A win for all: Faculty-student partnerships in surgical humanitarianism

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Dr. Master (far right) and Dr. Srinivasan (far left) perform an ovarian mass resection with assistance from medical students (left to right) Stefanie Reiff and Dr. Leeds. Gynecologic cases were more common in 2010 because the hospital had lost its staff gynecologist.

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The Hôpital St. Thérèse surgical ward filled with patients recovering from procedures completed by the group’s surgeons.

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Dr. Master (left) instructs and guides medical students (front to back) Ammara Abbasi and Amanda Cai through proper use of electrocautery during a herniorrhaphy procedure.

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From left: Dr. Srinivasan and Dr. Master perform an ultrasound evaluation of an abdominal mass while teaching medical students Lee Hugar and Pete Creighton the diagnostic technique. 2010’s surgical team brought a portable ultrasound machine for enhanced diagnostic imaging capabilities.

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Dr. Srinivasan completing an orchiectomy on a patient with a massive scrotal tumor.

Medical humanitarianism is an increasingly stable fixture in the international relief community. Although previously termed the “neglected stepchild of global health,”1 surgery’s unique ability to provide definitive results has allowed surgical humanitarianism to become an increasingly important player within health care-related humanitarian endeavors.1-3 There is a long history of incorporating an educational component into both long-term and short-term surgical missions.4,5 Although, in recent years, there has been a groundswell in the promulgation of international training opportunities for residents,6 medical students are rarely included in these surgical missions.7

For the last five years, Emory Medishare, a faculty-student collaboration at Emory University in Atlanta, GA, has facilitated a series of short-term surgical missions to rural Haiti’s Hôpital St. Thérèse in Hinche with the specific combined aims of providing appropriate surgical care to a population in desperate need and offering a credit-worthy educational experience (as part of medical students’ surgical clerkship rotation) for a team composed predominantly of medical students. However, some experienced surgeon-humanitarians have questioned the value of so heavily incorporating medical student participation and leadership into Emory Medishare’s surgical efforts.

It is important to note that this program does not simply provide medical students with the opportunity to obtain international experience. Instead, it is a surgical mission that authentically integrates medical education into its greater humanitarian objectives. In the strictest sense, these trips demand far more of medical students than just “showing up.” Such a program is a radical departure from the typical role of medical students in international health.

The design of a curriculum for inclusion of medical students in relief efforts, the clinical safety of patients, and the educational outcomes have all been described in other publications.8-10 The purpose of this article is to briefly synthesize the findings of prior work in the field, identify the major benefits of such medical student-dominated efforts, and reconcile the many criticisms and limitations of such projects.

“4-win” opportunity

The primary objectives of Emory Medishare have always been to provide the highest quality of care possible to the rural Haitian patient population it serves while also challenging participating medical students to gain new skills and knowledge from this unique educational opportunity. Two less-expected benefits to come out of this work have been the substantial effects such trips have had on supervising faculty and the benefits accruing to the field of surgical humanitarianism. These four wins—the benefits to patients, the benefits to medical student, the benefits to faculty, and the contributions to the field—are what have made this mission model so effective.

A win for patients

The burden of surgical disease among the world’s poorest nations has recently gained appropriate attention in the medical literature.11 The rising visibility of this global issue has led to the emergence of professional organizations, such as the Alliance for Surgery and Anesthesia Presence Today (ASAP Today), that serve to focus more U.S.-based resources on addressing the need for additional personnel and equipment.

Emory Medishare’s work in Haiti also demonstrates the need for more surgical care in low- and middle-income countries. The team’s completion of 19 open simple prostatectomies is an example of the group’s ability to provide care for untreated disease, as this procedure is the only available long-term therapy for patients with severe benign prostatic hypertrophy.9 In the industrialized world such a disease could be managed easily with medication and transurethral procedures for the most severe cases; however, these options are unavailable to Haitian patients due to the lack of consistent access to effective pharmaceuticals or available endoscopic technology. Emory Medishare’s work has allowed otherwise healthy Haitian men to walk about unencumbered by a catheter for the first time in years. These cases have also reinforced claims that surgical care in low-income countries can be a cost-effective intervention.9,12 The demand for such a procedure has not receded, and Emory Medishare has had to turn away individuals who arrive at the surgical hospital too late to fit them into the mission’s operating schedule.

As a previously published case series has demonstrated, the benefit of surgical missions is not limited to one particular procedure or pathology.9 Over the last four years, surgical needs in Haiti have varied from an imminent septic wound to a slow-growing abdominal tumor of unknown etiology. The Emory Medishare program in Hinche has provided surgical care to patients from as far away as Port-au-Prince because even the capital did not have a urologist available to perform orchiopexy for a young boy with bilateral cryptorchidism. With careful case selection (for example, technically complex but low-risk recovery) and appropriate long-term local partnerships, these missions have been an effective means of addressing surgical needs in resource-poor areas.

A win for students

Faculty provide appropriate clinical supervision and perform each surgical procedure, but the medical students manage the host of nonoperative duties that must also be completed. Non-narcotic pharmaceutical and surgical supply procurement is done largely without faculty support other than to confirm procurement lists and verify that the correct item is administered at point-of-care. Postoperative care protocols are first written by medical students who have participated in previous trips, and then they are edited and approved by faculty members. Likewise, medical students work with experts at their home institutions to design systems for monitoring and evaluating the success of each surgical mission with respect to patient care and student learning.

Outside of clinical care, medical students function exclusively as the mission’s logisticians and manage their own international and in-country transport, housing, and non-governmental organization (NGO) partnerships. It should be noted that these trips are not an international experience loosely connected to the medical students’ curriculum, but rather are considered to be a formal part of medical students’ third-year surgical clerkship.

