International surgery provides opportunities for residents to serve and learn

The surgeon’s character is one of a natural leader with a zest for exploring new opportunities and furthering one’s knowledge and experience. In an era of increasing globalization, the dramatic advances in transportation methods and social media have truly transformed the world into a veritable “global village.” As such, increasing numbers of surgical trainees are seeking to include international experience as a component of their surgical education. Many of these trainees will choose a residency based upon a program’s established rotations abroad, or upon the flexibility of the program in allowing a foreign surgical experience.

International surgical involvement within residency training often occurs in a setting with few medical and surgical resources and requires a dedicated effort on the part of the trainee to manage his or her time effectively, be cognizant of legal documentation requirements, and to become familiar with culturally competent care and practices. In fact, it is usually the cultural environment that heightens the experience for a visiting team of volunteers. There are several reasons to pursue these opportunities, and this article provide an overview of the benefits of international training experiences.

Benefits of international training

First, foreign surgical experience may enrich a surgical trainee’s personal education. This time away from home provides exposure to situations and medical conditions rare in North America. Dedicated ancillary staff and auxiliary high-technology radiological facilities are far less common in many countries, and consequently, a greater emphasis and reliance on surgical clinical examination and diagnosis is essential. Residents encounter more advanced disease and have to assimilate treatment plans with scarce resources. Furthermore, it is timely during this era of health care reform that trainees be exposed to differing health care delivery models and practices from around the world.

International experiences also ensure that people in need throughout the world have access to necessary medical and surgical services. Many less-developed countries have an overwhelming disease burden, and this situation is often compounded by a paucity of trained surgeons. Many residents plan to spend significant time abroad at the faculty level, helping to train surgeons in areas of the world that have a limited supply of trained surgeons or specialty-trained surgeons per capita. To this end, some surgical programs have successfully built in a supplementary year to train residents in rural and international surgery, and the graduating residents are now on staff as adjunct faculty working in underdeveloped areas of the U.S. and other parts of the world.1

Another benefit of overseas training is that it helps to encourage international collaboration. Although the Internet and other forms of telecommunication have greatly expedited our capabilities to transmit knowledge to one another with relative ease, and simulation has been developed recently to enhance learning of procedural skills, the traditional method of hands-on experience with experts in various fields can never be underestimated. A big part of surgical training is still based on an apprenticeship model and a continued fostering of the collaboration within our specialties and transference of concepts and techniques remains imperative.

Unfortunately, published data on the availability of international training opportunities within residency programs are limited. In a 2011 survey of U.S. general surgery program directors, Mitchell and colleagues found that 12 percent of U.S. programs had a formal international elective in place, with only 20 percent of these programs having a formal curriculum; 60 percent reported informal programs in place for international rotations for residents.2 A similar study in 2009 with 73 respondents reported 33 percent of U.S. programs with educational opportunities in global surgery, 86 percent of which offer rotations abroad.3

Most surgical residents have an expressed interest in international educational opportunities. A 2009 survey of 724 general surgery residents found that 92 percent were interested in an international elective.4 In fact, more than half of them were willing to use allotted vacation time to pursue this elective, and 74 percent would have participated even if cases did not count toward residency requirements. Furthermore, the interest in global surgical electives extends beyond general surgery into the surgical subspecialties, with most trainees in plastic surgery, otolaryngology, and other disciplines expressing a desire for such experiences.5,6 The most frequent barrier for these residents, understandably, was logistics. As such, a concerted effort to gain a wider awareness and acceptance of this need is important.

Volunteerism and education

The American College of Surgeons (ACS) Operation Giving Back program defines volunteerism as providing “prospective, planned care or services to patients outside of the routine practice environment with no anticipation of reimbursement or economic gain.”7 The value of volunteerism is often in providing much-needed medical expertise and care in resource-poor settings. Whether provided by a single surgeon visiting a rural hospital or by a group of medical professionals in an organized fashion, this care often includes necessary operations and services for patients who otherwise would not have access. Areas of the world with a paucity of general surgeons or of surgical subspecialists may benefit from time given by visiting volunteers.

In contrast, educational experiences place emphasis on the training of those visiting the country or the training of surgeons who reside in that country. Visiting physicians who are on international education rotations, often medical students or residents, have valuable opportunities to see pathology that is less common in their own country or to obtain more experience in less commonly performed procedures. Imperative in such situations is adequate trainee supervision during the rotation to ensure that residents practice within the parameters and usual limitations of the home training program. To act otherwise would be unethical.8

Training of international surgeons

The education that U.S. surgeons can provide to health care professionals in limited resource areas of the world is an area that continues to evolve.

For many Western surgeons, participation in medical missions historically was tied to their religious principles—part of an effort to fulfill their faith’s doctrine of serving others. Organized religions often supported these programs with the recognition that providing needed health care may lead to acceptance within the populations to which they hoped to spread their faith.

