DOCTOR – ETYMOLOGY
Middle English, doctour teacher, Anglo-French, from Mediaeval Latin doctor, from Latin, teacher, from docere to teach
Our understanding of how adults learn has undergone many advances in the last few years. This information needs to be used to build more effective training in anaesthesia throughout the world, especially in those countries where the need to train large numbers is critical to the development of effective medical services. Training a new generation of teachers is a key part of this.
We speak politely of the ‘developing countries’ but in many cases there has been little evidence of development in the last generation. Some authors have ascribed the current inequitable situation to accidents of geography , others to conspiracy and demographic entrapment .
Can we define what we would like the process of development in anaesthesia to achieve? It must include improving the availability, suitability and quality of anaesthesia. Sustainability can only come through anaesthetists who are both well trained and able to pass on their training to others. Suitable equipment can be moved around the world – the oxygen concentrator that sits under the stairs in Surbiton can save mothers' lives in Malawi; training may not be so easy to transfer.
In the past we have made parallel errors with both equipment and training, based on the assumption that if only the developing countries could have the same equipment and the same training as us, all would be well. Sending out ‘our’ equipment has in many cases simply filled ‘equipment graveyards.’ A flow of trainees in the reverse direction for training in the West has had two main consequences: many have decided not to return home, whereas those who have returned find that the training they received was inadequate. It did not prepare them to work in a situation where gases do not grow in pipes, nor drugs in cupboards, nor to lead, direct and train a workforce of non-physician anaesthetists, serving a population on average 40 years younger than most UK surgical patients.
Training, even more than equipment, must relate to local needs – so those who train the trainers need also to know the background and infrastructure; ideally they also should have been trained, or have worked, locally before setting out to train others.
The visiting expert – could this be you?
During a period of civil war in an African country, a western doctor arrived to help train residents. On arrival in the hospital he found that not only were there no compressed gases, there was no device in the hospital capable of measuring blood pressure, no electricity or running water. The anaesthetic trainees were nonetheless managing to provide a service. In spite of this setback, he persisted, watching the resident anaesthetists, and in time joining in. Some 3 months later one of the residents asked to speak privately with the (local) head of department: ‘It’s about Professor X – we think he'd be OK to work on his own now!
In clinical anaesthesia, many have been helped by the concept of the ‘triangle’ of anaesthesia , whose angles represent sleep, analgesia, and relaxation. In taking a broader view of the development of the specialty, we should perhaps think more of a 4-point ‘compass’ of anaesthesia representing the patient, drugs, equipment and the trained anaesthetist (Fig. 1) The development of the specialty requires attention to each of these.
The concept of training medical teachers is itself a recent one. Thirty years ago I was appointed as an honorary senior clinical lecturer in the University of Oxford. To the best of my knowledge, no inquiry was made at the time, or since, about my qualifications or abilities to teach, nor has any representative of the university ever attended one of my classes to observe, evaluate or correct! Together with those who have endured my teaching, I can only rejoice that in some respects the assumption is no longer made that just because the teacher knows something, they are capable of teaching it to others.
Staff shortages and the extreme pressure of clinical work in the developing world have made it impossible for many anaesthetists even to obtain sound, supervised basic training, let alone become involved in continuing professional development. Over several decades, the World Federation of Societies of Anaesthesiologists (WFSA) has run regular ‘refresher courses’; these have been very successful in achieving their limited aims – enabling local practitioners to meet one another (many work in isolation) and learn the basics of safe anaesthetic practice related to their own working environment. Although maximum attempts have been made to recruit local faculty, these courses remain largely dependent on external professional support and funding. Excellent training has been and is being provided, but there has been little progress towards self-sufficiency.
Until recently, high-level training for many anaesthetists from the developing world has involved overseas travel for a period of work and study, possibly gaining a foreign postgraduate qualification in the process. Latterly this has not only become more difficult, but has also been recognised as less desirable; the higher training provided has not been matched to the overseas doctor's needs. In response to this situation, many developing world universities have set up their own higher specialist degrees (typically M.Medical). Regional, independent colleges of surgeons have been founded for both West and East Africa – the West African College included anaesthetists as a faculty along the lines of the Royal College of Surgeons of England from the 1950s to 1980s. Sadly, many countries have found that they lacked a ‘critical mass’ of anaesthetists from which to form an academic body that could take a leading role in the planning and delivery of anaesthetic training.
