- Email: [email protected]
A Systematic Approach to Developing A Global Surgery Elective
GLOBAL HEALTH INITIATIVES
A Systematic Approach to Developing A Global Surgery Elective Richard S. Hoehn, MD,* Bradley R. Davis, MD,* Nathan L. Huber, MD,† Michael J. Edwards, MD,* Douglas Lungu, MD,‡ and Jocelyn M. Logan, MD* Department of Surgery, University of Cincinnati, Cincinnati, Ohio; †Lafayette Surgical Clinic, Lafayette, Indiana; and ‡Mzuzu Central Hospital, Mzuzu, Malawi *
BACKGROUND: Interest in global health has been increasing for years among American residents and medical students. Many residency programs have developed global health tracks or electives in response to this need. OBJECTIVES: Our goal was to create a global surgery
elective based on a synergistic partnership between our institution and a hospital in the developing world. DESIGN: We created a business plan and 1-year schedule for researching potential sites and completing a pilot rotation at our selected hospital. SETTING: We administered a survey to general surgery residents at the University of Cincinnati and visited medical facilities in Sierra Leone, Cameroon, and Malawi. PARTICIPANTS: The survey was given to all general
surgery residents. A resident and a faculty member executed the fact-finding trip as well as the pilot rotation. RESULTS: Our general surgery residents view an interna-
tional elective as integral to residency training and would participate in such an elective. After investigating 6 hospitals in sub-Saharan Africa, we conducted a pilot rotation at our selected hospital and gained the necessary information to organize a curriculum. We will begin sending senior residents for 8-week rotations in the coming academic year. CONCLUSIONS: By systematically approaching the proc-
ess of creating a global surgery elective, we were able to gain considerable insight into choosing a location and organizing C 2015 Association of the elective. ( J Surg 72:e15-e20. J Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: global health, surgery residency, surgical
elective, Malawi
Correspondence: Inquiries to Jocelyn M. Logan, MD, Department of Sugery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML 0558, Cincinnati, OH 45267-0558; fax: (513) 558-3788; e-mail: [email protected]
COMPETENCIES: Patient Care, Medical Knowledge, Inter-
personal and Communication Skills, System-Based Practice
BACKGROUND For many years now, interest in global health has been growing among American residents and medical students.1,2 The benefits of international health care experiences have been well published and include exposure to an increased breadth of pathology, improved physical examination skills, communication across cultural boundaries, and more efficient resource utilization.3-5 Moreover, medical students are increasingly choosing residency programs based on the opportunity to participate in a global health elective.6,7 In response to this growing interest, residency programs have been developing global health tracks and electives since the 1980s8-10 that are led mostly by primary care. Surgical specialties have faced several challenges to creating similar experiences including lack of formal accreditation, inability to count cases toward residency requirements, time constraints, and lack of funding for resident salaries and benefits while overseas.11 Subsequently, surgery residents who chose to pursue these experiences did so during vacation time or nonclinical research years. In 2011, the Accreditation Council for Graduate Medical Education Surgery Residency Review Committee (RRC) provided guidelines for creating approved global surgery electives, which resolved many of these issues and opened the door for programs to create formal, clinical experiences in global health.12 Similar to national trends, we have seen growing interest in global health at the University of Cincinnati among general surgery residents. Many residents have traveled during their research years for short-term surgical volunteer trips, using their own funding and vacation time. Increasing numbers of applicants to our residency program have asked about international opportunities during training. After the Accreditation Council for Graduate Medical Education formalized the process, we developed a plan for implementing a global surgery elective.
Journal of Surgical Education & 2015 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2015.01.011
e15
of whom complete a 5-year clinical residency as well as a 2-year research fellowship after their second clinical year.
OBJECTIVES Our primary goals were to create an RRC-approved global surgery elective based on a mutually beneficial institutional partnership. This requires identification of a hospital with sufficient surgical volume and capacity that would benefit from the services provided by a senior resident surgeon. Our goals were to (1) create an experience where residents benefit from clinical exposure to a broad range of surgical pathology and procedures in an austere environment, (2) improve the surgical capacity of the region through work force and materials, and (3) contribute to quality care improvement programs based on the needs of the hospital. Lastly, we hope to create an environment for future surgical outcomes and cost-effectiveness research.
DESIGN To assess current interest and needs in our department, we administered a web-based survey to all general surgery residents. This survey evaluated resident demographics, interest in global health, willingness to participate in an international elective, and logistic needs for doing so. We created a formal business plan detailing the goals for the global surgery elective, a budget, and methods for implementation. This plan proposed a 1-year schedule that included a fact-finding trip for investigating potential sites for our program as well as sites with established international partnerships. Potential sites for the elective were compiled based on the contacts of residents and surgeons in our department who had prior international surgery experience. We chose to focus on sub-Saharan Africa because of the vast need and our cumulative experience in that region. The goals of this trip were to learn firsthand about the hospitals we visited and assess their capacity for our proposed elective, to interview surgeons about the goals and the needs of their hospitals, and to learn about the successes and potential pitfalls from established partnerships between American and African surgical departments. We also planned and budgeted for a pilot rotation following the fact-finding trip. This was a 1-month rotation to thoroughly examine the hospital surgical volume and staffing before committing residents for the elective. We also aimed to gather logistic information from the surrounding community regarding food, lodging, transportation, and safety.
