Teaching the teacher: An ethical model for international surgical missions

in OR lounge adjusted cmyk

Waiting for room turnover at the MAFH. From left: Dr. Ahmed Nada, professor of surgery, Cairo University; Dr. Selim; Dr. Nabil Shedid, professor of surgery, Banha University; Gen. Fawzy Yousef, director of surgery; Dr. Salah Ayad, surgery attending (far back); and two of the surgery residents.

in OR

In the MAFH OR.

with surgery residents adjusted cmyk

Dr. Selim (second from left) with MAFH surgical residents on the fourth floor of the hospital, where the surgery offices and wards are located.


As many surgeons now know, there is always a need for well-trained, well-educated, and dedicated health care professionals throughout the world. This need can exist in marginalized populations and rural environments in both developed countries and in less economically developed countries. Over the past decades, globalization has necessitated a greater understanding of international health care issues and the need to train a workforce that can address the needs of underserved populations.

Unfortunately, however, it has become increasingly difficult for international surgeons to conduct their postgraduate training in developed countries. The regulations permitting these physicians to work in countries such as the U.S. and the U.K. have been tightened considerably. Eligibility criteria now preclude non-European Union physicians from applying for training posts in the U.K., which had previously relied on these physicians, mainly from developing countries, to fill empty posts.1 In the U.S., the credentialing process and state board requirements for medical licenses are fairly prohibitive. Surgeons seeking advancement or extra training currently rely on traveling to American or European academic centers to observe operations but have limited opportunities to engage in direct patient contact.

Many surgeons and their organizations have made strides toward fulfilling the health care needs of underserved populations at home and abroad. Notably, the American College of Surgeons established Operation Giving Back in 2004 as a resource for surgeons who are interested in participating in international outreach.2 The discussion surrounding international surgical work is growing, and interested parties have offered models for international collaboration.3

Residents in training also are expressing interest in participating in international programs. However, opportunities for residents are limited and often require personal funding and use of vacation time, and typically do not count toward graduation requirements as they are considered to be nonstandard rotations. The increased interest among surgery residents to complete an international rotation was surveyed and published by Powell and colleagues.4

This article describes the ongoing health care needs of patients in low-resource nations, describes the shortcomings of current efforts to deliver this care and foster surgical education in the developing world, and offers an ethical model for training a sustainable global surgical workforce.

Growing global need for surgeons

Despite the demonstrated interest of many surgeons and residents to provide health care to resource-poor countries, patients in these areas around the globe continue to have significant difficulty receiving necessary health care services. Surgical literature has revealed the lack of health care in low-income and middle-income countries.5 It has been estimated that approximately 11 percent of the world’s disability-adjusted life years (DALYs) are the result of surgical illnesses, and mortality from preventable or treatable surgical conditions accounted for 10.9 percent of all DALYs.6

These reports have concentrated on the need for basic surgical services but did not address the need for advanced surgical expertise in low- or middle-income countries. Furthermore, little information has been published on the magnitude of advanced surgical disease or the percentage of qualified, well-trained surgeons who can manage these diseases in developing nations.

In 2006, the World Health Organization (WHO) reported the total health workforce density to be 2.3 and 24.8 per 1,000 population for Africa and the Americas, respectively. In addition, WHO reported a critical shortage of physicians, nurses, and midwives in 36 of 46 African countries, requiring a 139 percent increase in providers to meet estimated patient needs.7 One could argue that the health care professionals in these countries are not only overworked, but also may lack the resources to travel abroad to gain the skills or training necessary to manage advanced diseases or become more efficient practitioners.

North American and European universities increasingly have been getting involved with long-term commitments in capacity-building and training among health care professionals in low-income and middle-income countries. These universities have the requisite resources to play a key role in reducing global health disparities and the diseases associated with poverty, specifically through increasing the training, research, and service capacity of educational institutions in low-income and middle-income countries.8

Furthermore, advanced surgical techniques, including minimally invasive surgery, can arguably be taught to surgeons in low-income nations to increase the number of patients treated while helping to solve the economic strains of providing hospital beds, nursing staff, and other resources required for inpatient stays.

