The Global Crisis in Anesthesia

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The Global Crisis in Anesthesia

• Angela Enright
• President WFSA
• Clinical Professor of Anesthesia
• UBC

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Issues

• Recruitment and retention
• Education and training
• Safety and quality
• Equipment and supplies
• CME availability
• Working conditions
• Physician wellness

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Anesthesiologists per 100,000 population
WFSA 2008
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Ratio of Anesthetists Asia
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Ratio of Anesthesiologists Africa
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Factors affecting recruitment - in resource-poor
environments

• Low status
• Non-physician providers
• Poor working conditions
• Lack of training programmes
• Lack of continuing medical education
• Public versus private practice
• Competition for graduates
• Lack of exposure of medical students to anesthesia

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Retention - physicians

• 1998 UN/WHO 56 doctors migrate from
  resource-poor to resource-rich countries
• UK 2002 11,234 new doctors 50 from
  non-European countries
• Ghana 60 doctors trained in 1980s have left
  200 left in 2002
• Norway 30 of medical workforce graduated in
  Germany
• Switzerland 60 from Germany
• Slovakia loses up to 20 anesthesia workforce
• Moldova loses up to 30 anesthesia workforce
• Uruguay has lost 30 anesthesiologists to Spain

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Reasons for Migration

• Push Factors
• Lack of postgraduate training opportunities
• Poor remuneration and service conditions
• Absence of established posts and career
  opportunities
• Underfunding of health facilities
• Governance and management shortcomings
• Civil unrest and personal security

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Reasons for Migration

• Pull factors
• Opportunities for training
• Career opportunities
• Availability of posts
• Better working conditions
• Attraction of centres of excellence
• Greater financial rewards

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Effect on source country

• Loss of personnel
• Cost Loss of African professional loss of
  184,000 to Africa
• 600 South African doctors in NZ cost SA 37m
• Africa spends 4b/year on salaries of foreign
  experts
• Med students and young doctors lack mentors
• Loss of urban doctors causes in-country migration

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What can be done?

• Train more physicians in resource rich world
• Aid education and training close to home
• Assist in development of specialist training
  programmes
• Target assistance to retain graduates
• Restrict duration of training abroad

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WFSA

• World organization
• 122 member societies
• Global view of anesthesia
• Focus on anesthesia education

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WFSA Activity 2004-2008

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WFSA Training Centres 2008
Cluj-Napoca
Tel Aviv
Tunis
Bangkok
Medellin
Vellore
Santiago
Cape Town
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Bangkok, Thailand

• Basic training in anesthesia
• In conjunction with Mahidol University
• 4 trainees per year
• 1 year duration
• 8 months in university hospital
• 4 months in regional hospital

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Bangkok Anesthesia Regional Training Centre
(BARTC)

• 1996 2009
• Mongolia 17
• Cambodia 11
• Lao PDR 13
• Vietnam 5
• Myanmar 4
• Bhutan 2
• Total 52

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BARTC Follow up

• Mongolia - advances in teaching, courses,
  residency programme, new techniques
• Lao - 4 regional, 7 teaching, 1 advanced training
• Cambodia 7 teaching, 2 provincial, organizing
  meetings
• Myanmar- 3 teaching, 1st meeting
• Vietnam 1 teaching, 1 private, 1 emigrant,
  organized ASEAN meeting
• Bhutan 1 in capital, 1 regional

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Vellore

• Pediatric Fellows
• India (2)
• Bangladesh (2)
• Afghanistan
• Maldives
• Bhutan
• Nepal
• Supported by
• Society for Pediatric Anesthesia

• ICU Fellows
• Nepal
• India
• Bangladesh

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Cluj-Napoca, Romania

• Fellows from Moldova
• 6 months basic training
• 9 per year
• Co-sponsored with European Society of
  Anaesthesiologists

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Wolfson, Israel

• Sub specialty fellowships in pain, ICU, cardiac,
  obstetric and pediatric anesthesia
• Bulgaria
• Moldova
• Romania
• Serbia
• Slovakia
• Kenya
• Nigeria

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Santiago, Chile
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Santiago

• Calvo McKenna Hospital
• Training in pediatric anesthesia
• Training in pediatric cardiac anesthesia
• 6-12 months duration
• Fellowships supported in part by Canadian
  Anesthesiologists Society

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Santiago Origin of Trainees
2
2
1
2
2
5
17 trainees including 2009
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Teach the Teachers
Bulgaria, Moldova, Poland, Slovakia, Serbia
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Africa 1

• Pediatric anesthesia fellowship programmes in
  Tunis and Cape Town
• Obstetric anesthesia fellowship programme in
  Tunis
• Individual fellowship training support
• Training support for non-physician anesthesia
  providers

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Africa 2

• CME support for physician and non-physician
  anesthesia providers
• Equipment workshops and training
• Primary trauma care
• Support for attendance at conferences

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Malawi Clinical Officer Exchange
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Africa 3

• Co-sponsors
• AAGBI
• American Society of Anesthesiologists
• Baxter Ltd
• Belgian Society of Anesthesiology (SBAR)
• Canada-Africa Community Health Alliance
• Canadian Anesthesiologists Society
• Diamedica Ltd
• Drager Ltd
• French Society of Anesthesiology (SFAR)
• Netherlands Society of Anesthesia (NVA)
• Penlon Ltd
• Primary Trauma Care Foundation

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Rwanda
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Rwanda programme

• Programme began in 2006
• Teachers provided for 10-12 months per year
• Teach residents, nurse anesthetists, nurse
  anesthesia students
• Continuing curriculum development
• Nurse educator for recovery room
• 2 nurse educators per year in pain management

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Rwanda

• 1 graduate 2007
• 3 graduates in 2008
• 2 in 2009
• Global cooperation Rwanda, Canada, USA,
  Belgium, France
• Organizational cooperation government,
  universities, national anesthesia societies,
  hospital administration

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Rwanda Population 9 million
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Rwanda thus far

• Rwandans have confidence in partners
• Assistance with forming Rwandan Society of
  Anesthesia (ARA)
• ARA admitted to membership of WFSA
• Anesthesia programme gaining status
• Recruitment easier
• Beginning faculty development
• Assisting with development of organizational
  expertise
• Support for attendance at conferences
• Assistance with publications and presentations

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Safety and Quality

• WFSA Guidelines
• Equipment education and training
• WFSA Global Oximetry project
• WHO Safer Surgery Checklist
• WHO Global oximetry project

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Engineers from UKAnesthetists and technicians
from Malawi, Rwanda, Tanzania and UgandaSupport
from equipment companies, WFSA, Association of
Anaesthetists of Great Britain and Ireland
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Global Oximetry ProjectBeginnings

• 2004 World Congress
• Safety and Quality of Practice Committee of WFSA
• Lack of pulse oximetry a priority for patient
  safety
• Formed a Global Oximetry Project team
• WFSA, AAGBI, GE Healthcare
• 4 pilot sites - India, Vietnam, Uganda,
  Philippines

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GO Project Results

• Large oximetry gap
• Need for education
• Identified the specifications for an ideal pulse
  oximeter for resource-poor settings
• Change in practice needs to be sustained
• Difficult to measure improvements in patient
  safety

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WHO Oximetry Project

• Developed from Safe Surgery initiative
• Pulse oximetry included in checklist
• Teams working on education, finances,
  specifications
• Pilot site applications underway
• Pilot projects in Fall 2009

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Summary

• Need to focus on recruitment into anesthesia
  everywhere
• Assistance should target development of
  programmes and training close to home
• Encourage adherence to accepted safety standards

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