Australia and New Zealand

Gastroenterology International

training association

www.anzgita.orgChris.hair@anzgita.org@Dr_chrishair+61 419 110 072

About ANZGITA

A compassionate Australian and New Zealand

gastroenterology not-for-profit acting for a just world

through the development of sustainable

gastroenterology services

www.anzgita.org

A public company limited by guaranteeACNC Registered and with DGR status

ANZGITA. - join us - its free to join

Vision

A world where all people can expect high quality

gastrointestinal healthcare throughout their lives.

Our Vision and Mission

Mission

Contribute to improving community health in

developing Asia-Pacific nations by enhancing

the standard of gastroenterology practice and

treatment of digestive diseases.

Skilled Gastroenterology

Professionals

The developing countries where we

have programs have more and better

skilled medical and nursing

professionals who provide continuing

gastroenterology services.

Our Goals

• Well Equipped and Operated

Partners’ Centres Assist our

partners to establish, equip,

manage and continually improve

their facilities.

Our Goals

• Establish new partnerships

and broaden existing ones,

consistent with our abilities

to support

Assess the possibilities and

proceed when we conclude

we can make an impactful and

sustainable contribution

Our Goals

• Teams are a combination of doctors and

nurses as they bring complementary

essential skills and knowledge necessary

for success

• Program work must be safe to patients,

trainers and trainees

• A spread of age groups amongst trainers is

encouraged, to ensure sustainability.

Our Principles

Programs are in-country skills and

knowledge transfer (teaching), not a

service delivery program

The design and implementation of

programs is responsive to articulated

needs of our in-country partners

Assistance is provided pro bono

Our Principles

• Fiji, Solomon Islands, Timor Leste,

Nepal

• 6 dedicated training programs in 4

countries annually

• Outreach support to Tonga, Samoa

• All nurses costs are covered.

Doctors fund their travel

SOLOMON ISLANDS 2012-2018

FIJI 2008-2018

TIMOR LESTE. 2016-2018

2012-2018

2018

Our Training Sites

• 91 clinicians have participated as

volunteers on our programs

– 60 doctors & 31 nurses

– 48 males & 43 females

– 31 have volunteered multiple times

• They have done 187 engagements

– 127 by a doctor and 60 by a nurse

• Over 300 weeks of training has been

delivered over 10 years

Our Trainers

• Partner with Hospital Nacional Guido

Valadares (HNGV) and country lead Dr

Chris Kiely, 1 local endoscopist, several

nurses

• 2 x one-week programs annually with

teams of 2 or 3 trainers

• Programs focus on endoscopy skills

training and general safe delivery of

endoscopy

Our Work – Timor-Leste 2016 to current

• Facilitation of Australian awards fellowship for

Dr Celia Santos to conduct endoscopy training

in Canberra 2018 (6 weeks)

• Installation of a semi-automatic equipment

reprocessing system in 2018

• Strong nursing staff (5) and 1 senior nurse lead

recently appointed

• Towards independent endoscopy by 2022

Our Work – Timor-Leste 2016 to current

• Only one Timorese endoscopist

– 2 registrars in training (3-4 yrs),

– 1 Timorese doctor will return from China

after receiving gastroenterology training

in 3 years,

– Nursing staffing is currently good (5 nurses)

– appointed a very capable senior nurse to

head the unit up.

Timor Leste challenges

• Natural disaster

– potential for flooding and fire

– Dili is fairly well shielded from major risks such as

earthquakes, cyclones and tsunamis.

• Economics

– very dependent on anzgita for servicing of scopes,

provision of accessories and bowel prep.

Timor Leste challenges

• 7 x two-week programs have been delivered

since 2014. Teams of around 5 doctors and

5 nurses visit.

• Partnered with Yangon General Hospital

(WGO supported National Endoscopy

Training Centre) 2015 - 2018.

• Programs are a mixture of endoscopy skills

training, lectures and clinical practice

including rounds

Our Work – Myanmar 2014 - 2018

• Four public hospitals in Yangon,

Mandalay and Nay Pyi Taw have

hosted programs

• Additional outreach work at

smaller hospitals with endoscopy

operations has been undertaken

during and outside of training

programs.