An international teaching philosophy

The famous saying, “Give a man a fish, and you feed him for a day. Teach a man to fish and you feed him for a lifetime,” summarizes the guiding principle in the effort to provide surgical training to health care practitioners in low- and middle-income nations.

Although face-to-face interaction is still the gold standard in medical and surgical education, the evolution of online resources, including digital media archives and the development of telecommunications, have narrowed the knowledge gap between countries. Medicine and surgery have benefited greatly from improvements in this technology in recent years. The use of state-of-the-art equipment, resources, and techniques has helped surgeons to offer patients better outcomes and colleges to offer wider varieties of educational programs. Unfortunately, some countries still lack the infrastructure to support these advancements. Surgeons and patients in many developing nations are still on the verge of acquiring the modern equipment. Furthermore, time zone differences may inhibit the utility of telecommunications technology.

As surgeons in developed countries started to realize and identify the needs in underserved areas around the world, they often volunteered to travel and provide surgical care. These efforts have been traditionally arranged as missions through not-for-profit organizations, such as Operation Smile, or religious and non-governmental organizations.9 Although these missions benefit many patients, lack of resources and time commitments often prohibit health care professionals from providing these areas with the tools necessary to operate independently. To ensure patients have sustained access to care, international missions should focus on fulfilling the following objectives: teach new technology, improve research, and advance patient care through new procedures and surgical care management at the homes of patients and practitioners.

One of the benefits of international surgical teaching missions is that patients will receive medical care otherwise unavailable to them. In remote areas, these patients will have access to basic medical and surgical care. In urban regions, more advanced medical and surgical care can be provided, as these locations are more likely to have the resources needed to provide higher-level services.

Benefits to patients can be maximized when global missions respect the culture in which they are working, including the society’s political, social, religious, and economic forces. Health care providers participating in these missions need to be aware that social determinants, including education, occupation, income, gender, age, and ethnicity, will affect their patients’ morbidity and mortality; lower socioeconomic status typically is associated with poorer health.

An overarching goal of these missions is to produce a reasonably self-sufficient surgeon who is able to cope with most local surgical problems and is confident in managing advanced diseases and complex operations. To this end, local surgeons will receive one-on-one training from an expert who is familiar with new technology and minimally invasive procedures. Bringing this training to the surgeons’ homeland will mollify the necessity of travel to obtain the same skills and circumvents the licensing issues discussed previously.

Visiting experts will enjoy new, potentially once-in-a-lifetime experiences. These opportunities will satisfy surgeons’ desire to help others while gaining personal and career satisfaction. Visiting surgeons also will learn how to operate with limited resources and how to improvise during disasters or emergencies in their homeland.

Before traveling abroad, it is a good idea for health care providers to participate in an orientation program. Such a program can focus on the barriers to health care that exist in the visited country, including lack of infrastructure and cultural and linguistic issues. These programs can also help visiting surgeons become familiar with the availability and cost of medications in the country.

International surgical program challenges

  • Difficulty in finding a mentor or a teacher
  • Language barrier
  • Locating the optimal international exchange programs
  • Limited resources or equipment
  • Lack of well-trained operating room team
  • Perceiving the visitor as a competitor or a threat
  • Condescending attitude toward local practitioners

A glimpse of what may be involved in an international experience also can be obtained by attending international conferences or browsing the Web. Some students or residents are fortunate to have exposure to mentors and professors who have relocated and may seek their advice on pursuing these international opportunities.

Traveling to teach or learn requires considerable resources. Travel expenses, accommodation, meals, and daily spending can add up very quickly. Time off from regular practice, disruptions to partners’ schedules, and time away from family add to the hidden costs of the traveling party. Overseas travel also is associated with a great deal of exhaustion from long flight hours, jet lag, change in daily routines, and the mental strain of trying to adapt to an unfamiliar environment. Problems that might contribute to the failure of the program are listed in the table.

Ideally, though, the international program fosters a friendly, harmonious camaraderie among physicians and surgeons from different countries.

