GLOBAL HEALTH INITIATIVES

An International Surgical Rotation as a Systems-Based Elective: The BotswanaUniversity of Pennsylvania Surgical Experience Jessica A. Cintolo-Gonzalez, MD,* Alemayehu Ginbo Bedada, MD,† Jon Morris, MD,* and Georges Azzie, MD‡ *

Department of Surgery, Hospital of the University of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; †Department of Surgery, Princess Marina Hospital, Gaborone, Botswana; and ‡Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada OBJECTIVE: There is a growing need to address the global burden of surgical disease along with increasing interest in international surgical practice, necessitating an understanding of the challenges and issues that arise on a systems level when practicing abroad. DESIGN: This elective is a month-long rotation in which senior surgical residents participate in patient care as part of a surgical team in the main tertiary and teaching hospital in Gaborone, the capital city of Botswana. Clinical experience is combined with formal readings and educational sessions, with the attending surgeon supervising the program to develop a systems-based curriculum that contextualizes the clinical experience. A formal debriefing and written reflections by the residents at the conclusion of the rotation are used to qualitatively assess resident development and insight into systems-based international surgical practice. SETTING: Princess Marina Hospital, Gaborone, Botswana. PARTICIPANTS: General surgery residents in their fourth

clinical year of training. RESULTS: Our elective met important requirements outlined in the literature for foreign practice, including adequate supervision of the American trainees and care to not detract from local trainees’ educational experience. Residents’ debriefing and written reflections demonstrated an increased understanding of systems-based practice and

Correspondence: Inquiries to Jessica A. Cintolo-Gonzalez, MD, Department of Surgery, Hospital of the University of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Maloney 4, Philadelphia, PA 19104; fax: (215) 662-7983; E-mail: [email protected], [email protected] partners.org

awareness of issues important to successful international surgical practice and collaboration. CONCLUSIONS: Our global surgery elective with a focus

on systems-based practice sensitizes residents to the challenges and issues they must be aware of when practicing C 2015 Association internationally. ( J Surg Ed 73:355-359. J of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: global surgery, international electives, sys-

tems-based practice, global health COMPETENCIES: Systems-Based Practice, Interpersonal

and Communication Skills, Patient Care, Professionalism

INTRODUCTION Surveys of American surgical program directors reveal a high degree of interest in and a growing number of global surgery electives for residents since international electives were approved in 2011 by the Residency Review Committee for credit toward graduation.1,2 Furthermore, the projected global burden of surgical disease and current unmet global surgical needs indicate a demand for surgical personnel3-6 with a grasp of what is needed to undertake the complex intervention of surgery in a global context.7 Short-term surgical missions have been criticized for inadequately addressing the needs of the region, failing to match their goals to the technology and infrastructure available, leaving behind complications, and failing to contribute to sustainable surgical practice.8-10 There is a growing sense that those

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.2015.09.019

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who are willing to practice surgery abroad should be able to address the challenges to implementing effective surgical care in a particular region and foment longer-term sustainability in underserved parts of the world. We have developed an international surgical elective for residents in their fourth clinical year of general surgical training that focuses on the systems-based aspects of practicing international surgery in lieu of prioritizing case volume and clinical experience. As one of the core competencies of the Accreditation Council for Graduate Medical Education (ACGME) and an Residency Review Committee program requirement, systems-based practice refers to “an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care.”11,12 Given that this is a core competency of the ACGME for residents being trained in the United States, it makes sense that this competency be highlighted in international practice, where systems-based issues greatly affect the surgeon’s practice and outcomes. Our elective is a formal surgical rotation, financed by the University of Pennsylvania Department of Surgery and offered to 2 residents in their fourth clinical year. Students rotate at the surgical department of Princess Marina Hospital (PMH), the main referral hospital in Gaborone, Botswana. Since the inauguration of the University of Botswana School of Medicine in 2009, it is also the main teaching hospital, at least until the opening of the new University Hospital. In addition to observing how the hospital runs and gaining insight about issues unique to the setting of PMH through its participation in the clinical service, residents are assigned articles to read about global health and surgery and meet at least once weekly with the supervising physician to discuss their experience in the hospital in the context of global health and are encouraged to identify the challenges particular to transitioning into this international setting. This elective in Botswana aims to deepen the appreciation of the issues and challenges that arise when working in a global health context. The external stakeholders have recognized and addressed local concerns regarding the program’s effect on quality of care and quality of training. In this article, we describe the structure of this systemsbased elective and its effect to date.

