Introduction
Population growth within low-resourced countries poses significant challenges for healthcare training and delivery. The rising cost of healthcare, combined with limited opportunities for low-resourced world physicians to gain the skills needed to manage complex medical problems, places further stress on already tenuous healthcare infrastructures. With many suffering hearing loss and head and neck problems, the need to train qualified physicians to identify and treat these conditions is an ongoing challenge. Sustainable medical educational partnerships between high-income and low-income nations provide one possible solution.
Established in 1955, Komfo Anokye Teaching Hospital in Kumasi, Ghana, is a teaching hospital for medical students from Kwame Nkrumah University of Science and Technology. Currently, this 1200-bed facility is a training centre endorsed by the Ghana College of Physicians and Surgeons, and the West African Colleges of Physicians and Surgeons. Komfo Anokye Teaching Hospital also trains midwives from the Kumasi Nurses and Midwifery Training College, nurses from other colleges, and pharmacy and medical laboratory students from Kwame Nkrumah University of Science and Technology. The catchment area of Komfo Anokye Teaching Hospital stretches beyond the Ashanti Region, Brong Ahafo, the 3 Northern Regions, and to some parts of Western and Central Regions, 1 encompassing approximately 10 million people.
When the University of Michigan Department of Otolaryngology/Head and Neck Surgery sought to establish a global outreach educational partnership, Komfo Anokye Teaching Hospital was an ideal candidate. For decades, the University of Michigan had established ties with Komfo Anokye Teaching Hospital through relationships that were originally fostered through their respective departments of obstetrics and gynaecology. This prompted an otolaryngology fact-finding visit to Komfo Anokye Teaching Hospital in October 2013, with three basic questions, as follows. (1) Is there a clinical, educational and research need in Ghana and/or the region for further otolaryngology practice development? (2) If so, is there sufficient infrastructure to support a high-level collaboration between the University of Michigan and Komfo Anokye Teaching Hospital for otolaryngology and the subdisciplines? (3) Lastly, is there a desire for a long-term medical educational partnership within Komfo Anokye Teaching Hospital?
Materials and methods
An otolaryngology partnership between Komfo Anokye Teaching Hospital in Kumasi, Ghana, and the University of Michigan Department of Otolaryngology/Head and Neck Surgery has been undertaken to enhance healthcare delivery at both institutions.
Results
We have established a temporal bone dissection laboratory, with the equipment to perform dedicated otological surgery, and academic platforms for clinical and medical education and residency training. This article describes the details of this partnership in otological surgery and hearing health.
Discussion
Otolaryngology in Ghana
Of the 41 trained otolaryngology surgeons in Ghana, only 25 are practising, and this small group collectively serves over 26 million people. Nine practise in the capital city of Accra, nine in Kumasi and the remaining in remote locations. The majority of otolaryngologists (17 out of 25) work in tertiary-care hospitals, while others are in regional or secondary level, or in district-level hospitals (Table I).
Distribution of otolaryngology surgeons in ghana
Of the 25 practising otolaryngology surgeons, 17 have completed fellowship level training, while 8 have Ghana College of Physicians and Surgeons membership, allowing them to practise as specialists in the district hospitals. One dedicated year of service in the district hospital is required before fellowship training begins. To meet training objectives, many Ghanaian physicians received their full otolaryngology training in the USA, the UK, Poland, former Yugoslavia and Germany, and returned to Ghana with their qualifications. In contrast to the 25 practising otolaryngology surgeons in all of Ghana, 9642 otolaryngologists practise in the USA and serve over 316 million people, as of 2013.Reference Vickery, Weterings and Cabrera-Muffly 2 , 3
Otolaryngology training
To meet growing medical needs, Ghana has witnessed increasing commitments from in-country physicians to acquire post-graduate specialty training. In 2004, the Ghana College of Physicians and Surgeons was established to define and standardise this specialty training. There are currently five attending otolaryngologists at Komfo Anokye Teaching Hospital. In the last 10 years, 14 otolaryngologists have been trained at Komfo Anokye Teaching Hospital (approximately 1.4 per year). Of those, six who have completed fellowship training are working in teaching or tertiary hospitals. The remaining otolaryngologists are practising in district hospitals, and would ideally return for further training in otolaryngology subspecialties within the teaching hospitals.