SETTING Cincinnati, Ohio The University of Cincinnati is an academic tertiary referral center for the southwest Ohio region. Our general surgery residency currently consists of 48 categorical residents, most e16
Sierra Leone Connaught Hospital is a 120-bed public hospital in Freetown, Sierra Leone. It was the first modern hospital constructed in West Africa in 1912.13 At the time of our visit, the hospital was staffed by 7 surgeons, mostly urologists and orthopedic surgeons. They train medical students but do not have a residency program. They average approximately 40 operative cases per week, most of which are hernia repairs and wound debridements. Cameroon Mbingo Baptist Hospital began in 1952 as a leprosy settlement in the village of Mbingo and has now grown into a 280-bed mission hospital and referral center for Cameroon and the West African subregion.14 It is also a training center for the Pan-African Academy of Christian Surgeons. Their training program consists of 5 clinical years with 2 African residents per year and is led by 2 American general surgeons. The surgery department is quite busy, performing more than 100 major cases on an average week. Malawi Daeyang Luke Hospital is a Korean mission hospital outside the city of Lilongwe with 200 beds and an adjacent nursing college. In 2013, they had a general surgeon who performed an estimated 10-12 cases per week. Kamuzu Central Hospital in Lilongwe is a government tertiary referral center for the central region of Malawi with an estimated 600-1000 beds that are usually occupied more than capacity.15 Kamuzu Central Hospital has a College of Surgeons of East, Central and Southern Africa–certified general surgery training program that began in 2009 with 2 residents per year. The University of North Carolina has an ongoing partnership with the hospital across multiple departments including surgery and has assisted in the development of the College of Surgeons of East, Central and Southern Africa training program.15 Malamulo Adventist Hospital is a 250-bed hospital in rural Malawi. The staff surgeon is a graduate of Loma Linda University School of Medicine who has organized an RRCapproved rotation with the Loma Linda department of surgery.16 The fourth-year surgical residents spend 8 weeks working as his junior colleagues. At the time of our visit, Loma Linda residents had provided almost 2 continuous years of coverage for the hospital. Mzuzu Central Hospital is the government-run hospital and referral center for the Northern Region of Malawi. It has approximately 300 beds and is staffed by 2 full-time general surgeons and a visiting thoracic surgeon. They train
Journal of Surgical Education Volume 72/Number 4 July/August 2015
medical interns and clinical officers but do not have surgical residents.
PARTICIPANTS A faculty surgeon and postgraduate year 3 research resident performed the fact-finding trip as well as the pilot rotation. All general surgery residents at the University of Cincinnati were offered the global health survey.
RESULTS Resident Survey on Global Health Survey results were collected from 21 of 45 (47%) residents in our program. Senior residents who were not eligible for the developing elective did not respond, but most junior residents did. Of those who responded, 81% indicated they would sign up for our proposed global surgery elective and 89% feel such an elective is important for residency training. A significant number of residents are married (55%) and have children (25%), and only 15% of responders have been to Africa. Most cited running water (87%) and international phone access (53%) as required accommodations for the elective. Fact-Finding Trip The first trip to Africa was exploratory and included visits to the aforementioned hospitals in 3 countries: Sierra Leone, Cameroon, and Malawi. We observed a variety of surgical volume and capacity. Some programs were busy with adequate general surgery staff, with the greatest limitation being operating room time. These programs would benefit more from visiting surgical subspecialists than residents to assist in the training of local surgeons. Other programs would benefit from our resident work force, but the infrastructure and surgical volume were not in place to provide a successful learning environment for surgical residents visiting on a short-term basis. Still others had adequate case volume and infrastructure, but the existence of a successful general surgery training program meant our presence would be of little benefit to the host institution. We also observed a wide range of leadership, supervision, and capacity for growth. We gained a critical perspective by speaking with the surgeons at the various hospitals as to what their needs were and whether a rotating senior level resident would be of benefit to them. We found an opportunity for a mutually beneficial partnership at Mzuzu Central Hospital (MCH) in Mzuzu, Malawi. The surgical department is led by 3 surgeons: a Malawian surgeon who completed his general surgery training in South Africa, a United Nations volunteer who was born and trained Tanzania, and a visiting thoracic
surgeon who trained in China. There are 5 clinical officers with varying experience who are trained as midlevel practitioners and can provide both medical and surgical care in the hospital setting. There are general medical interns who rotate on the surgical service for 12 weeks, but there is no surgical training program. Through interviews with surgeons at MCH, we were told that although there is ample surgical need and variety, the quality of perioperative care, operative volume, and outreach clinics were limited by a lack of work force. We identified that although there are clinical officers and medical interns who are interested in learning basic surgical care (critical to sustainably increasing the surgical capacity in the region), the staff surgeons simply do not have enough time to provide this training. Furthermore, we were invited to assist in quality improvement programs already in place in the hospital. We also learned through these interviews that our benefit would be maximized by longer rotations as well as a continuous presence on the ground to provide consistent services to MCH. Finally, we have several contacts, both Malawian and expatriate, in Mzuzu and elsewhere in Malawi. This proved quite useful when our flight home was unexpectedly canceled because of a fire in the Nairobi airport. Our investigations allowed us to identify a location that would not only provide a rich clinical experience for our residents but also where there were ample opportunities to provide valuable service to the host institution. Furthermore, we gained insight into the ideal structure for such an elective from the perspective of the host institution. Pilot Rotation After deciding that MCH was potentially an ideal partnership for our institution, we made plans for a 1-month pilot rotation. The goals were to fully evaluate the hospital and city to ensure that we could create a safe and productive experience for our residents and to collect all the logistic information necessary to create a curriculum for the elective and prepare residents for the 2 months they would spend in Mzuzu. A postgraduate year 3 research resident spent 4 weeks working with the department of surgery at MCH and was joined by an American attending surgeon for 1 week. The surgery department at MCH has 3 surgeons and a veteran clinical officer who take weekly home call and 4 junior clinical officers who take daily in-house call. They spend 2 days per week operating in the main theater and 1 day in the minor procedure room. In the 12 months before our pilot study, they averaged 20 operative cases per week, usually 5-8 per major theater day, and approximately 5 emergency cases on nights and weekends. There are obstetrics/gynecology and orthopedic surgery teams but no other specialists; therefore, urology, head and neck, and neurosurgery cases are performed by the general surgery team. They also provide endoscopy services and perform approximately 10-15 upper endoscopies per week.