METHODS Resident Selection Eligible participants are general surgery residents in their fourth clinical year. They must interview with the supervising physician, a Canadian surgeon (G.A.) from the University of Toronto, with an academic appointment at the University of Pennsylvania and a long-standing relationship with the surgical department of PMH and the Ministry 356

of Health in Botswana, before the start of the elective to assure proper understanding of and alignment with the goals of the rotation. Residents understand upfront that the development of systems-based insight supersedes the clinical experience alone. Basic instructions for the rotation are provided and the resident is put in contact with the Botswana-UPENN partnership (BUP) for further preparation. Elective Logistics Housing, transportation, safety, educational licensing with the Botswana Health Professions Council, and other logistics are taken care of as part of an already established partnership between the University of Pennsylvania, the Ministry of Health of Botswana, and the University of Botswana. This BUP was established in 2001 and sponsors several clinical programs at PMH, including programs addressing human immunodeficiency virus, tuberculosis, Women’s Health, and telemedicine to improve information technology infrastructure in the health system. The BUP provides additional recommended reading about Botswana and PMH as well as language and cultural references. The BUP also supports resident electives from a variety of specialties, including internal medicine, pediatrics, and dermatology, fostering collaboration and dialog among rotators across specialties, and is seeking to offer electives at Penn to medical students from Botswana. The office of graduate medical education at the University of Pennsylvania supports the salary and benefits of the participating residents whereas the department of surgery reimburses airfare and housing. The elective residents work with the same Canadian mentor (G.A.) who has established a longitudinal relationship with the surgical department at PMH. They have also been exposed to many health care providers at PMH, but have worked primarily with a single local consultant surgeon (A.G.B.), who has demonstrated an interest not only in their education but also in providing the guidance and supervision to satisfy the goals and objectives of this systems-based elective, ensuring that patient care and local trainee experience remain paramount. Program Evaluation To assess the effect of the rotation, participating residents are asked to write a piece at the end of their time reflecting on their experiences and how these experiences translate into their understanding of practicing global health from a systems-based perspective. There is an ongoing dialog during the rotation, and a formal debriefing at the end of the rotation. The supervising surgeon assesses written reflections qualitatively to determine the residents’ understanding of key issues that relate to systems-based practice and to better determine what residents have learned from the experience. While these reflections provide valuable

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insight into resident experiences, perceptions, and growth, they would also direct development of a more uniform assessment tool that links to clearly stated rotation objectives provided at the beginning of the rotation. They would supplement the broader written reflections to more systematically determine the evolution of residents’ comprehension of systems-based issues in global health practice.

RESULTS Since the start of this elective in 2010, 6 residents (n ¼ 6) have participated; 3 male and 3 female residents. They have chosen to pursue a variety of postgraduate subspecialties, including cardiac surgery (n ¼ 1), vascular surgery (n ¼ 1), trauma and critical care (n ¼ 1), colorectal surgery (n ¼ 1), and surgical oncology (n ¼ 2). During the course of the rotation, they have participated in a range of cases, including laparoscopic cholecystectomies, trauma cases, mastectomies, laparotomies, breast biopsies, amputations, skin grafts, and hernia repairs among others. All residents have led didactic sessions in the form of lectures, discussions, and skills development with students, interns, and medical officers. Some of the residents have served as mentors to students and doctors aspiring to become surgeons. Others have contributed to projects surrounding the creation of clinical pathways for common surgical problems pertinent to the setting and local practice patterns. The residents’ reflections in conjunction with the formal debriefing have revealed insight into several issues this rotation made residents aware of when practicing internationally. Topics highlighted included the variations in disease epidemiology; the limitations in infrastructure, technology, and personnel; the effect of other expatriates; and the cultural challenges of integrating into a new system as a foreigner. The variations in disease patterns were appreciated largely from clinical experiences and discussion of admitted patients in morning report as well as when teaching medical students. One resident noted, “while diverticulitis and inflammatory bowel disease tend to be high in the differential diagnosis of abdominal pain presentations in the U.S…, I am less likely to think initially of human immunodeficiency virus-related gastrointestinal complications, tuberculosis, typhoid, or undiagnosed congenital anomalies.” Understanding such variations in epidemiology had to be integrated into discussion of differential diagnosis during teaching sessions. The limitations of infrastructure, technology, and personnel were likewise evident in both clinical situations and didactics. When teaching management of breast masses and breast cancer, a resident noted that limited pathology services and incomplete access to postoperative radiation greatly affected subsequent management and precluded the integration of breast conservation therapy into treatment algorithms. Residents also commented on observing their senior attending needing to assess CO2 supplies well in

