Year : 2009 | Volume
: 3 | Issue : 1 | Page : 29--34
Update in anaesthesia service and residency training programme in KSA how far from the target?
Mohammed Abdullah Seraj
Professor of Anaesthesia, Riyadh, Saudi Arabia
Mohammed Abdullah Seraj
Professor of Anaesthesia, Riyadh
The Kingdom of Saud Arabia provides one of the best health care delivery systems in the Arab world. Both government and private sector have spent vast sums of money to establish, maintain and provide medical facilities all over the Kingdom, Primary, Secondary and Tertiary. The health care system is provided by the ministry of health hospitals (MOHH), the private sector hospitals (PSH) and other government hospitals (OGH). In (2005 G), the total numbers of anaesthetists in all hospitals were 1449 (688, 350 and 411 respectively). The workload of anaesthetist/year was 735 cases, while in (2007 G), the total numbers of anaesthetists were increased to 1640 (806,344 and 490 respectively). The workload of anaesthetist/year was 479 (average 467,313 and 739 cases).There is a slight increase in the numbers of anaesthetists in total but it is still beyond the international recommended number of 1 anaesthetist: 10000 populations
The residency training programmes started in the late eighties and the early nineties. Several modern programmes were established in the Arab world. They are:
Recently four post-anaesthetic fellowships were approved. They are cardiac anaesthesia, critical care, paediatrics anaesthesia and pain management.
- The first was King Saud fellowship started in 1989 by the author
- The second was King Faisal Fellowship in 1993 but the programme ceased.
- The Arab Board for the specialty of anaesthesia and intensive care in 1993
- The Saudi scientific council for the speciality in anaesthesia and intensive care in 1998.
|How to cite this article:|
Seraj MA. Update in anaesthesia service and residency training programme in KSA how far from the target?.Saudi J Anaesth 2009;3:29-34
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Seraj MA. Update in anaesthesia service and residency training programme in KSA how far from the target?. Saudi J Anaesth [serial online] 2009 [cited 2021 Oct 16 ];3:29-34
Available from: https://www.saudija.org/text.asp?2009/3/1/29/51832
THE OBJECTIVE OF THIS article is to update the readers with the anaesthesia service and the development of the residency training programmes (RTP) in KSA. Detail recommendations for further improvement in both services will be given.
Definition of the specialist was known as the unknown soldier in the medical practice. The specialist usually works long hours with low income, confined to the operating theatre, may be under administration of the surgical department with minimal direct contact with the conscious patient. Furthermore, the specialty has been marked in the past by high incidents of drug and/or alcohol addiction . A new study by the American Society of Anesthesiologists has shown that there is no increased incidence of drug addiction among anesthesiologists than any other medical practitioners . The specialty suffers a high incidence of suicidal attempts and cross infection. All these were detrimental factors against anaesthesia so majority of medical graduates were not attracted to the specialty of anaesthesia. The few graduates who loved the specialty joined. These physicians made daring changes by developing new subspecialties. These were intensive care, cardiac anaesthesia, pain management for cancer patients and intractable pain, the introduction of epidural services for painless child birth, thoracic anaesthesia, administrative management, resuscitation, and paediatric anaesthesia.
The development of new anaesthetic drugs, the state- of-the-art of anaesthesia machines and monitoring devices, the creation of top class residency training programmes and the birth of anaesthetic societies in every country. The early exposure of medical students to the specialty was to attract the graduates. All of these had an influence to accelerate the dramatic changes and improvement in the specialty. An inviting permanent career was created which helped to attract the cream of the graduates. This was the turning point that projected a better image of the specialty. Most recently, a new name or identity has been given to the specialty and the specialists, called perioperative medicine and perioperative physician.
A new and modern definition of anaesthesia based on all the above factors is as follows: He/ she is a physiologist, a pathologist and a master pharmacologist who with his/ her knowledge and skills will be able to provide the right and logical method of anaesthesia, dictated by the patient's condition, for the benefit of the surgeon who will be able to perform his/ her surgical procedures successfully and without ill effects on patient's vital organs during and after the procedure.