Otolaryngology residency training at Komfo Anokye Teaching Hospital is a three-year programme run through the Ghana College of Physicians and Surgeons. 4 In year one, basic head and neck examination, and surgical skills and procedures, are covered (i.e. ENT foreign bodies, facial trauma, tonsillectomy, adenoidectomy, mastoid abscess management and sinus operations). The following 2 years include 8 months of otolaryngology surgical training, and 16 months rotating in related specialties (ophthalmology, neurosurgery, thoracic and general surgery, anaesthesia, emergency medicine, oral and maxillofacial surgery, and plastic and reconstructive surgery). A two-year fellowship in general otolaryngology then follows, including training in audiology, laryngeal and pharyngeal surgery and voice rehabilitation, neck dissection, maxillectomy, salivary gland surgery, sinus and plastic surgery, endoscopy, and mastoid and middle-ear surgery. Additionally, the Ghana College of Physicians and Surgeons encourages post-fellowship subspecialty (i.e. otology, rhinology, plastics, oncology) training (one to two years) to improve services at tertiary centres.
Presently, during otology training, residents are only likely to perform minor procedures, including repair of pinna lacerations, excision of aural polyps and keloids, and incision and drainage of haematoma and abscesses (Table II). Residents typically only observe or assist during cases requiring cortical mastoidectomy, as the attending otolaryngologist uses a gouge and hammer. Prior to this medical partnership, no otological drills or microscopes were routinely employed for these cases.
Komfo anokye teaching hospital otological procedures over past five years
Data represent numbers of cases. GA = general anaesthesia; EAC = external auditory canal
Cases requiring extirpation or exteriorisation of cholesteatoma, ossicular chain reconstruction, or temporal bone resections are not performed, and patients are alternatively treated medically. Routine tympanoplasty is rarely performed; if attempted, it requires borrowing the only available operating microscope from ophthalmology. This microscope lacks a teaching television monitor, limiting training opportunities for the residents.
To supplement the lack of hands-on otological surgery, the Ghana College of Physicians and Surgeons requires that residents attend an established temporal bone dissection course, and attain proficiency in external and middle-ear surgical procedures prior to graduation. To fulfil these requirements, many residents must travel to centres in South Africa, India and the USA. Because Ghanaian physicians typically do not have medical licences to practise medicine outside of Ghana, these experiences are typically limited to observation and/or cadaveric dissection.
Otological needs
The lack of dedicated otological surgical training at Komfo Anokye Teaching Hospital, coupled with significant clinical demand in Ghana, makes medical and educational partnerships like the one described herein critical. Ear pathology is quite common at the Komfo Anokye Teaching Hospital out-patient otolaryngology clinic. Patients routinely present with problems ranging from impacted cerumen, ear canal foreign bodies, tympanic membrane perforations, acute otitis media and externa, sudden and progressive hearing impairment, and chronic otitis media with or without suppuration or cholesteatoma. Many of these conditions contribute to delayed speech or language acquisition. Other concomitant pathology often includes aural polyps, keloids, auricular cysts, mastoiditis, congenital ear malformations, temporal bone and soft tissue ear trauma, and vertigo associated with various causes. There are currently no published data on the burden of chronic ear disease in Ghana.
Currently in Ghana, otological surgical procedures are performed at two tertiary hospitals, located in Accra (Korle-Bu Teaching Hospital) and Kumasi (Komfo Anokye Teaching Hospital). The main limitation to effective treatment of otological disease at Komfo Anokye Teaching Hospital is the lack of up-to-date equipment (operating microscopes, otological drills and micro-instruments) and the advanced training required to use it. Consequently, many patients with early or manageable disease are often unable to obtain surgical care, leading to progressive disease with considerable morbidity (facial paralysis, labyrinthine fistula) and potential mortality (encephalocele, meningitis).
