Identification of essential topics and procedural skills for inclusion in a contextualised undergraduate anaesthesia and critical care clerkship in Rwanda: results of a modified Delphi process

Abstract

Introduction

Low anaesthesia workforce numbers contribute to shortfalls in access to surgical care globally. Investment in contextualised education and training can help address this issue by inspiring graduates to enter into training and imparting important knowledge and skills to non-specialists. We undertook a modified Delphi study to identify physician anaesthesiologist consensus on themes, topics, and skills for inclusion in undergraduate anaesthesia and critical care (ACC) medical school curricula in sub-Saharan Africa (SSA) and Rwanda.

Methods

A list of ACC topics/skills was compiled through grey literature review, guiding survey development for a 3-round Delphi process. The first two rounds solicited responses from physician anaesthesiologists across SSA. The final round included only Rwandan physician anaesthesiologists. Respondents rated topics/skills on a 4-point Likert scale from 1 (“exclude from the curriculum”) through 4 (“essential for inclusion”). Item-level Content Validity Index (I-CVI, the proportion of respondents rating a topic/skill as 3 or 4) was used for stratification. A first-round I-CVI threshold of 80% and 70% for subsequent rounds was used to define consensus for inclusion. Excluded topics/skills were considered for re-inclusion in subsequent rounds; 50% agreement was set as threshold for re-inclusion. The first round also sought consensus regarding aims, objectives, and delivery methodology.

Results

A total of 147 topics/skills across 12 domains were identified for initial survey inclusion.

Fifty-one respondents from 12 countries completed round one. Ninety-six (65.3%) topics/skills met consensus threshold. One additional skill (“pain assessment”) was incorporated into round two following suggestions from respondents. The clerkship outcome ranked as most important and achievable was to ‘inspire students to undertake anaesthesia specialty training’ (n = 25, 49.0% and n = 26, 51.0% respectively). Thirty-six respondents from 12 countries completed round two. Eighty (82.5%) topics/skills met consensus threshold. Seventeen Rwandan specialists completed round three. Seventy-eight (97.5%) topics/skills met consensus threshold. From 67 previously excluded topics/skills, 14 (20.9%) met re-inclusion threshold.

Discussion and conclusion

A modified Delphi process identified 92 essential topics/skills for inclusion in a Rwandan undergraduate ACC clerkship. Experts prioritised ‘inspiring students’ over ‘achieving clinical competence’ for undergraduates. A similar Delphi approach may be useful for educational content development in other settings across the African continent and for other specialties.

Trial registration

Not applicable (study described is not a clinical trial).

UGHE IRB protocol number: 194.

Introduction

Over 70% of the world’s population lack access to safe, timely, and affordable surgical care [1]. Access to safe anaesthesia care is an integral component of ensuring access to safe surgery. Following a 2017 global anaesthesia workforce survey, the World Federation of Societies of Anaesthesiologists (WFSA) recommended a minimum physician anaesthesia provider (PAP) target of 5 per 100 000 of the population [2]. This target was deemed necessary in order to ensure both effective leadership and delivery of anaesthesia care for emergency and essential surgery. At the time of publication, the WHO African region had a PAP density of just 0.41 per 100,000 and no country met the 5 per 100,000 PAP threshold [2]; in contrast the region had a non-physician anaesthesia provider (NPAPs) density of 1.17 per 100,000. The WFSA acknowledged the need for a marked increase in the training of both PAPs and NPAPs in order to be able to meet the target of providing safe anaesthesia care for all by 2030. Members of the WFSA and the International Federation of Nurse Anesthetists (IFNA) published an updated survey of the global anaesthesia workforce survey in early 2024 which showed that, despite a 10.4 increase in total provider density per 100,00 worldwide, there has been a 0.1 decrease in PAP density (and only a marginal increase in NPAP density to 1.4 per 100,000) for the African region [3]. Only Mauritius reported a PAP density of greater than 5 per 100,00 with an additional five countries having a density greater than 1 per 100,000 (South Africa, Tanzania, Namibia, Gabon, and Algeria). The authors reiterated the need for expanded training volumes globally, particularly in the setting of population growth, aging, and emigration.