advance of any planned laparoscopy and secure adequate amounts of CO2 when it was lacking. Another resident was dismayed to learn that he had used the last central line kit available in the hospital when trying to get vascular access for a patient. Limits in nursing staff and intensive care unit beds were also apparent to residents, particularly as they cared for complex patients. However, the importance to maintain a high standard of care despite these limitations was valued highly by all participants. Differing cultural attitudes and the reality of being a foreigner in the system also was a salient feature residents recognized while rotating at PMH. Many were cognizant that behavior considered acceptable and expected in their home institution would not necessarily be as welcome at PMH. A resident noticed that there was a struggle between the need to behave in an assertive manner to advocate for patients and the imperative to not be too abrasive or critical to build relationships with the staff, integrate into the team, and take care of patients better overall. A resident commented that “while there can be a fine boundary between promoting positive change and breaking trust…there needs to be a relationship of mutual investment in the system.” All residents agreed that culturally sensitive communication was essential to providing good patient care as part of the team and for integrating into the education of co-trainees and students. Likewise, to not negatively affect on the training of local trainees and students, accepting a lower caseload and flexibility in responsibilities was essential.

DISCUSSION Although this elective in global surgery addresses all the ACGME competencies, its focus is on calling residents’ attention to the systems-based components that affect international surgical care. Patient care, medical knowledge, practicebased learning and improvement, professionalism, and interpersonal skills and communication are all addressed in a contextualized manner, but the main objective is to provide insight into the differences surrounding systems-based practice in low-middle-income countries (in general) and in Botswana (in particular) by incorporating readings, actively discussing systems-based challenges throughout the rotation, and requiring a formal oral debriefing and reflective written evaluation on this theme at the conclusion of the rotation. This elective contrasts with other established surgical electives, which have reported a greater focus on caseload, exposure of residents to a variety of pathologies, and on the educational benefit of practicing with resource and technological limitations.13,14 The main value of these electives has been their operative volume, case diversity, and the effect of the experience on participating residents.14,15 Although valuable for the education of the resident, an overwhelming focus on the technical experience detracts from many of the important systems-based aspects one must be aware of to move forward in practicing

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responsible global surgery. Such aspects include epidemiologic, logistic, and cultural concerns as well as the challenge of contributing to sustainable services in underserved regions. This may translate into a more sensitive, if not enlightened, global surgical workforce, especially because a high number of residents who participate in global electives go on to participate in international initiatives.13,15 Of equal or even greater importance to such programs is the seldom-discussed impression by local stakeholders that the trainees from resource-rich environments come to learn, or even practice, on the more vulnerable constituents in resource-restricted environments, which creates mistrust and contributes to failure of subsequent collaboration. There is also a sense that the presence of such trainees negatively affects the education of local trainees.16 Thus, in structuring our elective, care has been taken to address some of the concerns inherent in international work to model responsible collaboration. These concerns have been addressed by thoughtful resident selection and subsequent integration. Residents toward the end of their fourth clinical year were targeted to ensure a more mature cohort with adequate clinical experience, a more advanced technical level, and abundant intensive care unit experience. This has helped assuage local concerns that residents would not be able to contribute adequately to patient care.17 Residents are adequately supervised for all surgeries. Any independence afforded to residents does not surpass the level of autonomy that they would be afforded at their home program for their clinical level of training, and often supervision is even more stringent than in their home program. Moreover, the impression of the senior supervisors has been that these mature residents are less focused on doing operations and more focused on the systems-based issues. Thoughtful integration of the residents into a receptive, well prepared local team has enhanced their ability to interact and work with local surgeons, house staff, and students. This has provided elective residents with direct insight into the local practice, resources, and hospital culture.17 The case numbers for residents on this rotation are lower than those reported for other international electives,13,14 residents share cases with medical officers, interns, and students such that they do not hinder the learning of the trainees of PMH.16 Furthermore, this permits them time to participate more in teaching of local students, interns, and medical officers, that is, contributing positively to the health care system. In these sessions, the residents work to address the clinical needs of the local students and house staff. The teaching addresses not only general cognitive issues but also the contextualization of this knowledge, tailoring the management to the realities of the restricted resources and practice patterns of PMH. These teaching experiences help enhance the education of local students and trainees, while pushing the US residents to be thoughtful about the context in which they are practicing, and the best way to instruct in this setting.18 Many such teaching sessions have also involved simulation 358