Our Work Myanmar 2014-2018

• Partner with National Referral Hospital

(NRH), Honiara and Pentax

• Typically, two one-week programs annually

with teams of 2 or 3 suits NRH

– Teaching medical, surgical and nursing

• Skill transfer and capacity development

• Maintain hygienic endoscopy

• Develop Endoscope maintenance

• Teaching endoscopy and GI healthcare

Our Work – Solomon Islands 2012

• A new NRH endoscopy unit

will open in 2018

• ANZGITA specified a semi-

automatic equipment

reprocessing system suitable

for the NRH environment

• Threats:

– Tsunami, floods, personal changes

– Health Economics, earthquakes

• he run

Our Work – Solomon Islands

• Regional Training Hub, Suva, Fiji

• Regional Training Hub Honiara, SI

• Pacific Outreach to Samoa and

Tonga, and beyond

– Collaborative partners Australian

Government Pacific Islands Program

(PIP), coordinated by RACS.

Our Work – Pacific activities

• Partnership with University of Hawaii

Telecommunications and Social Informatics

(Christina Higa)

– Strengthening use of digital technologies for tele-

education,

– mentoring

– immediate advice to colleagues working with

patients

• Partnership Kyushu University Hospital (Prof

Shuji Shimizu) to support live international

endoscopy teaching sessions from the world

to the Pacific

Our Work – Pacific activities

ANZGITA supports HepB Free and A/Prof Alice Lee

• HepB Free Treatment and vaccination

programs (timor leste, Nth Korea,

Kiribati, Solomon Islands)

• Support for HBV in Kiribati and Fiji

• IN discussions with Ministry of Health

in Fiji, Ed Gane (NZ)

• Creating a pacific HBV treatment

education platform

Excellent Industry Support

• WGO “model program”

• GESA ”excellence in charitable support”

• RACS/DFAT ”lead program in training and

mentorship”

• FNU – ‘the exemplar program for the

pacific’

ANZGITA Fiji program recognised and supported internationally

• Solomon Islands training

– 9-15 March. 1 nursing and 2 medical trainers.

– 18-23 June. 2 nursing and 2 medical trainers.

• CWMH, Suva Fiji , 22 July – 16 August.

– 4 nursing and 5 medical trainers.

(Two weeks durations for trainers)

• Timor Leste

– 5-10 May. 2 nursing and 2 medical trainers

– 6-11 October. 2 nursing and 1 medical

Our 2019 activities IN A FEW WORDS ANZGITA WAS…

• Rewarding

• Educational

• Appreciative

• Grateful

• Colonial

• Eye opening

• Third world

• Beautiful people

• Planned Outreach to Palau and Micronesia tba

• Samoa outreach program May 2019 (1 nursing, 2 medical)

• Tonga outreach program May 2019(1 nursing 1-2 medical )

• Pacific tele-education program (monthly) –welcome to all to attend and contribute

• ERCP in country support program – 2 days /month until end 2020

– 1 ERCPist, 1 ERCP nurse

Our 2019 activities

How did this start?

Pacific Ocean 2008 Minimal Endoscopy and no specialist gastroenterology

Samoa

Give a man a fish, feed him for a day.

Teach a man to fish, feed him for a lifetime

Provide specialist training within similar conditions to those expected at home

Samoa

Training for regional trainees who return home to practice

Support from ANZ GI specialist nurses, surgeons, physicians

Similar ’endoscopy’ environment to other PI nations

• Official launching of Suva WGO Training Centre - October 2008

• Skill transfer not service delivery

• Promoting training and advancing the knowledge of gastroenterology in the region.

• Local collaboration with Australian and New Zealand GI specialists and nurses to conduct its program through the Fiji School of Medicine.

2008 ‘collaborative training – 1st regional specialist training hub’

Samoa

CWMH WGO Suva philosophy - Endoscopy Training in Totality ‘ETiT’

Samoa

Management

Endoscopy unit

Consumable supply and store

Education

audit

Diagnostic and therapeutic Endoscopy

Gastroscopy Colonoscopy Capsule

UGIB, Stents and dilation

ERCP, polypectomy

Knowledge of GI disease

UGI disease

Small bowel

Lower GI disease

Hepatology and pancreas

Disinfection

Manual methods

cascades of disinfection

Unit policies

Chemical handling, Automated methods

ETiT

• 3 major components:

