RCPS(C) IDAC Grant “NPMR”

We are proud and grateful for the support we have as a three-year grant from the International Development, Aid and Collaboration (IDAC) Funding Program of the Royal College of Physicians and Surgeons of Canada. The project is titled : “A Physical Medicine and Rehabilitation Residency by, in and for Nepal” and abbreviated as NPMR.

Personnel: The Team

Attendees at the November 21 2021 Zoom planning meeting included below (top row) Drs Claire Weeks and Peter Wing, Clinical Emeritus Faculty UBC, Vancouver; Patryk Krolikowski, Orthopaedic manager, UBC, Dr Christine Groves, Associate Professor of Physical Medicine & Rehabilitation · Indiana University School of Medicine; (second row) Dr Raju Dhakal, Medical Director, Spinal Injury Rehabilitation Centre, Dr Anil Bahadur Shrestha, SIRC Board vice-chair and founding Medical Director of the Nepal Orthopedic Hospital, Esha Thapa Dhungana, Executive Director of the Spinal Injury Sangh Nepal (SISN); (third row) Hari Adhikari, SIRC Adminstrative Director.

Project description:

Nepal needs and wants more physiatrists trained for Nepali needs and this project, developing a training program in Physical Medicine and Rehabilitation (PMR) in and for Nepal, can provide them. In Nepal, a UN ‘Least Developed Country’, injury or disease is often far more disabling than in better-resourced countries. In addition to far greater mortality and medical morbidity, the functional outcomes of these conditions can be devastating. Interdisciplinary Rehabilitation Medicine aims to optimize the physical, psychological, social, familial, vocational and avocational lives of people with disabilities. To date, Nepal has only two physicians qualified as PMR specialists (physiatrists), Dr Raju Dhakal (RD) and Dr Jas Bahadur Gurung (JG).

The Spinal Injury Rehabilitation Centre (SIRC – our project partner) near Kathmandu was inaugurated in 2002 by Sir Edmund Hillary, who said: “From my work in the Solu Khumbu region, I know that this kind of facility is extremely important for this country. The hill people who injure their backs … require a rehabilitation centre such as this.” We have worked with them for 15 years on our primary goal of providing specialty training in the areas of medical rehabilitation and surgical care of people with spine and spinal cord injuries. SpiNepal, within the Orthopaedic Department of the University of British Columbia, has paid for part or all of the training of two Nepal-educated physicians, one (PP) in neurosurgery/spine, the two others (RD, JG) in PMR. Unable to train in Nepal as no program exists there, RD trained in Bangladesh. Because some training needs were not available there, these were addressed by additional courses and observerships in India, Thailand, Ireland, Switzerland, Canada and Australia. RD has been the Medical Director of SIRC since 2017.

Following its 2015 earthquake, the Nepal government published a Ten Years Action Plan on Disability Management, which noted the need to develop human resources for rehab. Dhakal and Groves (2019) emphasized that Nepal’s special situation warrants their cited WHO recommendations including the need for rehabilitation hospitals with specialized rehabilitation units for inpatients with complex needs.

In 2020 Nepal’s Ministry of Health and Population (MoHP), working with WHO and Handicap International, published “A Situation Assessment of Rehabilitation”, noting both underservicing and maldistribution of rehab professionals in Nepal. While minimal funding has been allocated to date for this important goal, the National Board of Medical Specialties (NBMS) has expressed interest in a PMR training program.

A Nepal-based, Nepal-focused PMR training program will have a huge multiplier effect in the country. We envision a future in which, at the very least, one inpatient/outpatient centre should have interdisciplinary rehab in each of Nepal’s 7 provinces with at least one physiatrist, working towards the best possible outcomes for patients who have sustained spinal cord injury, stroke, brain injury, and neuromuscular diseases as well as those needing general rehabilitation services, with re-integration into the lives they desire and a reduction of the Disability Adjusted Life Years lost.

Progress:

For various reasons relating to signing of appropriate contracts with and establishment of fund transfer requirements through UBC, and regulations of Nepal’s Social Welfare Council, we were delayed in our first transfer of funds to our colleagues in Nepal. However, much progress has been made in meetings with the Patan Academy of Health Sciences (PAHS) establishing a curriculum, a linked syllabus and finally leading to a recently signed Memorandum of Understanding. There are advantages to initiating this program as a two year fellowship to be offered to two successful applicants who have already received specialty accreditation in a relevant specialty, and who will be trained concurrently. The Canadian Royal College is supporting this approach.

We summarize here some of our major milestones. Through the spring and summer of 2023 we met with the full or part team every two weeks, alternating general topics and focused syllabus meetings.