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TABLE 1. Variety of Cases Observed During the 4-Week Pilot Rotation at Mzuzu Central Hospital
TABLE 3. Projected Expenses For Each Resident to Complete 2-Month Rotations at Mzuzu Central Hospital
Procedure Item
Thyroidectomy—total and subtotal Splenectomy Liver biopsy Exploratory laparotomy and lysis of adhesions Small bowel resection Large bowel resection Colostomy creation Hemorrhoidectomy Inguinal hernia repair—pediatric and adult Umbilical hernia repair—pediatric and adult Anal dilation Tracheostomy Mastectomy Breast lumpectomy Skin grafting Incision and drainage Excisional biopsy of unknown mass Prostatectomy Cystotomy for bladder stone removal Nasal polypectomy Urethral stricturoplasty Hydrocelectomy Circumcision Ventriculoperitoneal shunt
House rental Security guards (2 required) Gardener/housekeeper (1 required) Electricity Water Resident salary and benefits Airfare Transportation between Lilongwe airport and Mzuzu Internet access Phone access Pretravel costs (visa, immunizations, etc.) Temporary Malawi medical license Estimated total cost
The hospital is well equipped to handle a breadth of disease. The radiology department performs and reads radiographs, contrast studies, and ultrasounds. The laboratory reliably performs routine laboratory and microbiology assessments. Pathology specimens are sent to another hospital in Malawi once a week. They also have physical therapy, a nutritionist, and a palliative care team. We decided early during the pilot rotation that MCH was ideal for our elective based on the surgical volume, breadth of disease, and hospital infrastructure. Table 1 lists the variety of cases observed during the pilot rotation. There were clear opportunities to contribute through perioperative care, outreach surgical clinics, education of clinical officers and medical interns, as well as quality improvement programs at the request of the hospital administration. The remainder of the time was spent gathering information about the surrounding community. We wrote a detailed city guide for future residents, made contacts around the town, and explored potential housing options. We recently signed a lease for a 3-bedroom house within walking distance of the hospital based on the findings of this pilot rotation.
Cost Per 2-Month Rotation (USD) 400 300 150 100 50 14,000 1,800 200 70 50 300 300 17,720
Table 2 summarizes the cost of a thorough and systematic investigation over a 1-year period. The figures include reimbursement from the department of surgery for airfare, ground transportation, food, lodging, visas, travel insurance, and pretravel immunizations. Based on information gathered during the pilot rotation, we were able to create a proposed budget for the elective (Table 3). This budget represents the departmental cost per resident to participate in an 8-week elective.
CONCLUSIONS International health continues to grow as a field of interest among American surgical residents and residency applicants, and our program decided that it was time to create a global surgery elective. Results of a survey of our residents were similar to other reports1,2 demonstrating a strong desire to participate in an international elective from residents with a variety of family situations and travel experience. With several contacts in sub-Saharan Africa and no established international partnership, we established a 1-year plan for investigating potential sites for an elective, evaluating those sites, and then executing a pilot rotation at our chosen location. This systematic approach allowed us to gain firsthand knowledge about African health care and successful international partnerships and subsequently maximize our ability to create a positive experience for our residents.
