Enhancing American surgical training: Meeting the challenge of a globalizing world

Dr. Kaafarani (left) operating in the Central African Republic.

Dr. Sakran (left) teaching Mr. Tembo, a Malawian clinician, how to perform a split-thickness skin graft of a patient with a burn to his calf.

A Malawian child.

OR team performing surgical pause prior to excision of a right gluteal mass. Dr. Sakran and clinical officer Mr. Beza are at left.

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Surgical diseases historically have received less public health attention and less global support than have the conditions other medical specialties treat.¹ Over the past decade, however, the surgical specialties have seen exponential growth in both interest and involvement within the global health education community. Surgical societies have established international subcommittees and seminars, and currently a paradigm shift is occurring in global health education, with the acceptance of new training opportunities for medical students and residents, and even the development of fellowships in global surgery. Given the ongoing globalization of our society, providing surgical care in medically underserved areas is more important than ever. The recent American Board of Surgery (ABS) decision to allow international electives to be counted toward sitting for the general surgery boards (under certain stipulations) is a monumental step in American surgery. Program directors may now begin or, in some cases, continue to tailor surgical curricula to meet the needs of the current generation of trainees.

Does the need exist?

The global burden of surgical disease continues to rise, and remains one of the top killers in low- and middle-income countries (LMIC).² Nonetheless, noncommunicable diseases have received relatively scant attention in comparison with communicable diseases. Paul Farmer, MD, recently referred to surgery as the “neglected stepchild of global public health.”² Only 3.5 percent of 234 million major surgical procedures performed in 2004 took place in the countries representing the poorest 35 percentile of nations (those with health care expenditures <$100 per capita).³

Lack of funding for global surgery is one of the main obstacles that must be overcome to address the global surgery challenge. Lack of interest among surgeons, until recently, has also been a major barrier. Recognizing the increased interest among its members, the American College of Surgeons (ACS) leadership conducted a study from 2001 to 2003 to evaluate the interest in volunteerism among the College’s membership. The study resulted in the creation of the Operation Giving Back (OGB) program. Initiatives such as OGB are allowing health care professionals to narrow the inequities of care seen between LMIC and high-income countries.

To address these disparities, the surgical community must come together and use a multi-faceted approach to provide effective surgical care. American surgical training programs can, and should, be a key component in the reduction of the global burden of surgical disease, which at the same time will enhance training and meet the needs of those entering residencies in the twenty-first century.

Global surgery meets surgical training

In the last few years, surgical trainees have shown a clear and considerable increase in interest in global surgery. In a national survey sent to all resident members of the ACS in 2008, 92 percent of respondents expressed clear interest in global surgical work or international electives (n=724).⁴ In fact, 82 percent of respondents said they would prioritize such an experience over many of their electives, and most are willing to use their own vacation time for that purpose.

Despite the overwhelming enthusiasm residents have expressed for global surgery, and the potential value of such experiences for LMIC as well as the surgical trainee, less than one-third of residency programs offer any educational experiences in global surgery. Even a smaller percentage offer international electives.⁵ According to the residency program directors who answered the survey in 2008, the main barriers were time constraints, educational constraints, lack of funding, and lack of approval by the Accreditation Council for Graduate Medical Education (ACGME) and the Residency Review Committee (RRC). Nonetheless, more than half of the institutions surveyed were interested in establishing a curriculum for global surgery education as part of their residency training.

In recognition of the growing interest by surgical programs and surgical trainees in international electives, the RRC and ACGME have recently modified their policies and now accept international rotations in surgery under specific circumstances (see table).⁶ Although the specific conditions that allow residents to rotate outside U.S. borders may be somewhat challenging to meet, having a set of standard guidelines is a step in the right direction. It will allow the surgical community to provide the best possible educational experience to our trainees. These criteria will help prevent “medical tourism,” which in this context is characterized as rotations without a defined infrastructure, curriculum, and/or mentorship. Furthermore, we must ensure that the highest ethical standards are upheld in the communities we serve. Even with all these changes taking place, questions still remain regarding the scope of practice of surgical trainees in LMIC.