to address psychomotor skills. These sessions have included hand suture tying (using rope purchased at a local hardware store so as not to use up the precious hospital supply of suture) as well as intracorporeal knot tying and practicing of other basic laparoscopic skills on a basic box simulator with tools and materials used in the local context. In short-term missions, there is always the concern of the lack of sustainability and of leaving behind complications for local surgeons or health care workers to address.10 Residents in our elective program are paired with a Canadian surgeon (G.A.) who has fostered an ongoing relationship with the hospital and with local surgeons. He has developed a collegial relationship and has also provided valuable education that has in turn been propagated by the local surgeons, thereby modeling a sustainable ongoing global health practice. Such longitudinal relationships are important for sustainability and growth of bidirectional partnerships.19 A good example of the fruits of this relationship is the development of the laparoscopic surgical program at PMH, in which local surgeons, anesthesiologists, nurses, and technicians were trained in minimally access surgery. By partnering with the administration and local stakeholders in the public and private sector, a full perioperative team was established. These locally trained surgeons now mentor and teach this skill set to other local surgeons and to the elective residents from UPENN. This collaborative effort has led to a sustainable program for minimal access surgery20 and provides a model to residents as to how to implement similar programs. The increasing global surgical burden of disease and the need for experienced surgeons to be involved in work to alleviate global disparities in disease burden coupled with a increasing interest in global health by surgeons and surgical trainees make a deeper understanding of the issues involved in global health practice and the ways to responsibly practice global surgery essential. The growing number of international surgical electives for residents should incorporate a degree of systems-based practice into their curriculum. We have established an international surgical elective that focuses principally on understanding systems-based practice of global surgery and that sensitizes residents to the challenges and issues they must be prepared to recognize and address when practicing internationally.

ACKNOWLEDGMENTS We would like to thank the Botswana-UPENN partnership for its educational and logistical support and the Department of Surgical Education of the University of Pennsylvania.

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cooperation and consortium. World J Surg. 2011;35 (12):2617-2624. 2. Powell AC, Mueller C, Kingham P, Berman R,

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Samkange CA, Lane RH. Guidelines for surgeons on establishing projects in low-income countries. World J Surg. 2013;37(6):1203-1207. 9. Martiniuk AL, Manouchehrian M, Negin JA, Zwi AB.

Brain Gains: a literature review of medical missions to low and middle-income countries. BMC Health Serv Res. 2012;12:134. (ISSN: 1472-6963). 10. Wolfberg AJ. Volunteering overseas—lessons from sur-

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practice: improving the safety and quality of patient care by recognizing and improving the systems in which we work. Henriksen K, Battles JB, Keyes MA, et al. eds. Advances in Patient Safety: New Directions

World J Surg. 2012;36(6):1441-1442. 18. Mutabdzic D, Bedada AG, Bakanisi B, Motsumi J,

Azzie G. Designing a contextually appropriate surgical training program in low-resource settings: the Botswana experience. World J Surg. 2013;37(7): 1486-1491. 19. Chao TE, Riesel JN, Anderson GA, et al. Building a

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G. Establishing a contextually appropriate laparoscopic program in resource-restricted environments: experience in Botswana. Ann Surg. 2015;261(4):807-811.

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An International Surgical Rotation as a Systems-Based Elective: The Botswana-University of Pennsylvania Surgical Experience.

There is a growing need to address the global burden of surgical disease along with increasing interest in international surgical practice, necessitat...
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