered every two years with six modules in each year. Dr Finucane (January/February 2007) has chosen Anesthesia for Surgical Specialties. Dr Wiebe (February/March 2007) has chosen the module on Obstetric Anesthesia. The visiting faculty will provide reading lists to the residents ahead of time. Scheduling of Core Curriculum: In order to ensure that all residents can benefit from the teaching of the core programme, Dr Uwambazimana has agreed that all sessions should take place on Wednesday afternoons in Kigali. All residents based in Kigali will attend. This is important as missing part of the core curriculum could leave significant gaps in the resident’s education. On alternate Wednesdays, residents based in Butare will travel to Kigali for the sessions. In the weeks where the residents do not go to Kigali, the visiting faculty member will travel to Butare on Thursday am. He will spend time in the operating room with the residents in CHUB. On Thursday afternoon, he will teach the core seminar for that week to the Butare residents. The visitor will stay overnight in Butare, teach in the OR on Friday morning and then return to Kigali on Friday afternoon. In this way, all residents will benefit from the teaching of the core modules. (Appendix C) There were some logistic problems with the arrangements for travel to Butare in 2006. Discussions with the Minister for Health, the Rector NUR and the Dean of Medicine have resolved those. A car and driver plus overnight accommodation will be provided for the visiting faculty member. Additional Teaching: In addition to the core teaching programme, the visiting faculty will teach based on the cases available and on their own areas of interest. A formal teaching session will take place on Tuesday afternoons for the residents, the nurse anesthetists at CHUK and any faculty interested in attending. The residents and nurses will be encouraged to do the presentations at these sessions. The visiting faculty will also attend the 0700 rounds but these will be kept short in order to maintain an on-time start for the OR. Where circumstances permit, on the Wednesdays of the months with 5 weeks ie 4 times per year, the visiting teacher will help the local faculty and residents organize a Grand Round on topics of broad interest not just to anesthesia but also to surgery. These will present an opportunity to discuss approaches to problems of general interest e.g. the management of the head-injured patient. Refresher Courses: In order to increase the activities of the Association Rwandaise des Anesthesistes (ARA), it has been suggested that the executive of the ARA make use of the expertise of the visitors to organize refresher courses in anesthesia. These would benefit the members in many ways such as continuing medical education, development of organizational skills and enhanced presentation opportunities. The World Federation of Societies of Anaesthesiologists (WFSA) Committee on Education is willing to sponsor some of these. These would be a good developmental step to taking part in the World Congress of Anaesthesiologists which will take place in Cape Town in March 2008. The ARA is already an associate member of the WFSA. However a membership of 10 physician anesthesiologists is necessary to obtain full membership. Since there are now more than 10 physicians in anesthesia in Rwanda, it is very important that the ARA take its place among the nations of the world in the WFSA. The anesthesiologists of Rwanda are strongly encouraged to get involved in the ARA and to have the Society apply for full membership status of the WFSA. A vote would be taken at the WFSA general assembly in March 2008 in Cape Town. Mandatory Courses NUR: Another issue of importance arose in discussions with Dr Nsanze, the Dean of Medicine. The NUR requires all first year residents to attend six weeks of seminars prior to starting their clinical rotations. This would take them away from the hospitals for all of January and half of February. While the core curriculum in anesthesia could continue during that time, this would mean that the first year residents would miss six weeks of teaching which would not then be repeated during their first two years. If this will be the arrangement every year, then perhaps it would be better not to schedule a volunteer for those six weeks. Since the 2007 schedule for the volunteers is already set, one solution discussed with the Dean and Vice-Dean, would be to allow the anesthesia residents to attend the core curriculum in anesthesia on Wednesday afternoons. We will need to review this issue later this year. Theses: There are two fourth year residents in Butare. Dr Theo has his project underway. It concerns femoral nerve block for patients having hip surgery. Dr Sami from