The modern international style of residency training programmes
The modern resident training programmes started in North America. It is a blend of several old methods and is a structured training programme. The residents will be taught and prepared in the junior years which included the basic sciences, principles of general and local anaesthesia. This will prepare them to be promoted to the senior years of the professional subspecialties. Through out the entire training years the residents will attend the scheduled educational activities beside their own departmental academic activities. These include lectures, case presentations, seminars, courses and workshops approved by the council. The residents rotate through various accredited hospitals for the clinical training to acquire the necessary skills to prepare them for annual promotion and finally obtaining the degree. The training and evaluation is only carried out in recognised and accredited hospitals where academicians and consultants share the responsibility of teaching and the supervision of residents.
An accomplished physician in the specialty is graduated with the highest knowledge and skills that are able to provide logical and safe techniques in anaesthesia for any patient, at any time, any where. The graduate is taught to make the correct decision in cases he/she is unable to provide the ultimate proper and safe anaesthesia due to inappropriate facilities. World wide recognition of the new programme is acclaimed, not only for its simplicity but for its wider application in preparing the new candidates to understand, absorb and digest the amount of cognitive and didactic knowledge taught.
Development of anaesthesia services in KSA.
Kingdom of Saudi Arabia is considered to have one of the best modern health care systems in the Arab World. The government and the private sector provide different levels of health care systems through three different health care institutions. The ministry of health is the prime institution who is responsible for providing and supervising the lion share of the total hospital beds in the kingdom including the private sector hospitals. It carries the burden in providing a different level through out the vast geography of the kingdom. The following tables will show the statistics of years 2003, 2005 and 2007 as issued by the ministry of health in the annual statistics book year 2007 for the three health institutions in KSA.
The number of hospitals has increased from 339 to 386 in 5 years (average: 9.4 hospitals/ year) while the number of beds has increased by 7644 beds in the same period of an average of 1529 annually [Table 1]. The surgical cases performed were increased by 69493 cases (average of 17373 cases /year) [Table 2]. The number of anaesthetists working in the Kingdom's hospitals was increased in the last five years 2003-2005-2007 from 1248 to 1409 to 1640 respectively [Table 3]. The workload of the anaesthetists working in the ministry of health hospitals was also improved. Meanwhile, the workload of the anaesthetist working in the private sector hospitals has not improved as other health care institutions. Saudi Arabia needs 2100 to 2300 anaesthetists to perform the number of the surgical cases [Table 4]. The population of Saudi Arabia has increased from 21 Millions to 23 Millions in the last 5 years. There are slight increases in the number of anaesthetists in the total, and a marginal fall in the deficit but it is still below the international recommended number of 1 anaesthetist: 10000 populations.
Throughout the years the Saudi Anaesthesia Association (SAA) has published these figures and advocated that there is a shortage not only in the number but also in qualified consultant anaesthetists working in the Kingdom especially in the ministry and the private sector hospitals. The Saudi scientific council for the specialty in anaesthesia and intensive care sets stringent rules and regulations for recognition to join the programme. The majority of the ministry of health hospitals and all private sector hospitals failed to reach up to the required specific standard. The numbers of residents belonging to the ministry are limited. These hospitals constantly recruit more junior anaesthetists while other government hospitals recruit senior highly qualified consultants to perform the daily surgical lists. The other government hospitals have implemented the standard of care which stipulates to have a consultant/theatre cover and technician assisting the work in a fully equipped theatre. They have insurance cover plus these consultants are usually teaching and supervising the residents. They ultimately have far less work load/year and less litigation cases than both ministry and private hospitals.
Development of The Saudi residency training programmes
Since the development of the modern health care system in the Kingdom, anaesthesia was left behind in while other specialty leaped along. Anaesthesia was at a lower level than the western world due to several major problems, e.g. the specialty is considered to be inferior, lack of professional qualified anesthetists. Very few graduates obtained a scholarship to go abroad seeking their higher degree in anaesthesia. Upon their return they helped to establish the modern services of anaesthesia which took two forms.
I. The era of the technical training programme:
In the 60's and 70's, the only solution to solve the problem of having very few anesthetists working in the Kingdom was to create anaesthesia technicians  A three year diploma was established by the ministry of health who adopted the scheme started by the Scandinavian countries. The programme later was cared for by Dr. Isac Alkawashki who was the first Saudi qualified anaesthetist. The aim was to graduate sufficient numbers of technicians in order to provide a service under the control of a senior consultant anaesthetist. In 1990, only high school graduates were accepted in the programme. Recently, the Ministry of Health has agreed that the entire health institutes and colleges under their care will be transferred and managed by King Saud University. There are over 1050 anaesthesia technicians and uncounted number of nurse anaesthetists working in the health care system in the Kingdom. They are useful workers and are an asset to the anaesthetist, but they should not be left to practice anaesthesia on their own [Figure 1].