In the meantime, the climate of education has changed. The formal lecture (sometimes characterised as transfer of the contents of the lecturer's notes to the student's notes without passing through the brain of either) has increasingly been challenged, having been shown to produce the least amount of retained information among teaching methods . The archetypal powerpoint presentation, in which the speaker turns their back on the class and laboriously reads aloud all the words on the screen (with the optional addition of a trembling laser pointer) is also increasingly recognised as very largely a waste of time. Lecturers are no longer happy to have ‘got through all the material’ but are beginning to ask ‘how much did the students actually learn?’. A potent driving force for these changes has been the proliferation of ‘skill’ courses (Primary Trauma Care (PTC), Advanced Trauma Life Support (ATLS), Paediatric Advanced Life Support (PALS), Managing Obstetric Emergencies and Trauma (MOET), Advanced life support (ALS), Acute Life-Threatening Events Recognition and Treatment (ALERT), etc.), which in turn require a large body of instructors. In addition, more training of junior anaesthetists is now done in a formal setting, rather than in the previous ‘osmosis and apprenticeship’ model – possibly because the latter was more labour-intensive and time-consuming, as well as being potentially more haphazard.
Do these changes at home simply mark another widening gap between the rich and poor? There is certainly the potential for this. In many non-western countries training has traditionally been delivered by authoritarian figures to large audiences of students, who were later tested on their ability to regurgitate what had been said, and never to question the source. To change such a climate is difficult; it should not be undertaken unless it can be done without undermining existing teachers and training systems.
The problem with teachers is the same as with pulse oximeters – there aren't enough of them. How can we increase the numbers? First, we must encourage the idea that everyone should be both teacher and learner. The idea that training was something you did some time ago, to equip you for a professional lifetime, must be laid to rest. This is a good starting point, because once senior doctors realise they have to continue learning, they start to look much more critically at their own and their colleagues' teaching practices.
Some teachers appear to be naturally talented, others struggle, but no teacher is so good (nor none so bad) that they cannot improve. These principles are equally valid for teachers in high or low income countries – and equally new to many of them as well.
In the last few years a number of ‘training of trainers’ courses have appeared both in the UK  and elsewhere. The theory of these is simple: teaching is a practical skill that, like others (laryngoscopy, auscultation of the chest) can be learned. Everyone can remember both the inspiring teachers who have learned these skills, and the uninspiring ones who merely turn to the screen and read the words off the slide!
Teaching has to relate to the individual (and groups of) learners in the same way that anaesthesia has to relate to individual and groups of patients. Learners have different learning styles (some like listening, others prefer doing, others asking or answering questions). Effective teaching of a group needs to offer a corresponding variety of techniques , so that there is ‘something for everyone’. We would not be impressed by the clinician who used an identical anaesthetic technique for every patient; in the same way you should not use the same format for every subject or group that you teach .
Teaching adults differs in two important respects from teaching young children.
Adult learning can be reinforced by reflection – at the end of a session the learner asks him/herself some basic questions about what has been learned, or how a skill has been developed, and how this might affect their behaviour next time. This is something that the teacher also needs to learn to do at the end of every session – probably even more than the learner. The habit of using a simple framework –‘What went well? Why? What would I do differently next time?’– can be easily built in to our practice , replacing the more common thought of ‘thank goodness that’s over'.
Also, adults are (sometimes) strongly motivated to learn, by interest in the subject, the desire to understand more, to succeed, or to pass an exam. They are mostly ‘volunteers’, unlike children – as a result those who teach adults can sometimes ‘get away’ with poor teaching practice that would not survive 10 min in a class of teenagers.
In addition to considering How we teach we need to consider also What we teach. In former times the answer, particularly in relation to formal teaching, was simple –‘The syllabus’ (or, where that was lacking, ‘Things that may come up in your examination’). These are still of course the learners' top priorities, but especially in the context of clinical teaching, teachers must make a conscious effort to teach the professional attributes of attitudes, approach to patients, leadership, and dealing with difficult individuals. Modelling good technique can often achieve this, but sometimes a more explicit approach is needed.
