For decades, Fellows of the American College of Surgeons (ACS) have been engaged in humanitarian work, providing surgical care to underserved populations worldwide. In recent years, the ACS and the College of Surgeons of East, Central and Southern Africa (COSECSA) have been developing strategic partnerships to improve surgical education, address workforce shortages, and build a sustainable health care system. The most recent addition to these efforts has been the creation of an ACS-COSECSA Surgical Training Collaborative at Hawassa University, Ethiopia, which is set to start in January 2019.
ACS-COSECSA collaborative activities
In February 2016, the ACS Board of Regents had a retreat to develop strategies to address challenges in global surgical care. The Regents agreed to support efforts aimed at surgical workforce development in low-income countries, focusing initially on sub-Saharan Africa.
COSECSA is one of the sub-Saharan surgical colleges. This organization has approximately 2,000 members in 12 African countries, who serve a population of more than 350 million. COSECSA is responsible for the training and credentialing of surgeons.
Although several ACS Fellows have been actively working in the region, a formal initial discussion between ACS and COSECSA leadership occurred during a visit by Patricia L. Turner, MD, FACS, Director, ACS Division of Member Services, and Girma Tefera, MD, FACS, Medical Director, Operation Giving Back (OGB), in July 2016. Since then, based on COSECSA priorities, the ACS and COSECSA have engaged in several collaborative activities, including providing scholarships for graduating women residents, access to the ACS leadership training programs, access to limited educational resources, twinning of scientific journals, and recruitment of volunteers as external examiners and providers of surgical services at COSECSA training sites.
Academic global surgery programs and volunteer ACS Fellows have deployed to the region, providing training and clinical services. However, these initiatives have been poorly coordinated, with institutions working in silos, resulting in duplicative efforts and wasted resources. As more centers have launched global surgery programs, the problem has magnified.
To respond to these challenges, OGB’s Committee on Global Engagement recommended a pilot project to establish a centralized surgical training hub in sub-Saharan Africa where the quality of surgical training could be improved and the number of trainees could be scaled up.
A series of situational analysis surveys were sent to 30 African institutions; 16 responded. Of these, three were short listed and two underwent a site visit. Subsequently, Hawassa University—a 480-bed hospital that serves an area with nearly 18−20 million people—was chosen as the pilot site for the ACS-COSECSA Surgical Training Collaborative.
Departments of surgery at 13 U.S. hospitals with global surgery programs agreed to form a consortium and join hands to participate in this effort. A project planning meeting that included Hawassa University, the ACS, and the partner U.S. surgery departments met in July 2018 to develop shared goals and to devise a work plan for the coming years, focusing on ways to strengthen the education, clinical service, quality, and research infrastructure at Hawassa University. The ultimate goal of this project is to improve the quality of surgical training and increase the number of trainees. This endeavor opens up a great opportunity for U.S. residents and students to work and learn under supervision. We anticipate a year-round on-the-ground presence of U.S. faculty at Hawassa that will guarantee continuity of patient care and resident supervision.
Hawassa uses a four-year residency curriculum, which is undergoing revisions but is accepted by COSECSA. The university has a small skills lab, primarily for medical students, that could be expanded to bring additional skills training opportunities. Although endoscopy services are not yet available, Hawassa anticipates having the appropriate resources in place in the coming year, and we believe this partnership will expedite the process. Other skills training in laparoscopy, ultrasound for surgeons courses, and Advanced Trauma Life Support® training will be introduced next year. We believe these additions will add tremendous value to the educational experience of U.S. residents.
Hawassa University Hospital is the referral hospital for the region. Of the hospital’s 480 beds, 54 are assigned for general surgery. The hospital admits approximately 11,000 patients per year, and approximately 117,000 are evaluated in the outpatient services. The hospital has 10 operating room (OR) tables, but only two are reserved for general surgery. The members of the U.S. consortia schools will be integrated completely into the clinical activities of the university hospital.
Hawassa has a quality office that focuses on academic and clinical, as well as national, initiatives. A basic discussion of morbidity and mortality takes place during morning meetings, but the hospital has no database to measure surgical outcomes at this time. This group has agreed to develop some measurable quality endpoints.
Hawassa faculty members are expected to devote 25 percent of their time to research, as research and publications are part of the criterion for academic promotion. Nonethless, Hawassa faculty members have difficulty advancing their careers because of a lack of publishing opportunities. Hence, in addition to developing a research methodology for training residents, the faculty would appreciate collaborative scientific research.
Work plan and next steps
Hawassa is an excellent choice for piloting this program, as it is a relatively large teaching institution with a sound resident training model in place. The existing didactic curriculum will be strengthened by choosing a common textbook. Through our collaborative, we intend to improve skills and simulation training, partner with industry to procure simulation tools, and offer other opportunities to transfer skills. We also intend to improve Hawassa’s distance learning opportunities by creating an infrastructure that will support telehealth platforms for educational and consultative purposes.
Each of the 13 U.S. participating institutions will use telepresence technology to lead and participate in grand rounds. Visiting faculty will deploy in dyads to ensure an optimal mix of skills, talent, and resources.
We anticipate using Optimal Resources for Surgical Quality and Safety (the red book) as the guide for quality improvement initiatives, and we will further assess whether the ACS might be able to provide Hawassa with access to one of our databases for use in outcomes research and quality improvement.
Other ACS resources that may be of benefit to Hawassa students and trainees include educational materials, the Advanced Surgical Skills for Exposure in Trauma course, and Trauma Evaluation and Management training.
Just the beginning
I’m very excited about this program and am proud that the ACS will be leading this effort to improve global access to surgical care. I believe, ultimately, the ACS-COSECSA Surgical Training Collaborative will be scalable and reproducible in other locations.
I want to thank Dr. Tefera, Dr. Turner, and 2017−2018 ACS President Barbara Lee Bass, MD, FACS, for their ongoing efforts to bring this initiative to fruition. I want to recognize the OGB Committee on Global Engagement led by ACS Regent Henri R. Ford, MD, MHA, FACS, FRCS, FAAP, for working diligently on this project. With the leadership of OGB, COSECSA, and Hawassa University, we are taking an important first step toward improving the lives of surgical patients around the world.
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