TABLE 2. Total Expenses Paid by the UC Department of Surgery While Investigating Sites for the Global Surgery Elective Item
Cost ($)
Investigational trip: Staff surgeon and resident spent 3 weeks traveling to Sierra Leone, Cameroon, and Malawi Pilot rotation: Resident spent 4 weeks at Mzuzu Central Hospital and staff surgeon spent 1 week supervising Total costs for establishing a global surgery elective
18,453 5,582 24,035
UC, University of Cincinnati. e18
Journal of Surgical Education Volume 72/Number 4 July/August 2015
TABLE 4. Criteria to Establish Bidirectional Partnership for Global Surgery Rotation Criteria Host institution must desire an international partnership Senior surgical residents must be able to fulfill needs that are identified by the host institution (e.g., work force relief for operative burden and perioperative care or educational programs for clinical officers or junior surgical residents) If local surgical trainees are in place, the US resident should not interfere with the training of these residents Adequate surgical volume and breadth of cases Hospital infrastructure in place to support a consistent operative experience Willingness of local staff to participate in resident evaluations Plan to receive regular feedback and re-evaluation of the rotation by the host, the participating residents, and the home institution
After observing a variety of surgical departments, we were able to identify the criteria for choosing a partner institution that would allow residents to have an excellent clinical experience as well as provide an opportunity to improve and increase surgical care in the region (Table 4). There must be adequate surgical volume, breadth, and infrastructure to provide a positive educational experience for the surgical residents. For the partnership to be beneficial to the host institution there must be a void the residents can fill, such as work force to increase the surgical capacity of the hospital and education for the hospital staff and midlevel providers, and to contribute to system improvement efforts within the hospital itself. Determining what void can and should be filled has to result from interviews with surgeons and hospital administration of the host institution. We were also able to identify pitfalls to be avoided. Hospitals with low patient volume or significant infrastructural problems would not provide an adequate learning environment for our residents. Conversely, busy hospitals that are understaffed may prove to be overwhelming for residents who are only there for 2 months at a time. Other programs have a successful surgical training program in place, and the presence of our residents would be of little benefit to the institution. The insight gained from established international programs helped us settle on a format for our elective. The host institution and supervising surgeons will be intimately involved in the development of the program as well as its maintenance and improvements. Senior residents will spend 8 weeks working at MCH as junior surgeons with one of the local surgeons providing oversight at all times. The resident will operate, see patients in clinic, attend rounds, and take call. Resident rotations will overlap by a few days to allow residents to hand off to each other and provide detailed sign out regarding the patients, the hospital, and the city. Ultimately, we hope to provide continuous coverage for 12 months of the year so that we can establish a familiar and reliable presence. This may require partnerships with other US-based or locoregional training programs. Given that MCH has no surgical training program currently in place, senior residents can increase the surgical capacity of the hospital by operating,
taking call, visiting district hospitals, and running clinics with guidance provided by host surgeons. This supervised autonomy provides a rich learning environment for the visiting resident. Continued assessment of a new rotation is important to create positive resident experiences, avoid problems, and promote the success of a nascent international program.17 Needs assessments of both the parties at regular intervals is necessary in order to avoid problems and prevent the partnership from becoming ineffective or one-sided. Faculty and staff at the host site will be interviewed regularly to identify and discuss benefits and problems of the partnership as it evolves, as well as to establish a plan for improvement. Residents will complete a briefing and debriefing session before and after their rotation in order to provide feedback and alert our faculty to potential issues. There are certainly challenges to endeavors such as this. Our program must provide funding to cover transportation to and from Malawi, room and board in country, and resident salary and benefits for the time away. This will initially come from the surgery department alone, but in the future, we plan to seek out grant and philanthropy money to help with the significant expense of maintaining an international program. We also have to establish a standardized pre-elective program that provides the necessary cultural preparation and education, immunizations, and prophylaxis for working in a tropical hospital.18 Crime and political issues are always a concern, and although Malawi is a friendly and stable country, we must always be vigilant regarding resident safety. Emergency contacts with feet on the ground in the region as well as evacuation plans are important to ensure that residents can adapt to a lesspredictable infrastructure should a medical or transportation emergency arise. In conclusion, we feel we have given a successful approach to thoroughly outline goals for a global surgery elective, explore potential options, learn from past successes and failures, and create a program that is mutually beneficial for the visiting residents as well as the host institution. As global health experiences continue to expand within American training programs, it is important that these experiences remain positive for all parties involved.
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REFERENCES 1. Powell AC, Casey K, Liewehr DJ, Hayanga A, James
training: the Duke University experience. Am J Med. 1995;99(3):291-297.
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.
10. Pust RE, Moher SP. A core curriculum for interna-
2. Drain PK, Holmes KK, Skeff KM, Hall TL, Gardner P.
Farmer DL. Global health in general surgery residency: a national survey. J Am Coll Surg. 2009;208(3): 426-433.
Global health training and international clinical rotations during residency: current status, needs, and opportunities. Acad Med. 2009;84(3):320-325.
tional health: evaluating ten years’ experience at the University of Arizona. Acad Med. 1992;67(2):90-94. 11. Jayaraman SP, Ayzengart AL, Goetz LH, Ozgediz D,
12. Accreditation Council for Graduate Medical Education.
T, John C. International electives at the university of Minnesota global pediatric residency program: opportunities for education in all Accreditation Council for Graduate Medical Education competencies. Acad Pediatr. 2012;12(3):245-250.
International rotation application process. Chicago: Accreditation Council for Graduate Medical Education; 2000-2013 Available at: 〈http://www.acgme.org/ acgmeweb/Portals/0/PFAssets/ProgramResources/440_ Surgery_International_Rotation_Application_Process. docx〉 ; [cited 10.05.14].
4. Henry JA, Groen RS, Price RR, et al. The benefits of
13. The Electives Network. Connaught Hospital. Available at:
3. Gladding S, Zink T, Howard C, Campagna A, Slusher
international rotations to resource-limited settings for U.S. surgery residents. Surgery. 2013;153(4):445-454.
〈http://www.electives.net/hospital/5652〉; 2014 [cited 10.05.14].
