The Swiss–Myanmar Twinning Project for Neurosurgery



The Swiss–Myanmar Twinning Project for Neurosurgery

Philippe Schucht, MD1,2,4; Kyawzwa Aung, MD2; Dominique Kuhlen, MD3, Myat Thu, MD4
1Department of Neurosurgery, Inselspital, Bern University Hospital, and University of Bern, Switzerland
2Department of Neurosurgery, Medical University, Mandalay, Myanmar
3 Department of Neurosurgery, Hospitale Cantonale, Lugano, Switzerland
4 Department of Neurosurgery, Medical University 1, Yangon, Myanmar

Challenges of neurosurgery in Myanmar

Myanmar, a Southeast Asian country, which is home to more than 50 million people from over 100 ethnic groups, saw its surgical capacity curtailed during its years of political isolation. With as few as 10 surgeons available to provide basic neurosurgical care – only 4 of whom had received formal neurosurgical training abroad – common neurological disorders such as hydrocephalus, meningoceles, and traumatic brain injuries often had to be left un- or undertreated at the beginning of the 21st century. At that time, the country had 4 centers for neurosurgical care: (i) The Medical University 1 of Yangon, responsible for the city of Yangon; (ii) the Medical University 2 of Yangon, responsible for Southern Myanmar; and (iii) the Medical University of Mandalay, responsible for Northern Myanmar, as well as a subsidiary service in the new capital Naypyitaw.

Swiss–Myanmar Twinning Project

With the explicit aim of building neurosurgical capacity in Myanmar, we founded the Swiss Neurosur-geons International (SNI) in 2011. The twinning program officially started in 2013 with the primary goal of creating a workforce of 60 fully trained neurosurgeons within a 10-year period. We focused our efforts primarily on education, as we believed that only a stable and growing workforce within the country could achieve sustainable improvements in neurosurgical care. Additional activities, such as educational surgical visits to the country and assistance in the acquisition of neurosurgical instruments, would help to build capacity. The existing neurosurgeons in Myanmar would act as crystallization points, around whom new neurosurgeons would be educated, in both Myanmar and Switzerland. All 4 neurosurgical centers in Myanmar as well as the University Hospital of Bern and the Cantonal Hospital of Lugano in Switzerland participated in our twinning program. Funding was to come from private donors and project members. We neither sought, nor obtained, financial help from state institutions.

Activities in Myanmar

Project members made 14 visits to Myanmar from 2012 to 2020, with the aim of introducing and discussing modern neurosurgical tools and techniques. Together with the local neurosurgeons we chose a new topic every year: Microscope-based surgery (2014), spinal instrumentation (2015), and neuro-navigation (2016), trans-sphenoid pituitary surgery and carotid endarterectomy as well as intra-operative mapping and monitoring (2018). A cadaver workshop for craniotomies, based on a long-standing European course, was organized and conducted for 30 residents of the two partner universities in Myanmar in 2019. Most visits included a series of surgeries on frontal meningoceles, a frequently occurring and potentially lethal condition in Myanmar.1
In 2011, most of the instruments available to Myanmar’s neurosurgeons were decades old. SNI focused on advice, coordination, and training in operation of the new instruments, without interfering with the government’s task of financing them.2 To that extent, SNI was involved in the acquisition of the first intracranial pressure monitoring devices in Myanmar in 2012, neuro-navigation devices and craniotomy machines in 2013 and 2014, and an electrophysiology device for intra-operative mapping and monitoring in 2018. The introduction of each instrument was accompanied by on-site user-training through lectures, hands-on workshops, and conjoint operation of the equipment, which is crucial for assuring its sustainable use (Figure 1).3

Activities in Switzerland

The core of the activities of SNI in Switzerland is a fellowship program for neurosurgical personnel from Myanmar. Its main aim is to familiarize the fellows with contemporary strategies and technologies in neurosurgical care. The board of SNI and the chairpersons of the Myanmar twinning partner departments jointly select the candidates, who need to be proficient in the English language and have had at least 2 years of neurosurgical education in Myanmar. SNI covers all costs of the fellowship, including travel, accommodation, and an allowance for daily expenses. By the end of 2020, 32 medical personnel from the Medical University 1 Yangon as well as from the Medical University of Mandalay had been accepted for a medical fellowship in Switzerland as part of the SNI program. Fellowships were open to various professions within the area of neurosurgery: Participants have included not only 16 neurosurgeons but also 6 neuro-anesthesiologists, 6 operating theater (OT) nurses and 1 intensive care unit nurse. In addition, the introduction of intraoperative neurophysiological monitoring-based surgery included 6 months training for a Myanmar neurologist (and 3 months for his two technical assistants) in Switzerland, with continuous support ever since.

Survey and lessons learned

In February 2019 we conducted an anonymous, online survey of all former Myanmar fellows with the aim of further improving the twinning program.2 According to the survey, small group discussions, the interdisciplinary work environment, the morning meetings, the effectiveness and rapid initiation of treatment, the standardized routines in the OT, as well as the opportunity to observe the high-quality medical care were the most positive aspects of their time in Switzerland. When asked what they did differently after returning home, most former fellows reported an increased interest in interdisciplinary case discussions, an increase in surgical carefulness, and an overall increase in therapeutic open-mindedness. All the neurosurgical fellows assigned positive scores to the hands-on courses they had been able to attend during the fellowship; these are run by the neurosurgical residents of Switzerland.4 We therefore continue to include Myanmar fellows in all appropriate educational courses during their stay in Switzerland.