Ensuring high quality exposure to anaesthesia and critical care (ACC) during undergraduate medical school education is essential in order to comprehensively bridge this training gap whilst simultaneously benefiting medical students through exposure to vital knowledge and skills transferrable to other areas of clinical medicine such as IV access, recognition and resuscitation of the acutely unwell patients, and management of airway obstruction. The efficacy of such efforts will be enhanced by appropriate consideration of local burden of disease, investigation and treatment scope and capacity, and the expectations of graduates resulting from differing national models of healthcare delivery [4]. For example, given the dramatic shortfall in Surgical, Anaesthetic, and Obstetrics (SAO) provider numbers across the region, medical graduates from SSA are expected to display a certain level of procedural competence and confidence related to the provision of surgery, anaesthesia, and perioperative care. With far greater specialist provider numbers, graduating medical students from HICs such as the US anecdotally benefit from closer levels of supervised practice and are granted less clinical responsibility. Perhaps as a result, they gain relatively little exposure to performing vital procedural skills [5, 6]. Whilst suitable for regions with greater specialist provider numbers a curriculum which gives students limited practical experience of performing procedural skills would be insufficient for the SSA context. As well as a greater emphasis on procedural competency, an ACC clerkship in SSA might also seek to include content reflective of the regional burden of disease (for example covering the surgical sequelae of infectious diseases such as tuberculosis and typhoid and their anaesthetic management), and also provide students with a strong foundation in the knowledge required to effectively recognize, resuscitate, and refer patients with critical illness, given the relative lack of senior clinician support, particularly in more rural areas. Finally, prioritisation of the inspiration of graduating students to enter into post-graduate ACC training would also be valuable given the shortfall in SAO provider density for the region. Despite these differing clerkship requirements, undergraduate medical school programs in variable resource settings often adopt HIC curricula with minimal adaptation or consideration of context in their delivery.

The University of Global Health Equity (UGHE), based in rural northern Rwanda is an innovative new medical sciences institution committed to providing locally-driven, contextually relevant medical education for students from across SSA [7]. Housed within UGHE’s Center for Equity in Global Surgery (CEGS) [8], our curriculum development technical working group was formed to develop and deliver the inaugural Bachelor of Medicine, Bachelor of Surgery (MBBS) ACC senior clinical clerkship for students at the UGHE School of Medicine. Below we describe a modified Delphi process designed and overseen by the working group with the following specific aims:

• 1. To identify expert specialist physician ACC provider consensus on relevant themes, topics, and procedural skills for use in undergraduate medical education in SSA and Rwanda.

• 2. To determine consensus on appropriate pedagogical approach for undergraduate clerkship design and delivery in SSA and Rwanda.

Methods

Technical working group

Tasked with building a contextualised undergraduate curriculum for ACC in Rwanda, an internationally representative, locally-led curriculum development technical working group was formed. This group was composed of medical educators, specialist physician ACC providers and trainees, and full time researchers from more than 10 institutions and 4 continents. The group included representation from both Rwanda and SSA more broadly, as well as North America, Europe, and the Caribbean Islands.

Delphi methodology and modification

Balancing the need for greater consensus with time restraints in building an undergraduate curriculum, the working group opted to undertake a three-round modified Delphi process to establish consensus regarding topics and procedural skills to be included in the curriculum and how best to deliver education and training on these topics and procedural skills. This is in line with standard methodology for Delphi study which suggests that two to four rounds is usually sufficient for establishing consensus [9]. We defined an expert as any specialist physician anaesthesia provider practising clinically in SSA. This study differed from the standard Delphi approach [10] in two ways: firstly a list of topics and procedural skills was formulated through grey literature review of existing undergraduate anaesthesia curricula, prior to seeking expert consensus through surveying; and secondly only Rwandan experts were sought to participate in the third and final round of the Delphi process despite some having not participated in preceding rounds (of note the additional Rwanda-based experts participating in round 3 had not specifically been excluded from prior rounds). The first modification was undertaken to both streamline the consensus seeking exercise as well as to ensure a comprehensive initial list of topics and skills were generated. The second modification was undertaken with the intention of ensuring the final topic and procedural skill list was contextualised to the Rwandan setting. A similar approach, with regard to both modifications, has been applied to modified Delphi studies in surgical education [11]. Data for all three rounds was collected and managed using a REDCap electronic data capture tool.

