Surgical training abroad: It’s not about the cases

Emergency room entrance to Parirenyatwa Hospital in Harare, Zimbabwe.

Emergency room entrance to Parirenyatwa Hospital in Harare, Zimbabwe.

Surgical team makes formal teaching rounds at Parirenyatwa hospital in Harare, Zimbabwe. Dr. Cloyd next to Prof. Godfrey Muguti (back row).

Surgical team makes formal teaching rounds at Parirenyatwa hospital in Harare, Zimbabwe. Dr. Cloyd next to Prof. Godfrey Muguti (back row).

Visiting Stanford faculty David Spain, MD, FACS (far left), and Dr. Wren (fourth from right) before teaching rounds.

Visiting Stanford faculty David Spain, MD, FACS (far left), and Dr. Wren (fourth from right) before teaching rounds.

“How many cases did you do?” This quickly became the most common question I was asked after returning from a month-long surgical rotation in Zimbabwe. As the first resident to embark on a new international surgery elective at Stanford University, Palo Alto, CA, I certainly felt some pressure to compile a good operative case load to prove the value of the rotation to our program. However, once I arrived in Zimbabwe, the lessons I learned simply from practicing in a new and unique environment rapidly became more important than the number of cases logged. The focus that my peers, attending surgeons, and family and friends placed on operative volume seemed to only distract from these lessons.

Valuable experiences

One of the most valuable aspects of training abroad is exposure to new disease processes in a unique patient population. The patient with right lower quadrant pain and fever does not have appendicitis, but rather has perforated typhoid. The cause of the small bowel obstruction is not adhesions from prior surgery, but instead is intra-abdominal tuberculosis. Due to the absence of, or poor adherence to, cancer screening, patients with breast or colon cancer often first present with disease in advanced stages—a situation to which those of us who trained recently or are in training in the West are typically unaccustomed.

One of the first patients I met at Parirenyatwa Hospital in Harare, Zimbabwe’s capital, was a woman with a large lower extremity wound from a crocodile bite. Inaccessibility of adequate care in this rural area forced the wound to go largely untreated for several weeks. She eventually presented to the only university-affiliated hospital in the country with pseudomonas wound sepsis, which required aggressive debridement, antibiotics, and eventually soft tissue coverage. I witnessed countless cases like this one during my month abroad: The young child who required a scalp skin graft after being bitten by a venomous snake, the untreated epileptic with a large third-degree burn after falling into his cooking fire, and the woman who developed a Marjolin’s ulcer in a chronic burn scar. A significant portion of my experience was learning to manage late complications of burns and traumatic wounds.

The presence of multiple operating rooms (ORs), and a small intensive care unit could make it easy to forget the significant constraints on available resources, but seeing patients who are expected to produce the necessary funds before receiving care was a new experience. You quickly learn a few simple rules—almost everything is reusable, hardly anything is disposable, and nothing is wasted. This is especially true of blood products, which are a scarce commodity.

An anesthesia colleague told me of a striking case involving a patient undergoing a resection of a large neck tumor who had significant intraoperative bleeding. Although cross-matched blood had been prepared preoperatively, the anesthesia team would not administer it until the surgeon had proven he could control the hemorrhage. For similar reasons, trauma patients could only receive blood transfusions if survival was expected. Triage of scarce resources was a new concept for me.

Without access to computed tomography or magnetic resonance imaging, greater reliance on plain radiographs and occasionally sonography is required. Without daily labs available, postoperative management depends on astute history and physical exam skills. Without routine access to advanced endoscopy, surgery is the mainstay treatment for choledocholithiasis, bleeding peptic ulcer disease, or gastrointestinal obstruction. Without capabilities for minimally invasive surgery, familiarity with open surgery is required. This type of experience cannot be gained nowadays at large academic medical centers in the U.S., and the lessons learned through this international experience were invaluable.

