‘WE WATCH TEACHERS GROW’ LEARNING PARTNERSHIP WITH ADDIS ABABA UNIVERSITY YIELDS ETHIOPIAN LEADERS IN EMERGENCY MEDICINE

By Elaine Smith

While working in an Addis Ababa emergency room, Dr. Sarah Whynot recalls being shocked to discover that there was a shortage of paper for the ECG machine.

Dr. Whynot was in Ethiopia’s capital city for an elective during her emergency medicine fellowship with the University of Toronto’s Department of Family and Community Medicine (DFCM).

“We learned to work around issues like these,” says Dr. Whynot. “Working as part of the Toronto Addis Ababa Academic Collaboration in Emergency Medicine (TAAAC-EM) was eye-opening. I got so much out of it, but first and foremost was insight into what emergency medicine looks like and how things work in a resource-limited setting.”

TAAAC-EM began in 2010, as one of the many offshoots of an initial collaboration with Addis Ababa University (AAU) begun in 2003 under the leadership of Dr. Clare Pain, an associate professor of psychiatry at U of T, and psychiatrists at AAU. Drs. Megan Landes, head of DFCM’s Division of Emergency Medicine, and James Maskalyk, a TAAAC-EM strategic director, were the inaugural co-directors of the program.

“Addis Ababa University approached U of T with several priority areas for expansion and one of the first was emergency medicine,” says Dr. Landes. “James and I worked really closely with Clare to ensure we were implementing a partnership built on an ethical, thoughtful way of engaging across the North-South divide. We’d seen partnerships elsewhere, some done well and some done poorly, and we wanted to make our partnership a model of how you can engage in a truly bilateral fashion.”

At the time, Ethiopia had no training available for an emergency medicine specialty, and TAAAC-EM was created to meet that need by assisting AAU in building its own emergency medicine residency program. Faculty from the Division of Emergency Medicine at the DFCM and Department of Medicine (DOM) travelled to Addis Ababa three times a year, for a month at a time, to hold training sessions for residents. Teaching trips covered a longitudinal, three-year curriculum through didactic teaching sessions, practical seminars, point-of-care ultrasound, simulation and bedside clinical supervision. One or two emergency residents from DFCM or DOM with an interest in global health joined the trips as one of their residency electives, working in the emergency room alongside AAU residents and/or assisting with teaching.

The original goal of TAAAC-EM was to assist in the graduation of a self-sustaining critical mass of emergency medicine leaders at AAU who would continue to train future generations of Ethiopians, and spread emergency medicine expertise throughout the country and East Africa.

“For the first three-to-five years, U of T faculty did the bulk of the training,” says Dr. Eileen Cheung, a family and emergency medicine physician who travelled to Addis Ababa in 2014 as a resident and has since been there twice as a faculty member. She is now the program’s director of education and programming, working closely with Dr. Jennifer Bryan, TAAAC-EM’s director of operations.

“Now, the graduates of the residency program have assumed larger teaching roles.

“We had planned to make that transition and our inability to travel during the COVID-19 pandemic sped some things up and slowed some things down. Our Ethiopian colleagues now do the didactic teaching, but we haven’t handed over all the teaching. On our trips now, we run workshops and simulations and the faculty want continuing professional development, which would be the logical next step,” says Dr. Cheung.

Dr. Landes adds, “TAAAC-EM is a true expression of what we do as educators; we watch teachers grow.”

The collaboration began with a class of just six Ethiopian physicians. The current class of TAAAC-EM residents has 25 physicians. In addition, graduates of the residency program have started at least three similar programs in other Ethiopian hospitals, says Dr. Cheung. To date, there are 82 graduates of the emergency medicine residency practising in 13 hospitals across Ethiopia and there are 42 others in training. There are also graduates employed in high-level positions in Ethiopia’s Ministry of Health.

“There is a more than 95 per cent retention rate of these physicians in Ethiopia’s public medicine system,” Dr. Cheung notes. “That’s unprecedented. It speaks volumes.

“The key to building capacity at this level is providing in-country training to avoid a brain drain. I am continually blown away by the capacity of Ethiopian physicians. It’s interesting how far things have come, since Ethiopia didn’t have an emergency medicine specialty at all before TAAAC-EM.”

She anticipates the TAAAC-EM partnership will continue to change as the needs at AAU change.

“TAAAC-EM is a model that can be replicated elsewhere. Queen’s University is now with Haramaya University and the University of Calgary is involved in Uganda. Ethiopians are now seen as emergency medicine leaders in East Africa. The first two South Sudanese TAAAC-EM residents have just graduated in Ethiopia with the idea of returning home to have an impact. AAU can now be their own experts in helping other African countries build emergency care capacity and U of T could facilitate and mentor other universities in becoming engaged.”

Notes Dr. Landes, “There is still a role for the partnership, but it will change over time. A lot of us feel we have created deep friendships as a result.”

Dr. Cheung is very proud of the program’s success.

“It is rewarding to see the growth in emergency medicine in Ethiopia and how it has evolved differently than it has in

Canada; the pathology and structure are so different,” she says. “Meanwhile, we are also building a cadre of Canadian instructors who understand global health engagement in a longitudinal model. I love the model and medical education in general.”

Dr. Landes believes the TAAAC-EM program emphasizes humility in global health.

“There are often a lot of colonial overtones to global engagement, but so much bi-directional learning has happened through TAAAC-EM,” Dr. Landes says. “Our Canadian residents and physicians learn to practise in a different context, understand complex disease management, learn to work in a low-resource setting and to teach across different cultures. It makes us better physicians and we bring these lessons back to our own emergency departments.”

Seven DFCM residents have participated to date, along with 25 DFCM faculty members, and Dr. Whynot confirms that learning during a TAAAC-EM residency goes both ways.

“I was both a learner and a teacher,” says Dr. Whynot. “It is hard to be engaged in global health work without understanding the day-to-day issues. I learned a lot clinically from the Ethiopian physicians because they see diseases we don’t see here and I improved my own skills as a teacher in teaching simulations and getting feedback.

“It was a helpful growth experience and increased my desire to be part of global health initiatives throughout my own career.