5. Oliphant JL, Ruhlandt RR, Sherman SR, Schlatter
14. Cameroon Baptist Convention Health Services. Mbingo
MG, Green JA. Do international rotations make surgical residents more resource-efficient? A preliminary study J Surg Educ. 2012;69(3):311-319. 6. Bazemore AW, Henein M, Goldenhar LM, Szaflarski
M, Lindsell CJ, Diller P. The effect of offering international health training opportunities on family medicine residency recruiting. Fam Med. 2007;39(4): 255-260. 7. Dey CC, Grabowski JG, Gebreyes K, Hsu E, Van-
Rooyen MJ. Influence of international emergency medicine opportunities on residency program selection. Acad Emerg Med. 2002;9(7):679-683. 8. Gupta AR, Wells CK, Horwitz RI, Bia FJ, Barry M. The
International Health Program: the fifteen-year experience with Yale University’s Internal Medicine Residency Program. Am J Trop Med Hyg. 1999;61(6):1019-1023.
9. Miller WC, Corey GR, Lallinger GJ, Durack DT.
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Baptist Hospital. Available at: 〈http://www.cbchealth services.org/html/Mbingo.html〉; [cited 10.05.14].
15. UNC Department of Surgery. Kamuzu Central Hospi-
tal. Available at: 〈http://www.med.unc.edu/burn/ world/malawi〉; [cited 10.05.14].
16. Loma Linda University General Surgery Residency.
Malamulo Hospital. Available at: 〈http://www.llusur gery.org/index.php/surgical-services/malamulo-hospi tal-malawi〉; [cited 10.05.14].
17. Tarpley M, Hansen E, Tarpley JL. Early experience in
establishing and evaluating an ACGME-approved international general surgery rotation. J Surg Educ. 2013;70(6):709-714. 18. Sharafeldin E, Soonawala D, Vandenbroucke JP, Hack
E, Visser LG. Health risks encountered by Dutch medical students during an elective in the tropics and the quality and comprehensiveness of pre- and posttravel care. BMC Med Educ. 2010;10:89.
Journal of Surgical Education Volume 72/Number 4 July/August 2015
A Systematic Approach to Developing A Global Surgery Elective Richard S. Hoehn, MD,* Bradley R. Davis, MD,* Nathan L. Huber, MD,† Michael J. Edwards, MD,* Douglas Lungu, MD,‡ and Jocelyn M. Logan, MD* Department of Surgery, University of Cincinnati, Cincinnati, Ohio; †Lafayette Surgical Clinic, Lafayette, Indiana; and ‡Mzuzu Central Hospital, Mzuzu, Malawi *
BACKGROUND: Interest in global health has been increasing for years among American residents and medical students. Many residency programs have developed global health tracks or electives in response to this need. OBJECTIVES: Our goal was to create a global surgery
elective based on a synergistic partnership between our institution and a hospital in the developing world. DESIGN: We created a business plan and 1-year schedule for researching potential sites and completing a pilot rotation at our selected hospital. SETTING: We administered a survey to general surgery residents at the University of Cincinnati and visited medical facilities in Sierra Leone, Cameroon, and Malawi. PARTICIPANTS: The survey was given to all general
surgery residents. A resident and a faculty member executed the fact-finding trip as well as the pilot rotation. RESULTS: Our general surgery residents view an interna-
tional elective as integral to residency training and would participate in such an elective. After investigating 6 hospitals in sub-Saharan Africa, we conducted a pilot rotation at our selected hospital and gained the necessary information to organize a curriculum. We will begin sending senior residents for 8-week rotations in the coming academic year. CONCLUSIONS: By systematically approaching the proc-
ess of creating a global surgery elective, we were able to gain considerable insight into choosing a location and organizing C 2015 Association of the elective. ( J Surg 72:e15-e20. J Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: global health, surgery residency, surgical
elective, Malawi
Correspondence: Inquiries to Jocelyn M. Logan, MD, Department of Sugery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML 0558, Cincinnati, OH 45267-0558; fax: (513) 558-3788; e-mail: [email protected]
COMPETENCIES: Patient Care, Medical Knowledge, Inter-
personal and Communication Skills, System-Based Practice
BACKGROUND For many years now, interest in global health has been growing among American residents and medical students.1,2 The benefits of international health care experiences have been well published and include exposure to an increased breadth of pathology, improved physical examination skills, communication across cultural boundaries, and more efficient resource utilization.3-5 Moreover, medical students are increasingly choosing residency programs based on the opportunity to participate in a global health elective.6,7 In response to this growing interest, residency programs have been developing global health tracks and electives since the 1980s8-10 that are led mostly by primary care. Surgical specialties have faced several challenges to creating similar experiences including lack of formal accreditation, inability to count cases toward residency requirements, time constraints, and lack of funding for resident salaries and benefits while overseas.11 Subsequently, surgery residents who chose to pursue these experiences did so during vacation time or nonclinical research years. In 2011, the Accreditation Council for Graduate Medical Education Surgery Residency Review Committee (RRC) provided guidelines for creating approved global surgery electives, which resolved many of these issues and opened the door for programs to create formal, clinical experiences in global health.12 Similar to national trends, we have seen growing interest in global health at the University of Cincinnati among general surgery residents. Many residents have traveled during their research years for short-term surgical volunteer trips, using their own funding and vacation time. Increasing numbers of applicants to our residency program have asked about international opportunities during training. After the Accreditation Council for Graduate Medical Education formalized the process, we developed a plan for implementing a global surgery elective.