When asked what they liked least the fellows mentioned the persistent language barrier, the significant cultural differences, and the cold weather in Switzerland. While the weather might – unfortunately – improve over time, at present we invite fellows to visit from spring to autumn. In both Swiss twinning sites, all teaching is done in English if there are foreign guests present. To help make the cultural differences easier to cope with, we now invite all fellows in pairs instead of one by one. The fellows also reported a shift towards complex surgery, more effective treatment plans, and an overall increase in positive attitude toward colleagues and patients. Ultimately, 63% of the fellows would have liked the fellowship to be longer. Up to now, surgeons and anesthesiologists have been given 3-month fellowships and nurses have been invited for 1 month. In the wake of the survey and based on the positive effect of the program on daily neurosurgical care in Myanmar, we agreed to extend the fellowship to two 3-month stays in Switzerland.

The rise of neurosurgery in Myanmar

Over the past 8 years, 10 new surgeons have completed their neurosurgical education (Dr.Med.Sc), hence increasing the number of active neurosurgeons in Myanmar to 20. An additional 16 residents have obtained their M.Med.Sc in neurosurgery, and another 34 have recently entered neurosurgical education. Intracranial pressure monitoring, neurosurgical spine surgery, transsphenoidal surgery, and intra-operative electrophysiology for vascular and tumor cases have become established procedures. Most importantly, because this program has not been foreign-imposed, but rather is the result of a collaboration among peers, there is a strong sense of ownership by the local medical community in Myanmar of the neurosurgical educational program, which is at the core of its success.5, 6 Thanks are due to many colleagues that today our original goal of at least 60 certified neurosurgeons by 2023 seems within reach. Governmental bodies have both simplified and intensified neurosurgical education since 2013. From 2016 onwards a 3-year M.Med.Sc in neurosurgery is followed by a 3-year doctorate program (Dr.Med.Sc), replacing the earlier and somewhat unpopular 3 -year rotation in general surgery. The opportunity to learn from surgeons experienced in state-of-the-art neurosurgery is crucial for young residents. In Myanmar, a number of neurosurgeons from Japan, the USA, India, and Europe have participated in surgical training camps, organized not only by the SNI, but also by a US-led initiative based at the Medical University 2 of Yangon, led by Jack Rock of the Henry Ford Health System in Detroit.7 Many young residents from the Medical University 1 of Yangon and the Medical University of Mandalay have been invited for educational visits by Prof. Yoko Kato to the Fujita University in Nagoya, Japan, and by Prof. Ono, University of Okayama, Japan, since 2016.

Looking forward

The growth of the neurosurgical community in Myanmar leads to new challenges. The surge in the number of residents will require additional training positions, and possibly new twinning partners. The activities of the various foreign programs should be coordinated to avoid duplication, possibly under the umbrella of the Foundation for International Education in Neurological Surgery (FIENS), which strongly supports the strategy of building neurosurgical capacity through education.8 Lastly, joint efforts in the interactions with governmental bodies are needed to ensure that new neurosurgeons receive the resources needed to make the most of their newly learned skills to the benefit of the public.

Abbreviations

ICP, intracranial pressure; OT, operating theater; SNI, Swiss Neurosurgeons International; IOM, intra-operative electrophysiological monitoring.

Competing interests

The authors report that they received free board and lodgings from SNI during surgical and educational travel to Myanmar.

References

  1. Heidekrueger PI, Thu M, Mühlbauer W, Holm-Mühlbauer C, Schucht P, Anderl H, et al. Safe and sustainable: The extracranial approach toward frontoethmoidal meningoencephalocele repair. Journal of Neurosurgery: Pediatrics. 2017:334-340
  2. Schucht P, Zubak I, Kuhlen D, Abu-Isa J, Murek M, Raabe A, et al. Assisted education for specialized medicine: A sustainable development plan for neurosurgery in myanmar. World Neurosurg. 2019;130:e854-e861
  3. Kahamba JF, Assey AB, Dempsey RJ, Qureshi MM, Hartl R. The second african federation of neurological surgeons course in the east, central, and southern africa region held in dar es salaam, tanzania, january 2011. World Neurosurg. 2013;80:255-259
  4. Murek M, Jilch A, El-Rahal A, Zubak I, Fung C, Abu-Isa J, et al. It’s been a decade. Clinical and Translational Neuroscience. 2018;2:2514183X1878246
  5. Park KB, Johnson WD, Dempsey RJ. Global neurosurgery: The unmet need. World Neurosurg. 2016;88:32-35
  6. Dempsey RJ. Neurosurgery in the developing world: Specialty service and global health. World Neurosurg. 2018;112:325-327
  7. Rock J, Glick R, Germano IM, Dempsey R, Zervos J, Prentiss T, et al. The first neurosurgery boot camp in southeast asia: Evaluating impact on knowledge and regional collaboration in yangon, myanmar. World Neurosurgery. 2018;113:e239-e246
  8. Dempsey RN, P. Foundation for international education in neurological surgery (fiens) global health and neurosurgical volunteerism Neurosurgery. 2013;73:1070-1071

Figure 1: Swiss-Myanmar Twinning Program

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