Abstract
Objective Access to rheumatology education and care is limited in many African countries, leading to suboptimal clinical care and poor outcomes for patients. Virtual education is a feasible means to deliver curricula remotely. A virtual rheumatology course for medical residents in sub-Saharan Africa was developed. We describe the course and its evaluation.
Methods An annual 16-week virtual rheumatology program was delivered to internal medicine residents in Rwanda between 2021 and 2024. Lectures on core rheumatology topics were provided, in English, by an international faculty that included lecturers from Africa to ensure regionally relevant content. In 2023, the virtual course was supplemented by a weeklong in-person visit. Participants completed questionnaires to evaluate their experiences with the course, their confidence in evaluating rheumatologic conditions, and any recommendations for course improvement. Instructors evaluated their experiences with the course. Summary statistics and representative quotations are provided.
Results Postcourse evaluations were available from 55 residents and 7 instructors. All residents who completed the questionnaires reported the lectures were useful. Many (22/54 [41%]) requested additional time for case discussions and in-person teaching. After the course, residents rated their confidence in assessing and managing rheumatologic cases as good (median 7/10 [range 4-10]). Conflicting clinical duties prevented most residents (42/55 [76%]) from attending all lectures. Instructors reported some challenges, especially insufficient interaction during virtual lectures.
Conclusion A virtual rheumatology course is a feasible means to deliver rheumatology education to medical trainees but does not replace the need for in-person education. The program is adaptable to other regions with limited rheumatology resources.
Plain Language Summary
There are very few rheumatologists in many countries in sub-Saharan Africa including Rwanda, which has a population of nearly 14 million. Some African countries have no rheumatologists. Rheumatology teaching and rheumatology care is often provided by nonrheumatologists.
We ran an annual virtual rheumatology course for internal medicine residents in Kigali, Rwanda (2021-2024). The course was integrated into their training program in collaboration with the Department of Internal Medicine, University of Kigali, Rwanda. Teachers were rheumatologists from Africa, North America, and Europe. Several teachers went to Rwanda to provide additional hands-on teaching in 2023. Each year, students and teachers provided written anonymous feedback on their experiences with the course.
The students found the course to be valuable and to have improved their knowledge of rheumatology. Students felt that the topics and content were appropriate for the local conditions of medical practice in their resource-limited regions. Several residents expressed interest in further advanced rheumatology training. However, the students felt in-person teaching was best and asked teachers to continue to visit Kigali to supplement the virtual course. Some challenges were identified that were addressed when possible.
Musculoskeletal disorders (MSDs) are among the greatest contributors to physical disability worldwide, leading to a significant impact on individuals, families, and society. MSD-related disability is expected to increase substantially worldwide and particularly in sub-Saharan Africa.1 Early identification and optimal treatment of patients with MSDs by rheumatologists can reduce the burden caused by chronic inflammatory and noninflammatory rheumatic diseases. However, access to rheumatology care varies globally and is particularly limited in low- and middle-income countries where health budgets prioritize infectious diseases over noncommunicable diseases.2 To address this issue, in 2020, the Global Alliance for Musculoskeletal Health developed a blueprint for musculoskeletal health that includes pillars of workforce and service delivery.3,4
In 2023, there were over 1.4 billion people living in Africa, representing ~18% of the total world population.5 It is estimated that Africa has approximately 25% of the world’s rheumatic disease burden but only 2% of the world’s medical professionals.6 Inadequate human resources and limited budgetary allocation to health were considered top challenges to healthcare systems in Africa. In turn, increased training and capacity building, combined with increased budgetary resources and optimal management, were proposed as health system solutions.2 This is particularly relevant to rheumatology. A previous survey of the 54 African countries, with responses from 44 countries (81%), showed that most of the adult rheumatologists were based in North Africa, 12 (27%) countries had between one and 10 adult rheumatologists and 17 (39%) had no adult rheumatologists. Only 9 out of 54 countries (17%) had pediatric rheumatologists.7,8 With few or no rheumatologists to provide rheumatology specialty care, such care is often provided by nonrheumatology specialists with variable levels of rheumatology expertise, which leads to suboptimal care and contributes to substandard outcomes.9,10 Thus, an urgent need exists to increase local rheumatology education and capacity.
Virtual education has emerged as a feasible means to deliver educational curricula across distances.11 Although virtual education is well studied in North America,12 there are few examples for rheumatology education in Africa.13,14 Here, we describe a virtual rheumatology educational program developed for internal medicine residents in Rwanda.