This trend continued in the 20th century; however, many governmental and non-governmental secular organizations started to become involved as international travel made the containment and eradication of disease a global concern. Today, many organizations focus on short-term trips to provide care. Critics note that without proper planning, these trips may become self-serving and “provide value for visitors without meeting the local community’s needs” or be ineffective, providing only temporary and short-term therapies.9

A logical response to these concerns and a more effective means of providing care to a large population is to train the people living in that society. An example is the collaboration between U.S. surgeons and the Pan-African Academy of Christian Surgeons (PAACS). PAACS formed in 1996 when a group of general surgeons from mission hospitals in Africa partnered with the Christian Medical and Dental Association in the U.S. Since then, it has grown to encompass eight hospitals in Africa that serve as the training sites for seven formal general surgery residencies and a single pediatric surgery training program.9 Numerous secular U.S. institution-sponsored surgical residencies have been established in African nations as well, including one in Eritrea10 and one in Malawi.11

The desired outcome of these collaborations is the training of surgeons who will then go on to train other health care professionals within their country and culture, obviating the need for short-term missions. Once this aim is accomplished in a particular area, North American surgical residents can continue to benefit from training in these locations by rotating through now self-sustaining training programs abroad.

Getting involved

The benefit of the surgical volunteerism experience is a lifelong reward, and multiple opportunities are available to surgeons, including programs sponsored by Operation Giving Back. And, for students and residents who are interested in the experience of training abroad, many residency programs around the country now have an established curriculum involving international rotations.

Medical students applying for general surgery residency frequently inquire about the availability of these opportunities, and the authors support this practice. However, it is important to query program directors regarding the details about their rotations abroad. Important questions or topics to discuss with these individuals include whether the program has an established affiliation with an institution in the visiting country, the number of residents who are allowed to participate per year, whether the institution has a structured curriculum for that time, and whether the program provides residents with the ability to count cases performed abroad toward the Accreditation Council on Graduate Medical Education case log requirements. Applicants also are encouraged to contact residents from each program who have already participated in these rotations to get their feedback and perspectives.

Exploring your options

International training can be obtained in several ways. The most common is an elective rotation abroad, wherein a resident spends a predetermined time (usually four to eight weeks) at a structured medical facility. This is mostly limited to first through fourth postgraduate year (PGY) residents; chief residents may be allowed if their PGY-4 curriculum included chief-level rotations as all of these rotations must be completed in integrated institutions. The Residency Review Committee (RRC) has specific requirements that must be met in order for this time to count toward the required 48 weeks of clinical practice per year. A second option—more applicable to subspecialty and integrated residencies—involves participation in a mission under the supervision of a U.S.-based faculty. It is important to note that this experience may not count as clinical practice, and residents may need to use vacation time to participate.

As mentioned previously, general surgery residents as a group are interested in international training experiences.4 Residents in programs with already established electives need to discuss with their program director their interest as early as possible to allow for mandatory planning. The residency administration may require clearance both by the institutional graduate medical education office and the RRC on an individual basis, so timing is important.

Surgery residents who are enthusiastic about international rotations and enrolled in a program without an established elective may still be able to arrange for such experience, but early planning and communication are key to success. The RRC has developed the following list of requirements:12

  • Name and location of the international site
  • PGY level of the resident
  • Dates of the rotation
  • Verification that the rotation is an elective
  • Program’s accreditation status and cycle length (must be continued accreditation with at least a four-year cycle)
  • Statement that the American Board of Medical Specialties-certified faculty will supervise the resident (the RRC may be able to accept non-certified faculty if their review finds these professors acceptable, but this often translates to even further time until approval)
  • Description of the goals and objectives of the rotation
  • Educational rationale for the rotation
  • Verification of the process of resident evaluation during the rotation
  • Detailed description of the clinical experience
  • Verification of salary, expenses, and travel/evacuation insurance
  • Verification of access to educational resources (library or Web-based)
  • A copy of the program’s Letter of Agreement

Only programs in good standing are allowed to offer such an elective. Deficiencies in operative case volumes, duty-hour compliance, and board pass rates are likely to inhibit the development of an international rotation, as the residency program’s goals should first aim at improving the already established experience. The clinical setting needs to be well-defined. The type of institution, referral pattern, and scope of practice must be identified, and the institution’s operative volume, type, and mix must be assessed. The same is true for the ancillary, anesthetic, radiologic, and laboratory support.

The list of requirements may appear lengthy, but the rationale behind it is sound. The RRC is interested in enhancing resident education. To that end, the requirements are meant to ensure that residents will obtain valuable experience in a safe environment. The educational standards and supervision should be similar to that of any approved training program in the U.S., and the residency program must meet these mandates.

The factor that traditionally has inhibited residents from pursuing international experience has been the fact that the operative case volume from these rotations has not counted toward the ACGME case log requirements. However, because the RRC now recognizes that the operative experience obtained abroad can be unique and valuable, credit may be allowed for cases performed under the supervision of a U.S.-appointed teaching faculty, after appropriate communication with the RRC.

Program directors must exert significant effort to develop and maintain international experience as part of their curriculum. However, with residents’ increasing interest in this training and the ability to count the operative cases for ACGME case logs, more programs are getting involved with international training. For residents who are enthusiastic and committed to expanding their training in this domain, early recognition and communication are essential. The RRC must be intimately involved in the process, and, therefore, we encourage all interested parties to contact their RRC and obtain updated material in terms of requirements and guidelines before initiating a plan.


U.S. surgical training programs need to undergo remodeling to meet the needs of a globalizing world with dramatic health care disparities. Surgical trainees recognize these needs and relish the opportunity both to provide clinical services to people in underdeveloped countries and as a means of broadening their educational experience. The ACS has been supportive of the booming interest in creating programs that address the surgical needs in underserved areas of the U.S. and abroad. As natural leaders, surgeons need to overcome the challenges of an over-regulated training system and embrace a leadership role in forming international partnerships.


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