Challenges to international training

Considering all I learned on this rotation, both in the OR and out, I would recommend this experience for other general surgery residents, particularly those who plan to practice in rural areas. In fact, a 2009 survey of general surgery residents in the Resident and Associate Society of the American College of Surgeons (RAS-ACS) indicates that most surgery residents would value this opportunity (n=724). Notably, 92 percent of the respondents said they were interested in an international health elective, and 82 percent stated they would prioritize an international experience over other electives.1

Despite this strong interest among trainees, many obstacles have prevented wide adoption of formal international surgical training. Factors such as funding, timing of experience (that is, vacation, research years, or elective time), and identification of supervising surgeons who have received Residency Review Committee (RRC) approval are difficult to address. In part because of these challenges, a recent survey of U.S. general surgery residency program directors showed that only 11 percent of programs had formal international health electives, though many had reported informal international opportunities.2

Many of these informal programs consist of short-term missions, whereby U.S. volunteers from surgery, anesthesia, and nursing visit a resource-poor area, bring necessary equipment and supplies, provide basic surgical services, and then return home. In this scenario, the primary objective is philanthropic; resident education is secondary and mainly achieved through operative experience. (This type of experience also more closely mirrors what residents see and learn in the U.S. and not the practices of health care professionals in the local resource-constrained environment.) In fact, a previous survey of general surgery residents (n=52) found that 94 percent believed that the acquisition of technical and clinical skills was what they most expected to gain from participation in an international training program.3 Due to trends in training in the U.S. with regard to work hours, increased supervision, and decreased autonomy, some residents may increasingly feel that international case experiences are an opportunity to augment or replace those training gaps. Importantly, the involvement of trainees in surgical volunteerism in developing countries may raise important ethical issues that are sometimes set aside, such as quality of unsupervised practice and potential displacement of local trainees.4

Collaboration breeds opportunities

With these challenges in mind, the department of surgery at Stanford University has developed an international partnership with the University of Zimbabwe College of Health Sciences (UZCHS). U.S. residents complete a one-month general surgical rotation during postgraduate year three, working alongside Zimbabwean residents, interns, and medical students and learning from Zimbabwean faculty. The experience includes elective and emergency surgery, formal inpatient rounds, preoperative conferences, and didactic lectures. It is based primarily at the university-affiliated Parirenyatwa Hospital.

Approval from the Accreditation Council for Graduate Medical Education and the RRC has permitted credit towards American Board of Surgery graduation requirements. The on-site supervising surgeon is Zimbabwean, making this experience one of the first of its kind. The reciprocal agreement includes Stanford faculty providing educational modules as requested by UZCHS and visiting opportunities for Zimbabwean faculty and residents at Stanford.

The Stanford-Zimbabwe rotation has been constructed in a way to maximize the learning opportunities of training in a resource-poor environment halfway across the world. It is designed not only to offer a rich operative experience but also to emphasize a diverse patient population, uncommon disease processes, atypical patient presentations, cultural competency, and the practice of medicine with significant constraints on available resources. Although the operative experience gained while abroad is an important part of the international surgical experience, for me, the lessons learned outside the OR were just as valuable.

It is our hope that the Stanford-UZCHS relationship will serve as a collaborative model that other surgical training programs will choose to follow. This type of international partnership should serve to both enhance the training of U.S. residents and at the same time equip health care professionals in underserved nations to better care for their patients.


References

  1. 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.
  2. Mitchell KB, Tarpley MJ, Tarpley JL, Casey KM. Elective global surgery rotations for residents: A call for cooperation and consortium. World J Surg. 2011;35(12):2617-2624.
  3. Powell AC, Mueller C, Kingham P, Berman R, Pachter HL, Hopkins MA. International experience, electives, and volunteerism in surgical training: A survey of resident interest. J Am Coll Surg. 2007;205(1):162-168.
  4. Ramsey KM, Weijer C. Ethics of surgical training in developing countries. World J Surg. 2007;31(11):2067-2069; discussion 2070-2071.

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