The World Federation of Societies of Anaesthesiologists’ Fellowship Programs: Past, Present, and Future

See Article, page 1259 Papua New Guinea (PNG), a low-middle-income country (LMIC) in the Asia Pacific Region with a population of approximately 12 million people,1 is served by 33 physician anesthesiologists. Although the first recorded anesthetic was given in 1896 in PNG,2 no anesthesiology residency program was offered for about 100 years in either PNG or the Pacific region. Medical graduates who wished to pursue a career in anesthesia were required to train in Australia or Philippines, often involving stressful processes for medical licensing, emigration, financial challenges, and location of a suitable supervisor and training hospital. PNG began its anesthesia postgraduate training in the late 1980s with the first graduates finishing with a Master of Medicine (MMED) in 1991. The program was designed to produce competency in general anesthesiology and to expose trainees to the basics of subspecialty care.2 The next advance in anesthesia practice in PNG was the introduction of subspecialty care. In 2011, to offer cardiothoracic surgical services, the first subspecialty program was developed for cardiothoracic anesthesia. This was supported by the Royal Australian College of Surgeons (RACS). In 2016, 2 anesthesiologists from PNG completed a World Federation of Societies of Anaesthesiologists (WFSA) 6-month fellowship, one in pediatric anesthesia in Vellore, India and the other in obstetric anesthesia in Kuala Lumpur, Malaysia. Subsequently, with the goal of building a well-qualified team, the Australian and New Zealand College of Anaesthetists (ANZCA) supported additional opportunities in clinical practice, education, leadership, and research for these 2 anesthesiologists and their colleagues in PNG. Fortunately, today anesthesiology is increasingly seen as an attractive specialty to medical school graduates who have benefited from the leadership, teaching, and mentorship of subspecialist anesthesiologists. The national tertiary care hospital provides some specialized perioperative pediatric and obstetric services and, in conjunction with University of Papua New Guinea and ANZCA, subspecialty training in pediatric and obstetric anesthesia has started in PNG, with the initial in-country trained fellows due to graduate this year. PNG is the first Pacific Island country to offer subspecialty anesthesia training. This success story illustrates a positive outcome from the WFSA fellowships program and collaborative partners. The WFSA was established in 1955 with a vision of global health equality. Although the WFSA had been involved with anesthesia training programs in LMICs for a long time, the international fellowship programs are a more recent initiative conducted in conjunction with various partners. Professor Fujimori, the WFSA Education Committee Chair from 1992 to 1996, began the discussions on fellowship programs. The aim was to have fellows return home with capacity in leadership, education and research and the ability to make positive changes in their workplace.3–7 The first WFSA fellowship program led by the Chair of the WFSA Education Committee, Dr Haydn Perndt, and the head of the Bangkok Anaesthesia Regional Training Centre (BARTC), Professor Thara Tritrakarn, was started in 1996 for general anesthesia in Bangkok. Dr Perndt and the director of the training center in Santiago, Dr Sylvana Cavalieri, set up the first subspecialty pediatric anesthesia fellowship program in Santiago in 1998.4,6–10 Since then, more programs have been established globally and over 400 fellows have been trained from 62 different countries. Initially, funding to support these fellowships was limited so WFSA launched the “Fund a Fellow” campaign in 2016 to increase its reach to potential sponsors. The campaign, now called “Fund a Colleague’s Education (FACE)” includes sharing of testimonials of the WFSA fellows and reports.5,11,12 Despite significant progress in terms of numbers of fellows trained, there has been no formal evaluation of the impact of the fellowships program. Is the program working? Is change happening? In this issue of Anesthesia & Analgesia, Bould et al13 have attempted to answer these questions by evaluating the factors influencing the transfer of new skills and knowledge to home countries for 2 WFSA fellowship programs: the pediatric anesthesia fellowship in East Africa and the regional anesthesia fellowship in Asia. The authors are to be commended for conducting the first formal study evaluating the impact of the WFSA fellowship programs. They found that graduated fellows had a positive influence on clinical practice, service development, research, and teaching. Contextual differences between the fellowship program and the home institution created some barriers to skill and knowledge transfer. There are many challenges faced by fellows when they return home. The new fellows may find their new subspecialty is not supported and they are deployed to general, nonspecialty surgical cases. Their workplaces may lack the necessary anesthesia machines, monitors, and medications required to perform safe anesthesia or to apply new subspecialty skills. Fellows may become frustrated due to the high workload, poor financial incentives, and lack of leadership and support. We must ask ourselves “How do we evaluate educational outcomes for the WFSA fellowships? What is a success?” Bould et al13 make recommendations for improving the transfer of knowledge and skill to practice in the home institution post