Ethics of international teaching

Four ethical principles guide the international teaching model proposed in this article: respect for individuals, beneficence, non-maleficence, and justice. International health care missions begin with good intentions from all parties; however, good intentions alone do not ensure success or safety. International medical efforts, nonemergency surgery in particular, that lack the possibility of continued follow-up present an ethical concern.10 In a study published by Wall and colleagues, researchers note, “You have a moral obligation as a surgeon to insure that your patients receive appropriate postoperative care. It is unethical to perform complicated reconstructive operations only to have them fall apart because patients do not receive appropriate ongoing attention after you have gone.”10 Acute care and emergency surgery practices carry the same concerns.11 Positive surgical outcomes are the result not only of great surgical skills, but also meticulous preoperative planning and excellent postoperative care.

A hierarchical system in international teaching would help allay concerns related to appropriate post-operative care. Teaching the teacher, who, in turn, spreads this knowledge, will lead to quality patient care. It is possible to think of this arrangement as a system that resembles the World Wide Web, with multiple nodes and peripherals, keeping in mind that, generally, a node or a peripheral is dynamically interchangeable. In the teaching the teacher model, nodes consist of the developed countries’ universities and traveling experts. The peripherals consist of the receiving communities in low- and middle-income countries. Once a mission is concluded, the local surgeons who acquired knowledge and experience will be available to provide short- and long-term follow-up care to these patients. They also will manage any complications that may arise during patient recovery. These surgeons also will spread their acquired knowledge to less fortunate communities nearby. Established communication and, hopefully, friendship between local providers and visiting teachers will facilitate continued telecommunication as needed.

This model may present some challenges, however. Surgeons are sometimes known to be hard-headed and to have big egos. Putting ego aside is the cornerstone of this program’s success. Visiting experts must exercise humility, understanding, and patience. They need to be fully aware of the circumstances and receptive to the challenges that local surgeons face. Visiting surgeons need to be complimentary rather than critical and to keep in mind that the local surgeons are doing their best with the available resources.

The model in action

The international teaching model described in this article was recently applied in a collaborative effort between two tertiary centers, with a design similar to that originally proposed by Riviello and colleagues in 2010.12

On the receiving end was the Maadi Armed Forces Hospital (MAFH) in Cairo, Egypt, built in 1960 to provide medical care to high-ranking U.S. Army officers and their families. At that time, it was one of the biggest hospitals in the Middle East. Eventually, the facility began providing tertiary care to soldiers and lower-rank officers and their families. Over the years, the MAFH became known for its excellent services and advanced care, which led to the hospital providing care to Egyptian civilians. The MAFH now has 1,200 beds in multiple buildings on one campus.

In its efforts to provide superior care, the hospital, which is supported by powerful military resources, began inviting experts from abroad in the early 1990s to help teach and promote certain in-demand specialties. One of the most active services in these collaborations is gastrointestinal surgery. Surgeons acknowledge that the rapid advances in the field of gastrointestinal surgery, paired with the advances in minimally invasive technology, has led to a gap between countries. The local surgeons at the MAFH, who strive to maintain a high standard of care, realized that the best benefits arise from group learning opportunities led by an invited expert for a period of two weeks every year.

The MAFH also has its own surgical residency program. The residents greatly appreciated the opportunity to learn from a visiting expert and were actively involved in preparing cases and presenting them during clinic or ward rounds.
On the other side of the world, the University of Kansas Medical Center has grown to become one of the largest medical centers in the Midwestern U.S. Its gastroenterology and gastrointestinal surgical program, as well as its superior care and advanced medical science, have received national recognition.13 Reaching outside the U.S. was perceived as an opportunity to carry the institution’s teaching mission to the next level.

The model described here includes no financial benefits to either party. Travel expenses, accommodation, and local transportation were provided by the Egyptian armed forces and government.

The six working days per week included the following clinical activities: two outpatient clinics, four operating days, daily inpatient rounding, and endoscopy. Patients who needed advanced surgical opinions, bariatric services, or had previously undergone complicated operations were encouraged to register for evaluation prior to this collaboration period. These patients were pre-screened by an MAFH surgery panel prior to the visit, and a thorough workup pertaining to each patient’s disease was obtained.