K. C., Anaesthetic officer
There was a time that I was practising anaesthesia when I had only been ‘trained on job’, my skills only acquired by on-going observation. Ethically, I knew that I was often performing beyond my capability, but I would be encouraged and authorised by my employer. We did have a trained anaesthetic officer, but we would continue to perform surgery whilst he was on leave as patients would refuse transfer or referral to other hospitals for economic reasons.
The day I will never forget is the day I was made to anaesthetise a patient for thyroidectomy. The patient was a middle-aged woman with a 15-year history of enlarged goitre and the indication for surgery was essentially cosmetic.
The ward nurses explained the procedure to the patient and ensured appropriate starvation. There was no other pre-operative assessment or investigation. This was due to the fact that I did not know the protocol of anaesthetic management and reasons why these things should be done.
I ordered blood for the haemoglobin, group and cross-match and booked 2 units of blood. I prepared an oxygen cylinder with oxygen but I hardly knew how to open it.
The procedure was scheduled to be the first case of the day as it was a major operation and the surgeon needed ample time for it.
The patient was wheeled to theatre at 8:45 am and placed onto the operating table. I measured the blood pressure and pulse without knowing why they were being taken, and without knowing what the normal parameters were.
I diluted my drugs and told the patient to look at operating light and count whilst I gave the drugs intravenously. I had no knowledge of intubation and did not prepare for it. After inducing with ketamine and diazepam, I inserted an oro-pharyngeal airway, sand bags were placed under the shoulders and surgery was commenced. I wiped the saliva intermittently with a piece of gauze. I continued to give ketamine when the patient showed signs of responsiveness.
I inserted an intravenous line and kept giving normal saline. I did not understand the use of the precordial stethoscope very well, but I felt for the radial pulsation and observed the chest movement, which was difficult as it was obscured by the surgical field and I struggled to see it.
During the operation the chest movement kept stopping and surgeon was informed; he would leave his work, come to the head of the patient, position it, put the airway in properly and ventilate using a facemask and Ambubag and then shortly after, patient would normalise and he would go back to the field of surgery. The above sequence happened three times during the course of surgery.
I could only feel the pulse intermittently, which I reported to the surgeon, who ordered an increase in the flow of intravenous fluids.
Intra-operative notes, especially observations, were not recorded properly. My knowledge about the level of anaesthesia was so limited. The most important thing was for the surgeon to work, finish the operation, put the patient back on the trolley then take them back to the ward for the nurses to take care of them.
Unfortunately, the patient had a cardiac arrest immediately as she was put on the trolley. Cardiac massage was tried but it was in vain. This patient probably died of anaesthetic complications, especially hypoxia and hypovolaemia. The death of the woman was unnecessary and this made me vow to go for proper training.
Anaesthesia deals with patient's lives; drugs are given to make the patient sleep and not feel pain and this should be easily reversed. It should be practised by well-trained personnel, in a well-equipped environment. Policies governing the delivery of anaesthesia and the professional code of conduct must be observed. Monitors are also crucial. Trained anaesthetic staff are required around the clock.
Examples of successful ‘Training of Trainers’ (ToT) courses
PTC Instructor Courses [see p 61–4]
Instructor courses in primary trauma care are examples of courses that train people to teach a specific body of knowledge and skills – in this case the management of severely injured patients. They are normally condensed to a single day. All trainee instructors must be thoroughly familiar with the clinical materials – most often they have just completed the PTC provider course (Phase 1), and all examples used on the instructor course relate to PTC materials. This repetition strengthens the trainee instructors' familiarity with PTC, and immediately after the instructor course the newly trained instructors are expected to run and teach all the materials on their own PTC course.
As by this stage they are fully immersed in the materials, they are able both on the instructors' course, and on the course they subsequently lead, to concentrate on working to improve their teaching technique. At the beginning of the week, few of the trainees can believe that they will end the week as experienced teachers, but PTC pre- and post multiple choice questions (MCQs) (Fig. 2) confirm that the students in the class taught by new instructors fare as well as those taught by the foreign faculty.
