By Dr. Joel Parlow – Head, Department of Anesthesiology and Perioperative Medicine, Queen’s University
The mention of “Rwanda” to most Westerners conjures up images of the horrors of 1994, when the world stood by as almost 1 million people were massacred in the space of a few months, in one of the lowest points in humanity’s history. Over the past decade, this country has pulled off a veritable miracle, transforming itself into one of the safest countries in central/eastern Africa, and poising itself to be an economic hub of the area. It is also a stunningly beautiful country of rolling hills, lakes, and of course the mountain gorillas of Dian Fossey fame.
I closed 2012 with my second stint as a visiting faculty to the Anesthesiology residency program of the National University of Rwanda, based in the capital city of Kigali, and the university town of Butare. This program was started in 2006 with the assistance of the Canadian Anesthesiologists’ Society International
Education Foundation (CASIEF), a charitable arm of our national organization. At that time, there was one native Rwandan anesthesiologist in this country of around 10,000,000 people (to put it in perspective, there are close to 40 anesthesiologists in Kingston alone!).
Virtually every month since, a Canadian anesthesiologist has travelled to Kigali as a guest instructor, often accompanied by a resident, and sometimes by other personnel, such as a pain management nurse. In the five years since my first visit, I found some very significant and positive changes, in both the country and the residency program. About 10 physicians have graduated, the majority of whom have pursued further training internationally, and most of whom have returned to their country to work and teach future generations. This year, seven new residents were admitted to the program, and the aim of CASIEF is to complete its mission in a couple of years, hopefully leaving behind a sustainable training program. I saw many positive spinoffs from our program that did not exist in 2008: regular discussion of “anesthetic considerations” before attacking a difficult case, weekly morbidity and mortality rounds (the material is endless…) and often more dedicated adherence to the Surgical Safety Checklist than at home. There was even discussion of the non-scientific roles (RwanMeds?) that residents are slowly being expected to demonstrate.
Teaching in a developing country such as Rwanda provides Canadian physicians with numerous personal and benevolent opportunities. While clinical missions in resource-poor countries (such as those that many of our Queen’s faculty have organized and participated in) are critical and life altering, educational programs aim to provide local staff and trainees with the means to improve their own teaching skills and knowledge. Perhaps the best role models we provide are our own residents, with whom the learners can relate to as “peers”, as well as teachers. On each of my trips, I was fortunate to have one of our PGY5 residents accompany me, and take on a good share of the teaching responsibilities. During my most recent visit, Ryan Mahaffey created and taught a number of seminars to the residents (while at the same time studying for his own upcoming RCPSC exams!). He also spent each day working hands-on with residents in the OR, imparting techniques and ideas that he has refined during his own residency.
This was not a one-way street either- Ryan and I saw some weird and exciting things in our few weeks that we (fortunately I guess) never see in this part of the world, as diseases are never allowed to progress so far into their natural history.
We commented that some of the cases we dealt with would have been considered too unrealistic to be fairly used on a Canadian fellowship exam!
He also observed how clinicians in the developing world must deal with incredibly challenging situations without what we would consider the most basic of resources. For example, we were not able to order electrolytes, despite this being the largest university teaching hospital in the country! Furthermore, most medicine in the country is practiced in poorly resourced rural hospitals by undertrained providers, leading to shocking rates of perioperative and maternal complications and mortality.
Another of my interests in participating in this program was to involve our and their residents in scholarly work, resulting in a publication in 2008, as well as a current project. Ryan, Dr. Ana Johnson (Director of ICES@Queen’s) and I teamed up with a second year Rwandan resident to examine attitudes and practices regarding the management of postoperative pain. This project will be ongoing over the next few months.
Numerous Queen’s faculty members have taken roles in the provision of medical service and education in developing countries. I believe that most of us have shared the same mixed feelings upon returning to Kingston: that the “problems” that we struggle with daily seem to pale in comparison to the very basic needs that are unmet in so many areas of the world.