The attending surgeons who had helped to establish the two-week program as well as the surgery residents were present in every clinic. Interviewing, evaluating, and discussing the patients were done in a warm and respectful atmosphere. This close interaction allowed for great scientific discussions.

Cultural barriers between the patients and visiting experts were easier to surmount when native physicians were available. It is imperative to recognize that the approach to the patient may vary greatly between certain cultures. Fortunately, patient feedback was positive in regard to their experience.

Each operating morning, we all met to review the day’s cases before proceeding to the operating room (OR). The operating team was identified and consisted of the visiting expert plus a local surgeon. The learning needs were reviewed and recognized. The entire team was available for each of the 12 advanced cases in the OR—where the best learning is achieved—during a two-week period of time.

The program was closely monitored by the MAFH administrative leaders and the quality control department. They tracked the number of patients treated in the clinic, the number of surgical or endoscopy cases, outcomes and complications, patient satisfaction, and financial success. (The patients were primarily referred from other military and civilian hospitals.) The visiting expert was briefed on the results at the end of the visit, and feedback regarding the experience was reported to the visitor. The surgeons from the MAFH report that their patients have been very pleased with their outcomes and that the surgeons are now able to perform more laparoscopic and minimally invasive procedures. Because of these successes, the author has been asked to return for another “teach the teacher” program.

Summary

Concerns linger about how to provide equitable global health care and how to address the great unmet health care needs in many countries. The burden of outreach mostly falls on universities. Universities and educational institutions by design are capable of defining the necessary directions for change. The challenge for universities participating in global health care and education is creating and sustaining robust health systems tailored to each community by evaluating the existing system and taking note of stakeholders, opinion leaders, and the availability of sustained resources in the milieu of the rapidly changing global health care structures.14

The model described here is rooted in educational theory and based on the belief that sharing surgical knowledge is the most effective way to improve access to necessary care for underserved patient populations. Positive changes can be made by developing relationships among health care personnel and new approaches to educational problems. This positive outcome was largely due to the development of new attitudes by professionals and their approach to education and collaboration.

Development of a systemic approach to global health care problems is a daunting task. The solution is neither simple nor easy, and the active participation of the assisted party is highly encouraged.


Acknowledgment
The author would like to recognize members of the MAFH team: Osama Galal Fahmy, MB, ChB, FRCS, director of the MAFH gastrointestinal surgery unit; Salah Ayad, MB, ChB; Osama Ahmed, MB, ChB; Alaa Emara, MB, ChB; and Amro El Sobky, MB, ChB, each a consultant surgeon for the team; and Maadi Armed Forces Hospital, Corniche El Maadi, Cairo, Egypt.

Special thanks to Thomas McLean, MD, JD, FACS, for reviewing the article and his valuable comments.


References

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  2.  American College of Surgeons. Operation Giving Back. Available at: http://www.operationgivingback.facs.org/. Accessed July 19, 2013.
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  7. World Health Organization. The World Health Report 2006. Available at: http://www.who.int/whr/2006/en/index.html. Accessed July 21, 2013.
  8. Lorntz B, Boissevain JR, Dillingham R, Kelly J, Ballard A, Scheld WM, Guerrant RL. A trans-university center for global health. Acad Med. 2008;83(2):165-172.
  9. Operation Smile. About us. Available at: http://www.operationsmile.org/about_us/who-we-are/. Accessed July 21, 2013.
  10. Wall LL, Arrowsmith SD, Lassey AT, Danso K. Humanitarian ventures or “fistula tourism?”: The ethical perils of pelvic surgery in the developing world. Int Urogynecol J Pelvic Floor Dysfunct. 2006;17(6):559-562.
  11. Jesus JE. Ethical challenges and considerations of short-term international medical initiatives: An excursion to Ghana as a case study. Ann Emerg Med. 2010;55(1):17-22.
  12. Riviello R, Ozgediz D, Hsia RY, Azzie G, Newton M, Tarpley J. Role of collaborative academic partnerships in surgical training, education, and provision. World J Surg. 2010;34(3):459-465.
  13. U.S. News & World Report. Best hospitals 2013–2014. Available at: http://health.usnews.com/best-hospitals. Accessed April 14, 2014.
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