• Endoscopy skills and organisation

• Gastroenterology nursing training,

predominantly in the safe delivery of

endoscopy & unit management

• Medical training through lectures,

tutorials and clinical practice such as

ward rounds, and post grad treaching

Region specific, annual training month in Suva since 2008

Over a decade of regionally specific and delivered education in gastroenterology

• Regional PIC trainees

• 104 doctor attendances

• 96 nursing attendances

• Some multiple training visits

• 11 years of teaching of academic program in

GI medicine at Fiji National University ,

– post graduate education delivery by ANZGITA team

within gastroenterology

Outcomes

52 weeks over 11 years 45 medical volunteers 30 nursing volunteers Development of GI

services in the PI nations

Local Capacity

Hygienic endoscopy

Regular consumable supply

Endoscopes

Local Trainers

There has been an increase in important Pacific gastroenterology related research

Dr. Vikash Sharma: Upper Gastroenterological Bleeding in Adults Patients at the CWMH

Dr. Allen Alepio: The Prevalence of Hepatitis B at the National Referral Hospital, Honiara, Solomon Islands (1st January – 31st December) 2015

Dr. Simione Nadakuitavuki: To Estimate the Prevalence of Inflammatory Bowel Disease in Colonial War Memorial Hospital in the Fiji Islands (1st January to 31st December 2014 ( Retrospective Audit)

Dr. Reapi Natula: Epidemiology and Outcome of Hepatitis B in Blood Donors and Pregnant women at Colonial War Memorial Hospital, Suva, from 1st January- 31st December 2014

Dr. Sikiliti Poutasi: Evaluation of Colonoscopic Completion and standard at the CWMH Endoscopy Unit

Dr. Jerry Keena: Amoebic Abscess management at the CWMH

Beauty Tebaa: A Study of Pancreatobiliary Disease in Fiji: A Retrospective Audit.

• No request for out of country travel for endoscopy related cases

• Expansion of endoscopy services to Lautoka and Labasa

• 3 local gastroenterologists

• Multiple endoscopy trained competent nurses

• Expansion plans to ERCP by 2021

• Development of national endoscopy standards by 2020

Fiji now provides very competent diagnostic & therapeutic endoscopy services

The program has facilitated training general nurses and doctors many whom are now home

• Sprouting of endoscopy skills across the Pacific

• In this photo - samoa, kiribati, solomonislands, FSM, tonga, fiji, new zealand, australia, timor lest

ANZGITA FIJI 2017

Register your interest now for future programs at:

www.anzgita.org

There has been a decade of growth in endoscopy in the Pacific Island Nations

2010 2012 2014 2016

2018

2008

Give a man a fish, feed him for a day.

Teach a man to fish, feed him for a lifetime

• The fishing rods (endoscopes) are too expensive

• The fishing line is without hooks and sinkers (consumables)

• No-one can prepare the line when it breaks (biotech)

• There is no-one to fish, when the fisherman isn’t there (leave

cover)

• A big fish is hooked, but no-one knows how to take it off (instant

help)

• Only fish once in a while, don’t catch anything (retraining)

• Can fish well in Suva, but find fishing hard back home (outreach)

But sustainable fishing in the pacific is becoming harder than we first thought

What if ……

What now?

What now?

Pacific Island doctors face unique challenges to education and ongoing

support

• major geographic isolation and separation by

ocean,

• extremely high costs of travel and

telecommunications,

• small island populations,

• differing political and cultural environments,

• a critical shortage of both primary and

specialty care

Our regional trainees need follow-up support and mentorship

We can foster sustainable gastroenterology services

Outreach training programs and team

support

Provide remote education

opportunities

Developing networks that allow

instant assistance

Overcoming isolation – Pacific Island Outreach

Minimal disruption to Fiji Medical workforce

Outreach - Samoa 2017-18

• 2017, Invitation to Samoa

• Established endoscopy

service 2015

• 2 MMED grads and 2

MSurg Grads just returned

home

• Limited consumables

• Trained nurses (endoscopy)

Hands off endoscopy teaching

Endoscopy setup

Grand rounds

Endoscopy teaching

Samoa 2017-18

Providing support for young leaders (eg Dr Fololoto Levai, Samoa)Outreach support can come in various forms

FoloGuidelinesforalongenjoyableandvalueablecareer1. Prioritiseyourselfandfamilyfirst:withoutyouthereisnoDrFolo

2. Greatleadersneedfollowers:learntodelegateinterestingtaskstoothersthatyouwouldwanttodoyourself.

3. Aphysicianscareerisamarathon–breakyourcareerdownintoyearlystagesanddevelopyearlygoalorientedtasks

4. Getusedtowritingdownyourtaskseverymorningandprioritisethem,crossthemoffasyougotoclearyourmind

Folo’smindPriorityandconcept

DoIhavetodoit?