Journal of Surgical Education & 2015 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2015.01.011
e15
of whom complete a 5-year clinical residency as well as a 2-year research fellowship after their second clinical year.
OBJECTIVES Our primary goals were to create an RRC-approved global surgery elective based on a mutually beneficial institutional partnership. This requires identification of a hospital with sufficient surgical volume and capacity that would benefit from the services provided by a senior resident surgeon. Our goals were to (1) create an experience where residents benefit from clinical exposure to a broad range of surgical pathology and procedures in an austere environment, (2) improve the surgical capacity of the region through work force and materials, and (3) contribute to quality care improvement programs based on the needs of the hospital. Lastly, we hope to create an environment for future surgical outcomes and cost-effectiveness research.
DESIGN To assess current interest and needs in our department, we administered a web-based survey to all general surgery residents. This survey evaluated resident demographics, interest in global health, willingness to participate in an international elective, and logistic needs for doing so. We created a formal business plan detailing the goals for the global surgery elective, a budget, and methods for implementation. This plan proposed a 1-year schedule that included a fact-finding trip for investigating potential sites for our program as well as sites with established international partnerships. Potential sites for the elective were compiled based on the contacts of residents and surgeons in our department who had prior international surgery experience. We chose to focus on sub-Saharan Africa because of the vast need and our cumulative experience in that region. The goals of this trip were to learn firsthand about the hospitals we visited and assess their capacity for our proposed elective, to interview surgeons about the goals and the needs of their hospitals, and to learn about the successes and potential pitfalls from established partnerships between American and African surgical departments. We also planned and budgeted for a pilot rotation following the fact-finding trip. This was a 1-month rotation to thoroughly examine the hospital surgical volume and staffing before committing residents for the elective. We also aimed to gather logistic information from the surrounding community regarding food, lodging, transportation, and safety.
SETTING Cincinnati, Ohio The University of Cincinnati is an academic tertiary referral center for the southwest Ohio region. Our general surgery residency currently consists of 48 categorical residents, most e16
Sierra Leone Connaught Hospital is a 120-bed public hospital in Freetown, Sierra Leone. It was the first modern hospital constructed in West Africa in 1912.13 At the time of our visit, the hospital was staffed by 7 surgeons, mostly urologists and orthopedic surgeons. They train medical students but do not have a residency program. They average approximately 40 operative cases per week, most of which are hernia repairs and wound debridements. Cameroon Mbingo Baptist Hospital began in 1952 as a leprosy settlement in the village of Mbingo and has now grown into a 280-bed mission hospital and referral center for Cameroon and the West African subregion.14 It is also a training center for the Pan-African Academy of Christian Surgeons. Their training program consists of 5 clinical years with 2 African residents per year and is led by 2 American general surgeons. The surgery department is quite busy, performing more than 100 major cases on an average week. Malawi Daeyang Luke Hospital is a Korean mission hospital outside the city of Lilongwe with 200 beds and an adjacent nursing college. In 2013, they had a general surgeon who performed an estimated 10-12 cases per week. Kamuzu Central Hospital in Lilongwe is a government tertiary referral center for the central region of Malawi with an estimated 600-1000 beds that are usually occupied more than capacity.15 Kamuzu Central Hospital has a College of Surgeons of East, Central and Southern Africa–certified general surgery training program that began in 2009 with 2 residents per year. The University of North Carolina has an ongoing partnership with the hospital across multiple departments including surgery and has assisted in the development of the College of Surgeons of East, Central and Southern Africa training program.15 Malamulo Adventist Hospital is a 250-bed hospital in rural Malawi. The staff surgeon is a graduate of Loma Linda University School of Medicine who has organized an RRCapproved rotation with the Loma Linda department of surgery.16 The fourth-year surgical residents spend 8 weeks working as his junior colleagues. At the time of our visit, Loma Linda residents had provided almost 2 continuous years of coverage for the hospital. Mzuzu Central Hospital is the government-run hospital and referral center for the Northern Region of Malawi. It has approximately 300 beds and is staffed by 2 full-time general surgeons and a visiting thoracic surgeon. They train
Journal of Surgical Education Volume 72/Number 4 July/August 2015
medical interns and clinical officers but do not have surgical residents.
PARTICIPANTS A faculty surgeon and postgraduate year 3 research resident performed the fact-finding trip as well as the pilot rotation. All general surgery residents at the University of Cincinnati were offered the global health survey.