METHODS
Virtual course. In 2021 there were no practicing rheumatologists in Rwanda, a country with a population > 13 million.5 The postgraduate rheumatology curriculum was taught by internists with variable rheumatology experience. At the request of the College of Medicine and Health Sciences, University of Rwanda in Kigali, Rheumatology For All (RFA), an American based registered charity whose mission is to increase access to rheumatology care in underresourced regions, implemented a 16-week virtual rheumatology program for internal medicine residents attending the University of Rwanda from 2021 to 2024. Weekly lectures and interactive tutorials were provided, in English, by an international faculty with representation from Canada, the United States, the United Kingdom, and Africa, thereby ensuring regionally relevant content. The African rheumatologists were from West Africa (Ghana, Nigeria), East Africa (Kenya, Ethiopia, Rwanda), and South Africa as shown in the Figure. Course content was developed by a core committee within RFA with knowledge of regional educational needs. Content included basic rheumatology principles and conditions (Table 1). Content evolved based on faculty feedback and feasibility. Lectures were given during the residents’ scheduled teaching periods at a time and day suggested by the chief residents. The number of scheduled lectures (16 [range 16-17]) was limited by the time allocated in the residents’ teaching schedule. The chief medical residents coordinated the local organization logistics, circulated the weekly online link to residents and faculty, and monitored the chat comments during lectures. Lectures and tutorials were supplemented with clinical skills videos and additional educational resources, which were made available on Canvas, a learning management system hosted at Thomas Jefferson University. The course was repeated annually for 4 years to 2024. In 2021, faculty had the option to prerecord their lectures, which were uploaded to the central website prior to the scheduled teaching time, thereby allowing more case-based discussion during the livestreamed lecture period. After 2021, in response to feedback from participants, lectures and tutorials were all delivered virtually via livestream, and instructors had the option of sharing the educational content with the residents. In 2023, the virtual course was supplemented by a weeklong in-person visit at Centre Hospitalier Universitaire de Kigali (CHUK) – The University Teaching Hospital of Kigali. During this visit, 3 adult rheumatologists (IC, CAH, MM) and 1 pediatric rheumatologist (RS) provided clinical skills teaching including musculoskeletal physical examination, joint injection techniques, basic musculoskeletal radiograph interpretation, and supplemental lectures. The visiting rheumatologists were also available for clinical consultations, though they did not provide direct medical care. The in-person activities were attended by internal medicine residents, pediatric residents, and medical students. Following the 2024 virtual course, monthly resident-led case presentations were conducted virtually and attended by 1 or 2 RFA faculty who provided consultant input. The chief resident assisted with the organization, which included identifying residents to present cases and arranging the dates and times based on the residents’ schedules. Cases were chosen by the resident assigned to present.
Countries where African faculty practice.
Didactic course content.
Course evaluation. After each online course, and following the in-person teaching week, internal medicine participants were asked to complete an anonymous survey to assess their experiences with the course, their confidence in recognizing and evaluating rheumatologic conditions, and identify challenges and areas for course improvement. Instructors participating in the online teaching were also given the opportunity to evaluate their experiences with the course. Descriptive results from the surveys including illustrative quotations grouped by themes are reported.
RESULTS
Participants. Over the 4 years, there were 138 internal medicine residents in the Rwanda internal medicine program. The second-year residents (n = 44) were prioritized to attend the lectures, but others could attend as well. Virtual course evaluations were filled by 55 participants (13 in 2021, 13 in 2022, 4 in 2023, 25 in 2024) after course completion (Table 2). Most residents (42/55 [76%]) indicated they were not able to attend all lectures because of conflicting clinical duties. Additional materials were accessed by 49/54 (91%; missing, n = 1). The main reasons for not accessing online content included time constraints and difficulty accessing the website. Website access challenges were reduced by switching the course website to a university-based platform in 2022. Several participants (n = 17) indicated that this course was their first exposure to structured rheumatology teaching.
“… we do have shortage of rheumatologists in our setting, hence it was my first time to have such detailed and integrated rheumatology.” (2021 participant)
Student responses following each annual virtual course.
Evaluation of the virtual course. All respondents indicated that the lectures, tutorials, and additional materials were useful. Livestream lectures were preferred over recorded versions. Although there was variability in the preferred topics, individual participants valued teaching that covered assessment and management of more common conditions, incorporation of culturally appropriate images, and videos demonstrating physical examination of joints and procedures such as arthrocentesis. Participants requested additional interaction with faculty (22/54 [41%]; missing, n = 1)] and suggested additional time for case-based discussions including resident-led case presentations, even if this extended the duration of the course. Most participants requested in-person teaching, especially for clinical skills tutoring. After the course, residents’ confidence level with rheumatology cases was good, with a median rating of 7/10 (range 4-10). All students who took a formal exam developed by the course instructors and administered by the university passed.
