Service work focuses on treating the maximum number of patients in the limited available time. For this reason, practitioners will often bring their own equipment and drugs, so as not to be dependent on the local supply. In teaching settings, the trainees will need to be trained on their own equipment with drugs that will be available after the teachers leave. Hence, the visitors will have to make themselves familiar with anesthetic drugs, equipment, and techniques that they may not be used to, or, in fact, may never have seen or heard of before (Fig. 27.3). The volunteer may need to dedicate substantial preparation prior to the teaching trip to familiarize and train her- or himself in the methods and tools used by the students.

The practice setting is likely to be quite different as well. For example, it is not uncommon in some countries to have several operating tables in one room, so that multiple surgeries take place in parallel. Many locations will not have a preoperative area for evaluating the patient or a post-anesthesia care unit.

From a teaching perspective, infrastructure and facilities may be scant or absent. There may be very little in the way of educational facilities or classroom space, and frequently there will be no defined curriculum from which to work.

The pace of work can be quite different between service and education trips. Again, during service missions, the team attempts to maximize the number of cases done, and that means starting early and often working in the operating room until late at night. Usually, little else is done during the trip. During education work, the volunteer has to adapt to local customary start and end times, which are generally quite different from those in academic medical centers. Even though the hours are different, volunteer educators will work hard. The non-clinical time at the beginning and end of the day is packed with lecture preparation, test writing and grading, and meeting with students. In addition, it is not uncommon to become involved—whether planned or unplanned—in other educational activities such as medical school curriculum development, outside lectures, or teaching for practitioners outside the specialty.

Language barriers can be a major problem during both service and teaching work. For teaching, a good understanding of the level of education of the trainees, and of their background knowledge and clinical experience is required. This information can be difficult to obtain, and at times the teacher may not have worked previously with trainees with this mix of knowledge. For example, as mentioned above, it is not uncommon to work with people who have quite extensive clinical skill, but only a rudimentary understanding of physiology and pharmacology. Even a concept such as “tidal volume” may be unknown to the students, making effective teaching very challenging. The best approach is to be aware of and continuously challenge one’s assumptions about the learners’ knowledge by obtaining immediate feedback. Frequent questions on the degree of understanding of material just taught can provide this information. For example, including multiple-choice questions in presentations can quickly check understanding of material presented a few slides earlier.

Cultural mores and norms run deep and can challenge and surprise even the most effective teacher. An educator needs to be mentally prepared to find one morning that all of the students are absent because someone’s distant relative has died and they all needed to be at the funeral as a sign of respect. A visiting teacher needs to be ready for unexpected pushback during a discussion of ventricular fibrillation, because the students know from experience that none of those patients survive in their hospital, so it is not worth instituting treatment. While it is helpful to prepare by reading on the culture and religion of the area where the teaching will be done, the reality is that the visiting educator will be confronted with unexpected responses and behaviors. The ability to adapt and improvise is an important trait for both the service-based volunteer and teacher; however, a longer duration of a teaching trip means there will be more surprises.

Short- versus long-term involvement will be discussed in more detail later in this chapter, but in the context of a comparison between service and education, it is important to realize that education work will require more time in-country than does a service mission. Unless one commits to a long-term in-country stay, this means that the individual educator will only see a small slice of the whole job. After a service mission of 2 weeks, the volunteer anesthesiologist knows exactly how many patients were operated on and helped; after 2 weeks educating local anesthesia providers, progress may not be quite so visible, and it is easy to become discouraged about long-term prospects. The volunteer can mitigate the natural tendency to become discouraged by understanding the totality of the group’s mission, being mentally prepared not to see immediate results, and maintaining contact with people who have previously worked on the same project. On the other hand, educational work often affords practitioners more opportunity and more time for close personal contact and for developing friendships with the local teams, which can be professionally and personally satisfying. Also, educational activities come with the realization that one is adding to capacity, and not in any way taking away from or displacing local professionals.

It is unfortunately only too easy to come into a developing country with the best of intentions yet unprepared to really effectively help with an educational program. For each program, some important considerations need to be addressed. Below we discuss how to define the organizational structure, tailor the message and methods to the intended audience, incorporate technology, and be sensitive to the history of medical education in the country. Incorporating this level of understanding into teaching activities will increase the probability of implementing a successful medical education program.

In-country education programs that are driven by the local clinicians and administration—who are the only people who really understand the local needs and limitations—are more likely to accomplish their goals. Not even the most intense and frequent “scouting trips” and “evaluation visits” can match local knowledge. A formal needs assessment is important and very useful for planning the program, but it cannot replace direct input from local people. Local practitioners are also the people who know if other outside groups are involved in local teaching and can keep well-intentioned organizations with similar goals from duplicating each other’s work. In-depth interaction with the local stakeholders will assure that the program is unified and comprehensive, that separate efforts directed at a residency or mid-level training program are aligned, and that all visiting faculty teach according to a defined curriculum. Ideally the local faculty members are in charge of the entire process.

Practically, the level of instruction will differ between programs for residents and those geared for anesthesia technicians. Philosophically, many anesthesia educators in HICs feel that anesthesiologists should focus on training more physician providers. Whether efforts and resources should be spent on developing nascent residency programs or whether those efforts are better expended towards improving technician training is a heavily debated question. Physician anesthesiologist and anesthesia technician programs are sometimes at odds within the host country, and the visiting educator may need to negotiate these politics [3]. Because in over half the countries in the world technicians or nurses with an average of 1–2 years of training provide most of the anesthesia care, it is in the best interest of the local patients that technicians are optimally trained, and participation in their training is valuable [4, 5]. At the same time, the goal of having at least one anesthesiologist available in each hospital is an important one—physician anesthesiologists can advance anesthesia care with respect to other medical and surgical services, they can provide subspecialty services, and they can supervise and support technicians and mid-level practitioners. Ideally for the health of the population in LMICs, residencies will be started, and residents and technician education will have to take place simultaneously [6].

