ASRA Pain Medicine Update

Aug 7, 2019, 12:05 PM by Matthew Swisher, MD, MS; Edouard Uwamahoro, MD; Paulin R. Banguti, MD; Jean Bonaventure Uwineza, MD

The field of Rwandan anesthesiology was devastated with the 1994 Rwandan genocide against the Tutsi. After the genocide, only one anesthesiologist remained in the country.^[1] Through extensive development work over the past 13 years, the Canadian Anesthesiologists’ Society International Education Foundation, American Society of Anesthesiologists Global Humanitarian Outreach, and Human Resources for Health Program Rwanda have collaborated to help develop an anesthesiology residency training program in Rwanda in partnership with the University of Rwanda. Now the country has more than 30 anesthesiologists, many of whom are actively seeking ways to subspecialize, although their options remain extremely limited.

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The solution is to develop robust, within-country subspecialty training programs in partnership with specialist institutions to directly address barriers to clinical care, education, and medical migration.

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With the recent expansion of the residency program, Rwanda expects to have more than 60 anesthesiologists by 2024. As such, the country’s Ministry of Health has made it a government priority to develop medical subspecialty programs to advance clinical care in Rwanda. In particular, the anesthesia educational leadership at University of Rwanda has named five anesthesia subspecialties of priority: obstetric anesthesia, pediatric anesthesia, regional anesthesia and pain medicine, critical care medicine, and leadership in medical education and global health.

Currently, the African continent has no full-length regional anesthesia and acute pain management (RAAPM) fellowships and only a handful of other subspecialty anesthesia fellowships. Although some options exist for limited RAAPM training in countries overseas, training outside of Rwanda and returning to practice in Rwanda has led to a host of problems, mainly involving lack of experience in developing clinical programs in low-resource settings. In addition, developing out-of-country subspecialty fellowships has led to issues with the concept of medical migration and undermined the ability to achieve sustainable, subspecialty care.^[2] The solution is to develop robust, within-country subspecialty training programs in partnership with specialist institutions to directly address barriers to clinical care, education, and medical migration. This model of subspecialty training has been embraced by the World Federation of Societies of Anaesthesiologists (WFSA) in numerous successful subspecialty training programs.^[3]

Multiple prior visiting regional anesthesiologists to Rwanda have helped to develop the beginning of a regional anesthesia program at the main teaching hospital in Kigali, University Central Hospital of Kigali (CHUK). CHUK and King Faisal Hospital have dedicated ultrasound equipment, block needles, local anesthetics, and other supplies needed to perform regional anesthesia and acute pain medicine procedures. Although the intermittent, teaching-based visits have helped lay the groundwork for regional anesthesia, a consistent and structured Rwandan training program is needed to achieve sustainability and develop the first generation of regional anesthesiologists in East Africa. Rather than creating training programs focused on external observerships or rotations, we proposed developing an internal Rwanda-based fellowship training program with the aid of volunteer international regionalists in partnership with Rwandan anesthesiologists.

In collaboration with his Rwandan colleagues at the University of Rwanda, Matthew Swisher (University of California San Diego RAAPM fellowship director) founded a first-of-its-kind RAAPM fellowship program in Kigali, Rwanda. The East African RAAPM (EARAAPM) fellowship program began earlier in 2019 to address the need for RAAPM subspecialization in Rwanda and East Africa. The fellowship program is modeled after United States RAAPM fellowships with a similar educational curriculum.^[4] The design and development of regional anesthesia and acute pain medicine services in low-resource settings is a significant emphasis of the training program. At its inception, rotating United States and Canadian regional anesthesiologists will serve as the primary fellowship instructors until Rwandan anesthesiologists develop the necessary expertise.

EARAAPM fellows initially are recruited from graduating University of Rwanda anesthesiology residents and current Rwandan anesthesiologists. After developing a Rwandan expertise in regional anesthesia and acute pain medicine, the goal is to expand the fellowship to include anesthesiologists from other East African countries and abroad. The core teaching hospitals for the fellowship program are CHUK, King Faisal Hospital, and University Teaching Hospital of Butare. Fellows have the opportunity for month-long rotations at United States or Canadian institutions to complement their teaching in advanced techniques as well as learning program development in less resource-constrained settings.

As the global leader in international anesthesia fellowship training, WFSA is endorsing the EARAAPM fellowship program with the goal of beginning the first fellowship year in late 2019. Dr. Swisher and his EARAAPM program colleagues are actively seeking collaborators and sponsors for this innovative fellowship program. If interested in learning more or becoming involved, e-mail him at mwswisher@ucsd.edu.

References

1. Martin RF, Rangira C, Li J, d’Arc Uwambazimana J, Desai SP. The history and evolution of anesthetic care in Rwanda. J Anesth Hist. 2017;3(1):5–11. https://doi.org/10.1016/j.janh.2016.12.004
2. Walker IA. Con: pediatric anesthesia training in developing countries is best achieved by out of country scholarships. Paediatr Anaesth. 2009;19(1):45–49. https://doi.org/10.1111/j.1460-9592.2008.02844.x
3. Enright A, Wilson IH, Moyers JR. The World Federation of Societies of Anaesthesiologists: supporting education in the developing world. Anaesthesia. 2007;62(Suppl 1):67–71. https://doi.org/10.1111/j.1365-2044.2007.05303.x
4. Regional Anesthesiology and Acute Pain Medicine Fellowship Directors Group. Guidelines for fellowship training in regional anesthesiology and acute pain medicine: third edition, 2014. Reg Anesth Pain Med. 2015;40(3):213–217. https://doi.org/10.1097/AAP.0000000000000233