Chicago is assisting him with this. Dr Jules has not yet presented his project for approval. He is planning to study preoperative anxiety and the use of anxiolytic drugs. He should proceed to apply for faculty approval soon. I understand that most of the senior residents training abroad have not yet chosen their theses subjects. A successful defense of the thesis is a requirement for graduation from the NUR. The visiting faculty and possibly other academics from Canada and the USA would be willing to act as advisors for the residents if necessary. I understand from Dr Jerome Muhizi that members of the anesthesia departments of Nancy and Liege are also willing to supervise the residents in these projects. Training Outside Rwanda: There are varying opinions about the need to offer some portion of residency training outside the country. Some believe it should be part of the residency programme prior to completion. Others believe it would be better done after training is complete. There is no right or wrong answer to this question. However at the moment, there are areas of training not available to anesthesia residents in Rwanda such as thoracic and cardiac surgery. For a complete education, residents should have exposure to all areas of anesthesia. This issue will need to be discussed and followed up as the programme develops. Teaching at KHI: The visiting faculty will teach the nurse anesthesia students on a formal basis at KHI on Monday afternoons. Mr Rangira will supply a list of possible topics for the teachers to choose from. These sessions will fit into the formal curriculum of the nurse anesthesia students. When KHI is closed for holidays or examinations, these sessions will not take place. Clinical teaching will take place in the operating rooms when appropriate.</p><p>Resident Evaluation This is perhaps the weakest area of the residency training programme. The residents would like to have an evaluation system in place. Dr Jeanne and Dr Bart told me that they are keen to develop a system and that it should be operational by 2007. Dr Bart told me that a major examination will be held at the end of second year. The written portion should be based on the completed core curriculum. It should also include an oral and a clinical examination. Besides this formal examination, there should be ongoing evaluation of each trainee every three months. This would review clinical development, knowledge for level of training and attitudes. Having an evaluation such as this would allow the resident to get feedback on performance so that any issues could be addressed at an early stage. Each resident should have to maintain a log book of work done. This should be scrutinized by the programme directors at least every six months. Any obvious gaps in experience could then be filled during future rotations. The visiting faculty would be pleased to assist Dr Jeanne and Dr Bart in the evaluation process if desired. Prof Carli provided information on the resident evaluation system at McGill University which might be useful and which could be modified to suit the local situation. During my discussions with Dr Nsanze, the Dean, he was very interested in when and how evaluations and assessments are carried out.</p><p>Library Facilities In order to maintain an academic anesthesia programme, a complete library of anesthesia books and journals needs to be developed. The ASAOTP and the CASIEF are committed to assisting in this process. To this end, many books and discs have already been donated by the two organizations. Currently these are stored safely in the OR at CHUK. This makes them available at all hours. However it necessitates a no lending policy. The hospital libraries at CHUK and CHUB need to develop their collections. Where possible we will try to provide duplicate books for the library at Butare. On line, full text journals are readily available through a WHO sponsored programme. This information was provided by Dr Van Bastelaar and is not widely known. The code name, access code and password are available for this service. This is of tremendous value as residents in training need to be able to read current literature. However in the department of anesthesia at CHUK, there is no computer and no internet access. The department of surgery has this service available. I cannot speak of availability in the hospital libraries at CHUK and CHUB although the residents told me that internet at CHUB is much more available than at CHUK. I have requested from Dr Van Bastelaar that a computer and internet access be installed in the department of anesthesia at CHUK as soon as possible. This would be available, not just to the residents in anesthesia, but also to the visiting faculty, the anesthesiologists at CHUK and the nurse anesthesia staff. The importance of this cannot be overemphasized as, besides the journal access, there are a large number of teaching modules, continuing medical education updates and anesthesia sites available through the internet. These would be immensely helpful to all anesthesia staff and trainees at CHUK.