II. The era of the Residency training programme:
The services suffered a great deal not only due to lack of professional consultants, but unavailability of any training programmes in Saudi Arabia. From the sixties to the eighties a few qualified anaesthetists trickled into the services. I was the first Saudi qualified with fellowship in the mid seventies, later more qualified Saudi anaesthetists followed. They were Drs. Sami al-Marzoki, Dhafer Al-khedairy, Hussain Darweesh, Adnan Al-Mazroa and Walid AlYafy. Those were the cream of the crop who returned to the country. They were considered to be the fighting force who established the new image of anaesthesia. I had a dream to create and establish a state-of-the-art department during the initial working years at King Abdul-Aziz Hospital KAAH. The department started recruiting professional manpower. This was begun by Drs. Ameer Channa, Mohamed Al-Nakeeb, Moukhtar Astafan and Fayez Khan. The small department started to exhibit its own personality in the specialty and putting forward recommendations for plans and strategies laid down for the future. None of these were able to be implemented at KAAH. These plans and strategies were carried forward where they have been implemented in the newly opened King Khalid University Hospital (KKUH). The department with its both excellent services was fostering colleagues and residents alike to be trained and gave them guidance in their future carrier where ever they want to go. These tasks were classified into three objectives:
The first task was to represent the new image of the anaesthesia by first developing a top class department capable of providing state-of-the-art services based on applying the standard of care and monitoring, producing and enforcing policies and procedures. The department was successful to recruit one of the leading researchers on Muscle relaxant Professor Viby-Mogenson from Denmark and Dr. Trevor Dobinson a cardiac anesthetist from New Zealand. In 1987 I managed to recruit Prof. Philip Bromage the leader in epidural anaesthesia from Denver medical college to join the department. The department has encouraged and promoted research programmes which have yielded many publications. The department also has a major role in introducing the cardio-pulmonary resuscitation programme in Saudi Arabia, further more it help to establish and develop the accreditation scheme for training centres in the Kingdom and the Gulf region [Figure 2].
The second task was to establish the SAA. The association was launched in 1989 under the auspicious and the rules and regulations of the scientific societies of the university. I was appointed as chairman until I retired in September 2003. Its main objectives were to:
Update, improve and have an ongoing scheme to promote the new image of the specialty.Furnish the kingdom with the standard of care and monitoring.Hold scientific monthly and annual meetings in different regions of the Kingdom.Provide continuous medical education and out reach programmesLaunch the SAA newsletter which lasted thirteen years. This was successfully replaced recently by the Saudi Anaesthetic Journal which is edited by Professors Abdulhamid Alsaeed, Abdelazeem El-Dawlatly and Jamal Al-Hashemi.Initiate departmental malpractice insurance known as (Takaful Ejtemaei). Each member of the department deposits a sum of S.R. 2000 (500$) in order to have the compensation money needed for any litigation against any member of the department. The insured member can take his/her share and when leaving or can donate it to the SAA. At the same time, they all felt legally protected.Participate actively in world conferences and federations.
The third task was to create an upgraded residency training programme different from the local degrees and similar to what the western world provides. This was mainly to produce future Saudi qualified staff. When I returned to the country in 1977 it was a dream but as the years went by the dream became a reality. This task was achieved in the next ten years with a great deal of hard work from the team assigned to produce these programmes. The second half of the eighties was the period of icing the cake when the department managed to plan and produce the following:
1. Master Degree in Anaesthesia
In mid eighties, the post graduate centre set a plan to develop the higher degrees in different medical specialties. The department of anaesthesia agreed and assigned Prof. Amir Channa, Prof. Viby Mogenson and I to prepare and implement the project in 1986. A few candidates were enrolled, but never graduated due to the request to replace the master degree by a fellowship in the specialty of anaesthesia and intensive care. These residents were transferred to the new programme.