Aug 15 2023 a Memorandum of Understanding (MoU) was signed between SISN-SIRC and PAHS (full agreement https://www.pahs.edu.np/pahs-fellowship-program/application-call-for-admission-in-fellowship-programs-2024/ ) In 2023, Raju visited several regional health districts across all seven provinces in Nepal to lead 10 rehabilitation workshops, reaching a total of about 200 people and enhancing disability management and understanding of rehabilitation medicine. These included physicians and other health care workers.

PAHS endorsed the fellowship curriculum of Physical Medicine and Rehabilitation (PM&R) in its Academic Council. The partnership will support and facilitate the fellow trainees following the fellowship curriculum for Physical Medicine and Rehabilitation, while SIRC will cover the cost in terms of fellows’ admission fees and stipend “at least for first two batches”.

PAHS and SIRC will help prepare a full MD PM&R residency program in the future. Both institutions will collaborate to seek international faculty for PM&R fellowship training and explore international exposure placement for fellows. Raju is the PAHS Program Director.  Pending full approval of the program, Raju kept busy:

October 30 to November 2, 2023. WHO SE Asia Region meeting; Raju presented at the World Health meeting in New Delhi representing ISPRM (the International Society of Rehabilitation Medicine) https://www.youtube.com/watch?v=ivJ2vOmmvg0&t=39s

November 2023 Korean Academy of Rehabilitation Medicine annual meeting; he was an invited faculty member for an ASCoN (Asian Spinal Cord Network) training-of-trainers course.

Nov 30th to Dec 3 ISSICON (the International Spine and Spinal Injuries Conference run by India’s Spinal Cord Society) annual meeting was held in Anand, Gujarat; he was an invited faculty member.

Nov 2023 Raju was also an invited faculty member for the Himalayan Spine (Surgery) Symposium of the Association of Spine Surgeons of Nepal.

Jan 2024: Dr Dhakal was available for broadcasts when asked to spread awareness of disability management on air; this example is from https://youtu.be/xWDP2F35bd0?si=H2kQFSzmUiXCSQoE

And another, from two years ago: https://youtu.be/Tc1ICzsTBXE?si=Q8YENGoT7ZWw7G8X

Early 2024, Dr Jas Gurung, Dr Raju’s second in command, had to move back to Pokhara to support an elderly parent, his wife and two children remaining in KTM. He has returned to clinical work at Green Pastures Hospital GPH, where he worked before he trained in PMR. We hope he can continue to participate in the fellowship program and he is at this point still participating in our meetings. We hope that this challenge will be turned into an asset. For example, there are at GPH a number of stroke patients (10 at the time of writing) that could make this a good rehab rotation.

Feb 19-24 2024 Dr Dhakal attended the annual meeting of the Association of Academic Physiatrists (AAP) in Orlando. This year was his first within a 3-year AAP/GAPS (Global Academic Physiatry Subcommittee) leadership award which includes attendance at the Annual Meeting, and participation in a three-year course, the Program for Academic Leadership (PAL) each year. Thanks for this are due to colleagues and AAP members Christine Groves and Heakyung Kim and the generosity of the Association. SpiNepal paid for his first year’s attendance at the affiliated meeting of Residency and Fellowship Program Directors (RFPD) as well as the annual air fares (c $3300). The next meeting was planned in Phoenix.

April 28 2024 Nepal PM&R Syllabus was virtually complete:   https://docs.google.com/spreadsheets/d/1wZf6vLvq8SZEbbg4eChBoH6qp9xGTZoFpPS2QRooquc/edit?usp=sharing

 

April 2024  – Dr Raju and others organized a “hands on” two-day course in focused rehab at SIRC (above):

The PAHS Vice Chancellor, Rector and Dean along with the team also visited SIRC in April 2024. (Photo left)

Raju initiated and registered the Nepalese Society of Physical Medicine and Rehabilitation, which has a logo designed by SIRC volunteer Dipendra Paudel and the team (right) but as yet no web presence.

August 18 2024 NPMR update

https://www.pahs.edu.np/pahs-fellowship-program/application-call-for-admission-in-fellowship-programs-2024/ . And, our prospectus is fairly well developed:  https://www.pahs.edu.np/wp-content/uploads/2024/06/Prospectus-2024-Fellowship-in-Physical-Medicine-Rehabilitation.pdf

Aug 19 2024 Two excellent physicians – Drs Prashnna Napit and Smriti Shrestha began their fellowship training. A number of international teachers have joined our international faculty and we are now working hard to marry the teachers to the academic topics.