Devolution of PTC
• PTC receives request for a course
• Translation of manual
• Course leaders deliver course (Phase 1)
• Local trainers identified & undergo PTC instructors course (Phase 2)
• Newly trained instructors lead next course (Phase 3)
• National/regional committee formed
• National co-ordinator and committee arrange future courses
Programme of a typical 1-day PTC Instructors Course (Iran 2007)
|10 min||Registration & welcome|
|10 min||Introduction & aims for the day|
|20 min||PTC global view|
|15 min||Tips for effective teaching|
|60 min||Preparing a talk – theory, preparation & practice|
|20 min||Preparing the room & visual aids – slides/OHP/powerpoint/board/flipchart|
|90 min||Interactive teaching – theory, preparation & practice|
|40 min||LUNCH BREAK|
|20 min||Teaching a skill/How to run a skill station|
|60 min||Practical experience – skill stations|
|15 min||How to set up and initiate a PTC course|
|15 min||PTC course experiences from Pakistan|
|10 min||Writing a report|
|20 min||Integrating PTC in Iran|
|30 min||Allocating roles & planning tomorrow's course|
|5 min||Summary & conclusions|
ISIA (International School for Instructors in Anaesthesia)
ISIA is an educationally more ambitious project than PTC, as it aims to develop global teaching skills covering the entire subject matter of anaesthesia. It developed from the work of Professor Gaby Gurman of Beersheva University, Israel, and aims to develop the teaching and organisational skills of young specialists in Eastern Europe, and to create a network through which they can continue to support one another.
Four potential professional leaders were selected by their national societies of anaesthesia from Poland, Slovakia, Serbia, Bulgaria and Moldova (Fig. 4). Three 1-week courses have been planned, of which two have now been completed. Each course contains a number of elements: clinical material, often taught using case presentations, educational material concerning teaching strategies, and organisational aspects, such as how to set up postgraduate training.
Students are given ample opportunity to practise, aiming to be able to teach a variety of topics to a wide range of audiences. The objectives of the courses are to supplement rather than compete with existing educational facilities, which of course vary in style and scope from country to country. The students are encouraged to work actively on the course, with many opportunities for them to develop and practise new skills, and to report back from home (by means of an internet discussion group) on progress and the application of what they have learned. We are grateful to WFSA for generous support for the course expenses, but also to the students whose commitment is such that all have arranged for their own transportation and fares to the venue in Bratislava. As well as the potential benefits to participants and their countries of origin now and in the future, we anticipate that the courses will serve as a model for use in other regions of the world.
Most of the instructor course focuses on helping participants improve their teaching technique (Phase 2). Just like anaesthetic techniques, these are things that can be learned, and improve with practice! Key areas are preparation, planning, learning to teach in a range of settings (lecture, discussion group, brainstorming, interactive teaching, teaching a skill). In each area instruction is given, and then students prepare 5-min slots of ‘microteaching’ which they deliver to their peers, before reflection and receiving feedback (Fig. 3).
The third phase is for the newly trained instructors to deliver a full course themselves. In practice the foreign faculty are present, but in a support role only (usually their only job is to help with organisational aspects). By the end of this time our instructors are more than able to take on the responsibility of planning and scheduling of future courses, and even extension to neighbouring countries. PTC has been introduced so far into about 33 countries, among which seven (Indonesia, Paraguay, Ecuador, Pakistan, India, Zimbabwe and Lesotho) have gone forward to take PTC to neighbouring countries using locally trained instructors – an encouraging development as PTC in these areas has become not only self-sustaining but a self-propagating process no longer dependent on western input.
Training and retaining anaesthetists in Kenya: an alternative approach
Dr Dorothy Kamya, SpR Anaesthesia, Education Fellow University College Hospital, London, UK
Dr Vitalis Mung'ayi, Programme Director, Aga Khan University, Nairobi, Kenya
The provision of anaesthesia for urban and rural populations in Kenya
Kenya is a country of 31 million people. At present, there are approximately 80 physician anaesthetists and 300 non-physician anaesthetists. The majority of physician anaesthetists work in urban centres, whilst nurse anaesthetists and anaesthetic officers provide the bulk of rural anaesthetic care. Many trained practitioners are lost from the Kenyan service, demoralised by poor pay and working conditions, lack of basic equipment and a poor standard of living.