Internet facilities in most parts of the world are by now capable of video uplinks of very acceptable quality, and tele-education can be immensely valuable in many ways. As one important example, it allows a variety of specialists, not all of whom would be able or willing to travel to another country, to take part in educational activities. In addition, it allows residents or other learners to see behavior modeled by their counterparts in HIC. Case teleconferences can be an excellent learning tool for residents in LMICs and remote areas of HICs; for example, the University of Virginia runs a monthly case conference with the anesthesiology residency in Rwanda (see Fig. 27.4), and these are being evaluated positively [3]. Although operating room and bedside teaching are an essential part of medical training that cannot be replaced by distance learning, teaching be enhanced through the use of technology for case-based learning or simulation. A program such as the case conferences mentioned above can maximize educational value and minimize cost for training programs in LMICs.

When physician educators arrive to teach the curriculum and implement an educational program, they become ambassadors from their home country. What this means is that they are unavoidably a model for many of the trainees, and this may be one of the more important aspects of in-country teaching. A visiting physician educator walks a fine line between capacity building and recruiting anesthesia providers away from the home country.

Many developing countries suffer greatly from “brain drain”: For a variety of reasons, local physicians trained, at great difficulty and cost, are at high risk of leaving the country and finding more comfortable and lucrative employment elsewhere [7–10]. To prevent this, it is important that foreign teachers do more than train in technical and cognitive aspects. Working and teaching in the local setting can be a truly interesting job and this needs to be conveyed to the trainees. They also need to be made to feel part of the modern anesthesia world. In some ways, when one talks about techniques, drugs and approaches used in the western world, trainees in LMIC get a glimpse into their future. Our goal as anesthesia educators is for them to be part of that future—in their own country.

An important first step in contributing to in-country anesthesia training is to search for a reputable aid organization or program that is a good fit with the physician’s skills, interests and values. An established program has the advantages of having performed a needs assessment and having worked out relationships between key players at the overseas site. It is important that a visiting anesthesiologist not be a burden to already overworked health care providers by making demands on their time for assistance with orientation, housing and transportation needs. A good organization can help guide the educator with planning, communication, and setting reasonable expectations in order to increase the likelihood of a useful and productive trip.

If the anesthesiologist is not already aware of an educationally oriented organization, how does he/she find one? Fortunately in the past 5–10 years there has been a strong focus on workforce development and education in anesthesia and other specialties by academic institutions, the World Health Organization (WHO), and the US Government [12]. Good places to start looking are within the home institution, on websites such as the American College of Surgeons Operation Giving Back (OGB) [13], the American Society of Anesthesiologists (ASA) Global Humanitarian Outreach (GHO) [14], and subspecialty websites such as the Society for Pediatric Anesthesia [15] and the Society for Education in Anesthesia [16]. Networking with health care workers interested in global health at the home institution and at meetings can also be helpful. Other educationally oriented anesthesia organizations that are useful are the World Federation of Societies of Anaesthesiologists (WSFA) [17], Health Volunteers Overseas (HVO) [18], and Kybele [19], which are all represented in this text. An opportunity for longer involvement in teaching is the newly launched Rwanda Human Resources for Health Program [20].

Many residents are interested in global health and can contribute as well as benefit from an international teaching rotation. Residents can play a special role as peer mentors to local students who may relate better and be more comfortable asking questions of a fellow adult learner. Residents are often technically savvy and innovative which can help to bring new and exciting teaching techniques to a developing country. For example, one SEA HVO traveling fellow taught residents in Peru how to film procedures at their hospital using a cell phone and some inexpensive attachments. These filmed procedures could then be used to teach new residents how the procedure is performed at their hospital. Also, residents may at times be a better source of practical clinical information and clinical “pearls” than the academic faculty.

Some anesthesia residency programs have standing overseas teaching rotations. Residents in these programs are well advised to let their program director know early in their residency if they are interested in global health. Residents who do not find an opportunity within their own institution can apply to receive a month’s scholarship with the SEA HVO Traveling Fellowship. Applications can be found on the HVO or SEA websites on December 1st each year for the following academic year. Residents should be aware that traveling with an organization outside their own program may be considered an “out of program rotation” by the country’s accreditation body. For example, according to the American Board of Anesthesiology (ABA), international rotations have special requirements including (1) the rotation must occur during the first 9 months of the fourth postgraduate year of anesthesia training and (2) a letter requesting ABA approval must be obtained prior to departure for the rotation. Details on requirements for residents teaching abroad can be found on the SEA website [16].

Next, the anesthesiologist should evaluate his or her skills, values, interests, and needs and decide how these attributes best match with a program. To maximize the chances of a successful visit for the educator and the host, this issue should be addressed when choosing a program—not when in-country. A potential volunteer should take into consideration the following:

Anesthesiologists with a flexible, patient, and nonjudgmental approach and an enthusiasm for learning as well as teaching should do well when some effort has gone into finding the most appropriate program and site.

The health and safety of medical professionals is too often neglected in the enthusiasm for going overseas [21]. Illnesses and injuries—often avoidable—can be a disaster for the educator but can also be a burden for the host. It is a good idea to visit a travel clinic several months before leaving the country to get advice about vaccinations, malaria prophylaxis and how to handle postexposure HIV prophylaxis. Educators who are participating in hands-on teaching in the OR or ICU should be aware that many of the protective barriers and devices used at home as part of universal precautions are in short supply or not available in many low resource countries. Bringing gloves, masks, eye protection and hats will help the visitor maintain universal precautions and will prevent the hosts institution from being further depleted of supplies.