Report on Postgraduate Training Programme in Anesthesia
November 2006
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 ViceDean 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.
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.
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.
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.
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.
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
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
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.
Respectfully submitted
Angela Enright MB, BCh, FRCPC
Chair of Board of Trustees CASIEF
December 2006
Appendix A
Anesthesia Programme
People Interviewed
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
ASAOTP & CASIEF Volunteers
2006
Month
Name
E-Mail
Jan.
Ashish Desai
avdesaimd@yahoo.com
Feb.
March
April
May
June
July
August
Sept.
Oct.
Fiona Turpie
No volunteers
Arthur Ackerman
Shigemasa Ikeda
No volunteers
No volunteers
No Volunteers
Hafez Sami
Franco Carli & Catherine Paquet
fionaturpie@aol.com
Nov/Dec
Angela Enright
acksupremo@yahoo.com
sikeda01@earthlink.net
hafezsami@yahoo.com
franco.carli@mcgill.ca
cathpaquet@hotmail.com
ape@telus.net
2007
Jan/Feb
Feb/Mar
April
Brendan Finucane
Judy Nevett
Henry Wiebe
John Stanec & Janey McGee (Res)
May/June
David Archer and Desiree Teoh (Res)
June/July
Aug/Sept/Oct
Nov
Dec
John Cockburn
Mounir Hanna
Anne Moore
btfinuc@shaw.ca
judy.nevett@viha.ca
hjwiebe@hotmail.com
johnstanec@gmail.com
jmcgee@aims.unc.edu
david.archer@CalgaryHealthRegi
desireeteoh@hotmail.com
fishburn@sympatico.ca
mmhanna650@pol.net
akmmcgill@hotmail.com
Appendix C
Calendar
January
Mon
Tues
1
Wed
2
Thurs
Fri
3
4
Sat
5
Sun
6
7
Dr Finucane
arrives
Kigali
8
9
10
0700 CHUK
0700 CHUK
0700 CHUK
1400 KHI
1400 Seminar
1400 Residents
Residents &
Core Curriculum
Nurse Anesth
Seminar
15
16
11
0700 CHUK
17
12
13
14
19
20
21
27
28
0700 CHUK
18
0700 CHUK
0700 CHUK
0700 CHUK
0630 Depart
1400 KHI
1400 Seminar
1400 Residents
for Butare
Res & Nurse
Core Cur Sem
am at CHUB
Afternoon: Leave
1400 Residents
for Kigali
Anes
0700 CHUB
Core Cur Sem
22
23
24
0700 CHUK
0700 CHUK
0700 CHUK
1400 KHI
1400 Seminar
1400 Residents
Res & Nurse
Core Cur Sem
25
0700 CHUK
26
0700 CHUK
Anes
29
30
31
Feb 1
Feb 2
0700 CHUK
0700 CHUK
0700 CHUK
0630 Depart
0700 CHUB
1400 KHI
1400 Seminar
1400 Residents
for Butare
Afternoon: Leave
Res & Nurses
Core Cur Sem
am at CHUB
for Kigali
1400 Residents
Core Cur sem