Some of the other comments by the residents were as follows:
Need for rheumatology education: “Because rheumatology is a kind of ‘neglected’ area of internal medicine; many medics attribute all joint pain to old age and obesity but with the lectures I was able to discover a lot about it and be more conversant with different diseases of joints.” (2021 participant)
Need for in-person training: “We need physical presence of rheumatologists here in Rwanda, we need bedside clinical approach. Your physical presence can help us a lot. The online reading[s] are helpful but the experience [at the] beside will be much helpful.” (2022 participant)
Request for continuing the program: “We hope this will continue for the coming years and probably not only virtually but also [face-to-face] … It would be good if we share cases … (though we don’t have all investigations).” (2023 participant)
Stimulation of interest in rheumatology: “Lectures were so interesting, I would encourage many colleague residents to join rheumatology as a subspecialty because we [do not] have many [rheumatologists] in our country, yet we have many patients with rheumatologic conditions.” (2024 participant)
Additional comments are shown in Table 3.
Additional quotes from internal medicine residents participating in courses.
Evaluation of the in-person course. In 2023, 10 participants (8 internal medicine residents and 2 medical students) responded to a survey evaluating the in-person teaching. Similar to evaluations of the virtual course, all found the in-person training valuable and felt more confident in their ability to assess rheumatic diseases, perform musculoskeletal clinical exams, and carry out routine procedures such as arthrocentesis. However, most felt additional experience/practice was needed. Most participants requested additional in-person teaching throughout the year. Following the in-person course, internal medicine residents’ confidence level with rheumatology cases was good, with a median rating of 7 (range 5-8).
Instructors. Instructors were asked to share their experiences with conducting the virtual lectures. Most instructors had a current or past university affiliation. Seven instructors provided feedback on their experiences with the course. The main challenge reported by most instructors was a lack of effective interaction with the residents during the livestreamed lectures. Proposed reasons for this were language difficulties and a lack of visual interaction, as many students kept their cameras off during the lecture. Engagement improved if cameras were left on, with greater use of the chat feature, and with the use of interactive questions. Additional proposed suggestions to improve lecture experiences included beginning each lecture with either introductions, an informal assessment of topic knowledge, or student expectations. Instructors had the opportunity to post materials and recorded lectures to a central website for students; however, challenges with accessing the site and instructors’ impressions that students did not access posted materials reduced enthusiasm for posting. Several instructors appreciated the involvement of the Rwandan chief medical residents in assisting faculty before and during the lectures. Overall, instructors expressed keen enthusiasm for teaching African students and hoped that their efforts would raise interest in rheumatology, leading to increased local rheumatology capacity. They also expressed their willingness to continue future participation.
DISCUSSION
The virtual rheumatology course developed for East Africa is a feasible means to deliver rheumatology education to internal medicine residents, but it does not replace the need for in-person training. Participants considered the course highly beneficial because it provided exposure to rheumatology with content appropriate to the local conditions of medical practice in their resource-limited regions. Following the course, participants expressed confidence with assessing patients with rheumatologic conditions. Flexibility in course design enabled adaptation of the course delivery to better meet the learning needs of participants. One example was the addition of a focused in-person course component incorporating clinical skills. Despite having scheduled a consistent day and time for weekly lectures, most residents were not able to attend all lectures due to competing clinical responsibilities; protected time would likely improve course attendance. Importantly, after attending the course, interest among some students in pursuing additional rheumatology education increased. Instructors perceived some challenges relating to learner interaction and engagement during livestreamed lectures, possibly resulting from language barriers and the virtual platform. Such perceptions indicate a need to further refine the approach for online rheumatology teaching in this environment.