While American surgical residencies are some of the best and most sought-after positions throughout the world, myriad benefits can be obtained by expanding beyond our own borders. In the U.S., the quality of surgery programs is judged by success in six specific areas as defined by the ACGME. In 2006, leaders in the field eloquently described how an international elective would fulfill and potentially enhance each of those core competencies: medical knowledge, patient care, interpersonal and communication skills, practice-based learning and improvement, systems practice, and professionalism.⁷

A classic example of how an international elective would augment the ACGME core competencies is the adept completion of the physical exam, which has been replaced to some extent by radiographic imaging. Whereas learning how to become more proficient at interpreting radiographic imaging is an important skill for trainees to master, the art of medicine rests on the basics of performing a thorough history and physical exam. International electives will also provide trainees the opportunity to ascertain how clinicians transcend cultural barriers to allow for clear provider-patient dialogue. This is a vital competency in a culturally diverse community. Managing complex diseases in advanced stages in low-resource settings would be invaluable opportunities to improve surgical training. Surgical trainees will become more well-rounded by broadening their medical knowledge of diseases that are less prevalent in the U.S. These experiences would assist with developing better communication skills and gaining the ability to collaborate with other institutions. Considering the increased diversity of the U.S. population and the rapidly globalizing economy, an international experience will augment the experience of our surgical trainees.

Volunteering versus capacity building

The burden of surgical disease accounts for 11 percent of the total burden of disease in the world.⁸ In many LMICs, the gap in surgical care provision is even more pronounced. For example, in the Central African Republic (CAR), most health care is provided by non-governmental organizations (NGOs), mainly Médecins Sans Frontières (MSF), also known in English-speaking countries as Doctors Without Borders. In fact, the MSF budget for the CAR is nearly equal to that provided by the nation’s Ministry of Health. Undoubtedly, short-term volunteer missions by NGOs, such as MSF, are currently indispensable in these severely underserved areas; however, these missions are a temporary bandage on the problem that does not address the essence of the problem. With fewer than 100 total generalist and specialist physicians to provide care to more than 4 million citizens, the CAR urgently needs sustainable surgical capacity building and educational programs, so that its health care delivery system can eventually meet the society’s needs.

These strategies (short-term volunteering and long-term capacity building) are not mutually exclusive. In the spring of 2007, the NGO Surgeons for Global Health (SGH) mission to Embangweni, Malawi, demonstrated how to integrate education with surgical capacity building and allow for long-term, feasible interventions. Malawi is a small land-locked country in Africa that ranks among the poorest in the world. There are two physicians for every 100,000 people in Malawi.⁹ So, rather than relying on physicians for health care delivery, the backbone of the health care system is composed of clinical officers. Their training consists of a three-year course at a post-secondary school, followed by a lifetime of learning through direct patient care. While in Malawi, SGH effectively taught clinical officers how to perform basic procedures (such as split-thickness skin grafts, abdominal hernia repairs, and so on) over a two-month period. Five years later, those SGH health care workers are gone; however, the clinical officers continue to provide care for patients in their community.

Challenges to care

A number of factors in LMICs contribute to the significant morbidity and mortality associated with surgical disease and often demonstrates the hazards of limited access to care. Potential barriers to providing surgical care to the world’s poorest populations include insufficient human and consumable resources, a perception that surgical intervention is not cost-effective, and a lack of effective political advocacy.

Impediments to accessing surgical care include distance, poor roads, and lack of transportation, as well as limited resources and expertise. Other possible obstacles include the direct and indirect costs associated with provision of surgical care and the local cultures’ trepidation regarding surgery.¹⁰

Financial

The financial costs of treating surgical disease also have traditionally been thought to be prohibitive. In many countries, visits to surgical care facilities are deferred until people have accumulated enough money, resulting in more expensive and delayed formal health care. However, when surgical disease was analyzed through Disability Adjusted Life Years (DALYs), treatment was clearly found to be cost-effective. The average cost of basic surgical care is $33 to $38 for every DALY that is prevented.⁸ In comparison with other more publicized health care interventions, the cost of providing surgical care is reasonable; for example, anti-retroviral therapy for the human immunodeficiency virus costs $300 to $500 for every DALY that is prevented.⁸

Obtaining funding for surgical diseases remains a significant challenge unless public health professionals realize that a substantial investment (as had been made for communicable diseases) is required to tackle the problem. Even when funds for surgery become available, the efficacy is always questionable, as many LMIC governments suffer from a real corruption problem. As a result, a portion of the funds never reaches the intended population. This situation has made potential donors hesitant to provide funding and drives the trend toward implementing parallel systems rather than integration into one system.