RESULTS Resident Survey on Global Health Survey results were collected from 21 of 45 (47%) residents in our program. Senior residents who were not eligible for the developing elective did not respond, but most junior residents did. Of those who responded, 81% indicated they would sign up for our proposed global surgery elective and 89% feel such an elective is important for residency training. A significant number of residents are married (55%) and have children (25%), and only 15% of responders have been to Africa. Most cited running water (87%) and international phone access (53%) as required accommodations for the elective. Fact-Finding Trip The first trip to Africa was exploratory and included visits to the aforementioned hospitals in 3 countries: Sierra Leone, Cameroon, and Malawi. We observed a variety of surgical volume and capacity. Some programs were busy with adequate general surgery staff, with the greatest limitation being operating room time. These programs would benefit more from visiting surgical subspecialists than residents to assist in the training of local surgeons. Other programs would benefit from our resident work force, but the infrastructure and surgical volume were not in place to provide a successful learning environment for surgical residents visiting on a short-term basis. Still others had adequate case volume and infrastructure, but the existence of a successful general surgery training program meant our presence would be of little benefit to the host institution. We also observed a wide range of leadership, supervision, and capacity for growth. We gained a critical perspective by speaking with the surgeons at the various hospitals as to what their needs were and whether a rotating senior level resident would be of benefit to them. We found an opportunity for a mutually beneficial partnership at Mzuzu Central Hospital (MCH) in Mzuzu, Malawi. The surgical department is led by 3 surgeons: a Malawian surgeon who completed his general surgery training in South Africa, a United Nations volunteer who was born and trained Tanzania, and a visiting thoracic
surgeon who trained in China. There are 5 clinical officers with varying experience who are trained as midlevel practitioners and can provide both medical and surgical care in the hospital setting. There are general medical interns who rotate on the surgical service for 12 weeks, but there is no surgical training program. Through interviews with surgeons at MCH, we were told that although there is ample surgical need and variety, the quality of perioperative care, operative volume, and outreach clinics were limited by a lack of work force. We identified that although there are clinical officers and medical interns who are interested in learning basic surgical care (critical to sustainably increasing the surgical capacity in the region), the staff surgeons simply do not have enough time to provide this training. Furthermore, we were invited to assist in quality improvement programs already in place in the hospital. We also learned through these interviews that our benefit would be maximized by longer rotations as well as a continuous presence on the ground to provide consistent services to MCH. Finally, we have several contacts, both Malawian and expatriate, in Mzuzu and elsewhere in Malawi. This proved quite useful when our flight home was unexpectedly canceled because of a fire in the Nairobi airport. Our investigations allowed us to identify a location that would not only provide a rich clinical experience for our residents but also where there were ample opportunities to provide valuable service to the host institution. Furthermore, we gained insight into the ideal structure for such an elective from the perspective of the host institution. Pilot Rotation After deciding that MCH was potentially an ideal partnership for our institution, we made plans for a 1-month pilot rotation. The goals were to fully evaluate the hospital and city to ensure that we could create a safe and productive experience for our residents and to collect all the logistic information necessary to create a curriculum for the elective and prepare residents for the 2 months they would spend in Mzuzu. A postgraduate year 3 research resident spent 4 weeks working with the department of surgery at MCH and was joined by an American attending surgeon for 1 week. The surgery department at MCH has 3 surgeons and a veteran clinical officer who take weekly home call and 4 junior clinical officers who take daily in-house call. They spend 2 days per week operating in the main theater and 1 day in the minor procedure room. In the 12 months before our pilot study, they averaged 20 operative cases per week, usually 5-8 per major theater day, and approximately 5 emergency cases on nights and weekends. There are obstetrics/gynecology and orthopedic surgery teams but no other specialists; therefore, urology, head and neck, and neurosurgery cases are performed by the general surgery team. They also provide endoscopy services and perform approximately 10-15 upper endoscopies per week.
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TABLE 1. Variety of Cases Observed During the 4-Week Pilot Rotation at Mzuzu Central Hospital
TABLE 3. Projected Expenses For Each Resident to Complete 2-Month Rotations at Mzuzu Central Hospital
Procedure Item
Thyroidectomy—total and subtotal Splenectomy Liver biopsy Exploratory laparotomy and lysis of adhesions Small bowel resection Large bowel resection Colostomy creation Hemorrhoidectomy Inguinal hernia repair—pediatric and adult Umbilical hernia repair—pediatric and adult Anal dilation Tracheostomy Mastectomy Breast lumpectomy Skin grafting Incision and drainage Excisional biopsy of unknown mass Prostatectomy Cystotomy for bladder stone removal Nasal polypectomy Urethral stricturoplasty Hydrocelectomy Circumcision Ventriculoperitoneal shunt
House rental Security guards (2 required) Gardener/housekeeper (1 required) Electricity Water Resident salary and benefits Airfare Transportation between Lilongwe airport and Mzuzu Internet access Phone access Pretravel costs (visa, immunizations, etc.) Temporary Malawi medical license Estimated total cost
The hospital is well equipped to handle a breadth of disease. The radiology department performs and reads radiographs, contrast studies, and ultrasounds. The laboratory reliably performs routine laboratory and microbiology assessments. Pathology specimens are sent to another hospital in Malawi once a week. They also have physical therapy, a nutritionist, and a palliative care team. We decided early during the pilot rotation that MCH was ideal for our elective based on the surgical volume, breadth of disease, and hospital infrastructure. Table 1 lists the variety of cases observed during the pilot rotation. There were clear opportunities to contribute through perioperative care, outreach surgical clinics, education of clinical officers and medical interns, as well as quality improvement programs at the request of the hospital administration. The remainder of the time was spent gathering information about the surrounding community. We wrote a detailed city guide for future residents, made contacts around the town, and explored potential housing options. We recently signed a lease for a 3-bedroom house within walking distance of the hospital based on the findings of this pilot rotation.