Another challenge is the relative scarcity of detailed imaging scanners (computed tomography (CT) and magnetic resonance imaging (MRI)), which are vital in managing complex patients who present with advanced disease from extensive cholesteatoma. Recently, CT and MRI have become more accessible; however, the rising patient-associated costs are financially prohibitive, and therefore radiological imaging is often avoided. Ghana's National Health Insurance does not cover these imaging studies, and, as many patients cannot afford them, scans are only requested when surgery is anticipated or are not obtained at all.
Audiology
Another area that the University of Michigan – Komfo Anokye Teaching Hospital partnership is addressing is non-surgical hearing rehabilitation. At the Hearing Assessment Centre at Komfo Anokye Teaching Hospital, patients are referred by Komfo Anokye Teaching Hospital otolaryngologists or community providers, or are self-referred. An average of 1881 patients are seen at the Hearing Assessment Centre annually (Table III). Most are adults; those younger than 18 years constitute 45 per cent of the total.
Komfo anokye teaching hospital audiological assessments over past five years
Because of poor funding and the lack of equipment, clinical audiological testing is limited to pure tone air and bone conduction threshold measures. When indicated, distortion product otoacoustic emission screening and auditory distraction testing can be performed, with the latter being used for those aged 6 to 18 months to discriminate laterality of ear-specific information.Reference Wood, Davis and McCormick 5 Newborn hearing screens using auditory brainstem responses are unavailable at the Hearing Assessment Centre. Paediatricians occasionally refer high-risk infants and toddlers for hearing assessment using otoacoustic emission testing. In older children, behavioural distraction tests are employed in combination with pure tone audiometry.
At the Hearing Assessment Centre, graduate students in audiology, along with those in disability, rehabilitation and development programmes, measure pure tones in patients under the supervision of a lead audiometric technician who manages the Hearing Assessment Centre diagnostic and rehabilitation operations. Medical and nursing students, in addition to otolaryngology, family medicine and paediatric residents, also rotate through the Hearing Assessment Centre.
The Hearing Assessment Centre audiology teaching staff consist of three audiologists, a speech pathologist and otolaryngologists at Komfo Anokye Teaching Hospital. Kwame Nkrumah University of Science and Technology also contracts individuals who provide lectures for audiology students on practical and theoretical subject matters. Coursework and laboratories address the anatomy and physiology of the auditory and phonatory systems, basic acoustics, speech perception, psychosocial aspects of hearing loss, aural rehabilitation, paediatric and industrial audiology, and counselling in communication disorders. The Kwame Nkrumah University of Science and Technology training programme aims to produce audiologists with both a comprehensive knowledge base and a relevant skillset useful in the management of all patients with hearing loss.
Unfunded national and regional mandates require that students in high school, college, and medical and nursing training programmes receive hearing evaluations at entry. Individuals in many other professions are also required to have hearing evaluations. Despite the knowledge that noise-induced hearing loss is preventable, there are no guidelines promoting the benefits of hearing protection to at-risk employees at their worksites.
Despite an estimated 1.4 million hearing-impaired adults and children,Reference Kwawu 6 Ghanaians are expected to obtain their own hearing aids, as national health insurance does not provide these for residents. Hearing aids are usually purchased by patients or family members; however, the Hearing Assessment Centre is able to supply a minimal number of donated aids for some patients. A few people with the financial means order hearing aids from abroad.
Building lasting medical education
Regarding the assessment of needs and gaps in training, initial feedback from the first University of Michigan – Komfo Anokye Teaching Hospital otolaryngology interaction focused on the limited capacity to surgically manage acute and chronic ear disease in Ghana (Kumasi and North Ghana). Other identified needs included sinus and skull base surgery, and laryngeal microsurgery utilising minimally invasive techniques. Other opportunities included increased exposure to and skill development with local-regional tissue for head and neck reconstruction, and the improvement of head and neck surgical techniques through lectures, cadaveric dissections and in-country surgery.
Implementing a programme into the existing curriculum that addresses these concerns involved recruiting additional faculty from the University of Michigan. Original estimates to enhance the current residency paradigm, just to meet the primary concerns listed above, were three to five years. The goals for the project were submitted to institutional leadership, and the project was granted modest start-up funds for capital expenditures of equipment and travel fees.