 

Dr Smriti Shrestha, one of our new fellows, told us that: “I have worked as a general practitioner for a number of years and I am passionate about team work and providing holistic care to patients. PM & R requires a collaborative work and team-based approach and addresses not only physical but also emotional and social needs of patients with disability. By choosing to specialize in PM & R, I can contribute to promoting patient centered care. From my work experience in rural Nepal, I understand the challenges faced by patients with disabilities in places where rehabilitation services are limited or non-existent. The unmet need of patients with disabilities has not been addressed. By choosing PM & R, I hope to make a meaningful difference in the lives of such patients, helping them improve their quality of life. On my visit to SIRC ( Spinal Injury Rehabilitation Center ), I witnessed a young patient who was high in spirits on his follow up visit at the Center. He has regained independence and confidence after receiving rehabilitation services. As a PM & R specialist, I can help patients improve functional abilities and give them a sense of purpose, promoting inclusion and acceptance within our communities.

 

 

Dr Prashnna Napit, our other fellow, states: “I am passionate about the potential of rehabilitation to put a genuine smile on patients’ faces by restoring their independence and dignity. The opportunity to work in this field will allow me to make a lasting impact, not only on individual patients but also on the broader healthcare system in Nepal.

Despite the high demand for rehabilitation services in Nepal, especially given our country’s vulnerability to natural disasters, there is a significant lack of government focus and trained professionals in this field. I believe that by completing this fellowship, I can advocate for and contribute to a shift in perception within Nepal, where rehabilitation is not yet prioritized as it should be. My goal is to help change this landscape, ensuring that more patients have access to the care they need and that the field of rehabilitation receives the attention and resources it deserves.”

 

 

August 19 2024 NPMR update: the fellowship begins:

The fellows met Raju and the PAHS Dean, orthopaedic surgeon prof. Dr Balkrishna Acharya at the Patan campus to formally begin the program at the SIRC complex.

Later, up at the SIRC:

At the bedside:

December 31 2024 – Return to Kathmandu

We (Claire Weeks and Peter Wing) arrived in Kathmandu Dec 13th and were busy until the day before we left on Dec 31st. You can find a fuller report through the link below; suffice it to say that the fellowship program is going well, reflecting the many hours of work from the hospital staff, the medical school dean and faculty at the Patan Academy of Health Sciences, and members of the Board.

On arrival in Nepal we stayed first with Kanak and Shanta, the couple who started the Spinal Injury Rehab Centre (SIRC) with Kanak as the founding chair and now continuing under Shanta‘s board leadership. We attended a board meeting (right) shortly before leaving Kathmandu, and felt the warmth, appreciation and deep respect that we and the board mutually feel for each other’s work, only made possible by our supporters over the years.  Board members were clearly very pleased with our ongoing support of their program and must, of course, take much credit for fostering the environment and generating the inter-professional relationships with the academic centres that have made the fellowship program possible.

Here are the main participants in the program, the photo taken when we all got together shortly before we left:

Left to right, back row: Hari and Sheetal Adhikari with daughter Harshika, Prashnna and Aastha Napit, Dipash and Smriti Shrestha with Claire between them, Prakash Paudel, Sheela Gyanwali (Raju’s wife), Karuna Amgain (Raju’s niece, helps with Raju and Sheela’s children), Jas Gurung with son Prashray, Peter, Unika Mulmi with husband Yaju, Raju Dhakal.
Left to right, front row  Ishita Paudel (seated), ‘Sofia’ Napit, Ritika Paudel, Suravi Shrestha, Laxmi KC (Prakash’ wife), Evanee Dhakal.

Most people in Nepal work 6 days weekly; Saturday is the equivalent of our weekend – schools are also closed that day. We chose the last Saturday to bring together all the people who have been instrumental in making the program work and their families. The largely social meeting was held at the Grand Norling Resort – Dr Raju has held many meetings there in the years we have worked together. With us in this photo you can see a neurosurgeon and five physiatrists (well, two are well on their way) who have all been supported by SpiNepal at key points in their training.  This was most satisfying – the kids played soccer and enjoyed watercolor painting, the adults talked, we enjoyed meeting the families and we could finally relax, knowing that we are privileged to have met some excellent physicians who will become well known for the quality of care they will provide to the good people of Nepal.

Summary report of our visit to Nepal.

Links:

Spinal Injury Sangh Nepal (SISN) https://sisn.org.np/

Patan Academy of Health Sciences (PAHS) https://www.pahs.edu.np/pahs-fellowship-program/

Nepal Orthopaedic Hospital (NOH) https://www.noh.org.np/index.php/about-us/introduction

Royal College of Physicians and Surgeons of Canada news item June 2023: Supporting communities in need through Royal College International

UBC Department of Orthopaedic Surgery UBC GO Spotlight June 2023: Claire Weeks and Peter Wing