fellowship. They suggest that programs select fellows from institutions with potential to support the fellow’s subspecialty practice. They highlight the importance of fellowship training extending beyond medical knowledge and skills to include training in effective leadership, teaching, research, and change management. The authors also recommend strategic partnerships to facilitate the supply of essential monitors, equipment, and medications. It is disheartening and counterproductive for a fellow trained in regional anesthesia to have no access to an ultrasound machine or regional block needles. Other examples of success deserve consideration. The early years of Mongolia’s anesthesia history had many difficulties including workforce shortages, absence of formal training programs and a lack of leadership and advocacy. A positive change began with the establishment of the Bangkok Anesthesia Regional Training Center in Thailand. Twenty-six Mongolian trainees completed this fellowship program and returned to Mongolia to be the driving force in the development of Mongolia’s anesthesia educational programs, improving clinical practice and providing advocacy and leadership. The returning graduates were supported by the Mongolian Society of Anesthesiologists and the Australian Society of Anaesthetists, who developed a strategic plan to modernize the training of Mongolian anesthesiologists.14 These collaborations were essential for reducing the postfellowship system barriers and promoting ongoing mentorship and postfellowship collegiality. The graduates have become mentors and educators for the next generation of anesthesiologists. We must highlight the importance of bidirectional knowledge and ongoing mentorship postfellowship.13 Ideally, fellowship supervisors in the host institution should have some familiarity with the working conditions of the visiting fellows so that the program can be best adapted to create conditions for success on returning to the home country. It would be of great value to maintain communication and mentorship between the supervisor and fellow postfellowship. Through a process of mutual learning, the supervisors can continue to improve their ability to train future fellows. The on-site presence of a supervisor allows continuous exchange of knowledge and skills, including mentorship in research, teaching, and leadership. This on-site presence fosters motivation.15 Keeping motivation high, and constant, is not easy but is essential to driving change. Choosing fellowship centers appropriately may be one of the key factors in the success. Ideally, fellows should acquire new knowledge and skills for better anesthetic care in an environment that resembles conditions in their home country but includes opportunities their home country lacks. Therefore, rather than training in high-income countries, we recommend that anesthesiologists from LMICs complete fellowships in another LMIC where there are qualified supervisors and better facilities, equipment, and medications. The surgical profile should be close to that of the home country. In addition to making training more meaningful and relevant to fellows, supervisors will be more effective when they understand the context from which the fellow originates. There is an urgent need to train more anesthesiologists from LMICs. Subspecialty training is also crucial, and numbers of subspecialty trained anesthesiologists must be increased in parallel with the increase in general training. There is also the challenge to reach more sponsors and funds to facilitate training, particularly if bidirectional exchange is to be supported. But what would be more feasible and less costly in the long term is to support the fellows to develop the anesthesia training programs in their home countries. The advantage of this is that the programs are contextualized and the capacity to enroll more anesthesiologists is greater. Ultimately, the goal is to establish subspecialty training programs within home countries with regional support, as Bould et al. recommend. This will strengthen the quality of care and enrich the institutional learning environment. Anesthesiologists in LMICs are a very precious commodity. It is hard to spare an anesthesiologist for 6 to 12 months of subspecialty training. Nevertheless, as Bould et al highlight, fellows have great potential to make a positive impact in their home countries, through education, leadership, and clinical services. The situation we describe in PNG is 1 example of success from WFSA fellowship training. DISCLOSURES Name: Pauline B. Wake, MBBS, DA, MMED. Contribution: This author contributed to conceptual development, writing, editing, and reviewing of the manuscript. Conflicts of Interest: P. B. Wake is a previous WFSA pediatric anesthesia fellow. Name: Patricia Livingston, OC, MD, FRCPC, Med. Contribution: This author contributed to conceptual development, writing, editing, and reviewing of the manuscript. Conflicts of Interest: None. Name: Ekta Rai, MBBS, MD, MRCA. Contribution: This author contributed to conceptual development, writing, editing, and reviewing of the manuscript. Conflicts of Interest: E. Rai is head of WFSA pediatric anesthesia training center at Christian Medical College, Vellore, Tamil Nadu, India. Name: Robert J. McDougall, MBBS, FANZCA. Contribution: This author contributed to conceptual development, writing, editing, and reviewing of the manuscript. Conflicts of Interest: None. This manuscript was handled by: Angela Enright, MB, FRCPC.

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