Pursuing a career in humanitarian and rural surgery: When is the best time to start?

At a meeting of the World Health Organization (WHO) Global Initiative for Emergency and Essential Surgical Care in November 2011, many medical students and surgical residents expressed interest in finding a way to prepare for a surgical career by combining work in resource-limited locations in the U.S. and service to developing countries.1

Resources

  • Alliance for Surgical and Anesthesia Presence Today (former Burden of Surgical Disease Working Group)
  • Mission Doctors Association
    3435 Wilshire Blvd., Suite 1940
    Los Angeles, CA 90010
    in collaboration with St. Martin de Porres Mission Hospital
    Njinikom, Northwest Province,
    Cameroon
  • Chinle Comprehensive Health Care Facility, Indian Health Service
    P.O. Box “PH”
    Chinle, AZ 86503
  • Unite for Sight U.S.A. Headquarters
    234 Church Street, 15th floor
    New Haven, CT 06510
  • London School of Hygiene and Tropical Medicine
    Keppel Street, London WC1E7HT UK

Because more and more trainees in surgery are showing an interest in providing surgical care in resource-limited settings and because the number of rural surgeons in America continues to decline, it is important to inform future surgeons regarding how they can establish a career in volunteer and rural surgery.2,3 Several surgical residency programs, such as the Duke Global Surgery residency program, Durham, University of North Carolina-Chapel Hill School of Public Health, have well-established global health programs; but what can residents do if they have chosen a community setting for residency or did not realize until later into residency that this was a path they wanted to pursue?

This article offers some suggestions on how surgical residents—
especially those training at community-based teaching hospitals—
can forge a career path in rural and humanitarian surgery.

Take control of your education

Finding mentors to foster a career in global surgery can be challenging, so residents should take control of their education and do some self-instruction. For example, during postgraduate training, residents should center their grand rounds assignments on global and rural surgical health care issues. This strategy will provide opportunities to research the current literature, learn the language of global health, become familiar with the names of surgeons who write about global surgery, and increase other surgeons’ and residents’ awareness of the topic.

Residents may also choose to pursue a master’s degree in global health policy or public health either online or during research years, if their program permits. Earning a degree in these areas will provide a foundation so that the surgical epidemiology of humanitarian care will seem less foreign. Pursing these programs will also allow residents to develop their skills in research design and implementation as this is the focus of several public health programs and is a necessary skill for capacity-building in developing countries. These programs help increase understanding about the policy environment associated with issues of global health, and provide education regarding common tropical ailments encountered in these environments as well as fundamentals of epidemiology.

Participate in Global Surgery Week

Residents may increase their own and others’ awareness of global surgery by hosting a Global Surgery Week at their institution. Global Surgery Week activities may include distributing flyers with facts on global health care, placing key articles in physician lounges and auditoriums, and giving and coordinating presentations on the issue. Information to help host such activities can be found through organizations such as the WHO Global Initiative on Emergency and Essential Surgical Care and through an organization called Surgeons Overseas.

Sign up to receive tweets during this week from Adam Kushner, MD, MPH, FACS, a recognized leader in global surgery through his work with Surgeons Overseas and his lectures at Columbia University in New York, NY. Indeed, residents should take full advantage of social networking by following authors who have written articles on global surgery on Twitter and Facebook. Residents may have many questions not only regarding which skills are necessary for this kind of work, but also questions on topics ranging from financial commitments, security, and how residents can maintain their own health while overseas. Many professionals in this field are more than willing to correspond by e-mail or telephone with other surgeons and residents who are interested in global health care.

Go beyond general surgery

Operating in low- and middle-income countries (LMIC) and even in rural America can call for a whole different set of skills and mastery of some techniques that may be unfamiliar to many general surgery residents. At a community hospital residency program, learning these skills can be a pretty straightforward experience, especially if the facility doesn’t feature any competing residencies or fellowships. However, it can be challenging to arrange an international elective during residency due to the requirements set forth by the Accreditation Council for Graduate Medical Education (ACGME) as well as by various training programs. The requirements of the ACGME for an international elective involve the completion of a stringent application. Additionally, the number of electives allowed by the ACGME during surgical residency are limited, which can make it challenging for a resident to obtain both an international rotation and subspecialty rotations. Although residents may affiliate with other programs that offer rotations in international surgery, another option is to perform an elective in a subspecialty that is useful in delivering care to patients in LMICs and in rural America. One of the most important subspecialties is obstetrics and gynecology, as humanitarian surgeons commonly need to perform cesarean sections (c-sections).4 Orthopaedic and urological procedures are also commonly performed.

One humanitarian surgeon’s
career path

Following is a timeline of how the author pursued a career in global and rural surgery, starting in her second year of residency (PGY-II).

PGY-II
Led grand rounds on HIV/AIDS: The Forgotten Crisis and Implications for the General Surgeon.

Began reading The World Journal of Surgery, focusing on topics that are particularly relevant in global surgery such as burden of disease, tropical surgical ailments, and capacity building.

PGY-III
Led grand rounds on damage control for the rural surgeon.