</p><p>Equipment and Drug Availability: I did not review these at all but am aware of significant deficits in these areas. In order to fully develop anesthesia as a specialty, these deficiencies will need to be remedied. This could be an area for study at a future date. Summary</p><p>Overall the programme has begun well. There is lots of energy, enthusiasm and good will from NUR faculty, KHI faculty, volunteers, residents in anesthesia and nurse anesthetists. Much progress has been made in one year. Issues requiring attention: 1. Organization of core curriculum teaching 2. Resident attendance at core curriculum seminars 3. Continuing medical education for all staff 4. Support for the ARA 5. Choice and submission of resident theses to NUR 6. Resident evaluations 7. Development of appropriate library resources 8. Availability of computers and internet access for faculty and residents 9. Training in areas not available in Rwanda</p><p>As we solve each of these problems, the programme will grow steadily better. As residents finish their training and join the faculty, they will gradually take on the teaching roles in the training programme. This will lead eventually to complete self sufficiency.</p><p>Respectfully submitted</p><p>Angela Enright MB, BCh, FRCPC Chair of Board of Trustees CASIEF December 2006 Appendix A Anesthesia Programme People Interviewed</p><p>Dr Jean Damascene Ntawukuliryayo Minister for Health Mr R Carr-Ribeiro Canadian Consul Rwanda Prof Silas Lwakabamba Rector NUR Dr D Ndushabandi Rector KHI Dr H Nsanze Dean of Medicine Dr J Kakoma Vice-Dean of Medicine Dr J Uwambazimana Head Department of Anesthesia NUR Dr B Troubleyn Chief of Anesthesia CHUK Dr P Munyarugamba Medical Director CHUK Dr S Van Bastelaare Medical Director BTC CHUK Dr D Midonzi Anesthesiologist CHUB Dr Mpanjato Rasoloherimampiononiaina Anesthesiologist CHUK Dr Ibrahim Anesthesiologist CHUK Dr D Mukamusoni Dean Allied Health Sciences KHI Mr Charles Rangira Head Nurse Anesthesia Programme KHI Dr Simeon Bigirimana Anesthesiologist Faculty KHI Ms Christine Faculty KHI Ms Assunta Faculty KHI Mr Schadrack Faculty KHI Dr Paulin Banguti Resident 1 in Anesthesia Dr Bonaventure Uwineza Resident 1 in Anesthesia Dr Jules Ndoli Resident 4 in Anesthesia Dr Theogene Twagirumugabe Resident 4 in Anesthesia Ms Janviere Head Nurse Anesthetist CHUK Mr Damascene Gasasira Nurse anesthetist CHUK Secretary Assoc Rwandaise des Anesthesistes (ARA) Mr Michel Ntumzwenayo Nurse anesthetist CHUK President ARA Ms Grace Kbanyana Nurse anesthetist CHUK Vice-treasurer ARA Group of Nurse Anesthetists CHUK Dr Betty Khainza Anesthesiologist King Faisal Hospital Dr Max Rivero Anesthesiologist King Faisal Hospital Dr Jerome Muhizi Anesthesiologist, Nancy Appendix B</p><p>ASAOTP & CASIEF Volunteers</p><p>2006 Month Name E-Mail</p><p>Jan. Ashish Desai [email protected]</p><p>Feb. Fiona Turpie [email protected] March No volunteers April Arthur Ackerman [email protected] May Shigemasa Ikeda [email protected] June No volunteers July No volunteers August No Volunteers Sept. Hafez Sami [email protected] Oct. Franco Carli & Catherine Paquet [email protected] [email protected] Nov/Dec Angela Enright [email protected]</p><p>2007</p><p>Jan/Feb Brendan Finucane [email protected] Judy Nevett [email protected] Feb/Mar Henry Wiebe [email protected] April John Stanec & Janey McGee (Res) [email protected] [email protected] May/June David Archer and Desiree Teoh (Res) [email protected] [email protected]</p><p>June/July John Cockburn [email protected] Aug/Sept/Oct Mounir Hanna [email protected] Nov Anne Moore [email protected] Dec Appendix C</p><p>Calendar</p><p>January</p><p>Mon Tues Wed Thurs Fri Sat Sun 1 2 3 4 5 6 7 Dr Finucane arrives Kigali</p><p>8 9 10 11 12 13 14 0700 CHUK 0700 CHUK 0700 CHUK 0700 CHUK 0700 CHUK 1400 KHI 1400 Seminar 1400 Residents Residents & Core Curriculum Nurse Anesth Seminar</p><p>15 16 17 18 19 20 21 0700 CHUK 0700 CHUK 0700 CHUK 0630 Depart for 0700 CHUB 1400 KHI 1400 Seminar 1400 Residents Butare Res & Nurse Anes Core Cur Sem am at CHUB Afternoon: Leave 1400 Residents for Kigali Core Cur Sem</p><p>22 23 24 25 26 27 28 0700 CHUK 0700 CHUK 0700 CHUK 0700 CHUK 0700 CHUK 1400 KHI 1400 Seminar 1400 Residents Res & Nurse Core Cur Sem Anes</p><p>29 30 31 Feb 1 Feb 2 0700 CHUK 0700 CHUK 0700 CHUK 0630 Depart for 0700 CHUB 1400 KHI 1400 Seminar 1400 Residents Butare Afternoon: Leave Res & Nurses Core Cur Sem am at CHUB for Kigali 1400 Residents Core Cur sem</p>