Preparation for capacity development
We will now consider the development of clinic and operating theatre initiatives (from a nursing and physician standpoint). While formal training in many subspecialties of otolaryngology is needed at Komfo Anokye Teaching Hospital, clinical and surgical education in otology was determined to be the greatest initial need. In low-resourced countries, chronic suppurative otitis media with cholesteatoma is quite common. This condition is often associated with advanced disease, leading to significant morbidity and mortality.Reference Lasisi, Olatoke, Sandabe and Kondiya 7
Equipment needs for otological evaluation and procedures at Komfo Anokye Teaching Hospital were significant. There were no dedicated operative otological microscopes, otological drills or basic otological micro-instruments. Previous procedures used limited instruments, including gouges and curettes. Importantly, the University of Michigan – Komfo Anokye Teaching Hospital partnership involves nursing support for the otological patient that includes instruction on the proper use and care of delicate otological instruments.
The University of Michigan nursing staff initially assessed Komfo Anokye Teaching Hospital's capacity to sterilise these items, and procured high-speed otological drills and otological instruments for the operating theatre. Gelatine foam, bone wax, suction-irrigator components, Merocel wicks, drill burs, medications and so on were also necessary. The University of Michigan collected these items for the initial programme start-up, with the expectation that Komfo Anokye Teaching Hospital would acquire or purchase these on an ongoing basis. A list of local vendors for the items was compiled, and presented to Komfo Anokye Teaching Hospital nursing staff and faculty members.
In March 2015, the University of Michigan brought the bulk of the equipment needed for otological training. During the one-week visit, a series of lectures on temporal bone anatomy, otological pathology and drilling techniques were given, culminating in the construction of the first temporal bone dissection laboratory in Ghana. The laboratory consisted of two fully equipped workstations, with microscopes, drills, and a suction and irrigation system. A training course was given to two attending otolaryngologists. An operative microscope was assembled for the surgical operating theatre, and instruments in the clinic and operating theatre were organised. Utilising resources already available at Komfo Anokye Teaching Hospital, a sterilisation protocol was established.
Based on the screening of clinic patients earlier in the week, three otological procedures (two tympanoplasties and one intact canal wall mastoidectomy) were performed by the University of Michigan otologist, with Komfo Anokye Teaching Hospital physicians observing.
Educational reciprocity
Implementing programmes and teaching into existing core curriculum
Following the first visit to Komfo Anokye Teaching Hospital to establish the medical and educational partnership, two attending otolaryngologists from Komfo Anokye Teaching Hospital travelled to the University of Michigan and enrolled in a temporal bone dissection course, where they expanded their knowledge and drilling skills. During two additional weeks following the course, they observed otology cases in University of Michigan operating theatres and spent time shadowing in the clinic. Additionally, the head of the Otolaryngology Department at Komfo Anokye Teaching Hospital visited the University of Michigan to review our resident training programme, our audiology and speech therapy programmes, and our multidisciplinary approach to care.
These individuals will return to the University of Michigan to participate in head and neck dissection, facial plastics, and sinus simulation courses, which are held annually as part of the University of Michigan Otolaryngology Residency Training Program. During these courses, Komfo Anokye Teaching Hospital faculty will engage in didactic lectures and hands-on surgical simulation experiences with University of Michigan residents.
This intensive submersion experience supplements the initial temporal bone teachings and surgical approach taught at Komfo Anokye Teaching Hospital, and highlights the importance of training reciprocity.
This dynamic will continue with a planned resident exchange. University of Michigan residents will formally rotate for one-month blocks at Komfo Anokye Teaching Hospital on all services as members of the training programme, while Komfo Anokye Teaching Hospital residents will rotate to the University of Michigan for clinical and surgical observation, lectures, and surgical simulation experience. Additional discussions regarding this exchange and curricula were formalised in a memorandum of understanding between the University of Michigan and the Komfo Anokye Teaching Hospital.