Embarked on research project on HIV-positive patients requiring surgical consultations to become familiar with infectious disease.

PGY-IV
Led grand rounds on Telesurgery As a Resource for General Surgeons in Rural Areas.

Investigated various humanitarian organizations and either became a resident member or applied for an assignment with such organizations as Doctors Without Borders, Mission Doctors Association, Surgeons Overseas, and the International Medical Corps.

Took an online course on not-for-profit fundraising and another on management of not-for-profit organizations offered through a local college. Each course was approximately one month long.

PGY-V
Led grand rounds on Tropical Medicine: A Compendium for the Surgery of Poverty and Neglect.

Joined the Alliance for Surgical and Anesthesia Presence Today listserv and offered services in the form of literature reviews, fundraising, and research collaboration to global health working groups.

Began French studies through both online courses and a private tutor from a local college.
Chose first assignments (St. Martin de Porres Catholic Mission Hospital Njinikom, Cameroon, for three months and a locum tenens position for one month with Indian Health Service prior to departure).

Commenced work on certificates in global health and management with Unite for Sight’s Global Health University. (The author has received a certificate in global health practice and is currently working on a global health management certification).

Initiated online studies for the master of science degree in global health policy with the London School of Hygiene and Tropical Medicine.

Endoscopic skills are a must for practice in rural America.5 Many residencies are affiliated with rural rotations, so it would be feasible to do an elective with one of these rotations or, with program director approval, at one of the Indian Health Service sites.

It is important to maintain an open dialogue with attending surgeons, informing them of your plans—and, while you’re at it, start to think like an LMIC surgeon. For example, when assisting with a procedure, ask the operating surgeon questions such as, “What if this technology or instrumentation were not available? What would you do then?” These are especially important questions because health care facilities in LMICs typically have limited or no imaging, interventional radiology, and operating equipment.

To summarize, residents interested in surgical volunteerism and humanitarian relief need to learn the “big five”:

  • Endoscopy for practice in rural America
  • C-section and gynecologic procedures (many rural settings in the U.S. require the general surgeon to perform c-sections)
  • Basic urology, such as placement of suprapubic catheters
  • Basic fracture treatment
  • Skin grafting

How to support yourself

Finding flexibility for humanitarian work and financial stability can be a real challenge. Working with the underserved in America through locum tenens companies can make this happen. When offered positions, residents should take a quick look at the easily searchable U.S. Department of Health and Human Services database available at http://muafind.hrsa.gov/ to see if the position is located in a designated rural and/or underserved area.

To finance missions, think of creative fundraising sources. There are many books, online courses, and generous people that can help residents find funding for humanitarian efforts.

Learn a foreign language

Learning a foreign language may be crucial for placement with various organizations that cover the expense of a humanitarian assignment, and familiarity with foreign languages is a necessity for surgeons who choose global health care as a career path. A career can shift in the form of directorships or WHO collaborations, and fluency in a foreign language may be what makes or breaks an opportunity.

Choosing a language depends on each resident’s area of interest. Spanish would be obvious for Latin America and South America, but French is the language of many humanitarian programs in Africa.

Look for opportunities

Although it is not necessary to have a precise plan, residents should keep their eyes open for opportunities and seize them as they become available. Trying to establish a career in any area of medicine takes innovation and ingenuity. To be successful, physicians need the courage to step out of the typical boundaries and make their own paths. As increasing numbers of general surgery residents pursue fellowships, it can be nerve-wracking to transition from residency into practice. Residents should have faith in those who trained them; no respectable program director will turn a physician loose who isn’t ready to provide high-quality patient care.

Future needs

A career in humanitarian surgery, at present, is ill-defined, and many interested surgical residents are without guidance in this pursuit. Future surgeons should be aware of the opportunities available to pursue humanitarian surgery and public health leadership. In an ever-changing political and funding climate, the stability of this career path is definitely unpredictable. Our upcoming generations of surgeons need the training and the financial resources necessary to make this a successful career option and to ensure that humanitarian efforts in surgery can continue.


References

  1. Fourth Biennial World Health Organization Global Initiative for Emergency and Essential Surgical Care Meeting. November 9, 2011. University of San Diego San Diego, CA. Available at www.who.int/surgery/globalinitiative/WHO_GIEESC_MeetingReportNov2011.pdf.
  2. Powell AC, Casey K, Liewehr DJ, Hayanga A, James TA, Cherr GS. Results of a national survey of surgical resident interest in international experience, electives, and volunteerism. J Am Coll Surg. 2009;208(2):304-312.
  3. Lynge DC, Larson EH. Workforce issues in rural surgery. Surg Clin North Am. 2009;89(6):1285-1291.
  4. Chu KM, Trelles M, Ford NP. Quality of care in humanitarian surgery. World J. Surg. 2011;35(6):1169-1172.
  5. Ritchie WP Jr., Rhodes RS, Biester TW. Work loads and practice patterns of general surgeons in the United States, 1995–1997: A report from the American Board of Surgery. Ann Surg. 1999;230(4):533-542.

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