Although gaps exist in rheumatology education globally,15 medical education in Africa is particularly challenged by a shortage and uneven distribution of medical schools across the continent.16 This allocation constraint, combined with a lack of formally trained rheumatologists, leads to limited rheumatology education for medical trainees.17,18 The need for improved rheumatology education in East Africa is highlighted by a recent survey of 359 medical students from 9 medical centers in Uganda, in which only 35% of students reported having adequate rheumatology knowledge. Although over 80% of these students had some formal education in rheumatology, only 35% had bedside clinical teaching and this was focused primarily on rheumatoid arthritis.17
Several approaches have been used to address gaps in rheumatology education in low- to middle-income countries. Historically, rheumatology specialty training was limited to international training sites, with few rheumatology training programs on the African continent. However, such expatriate training may not reflect the local practice of medicine in many resource-constrained African countries and may contribute to “brain drain” when physicians do not return to Africa. Thus, initiatives delivering education within Africa are preferred. Education delivery models have included visiting professor programs where international clinicians, usually from Europe or North America, provide focused in-person training to clinicians and students, often adopting a “train the trainer” approach, and student/clinician exchanges.19,20
Our work complements other international initiatives providing virtual rheumatology educational resources. In North America, Project ECHO, a virtual medical educational program for practicing clinicians, includes a rheumatology subcourse that covers a variety of musculoskeletal topics and is supplemented by case presentations.21 Similarly, the American College of Rheumatology22 and the European League of Associations of Rheumatology23 have multiple virtual educational resources, many of which are free or subsidized for individuals from low-income regions. For pediatrics, the Pediatric Rheumatology European Society Sister Hospitals Initiative pairs pediatric rheumatology teams in low-income regions with other countries to facilitate collaboration for clinical and educational purposes.24 Our program differs from these initiatives in that it was developed for implementation during resident training and was started when there were no local practicing rheumatologists. By training residents who will likely assume teaching of junior residents as they progress through their programs, we expect to expand awareness of rheumatology among a broad range of specialist clinicians and hopefully increase interest in pursuing more advanced rheumatology training.
Educational content needs to be adapted to local conditions. In addition to covering core content areas, the delivered rheumatology curriculum aimed to cover conditions that are uniquely relevant to sub-Saharan Africa. Content aimed to stress the importance of clinical assessment, rational use of investigations, and management approaches that are appropriate to the local conditions seen in medical practice in their resource-limited regions including limited access to investigations and therapies.9,25,26 Our program was delivered by experienced clinician teachers working in both academic and community-based rheumatology clinics; over half of the instructors were based in Africa to ensure regional relevance of delivered content. Those not based in Africa had at least some exposure to the realities of African medical practice.
The concept of distance education is not new to Africa.27 Multiple online universities have been established in African regions, including sub-Saharan Africa, in initiatives supported by the United Nations Educational, Scientific and Cultural Organization (UNESCO). Quality control and evaluation of online programs remain critical to ensuring quality educational delivery. We solicited formal quality assurance evaluations by means of anonymous surveys of students and lecturers. Students requested face-to-face interactions, which were implemented. This model of blended learning offers effective instruction and is particularly important to delivering clinical skills, including physical exam and procedural skills, which are core competencies of rheumatology education programs. Although in-person instruction is perceived as more effective in delivering clinical skills by the residents, it is a more costly method of instruction and implementation may not always be feasible. The in-person training portion of the rheumatology course assessed herein was fully self-funded by each instructor.
Our program continues to evolve to address the identified limitations. Online technology limitations exist; platform and internet access varies. Internet connectivity in Africa remains well below global standards yet is improving through adaptation of mobile networks for distance communications and learning.27 Online universities established in African regions including sub-Saharan Africa have adopted strategies using these technologies. We found that a committed advocate and champions, which in our model were the chief residents, was needed to ensure effective coordination of the program with the residents, department, and lecturers, and to take responsibility for the completion of evaluations. Protected time for residents to attend the course is critical to enhancing the results of the virtual course. The perceived lack of student engagement during livestreamed lectures may have been attributable to the virtual environment. Yet additional factors may include culturally specific principles, teaching styles, and language comprehension. Of note, Rwanda has 4 official languages. Kinyarwanda is the national language, spoken universally, and French is widely spoken as the former colonial language; English was added in 2008 and Swahili in 2017.28 The language of instruction at the University of Rwanda changed from French to English in 2008. Although residents had a postcourse examination with questions provided by instructors and administered by the university, we have limited data on knowledge retention. Although studies evaluating the long-term effect of the course on the competency of assessment, provision of appropriate care, and determination of outcomes for rheumatology patients in Rwanda are needed, our previous educational initiatives in Ethiopia led to changes in clinical management.29 In addition, some Rwandan residents expressed interest in pursuing advanced rheumatology education, suggesting potential for increased rheumatology capacity. Prior to our educational programs in Ethiopia, there were no practicing adult rheumatologists to serve a population of over 120 million.5 There are now 3 new university-affiliated rheumatologists who are providing rheumatology care for patients with rheumatic disease and rheumatology education to trainees.
Future directions for this work include initiating similar virtual and onsite programs for internal medicine residents training in other countries in Africa who have expressed interest in the program. Course content will be adapted to regional needs. Planned onsite visits will include educational opportunities for allied health professionals and other practicing clinicians, if these are feasible and requested by the host institutions.