Building simulation dissection courses and laboratories
Building simulation laboratories and dissection courses (temporal bone dissection laboratory, head and neck dissection course, sinus course) for the otolaryngologists in Ghana is essential for their training and development as independent skilled providers. Implementing low-cost simulation models in low-income countries has been proven feasible and effective.Reference Long, Spears, Kenady and Roth 8 , Reference Beard, Akoko, Mwanga, Mkony and O'Sullivan 9
In Ghana, obtaining cadaveric heads for temporal bone drilling, head and neck dissection, and sinus simulation was not a barrier to laboratory experience. Pathology personnel at Komfo Anokye Teaching Hospital were instructed on harvest techniques for cadaveric heads for use in the newly constructed temporal bone dissection laboratory. Through allocations from the University of Michigan, otological microscopes, drills, drill bits, microsurgical instruments and irrigations systems were obtained for the laboratory and operating theatre.
Strategies for sustainability
We will now consider the establishment of metrics to objectify educational impact and outcomes. The third visit to Komfo Anokye Teaching Hospital in June 2016 saw continued teaching and progress in the temporal bone laboratory, operating theatre and clinic. The greatest progress was made in the clinic, as proper instruments were then available for two examination rooms. Specific otolaryngology nursing personnel were identified, who were responsible for the decontamination and availability of the instruments. Komfo Anokye Teaching Hospital otolaryngology physicians began to show proficiency in binocular otological examinations and diagnostic testing (i.e. audiograms, CTs), and in the effective use of otological micro-instruments. They also gave formal lectures to students and visiting University of Michigan faculty, covering relevant topics (e.g. facial nerve and temporal bone anatomy, and chronic otitis media management).
Going forward, another otology trip is planned in March 2017, whereupon multiple otologists from the USA will join the University of Michigan team. For a meaningful impact on education and skill development, it was deemed necessary that an ‘otology team’ (surgeon and nurse) visit Komfo Anokye Teaching Hospital at least every quarter. The impetus for this approach was to have more consistent and regular presence in-country, in order to provide timely and efficient guidance for skills acquisition.
To achieve this, multiple individuals from US institutions were recruited, and a common curriculum was established that encompassed the pillars of this educational and medical partnership. This curriculum includes: clinical and surgical skills acquisition through objectified metrics of performance, academic contributions to Komfo Anokye Teaching Hospital resident education (lectures and surgical simulation), and the development of research initiatives (publications and grants).
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• There are insufficient numbers of otolaryngologists practising in Ghana to serve its population
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• There is limited opportunity for Ghanaian physicians to acquire training for ENT specialties
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• The University of Michigan has partnered with Komfo Anokye Teaching Hospital in Kumasi, Ghana
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• This medical and educational partnership addresses skill acquisition, research and residency programme development needs
Metrics for clinical and surgical competency are being established by the partnership, in part modelled from those used in US residencies, in order to evaluate trainees’ performance in core otological cases, including canalplasty, tympanoplasty, and mastoidectomy with wall up and wall down techniques.
Conclusion
The ongoing need to train physicians in low- and middle-income countries continues to be a challenge. To meet those demands, sustainable and committed partnerships with programmes in high-resourced countries need to flourish. The emerging medical and educational partnership between the University of Michigan and the Komfo Anokye Teaching Hospital is one example of this dedicated partnership. The partnership aims to enhance the training of Ghanaian physicians in the subspecialties of otolaryngology and head and neck surgery, to enable them to adequately train future Ghanaian physicians.
Through collaborative research, hands-on clinical and surgical mentoring, surgical simulation, and implementation with and training on needed surgical equipment, low-income world physicians can gain the necessary skills to improve patient care and train the next generation of physicians.
Acknowledgements
We would like to acknowledge Dr Joseph Kolars (Senior Associate Dean for Education and Global Initiatives, Professor of Health Professions Education, Professor of Internal Medicine, and Professor of Learning Health Sciences Internal Medicine-Gastroenterology), for his generous donation to this initiative. We would also like to acknowledge the Department of Otolaryngology/Head and Neck Surgery at the University of Michigan Health System for the donation to this educational programme. Start-up funding for this project was provided by the School of Medicine and the Department of Otolaryngology/Head and Neck Surgery at the University of Michigan under the auspices of Dr Kolars and Dr Carol Bradford. More information about this medical/educational partnership can be found at: http://global.umich.edu/newsroom/helping-africa-hear/.