Grey literature review

The working group identified and collated a topic and procedural skill list from existing available undergraduate syllabuses from the SSA region. These were obtained through professional connections and networks. This list was then supplemented with additional recommendations from the core working group and pertinent content from peer-reviewed literature retrieved from the PubMed database through use of the following search terms: ((Anaesthesia[Title] OR anesthesia[Title]) AND (Curriculum[Title] OR education[Title])) AND (medical student[Title] OR undergraduate[Title]). All topics identified from the grey literature review were included in a final list of topics and procedural skills which was then used to develop a new (not previously published) survey (appendix 1). Beyond collating similar or synonymous topics and skills, no content analysis or modification to the list of identified topics and skills was undertaken at this point.

Round one

Information was collected on respondent demographics and expert opinion of what constitutes the ideal aims and objectives, mode of delivery, duration, breakdown (proportion of time spent in anaesthesia vs critical care), and topic and procedural skill competencies for an undergraduate ACC clerkship in SSA. Self-identified demographic information collected included country or countries of training, current country of practice, current domain of practice (University teaching hospital, public referral hospital, public district general hospital, private, or other), subspecialty training experience, and years of practice as a specialist.

Respondents next ranked proposed expected curriculum outcomes both in terms of ‘importance’ and ‘achievability’, and modes of curriculum delivery in terms of their perceptions of ‘effectiveness’. Proposed outcomes and modes of delivery are provided in appendix 2. Respondents were also asked to propose the ideal duration of an undergraduate clerkship (minimum of 2 weeks and maximum of 8 weeks) and the ideal duration for anaesthesia versus critical care.

The expert respondents were subsequently given the list of topics and procedural skills collated from the grey literature review and asked to rate each one on a 4-point Likert scale (1—‘less important’, 2—‘somewhat important’, 3 – ‘very important’, 4 – ‘essential’; Section V, Appendix 1). Respondents were also given the opportunity to recommend any topics or procedural skills they felt should be included in a curriculum that hadn’t already been listed. The Item-level Content Validity Index (I-CVI) [12] defined for the purposes of our study as the proportion of respondents rating a topic or procedural skill as either ‘very important’ [3] or ‘essential’ [4], was calculated.

What constitutes consensus is not well defined in Delphi study methodology with recommendations ranging from as low as 51% agreement through to as high as 90%. For round one, we defined consensus as an I-CVI of 80% [13]. The survey was distributed to specialist anaesthesia providers across SSA using a hub-and-spoke model. Using existing professional networks, regional leads with access to potential respondent contact information were identified. The REDCap survey link was then distributed via both email and WhatsApp over a 12-week period from June 21st to September 9th 2022.

Round two

The second round of the survey mirrored the approach taken in the first round. Demographic information was again collected and respondents were asked to rank mode of delivery in terms of effectiveness given a 4-week clerkship duration. Respondents were next asked to rate all topics and procedural skills that had met the 80% I-CVI threshold from the preceding round as well as any additional topics recommended by experts in the first round. A 4-point Likert scale was used with descriptive parameters adjusted as follows: 1 – ‘ exclude from the curriculum’, 2—‘important’, 3 – ‘very important’, 4 – ‘essential’. This adjustment was made with the aim of encouraging greater discrimination. The experts were also given a list of excluded topics and procedural skills from the prior round and asked to highlight which, if any, they felt should be included in an undergraduate curriculum.

The survey was distributed via email, only to those who had completed the first round. Responses were collected over a 6-week period from September 14th to October 26th 2022. We defined consensus for this round as an I-CVI of 70% [13]. We also used a threshold of 50% respondent agreement for re-inclusion of previously excluded topics and procedural skills.

Round three

For the final round of the Delphi survey, respondents were limited to those currently practising clinically within Rwanda. The survey was distributed via email and WhatsApp to Rwandan anaesthesiologists over a 6-week period from May 2nd to June 12th 2023. As well as providing demographic information, respondents were asked to rate all topics and procedural skills that had met the 70% I-CVI threshold from round two and again were given the list of excluded topics and procedural skills for identification of those they felt should be re-included. Finally, there was the opportunity for respondents to provide further recommendations and feedback.

For each of the three rounds, intraclass correlation coefficients (ICC) were calculated using Microsoft Excel (version 16.92).

Ethics

Ethical clearance for the study was sought through submission to the UGHE Institutional Review Board (IRB). After full review it was deemed IRB exempt (reference #: 194). All respondents were consented prior to undertaking the survey. A website link to a consent information form was included on the homepage of each round of the survey. Participants were unable to proceed with the survey until they had clicked on this link to provide documented informed consent. Continued participation in the survey from this point onward was taken as informed consent for publication of non-identifiable information and responses.