2. King Saud fellowship in anaesthesia & intensive care
Professor P. Bromage, Drs A. Channa, T. Dobinson and I accepted the challenge. We had to gather and review all available fellowship materials internationally. We created a programme similar to the Canadian programme for its collectiveness and simplicity in application, preparing and producing a professional anaesthetist. The four years training programme was started in 1989. The residents rotate in all specialties, produce a log-book containing a performed 2000 cases and were successfully passing yearly examinations. The coordinator of the programme was Dr. Amir Channa for several years followed by Prof. Mohamed Naguib who continued until he moved to America. The first graduate from the programme was Dr. Abdulhamid Alsaeed in 1993, who recently became the second professor of anaesthesia in the Kingdom of Saudi Arabia. Recently Dr. Jamal Al-Hashemi has been promoted and became the third Saudi Professor, working in Jeddah, King Abdulaziz University. The total graduates and the holders of King Saud fellowship are thirty six, while there are fifteen residents enrolled in the ongoing programme some of these graduates and the residents are non Saudi.
3. Arab Board in Anaesthesia and Intensive Care
The Pan Arab federation of anesthetic societies realized the department's achievement and requested in November 1991 to prepare the statutes of the programme. The task was completed and presented to the Arab Council for medical specialties in Damascus and approved in November 1993. I was appointed as the general secretary for two terms and vice president for two years. The Board started slowly, but gained more popularity along the years and the number of candidates kept increasing and reached over 1301 and the graduates have exceeded 150. Fourteen Arab countries are members of the Arab scientific board in the specialty of anaesthesia and intensive care.
4. Fellowship of King Faisal University
It was started in 1993. The programme started successfully, but unfortunately it only lasted for a few years. Only two fellows were graduated. Reason for its cessation is unknown.
5. Saudi Board in the Specialty of Anaesthesia and Intensive Care
Three academesions and a consultant from prince Sultan Cardiac centre in Riyadh were selected to the committee by the Saudi Council for health specialties. Their task was to prepare the statutes of the Saudi Board in the specialty in anaesthesia and intensive care. They completed and obtained the approval in 1998. Once again I was selected to be the chairman for two terms and member for a third term. The new five year programme was approved recently and will start in October 2008. The start was slow but the number of candidates enrolled in the programme has increased to 122. The numbers of Saudi residents are 105. Seven residents completed their training programme and are eligible to enter the final examination. The number of graduates is twenty with some of these being expatriates.
6. Sub-Specialties Post Anaesthesia Fellowships
The members of the Saudi scientific council for anaesthesia and intensive care decided to create post specialty fellowships. Four ad-hoc committees were selected to develop state-of-the-art training programmes of two years. They completed the task which was discussed and approved by the members of Saudi Council in the specialty and sanctioned by the Saudi Commission For Health Specialties. The graduates will obtain his/her degree which will facilitate their appointment immediately as a consultant. A fellowship degree will be granted in the following sub-specialties:
Cardiac anaesthesia fellowship. Three specialists joined the programme..Critical care fellowship. The programme has produced 4 graduates and has 7 residents.Paediatric anaesthesia. The programme has 3 residents.Pain management. Acceptance will start next January 2009.
An accolade should be bestowed on all professionals who climbed the mountain with their efforts, enthusiasm, perseverance, and persistence. Those were the ones who started the creation of an updated, modern and sophisticated department with state-of-the-art equipment and monitoring, managed by professionals in the specialty. The aim was to have the most excellent and elaborate department which is the envy of colleagues in the Arab world. Those were the professionals who worked behind the scenes and did not ask for glory and made the dream become a reality. Hundred researches papers were read and published by members of the department in national and international reputed journals. They continue their march by establishing the SAA under the auspicious of the university rules and regulations of the scientific associations. They managed to spread knowledge and create the new image of anaesthesia in the Kingdom through the activities of the association. They achieved this by holding regular monthly club meetings and annual scientific meetings in various regions of the Kingdom and started outreach programmes designed for the colleagues working in remote hospitals. The association launched its newsletter and was distributed nationally and internationally. It also created some thing new that was the mal practice insurance cover known as El-Takaful Al-Ejtemaei.
The same professionals made their final task an achievement. This was the establishment of the various residency training programmes in the Arab world. The aim was to replace the old unstructed training programmes into a modern sophisticated residency training programmes. Several programmes were established in successive years. The final higher degree was the establishment of the Saudi Council for the specialty in anaesthesia and intensive care. This council made more advanced progress than its counterpart by establishing the post graduates sub-specialties degrees in cardiac anaesthesia, critical care, pediatric anaesthesia and finally the pain medicine.
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