There is a growing demand for qualified anaesthetists in Kenya, especially for service in the rural areas, which suffer most from the paucity of medical resources. During my secondment to the training program at the Aga Khan University Hospital I witnessed a number of innovative ways in which Kenyan anaesthetists have addressed this need. Their programme provides a model for training and retention of anaesthetists in Kenya that could be adopted by other developing countries.
The Aga Khan University Hospital Training Programme
The Aga Khan University (AKU) Hospital in Nairobi is 254-bed private hospital which started postgraduate medical training in 2004. My role was as the training programme co-ordinator for a nascent training scheme for physician anaesthetists. The program is a 4-year Masters of Medicine in Anaesthesia (M.Medical Anaesthesia), with a primary Fellowship of the Royal College of Anaesthetists (FRCA)-style exam at 2 years and an exit exam at 4 years. Anaesthesia at the AKU hospital is to a modern ‘western’ standard, using up-to-date equipment and monitoring, and trainees benefit from exposure to evidence-based practice, access to journals from a well-stocked library, use of the Internet and information technology. Training for M.Medical degrees in Kenya does not usually attract a salary, even though the trainees are expected to provide an element of service delivery. Applications to the AKU M.Medical programme is encouraged by paying a modest salary and providing study leave funding to discourage ‘moonlighting’ whilst in training. Trainees are not allowed to undertake any private practice or locum work, as is common with other Kenyan trainees, who are forced to use these as a source of funding for postgraduate training.
Post qualification, residents are encouraged to take salaried positions within the department to expand the staff numbers, and to work towards being faculty members. The department benefits from a small but very dedicated team of clinical teachers who have risen to the challenge of setting up and running the scheme. Potential pitfalls are many, not least the low profile of anaesthesia, but they are changing attitudes to education and mentoring for the new trainees who are truly the ‘guinea-pigs’ of the process!
Training programme as provider of rural anaesthesia services
Free surgical ‘camps’ are held tri-monthly in rural hospitals. The trainees are encouraged to visit rural provinces to observe anaesthesia practised by the resident anaesthetic officers. They are encouraged to innovate or merge their knowledge within the rural set-ups they encounter, without being superior or know-it-alls. It is an excellent opportunity to learn from those who can administer safe anaesthesia without modern gadgetry. Feedback from these trips is always enthusiastic. In future it is hoped that these trainees will retain their links with the rural outposts, providing continuing medical education to those who work there.
Improving the profile of anaesthesia in Kenya
Following the establishment of the training scheme, we set up a dedicated obstetric theatre in the maternity unit and started an obstetric regional anaesthesia and analgesia service. Prior to the programme there was one non-dedicated theatre for emergency sections which was far from the maternity unit. There was no labour analgesia service to speak of and 98% Caesarean sections were under general anaesthesia. With such a gulf between what we were teaching the new trainees about standards of obstetric care and risk factors for maternal mortality, it behoved us to improve the standard at the hospital. With the enthusiasm of the newly converted, the trainees disseminated information about the new service through seminars with midwives, nurses and theatre assistants, and a conference to the general public. Within 16 months the general anaesthetic Caesarean section rate was down to 60–70% and painless labour became a realistic option for mothers, although uptake was initially slow.
The future: retaining the trained physician anaesthetists
This training programme, funded by a private university hospital, is due to expand to train a larger group of anaesthetists each year. Retention of trained professionals is a problem in Kenya, but this can be addressed by offering realistic employment prospects for those who are trained locally. Access to continued professional development and learning, and a good standard of living make the prospect of working in Kenya very attractive, not least the ability to make a significant contribution to the country's needs. The ability to innovate and rise to new challenges, such as we found with our obstetric experience, keeps the anaesthetists keen and interested.
The newly qualified trainees of this programme can expect to earn a salary that is less than that in private practice, but they can look forward to security of employment and a good standard of living. They will be the future trainers of Kenya's anaesthetists.
They will also be able to make a substantial contribution to rural anaesthesia in Kenya by keeping up the links they forge during their training and contributing their skills, energy and knowledge. They are dedicated to their country, are settled in it, and will stay if made comfortable. In a continent where it often seems that the best that can be offered is the minimum, this programme offers a model for future training and retention of African anaesthetists.