Results

From the grey literature review a total of 147 topics or procedural skills were identified and organised into 12 domains for inclusion in the first round of the Delphi survey. This list is available in appendix 3 and ranges from basic anatomy and physiology to clinical topics and procedural skills.

Round one

Fifty-one respondents from twelve different countries completed the first round survey (Fig. 1). The majority of these respondents had completed training in SSA although a small minority (n = 3) completed some or all of their training outside of the region, either in the UK or The Netherlands. Most respondents were currently working in a University teaching hospital (n = 36, 70.6%), with a further 15.7% (n = 8) working in a public referral hospital. Only 9.8% (n = 5) were working in a public district general hospital. There was a range of experience-levels of respondents with 19.6% (n = 10) in their first year of practice as a specialist, but a third of respondents (n = 17) having worked as a specialist for 10 or more years.

Fig. 1

Respondent country of practice (round one)

The outcome ranked most commonly as both most important and most achievable was to ‘inspire medical students to undertake specialty training in anaesthesia and/or critical care on graduation’ (n = 25, 49.0% and n = 26, 51.0% respectively). Thirty-seven respondents (72.5%) felt ‘equipping medical students with the knowledge and skills required to independently perform anaesthesia and critical care in rural settings’ was least important and the same proportion also felt it was least achievable (Fig. 2). The majority of respondents (n = 26, 59.1%) felt 8 weeks was an ideal duration for an ACC undergraduate clerkship whilst a quarter (n = 11) felt 4 weeks was sufficient. There was no significant difference in recommended clerkship length based on the respondents’ prioritised goals (Fisher’s exact, p = 0.51).

Fig. 2

Respondent rankings for proposed clerkship outcomes in terms of importance and achievability (round one)

Most respondents ranked didactic teaching as the least effective (n = 35, 68.2%). Simulation was thought to be the most effective (n = 20, 39.2%), although a significant minority also felt both interactive sessions and clinical placements were most effective (n = 15, 29.4% and n = 12, 23.5% respectively) (Fig. 3). Thirty-one respondents (60.8%) felt that 8 weeks constituted the ideal clerkship duration, whilst just 13 (25.5%) proposed 4 weeks to be most appropriate. No respondents felt that a clerkship should be shorter than 4 weeks’ duration (Fig. 4).

Fig. 3

Respondent rankings for proposed teaching modalities in terms of effectiveness (round one)

Fig. 4

Respondent perceived ideal duration for an undergraduate ACC clerkship and proportion of time spent in anaesthesia compared to critical care (round one)

Of 147 topics and procedural skills, 96 (65.3%) met the 80% I-CVI consensus threshold (Table 1, ICC = 0.212). One additional unique procedural skill was recommended by respondents (‘assessment of pain’). This additional procedural skill was included in the second round of the survey to give a total number of 97 topics and procedural skills for inclusion in the second round survey.

Table 1 round one and two topic and procedural skill Delphi ranking based on I-CVI. Blue = anaesthesia topic, Purple = critical care topic, Yellow = procedural skill, Green = meets consensus threshold, Orange = does not meet consensus threshold

Round two

Thirty-six out of fifty-one experts from 12 different countries across SSA completed the second round survey resulting in a 70.6% response rate. The majority (n = 35, 97.2%) had completed their speciality training in SSA. Five respondents (13.9%) were in their first year of specialty practice, with thirteen (36.1%) having practiced for 10 or more years.

In contrast to the first round, interactive sessions were most commonly ranked as the most effective modality (n = 16, 44.4% of respondents). Again, both simulation and clinical placements were identified as effective teaching modalities by a notable proportion of respondents, with 12 (33.3%) and 7 (19.4%) respondents ranking these modalities as most effective respectively. Of the 97 topics and procedural skills that progressed from the first round, 80 (82.5%) met the revised 70% I-CVI consensus threshold (Table 1, ICC = 0.292). None of the excluded topics from the first round met the threshold for re-inclusion and no additional topics or procedural skills were identified.

Round three

Seventeen of thirty Rwandan anaesthesiologists (56.7% response rate) completed the third and final round of the Delphi survey. All seventeen had completed their training in Rwanda, with some having also undertaken subspecialty fellowships in countries outside of SSA, including the USA, Canada, and Belgium. The majority (n = 14, 82.4%) were working in University teaching hospitals with the remaining three respondents working in public referral hospitals (n = 1, 5.9%) and public district hospitals (n = 2, 11.8%). Most of the respondents (n = 12, 70.6%) were in their first three years of post-training specialty practice, with only 11.8% (n = 2) having 10 or more years of independent specialty experience.

