Development of novel endoscopic procedures has skyrocketed in the last 10 years, superseding more invasive procedures and offering lower cost, lower morbidity solutions for patients. In resource-limited environments, endoscopy is even more starkly advantageous, allowing far more access to treatment than conventional surgery. The need for competence in endoscopy in the subcontinent of Africa is growing, and the landscape of disease has changed as development increases. African countries have GI diseases associated with socioeconomic disadvantage, but increasingly also the complex GI diseases of developed nations. With development, the demand for better health services, and for screening programs is also growing.
To meet the needs for high quality endoscopic services in Africa, several key components are required. Along with adequate health care standards and equipment availability, doctors need to be trained in endoscopic procedures to perform them safely and well. The paucity of depth of training in new GI units limits access to good quality training. One way of boot-strapping endoscopy in Africa is to train a large number of physicians to perform procedures, providing a service and teaching base from which local training can progress exponentially.
WEO is developing a program whereby expert centers in India will provide access to high volume, high quality endoscopy training to doctors from Africa. India offers training experience with diseases similar to those encountered in Africa, an affordable cost of living for trainees, and exposure to world-class endoscopy facilities and experienced trainers. Featured here are Here four centers that will pioneer this collaboration.
Institute of Advanced Endoscopy, Mumbai. Director: Amit Maydeo.
In Mumbai, the beating heart of India with over 20 million people, is found one of the best equipped centers of excellence in endoscopy. The Institute of Advanced Endoscopy offers a full range of procedures, with particular focus on ERCP and other advanced techniques. The unit is also engaged in developing equipment and accessories, with a big focus on innovation.
Dr. Amit Maydeo is a surgeon-endoscopist, world famous for his work on pancreatic stones and endoscopic shockwave lithotripsy. He is a well-known figure on the world lecture circuit and his live demonstrations have delighted endoscopy audiences in conferences everywhere. Dr. Amit is well supported by excellent clinicians who run the day-to-day activity of the facility. With decades of experience in training African and other international endoscopists, he has been instrumental in running high-tech training courses on location in Africa, as well as in remote mentoring.
The center already has an active training program in place with several international trainees per year in addition to a number of Indian fellows. The center offers mandatory training on simulation models to achieve basic hand–eye coordination which is carefully assessed before patient-centered training. Trainees also have ample research opportunities with an in-house specialized research coordinator who is proactive and keen on building cross-institutional collaboration. The Institute provides subsidized off-site accommodation and facilitates trainee induction.
IDL Care, Mumbai. Director: Vinay Dhir
Just a short taxi ride from world-famous Juhu beach, IDL care is a boutique health center in the heart of Mumbai. A dedicated lift takes you to the modern medical center. There are a number of well-equipped endoscopy rooms with state-of-the-art equipment, dedicated patient care areas, and a holistic approach to treatment, with support services offered by physicians. This center focuses on basic endoscopy and endoscopic ultrasound (EUS) scanning although other advanced procedures are also performed. IDL Care has a unique school of EUS in the facility, with dedicated lecture sessions, training videos, and custom-designed models.
Dr Vinay Dhir is a dedicated and experienced endoscopist with internationally renowned expertise in endoscopic ultrasound. There is a very strong emphasis on training with two or three trainees, including international trainees, in the unit at any one time for dedicated hands-on training.
Clinically, the caseloads are very similar to what can be found in Europe and Australia, with individualized attention to each patient. An impressive wall of monitors and high-tech equipment allows for livestreaming of cases for remote collaboration and case discussion.
Midas Hospital, Nagpur. Director: Saurabh Mukewar
Nagpur, the “orange city,” home to one of India’s most famous food exporters, Haldiram’s, is a fast-developing metropolis in central India. A site visit to the vast new green hospital site revealed an impressive building, which will be even more imposing when it is finished. The hospital will have 100 beds including 60 inpatient beds, and has provision for laboratory, radiology, cardiology, dialysis, and cardiac services. Endoscopy has been set up with six rooms, including two with C-arms, and two scope-cleaning areas. New Olympus equipment has been purchased, and it is expected that the new facility will have been opened by December this year.
There are three endoscopists but most of the interventional work is done by Dr. Saurabh Mukewar himself, who returned home after 10 years of working in top centers in the USA including Columbia University, UCLA, the Mayo Clinic, and the Cleveland Clinic Foundation. Dr. Mukewar’s main interest is in developing a strong interventional EUS service in central India.
There are currently three trainees from various parts of India. They commented on the excellent training and hands-on experience. The site is also a part of the gastroenterology training program set up by Prof. Kulwinder Dua in conjunction with the Rwandan Government and the Medical College of Wisconsin.
During the WEO site visit, preparations were being made for livestreaming to local centers as the regional gastroenterology group meeting was to be held the next day. The current audiovisual facilities, incorporated into the design of the new facility, seem reasonably able to achieve this.
The new hospital can also provide supported housing for the trainees.
Asian Institute of Gastroenterology, Hyderabad. Director: Nageshwar Reddy
While I have visited the AIG previously, this time I was able to see the endoscopy facility in action. This is a state-of-the-art, world-class hospital in Hyderabad with 30 endoscopists, most of whom do everything, and do it well. There is an active teaching program, with a heavy academic emphasis, and several multidisciplinary team meetings per week. There is a liver transplant unit and intensive care unit (ICU). The gastroenterology unit takes part in outreach services to rural regions, which will be excellent exposure for African trainees. There are three advanced procedure rooms and nine general endoscopy rooms, with over 700 procedures performed per day.
The unit is heavily engaged in training. At the time of my visit, there were eight trainees and six advanced trainees, three of whom came from Nepal, Chile, and Italy. I spoke with Antonio, a trainee from Prof. Repici’s department in Milan. He described excellent procedural supervision and, additionally, development of the intellectual processes required to perform procedures safely. He was being given ample experience with two or three ERCPs per day over a 3-month period. The capacity for research is impressive and is well supported.
The center is a suitable site for trainees who have some experience and who have mastered the basics, as the AIG can offer large case volumes that support upskilling in a short period of time. There is supported accommodation for trainees on site and cheap food. The Institute is very keen to collaborate with WEO regarding training and certification.
Summary
Delivery of on-site endoscopy training in Africa by visiting faculty has many advantages, including using the trainees’ own equipment, and studying the local diseases. Additionally, the practice of endoscopy in the local unit can be assisted, encompassing endoscopy care, patient flow, and nurse training. To date, the limitations to this model have mainly been the availability of trainers who can travel to Africa, and the limited caseload that can be addressed during one visit.
Indian centers of endoscopy excellence are ideal training sites for African colleagues. These centers have large caseloads that include varied and interesting pathology, state-of-the-art facilities, and world-class experts. The featured centers were uniformly in favor of starting international training in collaboration with WEO. We will endeavor to provide valuable pre-training evaluation of the candidates, link them with the most appropriate training center, and optimize the placements. WEO is the preferred partner of these centers to initiate, implement, and assess training programs and to provide quality control advice to both trainees and trainers.
Online application forms will be coming soon to the WEO website.