Transportation

Another challenge in providing global surgical services is improving patient access to the health care system, or bringing the clinic to the patient. Overcoming this frequent barrier often is referred to as the “problem of the last mile” and requires ingenuity on the part of health care personnel.¹¹
Although consumable resources are available in some areas, a lack of appropriate distribution strategies exists, which highlights the dearth of organized health systems in many LMICs. For example, the lack of organized emergency medical services is one of the most significant impediments to providing optimal trauma care. In a study comparing prehospital death rates, 59 percent of trauma deaths occurred in the field in high-income settings versus 72 percent in middle-income, and 81 percent in low-income environments.¹²

Social

Transcending cultural differences plays a key role in the ability to deliver global surgical care. Patients are often apprehensive about undergoing surgical procedures, especially under anesthesia, fearing a poor outcome. This problem highlights the importance of foreign health care workers integrating themselves into the community of interest. Allowing the locals to play a direct role in the various interventions being put into practice is paramount. Implementing an educational component that illustrates an understanding of the disease process that is being targeted, raising awareness about good health practices, and providing training for community health care workers can produce far-reaching positive results.

Advocacy

Advocacy involves devising strategies, evaluating measures, and proposing solutions to influence decision making at the local, state, and national level to create positive change for people and their environment.

To address the lack of adequate surgical services in Uganda, a diverse group of local stakeholders met in Kampala in May 2008 to develop a roadmap of key policy actions that would improve surgical services at the national level.¹³ Their primary goal was to generate a list of priority areas of health policy to improve surgical services in Uganda. The priority areas of action were identified as follows:

• Human resources: Improving conditions for the surgical workforce, addressing the surgical workforce shortage temporarily through task extension, redesigning the undergraduate medical curriculum, increasing practical surgical skills of graduates, and placing the focus on surgical anesthesia and nursing
• Health systems: Including surgical services in established policies, ensuring infrastructure for safe surgery, and coordinating policy initiatives to develop surgical services
• Research and advocacy: Promoting evidence-based medicine, raising public awareness about surgical services, advocating donor support on both a national and international level for collaboration among surgical specialties, and encouraging a change in the “job description” of specialty-trained surgeons to be modified from providing surgical care to include training and supervision of community health care providers

Although general health education is readily available in affluent countries, education and advocacy regarding poverty-induced health crises throughout the world are needed to provide the continued impetus for high-income countries to play a greater role in LMICs.

Despite recent increases in global health funding, available resources are far below what is needed to meet the United Nations Millennium Development Goals. Significant challenges exist, including a lack of consensus on funding priorities and increased “competition” among advocates for specific disease treatments.¹⁴

To overcome these issues, actions need to be undertaken in both the government and private sectors. Offering incentives for the private sector to increase their involvement and help fill critical funding gaps is one possibility. In the government sector, the objective is to track the effectiveness of donor spending on health. Also, sharing the evidence of progress and successes in global health initiatives has been implemented.

Whereas evidence about the impact of health care initiatives on global health is lacking, measures to collect objective evidence should be undertaken and used to formulate effective policies and innovative solutions. The strength of such evidence is required to convince policymakers about the importance of funding surgical global health priorities. The successes of current efforts in global health will be essential to galvanize support for future investments.

Conclusion

The field of global health within the surgical community is rapidly changing. We live in a continuously globalizing world that is integrating across a wide range of disciplines. The international community is more interconnected than ever before; however, the fruits of this globalization have not been equally shared. Although mortality from surgical disease in high-income countries has dramatically improved over the past 50 years, the same cannot be said for LMICs. The disparity is tremendous.

This realization became evident to one of the authors of this article, Dr. Sakran, while he was in Embangweni, Malawi. A man named Reza was carried into a makeshift trauma bay after crashing his bicycle on one of Malawi’s typically decrepit streets. The rusty handle bar eviscerated him. There was no emergency response, and he was first taken to a clinical officer. Despite the excellent skills that these clinical officers gain over time through hands-on experience, the constant interruption of supply chains that provide medical supplies, a lack of blood products, and frequent late arrival after road traffic injuries usually result in the patient’s demise—as it did for Reza. We must find a way to reduce these inequities, and provide for more long-term feasible interventions.

Clearly, interest in global health is prominent among medical students and residents currently in training. People concerned about patient care in LMICs must advocate for and take action to promote the health rights of all human beings. It will be up to our future leaders in global health care education to carry out that vision and to help foster the necessary dialogue and collaboration among citizens, professionals, communities, and policymakers.

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References

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