Out of the 80 topics and procedural skills, 78 (97.5%) met the I-CVI consensus threshold of 70% (Table 2, ICC = 0.383). A further 14 of the 67 excluded topics (20.9%, Table 3) from previous rounds of the survey met the 50% re-inclusion threshold. Thus a final total of 92 topics and procedural skills were considered to meet consensus threshold for inclusion in a Rwandan undergraduate ACC curriculum.

Table 2 Round three topic and procedural skill Delphi ranking based on I-CVI. Blue = anaesthesia topic, Purple = critical care topic, Yellow = procedural skill, Green = meets consensus threshold, Orange = does not meet consensus threshold

Table 3 Round three re-inclusion ranking for previously excluded topics and procedural skills. Blue = anaesthesia topic, Purple = critical care topic, Green = meets consensus threshold, Orange = does not meet consensus threshold

Discussion

This study outlines what expert ACC providers across SSA, believe should be included in undergraduate anaesthesia education and training. The final list of 92 ‘essential’ topics and skills, along with identified effective pedagogical approaches, and most appropriate clerkship aims were all used to help build and deliver an inaugural ACC clerkship for MBBS students at UGHE in 2023.

There is a significant shortfall in PAP numbers in Rwanda. For a population of almost 13.8 million, there are currently just 30 physician specialists [3]. This translates into the need for over 650 more physician anaesthesiologists in order for the country to meet the WFSA target of 5 providers per 100,000 of the population. This is a pattern, commonly observed across SSA and much of the Global South. This shortfall must be addressed through multiple avenues, with increased training of specialists an integral component (though not feasibly the only means of meeting this target). Interest in specialty training varies globally; one study in New Zealand identified that up to 15% of medical student cohorts were interested in undertaking postgraduate specialty training in anaesthesia [14], in contrast with just 0.7% of final year medical students in Nigeria according to a 2016 study [15]. Chan et al. [16] surveying 79 medical students in Rwanda, found that 6% of final year students identified anaesthesia as one of their top 3 specialty choices. The authors in this study identified quality of exposure of students to anaesthesia practice during their medical school training as vital in shaping perceptions of and driving interest in anaesthesia specialisation—an observation paralleled across contexts and specialties in the existing literature [17,18,19]. As such, the role of this Delphi study in helping to develop a high-quality expert-approved contextually relevant clerkship is vital. This approach was undertaken in part with the aim of increasing Rwandan students’ interest in entering into postgraduate training, thus helping to address the ongoing PAP shortfall. Furthermore, by specifically building a contextualised clerkship we hoped to address issues relating to medical students’ misperceptions regarding the practice of anaesthesia in Rwanda, highlighted by Tuyishime [20] in their response to Chan et al.. Tuyishime argued that reframing misperceptions of anaesthesia as a specialty was critical for improving enrolment numbers in postgraduate anaesthesia training for the country.

Whilst some have described current practice and subsequently extrapolated ‘best practice’ regarding the delivery of anaesthesia education for the undergraduate medical student [21,22,23,24,25], to date there have been few peer-reviewed publications describing the adoption of more systematic expert consensus-driven approaches to curriculum development. Some relevant studies have been undertaken in HICs, however the model of clinical anaesthetic practice in such countries differs significantly from Rwanda and most of SSA [26,27,28]. They therefore bear limited relevance for those striving to build a contextualised curriculum for Rwanda or elsewhere in SSA. In Ireland, Australia, and New Zealand, where these existing Delphi studies have been conducted, anaesthesia care is provided exclusively by PAP specialists with country-wide specialist workforce densities of 17.5, 20.6, and 18.3 per 100, 000 respectively; far in excess of the 0.22 per 100, 000 in Rwanda [2, 3]. The vast majority of PAPs in Rwanda are located in urban-based teaching hospitals with the majority of anaesthesia care in rural district hospitals provided by NPAPs. As such, and not withstanding that medical students and recent medical graduates do not provide independent anaesthesia care across any of these settings, one might expect that the requirements of those graduating from medical school, the goals for an ACC clerkship, and the topics to be taught would differ across these contexts.