In conclusion, this virtual course, intended to provide rheumatology education until local capacity increases, is a feasible bridge to deliver rheumatology education to medical trainees in Rwanda and is adaptable to other regions beyond sub-Saharan Africa. However in-person educational activities, the more cost-constrained approach, remains the optimal means for delivering both didactic and practical clinical training.
ACKNOWLEDGMENT
This work would not be possible without the commitment of the volunteer course faculty, Drs. B.A. Adugna, R.O. Akintayo, P. Caldron, I. Colmegna, B.D. Desyibelew, D. Dey, C.A. Hitchon, J. Murayire, P. McGill, M. Meltzer, A. Migowa, G.M. Mody, H.A. Olaosebikan, E. Peters, A. Ponce, R. Scuccimarri, and M. Tikly; the assistance of the Internal Medicine chief residents Drs. Uwamariya and Ingabire; and institutional support from Florence Masaisa, MD, Chief of the Department of Internal Medicine, University of Rwanda, Rwanda, who facilitated integration of the virtual rheumatology program into the curriculum. Rheumatology For All Rwanda Program Group members: Becky A. Adugna, MD, Department of Internal Medicine Addis Ababa University, Addis Ababa, Ethiopia; Richard O. Akintayo, FRCP, Dumfries and Galloway Royal Infirmary, Aberdeen, UK; Paul Caldron, DO, Arizona Arthritis and Rheumatology Associates (Emeritus), Phoenix, Arizona, USA; Birhanu D. Desyibelew, MD, Department of Internal Medicine, Addis Ababa University, Addis Ababa, Ethiopia; Dzifa Dey, University of Ghana Medical School, University of Ghana, Accra, Ghana; Prosper Ingabire, MD, Department of Internal Medicine, University of Rwanda, Kigali, Rwanda; Janvier Murayire, MD, King Faisal Hospital Kigali, Kigali, Rwanda; Florence Masaisa, MD, Department of Internal Medicine, University of Rwanda, Kigali, Rwanda; Paul McGill, MD, Stobhill General Hospital, Glasgow, UK; Angela Migowa, MD, Aga Khan University Hospital, Nairobi, Kenya; Babatunde Hakeen Olaosebikan, MD, Department of Medicine, Lagos State University Teaching Hospital, Lagos, Nigeria; Eric Peters, MD, Arizona Arthritis and Rheumatology Associates, Phoenix, Arizona, USA; Andre Ponce, MD, Thomas Jefferson University, Philadelphia, Pennsylvania, USA; Mohammed Tikly, Department of Medicine, University of the Witwatersrand, Johannesburg, South Africa; Veronique Uwamariya, MD, Department of Internal Medicine, University of Rwanda, Kigali, Rwanda.
Footnotes
CONTRIBUTIONS
CAH: study design, data acquisition, data analysis, data interpretation, drafted manuscript. RS: study design, data acquisition, data interpretation, reviewed the manuscript. IC: study design, data acquisition, data interpretation, reviewed the manuscript. FM: data acquisition, data interpretation, reviewed the manuscript. GMM, MM: study design, data acquisition, data interpretation, reviewed the manuscript. Rheumatology For All Rwanda Program Group members: data acquisition, reviewed the manuscript. All authors approved the final version and are accountable for this work.
FUNDING
We acknowledge partial project-specific funding from the Royal College of Physicians and Surgeons of Canada International Development Aid and Collaboration grant.
COMPETING INTERESTS
The authors declare no conflicts of interest related to this study. CAH reports unrelated research funds from Pfizer Canada, advisory board for AstraZeneca, Fresenius-Kabi, and peer reviewed funds from Canadian Institutes of Health Research, Arthritis Society of Canada, and Health Sciences Centre Foundation.
ETHICS AND PATIENT CONSENT
Publication was approved by the ethics committee of the Centre Hospitalier Universitaire University Teaching Hospital of Kigali (EC/CHUK/CR/002/2024). This work complies with article 2.5 of the Canadian Institutes of Health Research Tri-Council Policy Statement: Ethical Conduct for Research 2 (TCPS 2) as a program evaluation activity. All course evaluations were anonymous.
DATA AVAILABILITY
Select data can be made available upon reasonable request to the corresponding author.
PLAIN LANGUAGE SUMMARY
A plain language summary of this article (text or graphical) is also included as online supplementary material.
- Accepted for publication April 25, 2025.
- Copyright © 2025 by the Journal of Rheumatology