These efforts have been hugely rewarding for medical students, and previously published work on the program’s impact on students demonstrates the unique teaching points such trips provide while satisfactorily maintaining the same educational standards of a required surgical clerkship.10,13 Students have routinely reported that the empowering roles they hold as nonclinical trip leaders and the intensely fulfilling mentoring relationships formed in the months preceding the trip are unseen elsewhere in the traditional medical student curriculum. These trips also mark one of the few times in their medical school clinical training where students meet patients at first presentation and diagnosis, follow them to the operating room (OR), coordinate all facets of postoperative care, and then provide for discharge. Consistent with today’s trends in health care systems training, students are encouraged to consider the optimal care pathway given the patient’s limited external resources and the lack of access to further diagnostic testing.

A win for attending surgeons

One of the most surprising benefits of this program has been the degree to which attending surgeons find personal development from the experience. With unnerving consistency, each year produces a few clinical cases that push the attending faculty to balance their surgical scope of expertise with the utter lack of resources or support if unexpected problems arise.9 For this reason, the leaders of Emory Medishare have spent a considerable amount of time identifying experienced faculty members with both breadth and depth of surgical training necessary to ensure the best “human armamentarium.” This strategy has given the team the capability of performing highly technical, low-technology procedures, such as urethral reconstruction and complex tumor resections, in appropriate patients.

The participating faculty have noted that opportunity to perform these types of procedures in settings that do not otherwise lend themselves to surgical care is immensely rewarding and is part of what motivates them to make the sacrifices of time and personal resources that are a consequence of participating in these missions.

A win for the field

The Emory Medishare surgical program has had an impact on the field of humanitarian surgery that has not yet been fully realized. First, the broad array of research interests among participants has led to a number of scholarly presentations and publications stemming from the program. The depth of commitment from students and faculty over the past several years has resulted in contributions to the surgical literature that mimic traditional research activities built up over an academic career. These scholarly activities have engaged student participants in global health in a manner far exceeding one or two weeks of international field work. Prior participants have helped craft Emory University’s policies on extramural clinical experiences, have gone on to residency positions with formal global health components, and have met with thought leaders in the greater global surgery community at national meetings.

Criticisms and limitations

The most frequently cited concern regarding Emory Medishare’s surgical program is the minor role of local partners. In practice, logistical and administrative needs in Haiti are filled by the project’s lead local partner, Project Medishare for Haiti. Clinical responsibilities during the trips are conducted almost exclusively by visiting team members before arranging outpatient follow-up and formally transferring care of the few remaining inpatients to the local surgical practice. Both internal and external critics have noted the opportunity for educating local Haitian surgical trainees and for collaborative international research. Furthermore, this cooperative division is not aligned with accepted best practices in humanitarian surgery, nor does it adhere to the program’s long-term objectives.2

Previous efforts to address this partnership deficit have been mixed. First, health care workforce shortages in Haiti combined with repeated national emergencies, including the 2010 earthquake and multiple cholera outbreaks, have limited the availability of local personnel. Second, the Emory team has had difficulty creating local training opportunities without detracting from one of the four benefits previously noted, namely the benefits to patients, the benefits to medical students, the benefits to faculty, and contributions to the field. Historically, the team has experimented with inviting local surgeons and nursing staff to participate in the OR, but these experiences have either severely curtailed clinical productivity or limited the involvement of medical student members of the team. Given the substantial investment of personal and institutional resources and the formalized curricular role of the trip, both of these trade-offs are inconsistent with the present program structure but will likely undergo additional refinement over time.

Our experiences do not rule out an obligation to involve local partners. Each year of the program, various methods were employed for balancing inclusion of local partners while maximizing short-term objectives. Evening rounds were instituted on later trips with invitations to local clinical staff to participate as appropriate. Similarly, 360-degree roundtable discussions were formally implemented at various points of each trip to ensure all voices of compliment and concern were heard. Further discussions with Emory’s administration have resulted in an extension of the trip to include a dedicated postoperative week, which has improved both short-term clinical follow-up and the process of transferring recovering inpatients to local partners. Through these efforts, Emory Medishare continues to review the relationships with local partners and maintains an ongoing dialog for revision.

Many of these criticisms center on the two-sided nature of humanitarian medicine rather than the unique medical student-driven approach adopted by Emory Medishare. One could argue that humanitarian efforts are intrinsically flawed by their disruptive effects on existing health systems and their role as palliative rather than curative therapy for an underlying social problem. A potential solution, then, is not to further inhibit medical student participation, as some have suggested, but to encourage it with the hopes of exposing future humanitarian physicians to the immensely difficult issues encountered in the field and encourage them to dedicate their careers to improve upon the existing paradigm.

Conclusion

The results of the Emory Medishare surgical program highlight the fact that surgical humanitarianism can be conducted safely and effectively with robust medical student involvement. We recognize such missions raise a host of ethical issues. Contrary to what others have argued, we suggest that the involvement of medical students diminishes these issues.7, 14-15 With medical education formally integrated into such trips, surgical humanitarianism contributes to the education and training of future generations of physicians. The intersection of medical education and international medical humanitarianism is primed for medical students to take on a more serious role. Whereas traditional medical education will never be replaced by overseas training experiences, student involvement in surgical humanitarianism represents a unique enrichment opportunity that is currently underutilized.

More information on Emory Medishare’s platform of programs can be found at www.emorymedishare.org.


Acknowledgment
The authors gratefully acknowledge comments by Emory University medical student Sandra Zaeh, MSc, on earlier versions of this article.


References

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