Cost Per 2-Month Rotation (USD) 400 300 150 100 50 14,000 1,800 200 70 50 300 300 17,720
Table 2 summarizes the cost of a thorough and systematic investigation over a 1-year period. The figures include reimbursement from the department of surgery for airfare, ground transportation, food, lodging, visas, travel insurance, and pretravel immunizations. Based on information gathered during the pilot rotation, we were able to create a proposed budget for the elective (Table 3). This budget represents the departmental cost per resident to participate in an 8-week elective.
CONCLUSIONS International health continues to grow as a field of interest among American surgical residents and residency applicants, and our program decided that it was time to create a global surgery elective. Results of a survey of our residents were similar to other reports1,2 demonstrating a strong desire to participate in an international elective from residents with a variety of family situations and travel experience. With several contacts in sub-Saharan Africa and no established international partnership, we established a 1-year plan for investigating potential sites for an elective, evaluating those sites, and then executing a pilot rotation at our chosen location. This systematic approach allowed us to gain firsthand knowledge about African health care and successful international partnerships and subsequently maximize our ability to create a positive experience for our residents.
TABLE 2. Total Expenses Paid by the UC Department of Surgery While Investigating Sites for the Global Surgery Elective Item
Cost ($)
Investigational trip: Staff surgeon and resident spent 3 weeks traveling to Sierra Leone, Cameroon, and Malawi Pilot rotation: Resident spent 4 weeks at Mzuzu Central Hospital and staff surgeon spent 1 week supervising Total costs for establishing a global surgery elective
18,453 5,582 24,035
UC, University of Cincinnati. e18
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TABLE 4. Criteria to Establish Bidirectional Partnership for Global Surgery Rotation Criteria Host institution must desire an international partnership Senior surgical residents must be able to fulfill needs that are identified by the host institution (e.g., work force relief for operative burden and perioperative care or educational programs for clinical officers or junior surgical residents) If local surgical trainees are in place, the US resident should not interfere with the training of these residents Adequate surgical volume and breadth of cases Hospital infrastructure in place to support a consistent operative experience Willingness of local staff to participate in resident evaluations Plan to receive regular feedback and re-evaluation of the rotation by the host, the participating residents, and the home institution
After observing a variety of surgical departments, we were able to identify the criteria for choosing a partner institution that would allow residents to have an excellent clinical experience as well as provide an opportunity to improve and increase surgical care in the region (Table 4). There must be adequate surgical volume, breadth, and infrastructure to provide a positive educational experience for the surgical residents. For the partnership to be beneficial to the host institution there must be a void the residents can fill, such as work force to increase the surgical capacity of the hospital and education for the hospital staff and midlevel providers, and to contribute to system improvement efforts within the hospital itself. Determining what void can and should be filled has to result from interviews with surgeons and hospital administration of the host institution. We were also able to identify pitfalls to be avoided. Hospitals with low patient volume or significant infrastructural problems would not provide an adequate learning environment for our residents. Conversely, busy hospitals that are understaffed may prove to be overwhelming for residents who are only there for 2 months at a time. Other programs have a successful surgical training program in place, and the presence of our residents would be of little benefit to the institution. The insight gained from established international programs helped us settle on a format for our elective. The host institution and supervising surgeons will be intimately involved in the development of the program as well as its maintenance and improvements. Senior residents will spend 8 weeks working at MCH as junior surgeons with one of the local surgeons providing oversight at all times. The resident will operate, see patients in clinic, attend rounds, and take call. Resident rotations will overlap by a few days to allow residents to hand off to each other and provide detailed sign out regarding the patients, the hospital, and the city. Ultimately, we hope to provide continuous coverage for 12 months of the year so that we can establish a familiar and reliable presence. This may require partnerships with other US-based or locoregional training programs. Given that MCH has no surgical training program currently in place, senior residents can increase the surgical capacity of the hospital by operating,
taking call, visiting district hospitals, and running clinics with guidance provided by host surgeons. This supervised autonomy provides a rich learning environment for the visiting resident. Continued assessment of a new rotation is important to create positive resident experiences, avoid problems, and promote the success of a nascent international program.17 Needs assessments of both the parties at regular intervals is necessary in order to avoid problems and prevent the partnership from becoming ineffective or one-sided. Faculty and staff at the host site will be interviewed regularly to identify and discuss benefits and problems of the partnership as it evolves, as well as to establish a plan for improvement. Residents will complete a briefing and debriefing session before and after their rotation in order to provide feedback and alert our faculty to potential issues. There are certainly challenges to endeavors such as this. Our program must provide funding to cover transportation to and from Malawi, room and board in country, and resident salary and benefits for the time away. This will initially come from the surgery department alone, but in the future, we plan to seek out grant and philanthropy money to help with the significant expense of maintaining an international program. We also have to establish a standardized pre-elective program that provides the necessary cultural preparation and education, immunizations, and prophylaxis for working in a tropical hospital.18 Crime and political issues are always a concern, and although Malawi is a friendly and stable country, we must always be vigilant regarding resident safety. Emergency contacts with feet on the ground in the region as well as evacuation plans are important to ensure that residents can adapt to a lesspredictable infrastructure should a medical or transportation emergency arise. In conclusion, we feel we have given a successful approach to thoroughly outline goals for a global surgery elective, explore potential options, learn from past successes and failures, and create a program that is mutually beneficial for the visiting residents as well as the host institution. As global health experiences continue to expand within American training programs, it is important that these experiences remain positive for all parties involved.
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