Overton et al. [27] found that the ideal duration of anaesthesia training for undergraduates should be 3–4 weeks with the most important aim being to produce safe interns, and the least important aim being the need to teach details of anaesthesia. Despite not explicitly identifying these parameters Rohan et al. [26] made similar recommendations, highlighting the optimal duration of 3–4 weeks and a clear emphasis on clinical exposure. Interestingly, in our study PAPs from across SSA felt a longer duration of placement was optimal with 31 of 51 respondents specifying that an 8 week placement was most appropriate. In line with the findings of Overton et al., our respondents from SSA felt that an ability to perform anaesthesia was least important. In contrast, gaining an understanding of the role of an anaesthesiologist and inspiring medical students to undertake anaesthesia specialty training were felt to be most important in our study—these goals were not identified in either of the other two Delphi studies. Understandably, there was a high degree of crossover of items identified across the 3 studies; airway management, cardiovascular resuscitation and fluid management, critical care, and pain assessment and management were integral content areas for all three contexts.

From the results of this Delphi study, three topics and skills stand out by their omission. Tracheal intubation (both as a knowledge topic and as a practical skill), spinal anaesthesia (as a practical skill), and perioperative medicine (as a knowledge topic) all did not meet consensus in the final round of the Delphi survey. Tracheal intubation and spinal anaesthesia (as practical skills) are included in the existing undergraduate curricula for Rwanda, at the University of Rwanda, whilst practical skill exposure during medical school has been shown to be associated with greater interest amongst graduating students in procedural specialties like surgery and anaesthesia [29]. Perioperative medicine is increasingly considered to fall under the remit of the anaesthesiologist with the content of clear value for the students beyond just their ACC clerkship. For these reasons, and with the desire to produce graduates best equipped to provide high quality, holistic care for patients in rural settings, the clerkship delivery committee eventually opted to include all three topics and practical skills in the UGHE clerkship as ‘non-essential’ topics/skills.

Whilst 92 ‘essential’ topics or skills were identified through our Delphi study, notably the study also highlighted consensus from across the continent that undergraduate curricula should focus on inspiring students’ interest in ACC rather than ensuring the acquisition of specific knowledge and/or skills. In delivering a clerkship for students based on the results of this study, this was useful to consider given the long list of identified topics and skills combined with the relatively short period of time allotted. In operationalising the curriculum, a clerkship delivery committee utilised a range of educational approaches with the essential topics and skills highlighted as indicative content for the students ahead of commencement of the clerkship. An in-person intensive bootcamp week where students engaged in case-based classroom sessions along with simulation-based training was followed by 3-week clinical placements in the operating rooms and critical care units. During clinical placements, students engaged in regular hybrid format case presentations of patients they had helped care for. The bootcamp week sessions and content, the discussion points for case presentations, and both the formative and summative assessments were based primarily on the indicative content from the Delphi study.

Limitations

Given the fact that much of the anaesthesia care across SSA is provided by NPAPs, there may have been value in also surveying non-physician providers. This would have provided greater representation of those working in rural settings, rather than tertiary urban settings. The decision was made to limit distribution of the survey to physicians only as it is primarily physicians involved in medical education of undergraduate medical students and they thus are likely to have a greater understanding of educational needs, logistics, and feasibility of delivery. Furthermore, whilst the majority of physician providers are based in urban centres, they nonetheless do still have experience of delivering care in rural settings.

The number of survey respondents was sufficient and in line with standard Delphi methodology, however only 12 countries from across SSA were represented in the first two rounds of the survey. Respondents based across a broader spread of countries might have provided a more representative consensus. Attempts were made to distribute the survey as widely as possible but this may limit the generalisability of the results, particularly for less represented regions.

Conclusion

Here we describe the results of a continent-wide African Delphi study of topics and procedural skills for inclusion in an undergraduate ACC clerkship, the results of which were used to guide delivery of a new clerkship in rural Rwanda. Such consensus seeking exercises have been utilised previously by the CEGS team at UGHE [11] and constitute high standards of practice for the building of contextualised education and training programs for the region. This approach can be adopted for other specialties and in other regions. Indeed the first two rounds of this study would form a valuable platform off which to build similar undergraduate ACC curricula at other institutions across the continent.

The final list of 92 ‘essential’ topics and procedural skills highlights priority areas for anaesthesia training on the African continent and in Rwanda specifically. Anaesthesia providers and educators need to spark medical students’ interest in the field of ACC in a region where specialist physician provider numbers are critically low. We hope this study can contribute to a multi-modal approach to expanding physician anaesthesia provider numbers for Rwanda and SSA in the coming years.