Doessamoabenefit?

DoIbenefit? Isitattainable?

1.PatientCare Yes Yes Yes(1) Yes,butIneedtoimprovethewayIdoit

2.mortalitymeeting

Yes Yes(1) Yes(3) Yes

3.ClinicalGuidelines

Yes Yes(2) Yes Yes,butIneedhelpfromothers

4Research No Yes(3) Yes(2) Ideasneedstudentsandreg’s

UnitMeeting No Maybe Yeshighly Ineedtomaketime

Teachingofothers

Registrarismypriority

Yes Yes TeachingimprovesasIallocatetime

Trainingmyself Yes Yes Absolutely

Howdoesthisallcometogether?Unitmeetings Mortalityreview

Mygoal#1ImprovedpatientCareGuidelines teaching CME researchInsharingmyworkloadtoothers,Iwillmaketimetoimprovepatientcare./Icantdoitalone.

Pacific GI

network

instant case discussion and advice

planned GI education

Pacific Grand Round

planned GI consultation

endoscopy conferencing

A Pacific GI telemed network that delivers multiple services to reduce isolation:

Instant Messaging app

Multi-user video conferencingInternational collaboration with partners

Multi-user Video-teleconferencing (ZOOM) connecting multiple nations previously isolated by distance

Collaboration with UniHawaii, support from Japan

Conferencing with Northern Pacific and South Pacific colleagues

Multi-user Pacific Island teleconferencing has

created an enormous learning group

• May 2018 - How do I biopsy a suspected CRC – Assoc Prof Chris Hair

• June 2018 - GIST – diagnosis and management options – Assoc Prof Chris Hair

• July 2018 - Hepatitis B program in pacific – Assoc Prof Alice Lee

• August 2018 - Polypectomy: how to perform cold polypectomy - AssocProf Chris Hair

• 28th Sept 2018 - Hepatic encephalopathy – how to optimise manage: precipitants and manage Assoc Prof Chris Hair

• 26th October – sustainable endoscopy – Conference presentation PaluaMedical Association - Assoc Prof Chris Hair

• 2 Nov 2018 – Introduction to colorectal cancer – Prof Finlay Macrae

2018 topics and cases

We can use instant messanging apps to reduce professional

isolation by providing instant consultation and mentorship

from within and afar

PhysicianNeurologist

Endocrinologist

Cardiologist

Surgeon

Infectious Disease

Intensivist

Gastro

Instant messaging apps can create the instant grand round and instant advice line

46 users: Connecting physicians and surgeons in the Pacific with international specialists (USA, NZ, Aus, Bangladesh)

Cases posted for discussion in Viber, instantly received and viewed – endoscopy, imaging, pathology

“Does anyone know how to manage pain after suspected ciguatera fish poisoning”

• Locum support

– Relief for pacific island doctors to attend conferences (and holidays)

• Develop telemed in clinical area (hospital)

– Not available in Suva, vanuatu or Tonga, Kiribati

• Funding support

– expensive programs and technology– MFAT (NGO funding), DFAT– Industry (internationald and local in country)

• Strengthen collaborations

– Japan telemed– NZ and Otago and the Pacific – Harnass US support for northern nations

Further advocacy

• Anzgita offer Administrative experience in the

Pacific and beyond

• Professional guidance to support your

engagement in the region

• Warm local reception and immediate

establishment of personal relationships with

in country partners

• Ready appetite for learning from trainees

• Great opportunity to experience clinical medicine

outside the privileged environments in which we

work

• Without exception, our trainees return full

admiration for the expertise of our in country

partners and learn so much themselves

ANZGITA: a fabulous opportunity to share your expertise

Samoa

Thank You for Your Interest

Join ANZGITA: It’s rewarding!

www.anzgita.org