GLOBAL HEALTH INITIATIVES
Global Surgery Opportunities for U.S. Surgical Residents: An Interim Report M. Margaret Knudson, MD,* Margaret J. Tarpley, MLS,† and Patricia J. Numann, MD‡ *
Department of Surgery, University of California, San Francisco General Hospital and Trauma Center, San Francisco, California; †Department of Surgery, Vanderbilt University, Nashville, Tennessee; and ‡ Department of Surgery Emerita, SUNY Upstate Medical University, Syracuse, New York INTRODUCTION: In 2011, the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Surgery developed guidelines that allowed time spent and cases performed outside of the United States by surgical residents from ACGME-accredited training programs to be applied toward program completion. We hypothesized that the number of programs with global surgical rotations would have increased after that important development. We also sought to determine the characteristics that led to sustainment of such programs. METHODS: An Institutional Review Board–approved elec-
tronic survey was sent to all 253 program directors of ACGME-approved general surgery residencies requesting information on international rotations available to residents. Responses were requested from program directors with extant rotations. Survey questions focused on locations, funding, nature of the rotations, faculty involvement, keys to success, and the barriers to overcome during program development and sustainment. RESULTS: The survey reported 34 surgery residency programs offering global surgery rotations, up from 23 just 5 years previously. Of these reporting programs, 25 have been approved by the ACGME. Most rotations occur in the postgraduate year 3 or 4 and are primarily clinical rotations. Africa is the main destination. Resident supervision is provided by a mixture of host and home surgeons. A dedicated faculty is considered to be the most important element for success while funding remains a major impediment.
Paper presented at the 2014 Clinical Congress of the American College of Surgeons. Vanderbilt Institute for Clinical and Translational Research provided grant support (UL1TR000445 from NCATS/NIH, USA) by providing REDCap (Research Electronic Data Capture) that is hosted at Vanderbilt for study data collection and management. Correspondence: Inquiries to Margaret J. Tarpley, MLS, Department of Surgery, Vanderbilt University, D-4314 Medical Center North, 1161 21st Avenue South, Nashville, TN 37232-2730; e-mail: [email protected]
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CONCLUSIONS: The interest in global surgery continues
to increase, and general surgical programs will strive to meet the expectations of residents looking for international exposure. Collaboration could facilitate resident opportunities and potentially be more cost-effective. ( J Surg 72:e60C 2015 Association of Program Directors in Surgery. e65. J Published by Elsevier Inc. All rights reserved.) KEY WORDS: international surgical rotations, surgery
education, global surgery, surgery electives, international medical education, graduate medical education COMPETENCIES: Patient Care, Medical Knowledge, Professionalism, Interpersonal and Communication Skills, PracticeBased Learning and Improvement, Systems-Based Practice
INTRODUCTION In 2008, a national survey regarding opportunities for U.S. surgical residents in global surgery revealed that only 23 of 253 accredited general surgery programs offered educational activities in global surgery.1 One of the barriers for international program development identified in that survey was the lack of approval from the Accreditation Council for Graduate Medical Education (ACGME) and the Residency Review Committee (RRC) for time spent working in underserved areas outside of the parent institution. In 2011, in response to the growing interest in global surgery among residents, the ACGME-RRC together with the American Board of Surgery (ABS) developed guidelines for international general surgery elective rotations that would allow cases performed and time spent abroad to be officially credited toward program completion.2 The purpose of this current study was to compile an updated list of programs offering international rotations for general surgery residents. We postulated that after the historic ACGME/ABS validation decision, the number of such programs would have increased in number from the survey 5 years before. We further sought to identify the
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.2015.03.010
TABLE 1. Survey Questions With Instructions International Rotations Short Survey Dear Program Director: As you are aware, surgical trainees are seeking out opportunities to gain experience in global surgery. However, identifying international rotations with accredited faculty and providing funding for such rotations presents unique challenges for surgical training programs. Members of the American Surgical Association are compiling a list of programs that have already embarked on international surgical work and can provide leadership and share experience with other programs as they develop in this area. If your program has an international rotation, we would very much appreciate it if you could respond to this e-mail by answering the following questions: 1. What is the name of your program? 2. Who is the program director? 3. What countries are included in your international surgical rotations? 4. What year(s) of surgical residency is/are considered eligible for the rotation? 5. Are these rotations primarily clinical or research focused? 6. Is the rotation required or elective? 7. How is the program funded? 8. Who supervises the residents during the rotation? 9. Do you have a global surgery “track” in your program? 10. Would you allow a resident from another program to participate? 11. What is the name of your program? 12. Who is the program director? 13. What countries are included in your international surgical rotations? 14. What year(s) of surgical residency is/are considered eligible for the rotation? 15. Are these rotations primarily clinical or research focused? 16. Is the rotation required or elective? 17. How is the program funded? 18. Who supervises the residents during the rotation? 19. Do you have a global surgery “track” in your program? 20. Would you allow a resident from another program to participate?
essential components that resulted in successful international efforts.
METHODS The survey questions (Table 1) were developed by the authors and approved by the Vanderbilt Institutional Review Board. The e-mail addresses used to reach the program directors (PDs) were copied from the publicly available Association of Program Directors in Surgery (APDS) directory found on the APDS website (www.apds. org). The survey was distributed electronically to the 253 ACGME general surgery PDs via e-mail containing a link to the REDCap survey instrument. Reminders were sent to the
nonresponders. Results of the survey were entered into the REDCap secured database at Vanderbilt University. Those PDs who responded to this nonanonymous survey affirmatively as to the availability of international rotations through their institutions were contacted again via e-mail and asked to provide insight on the barriers to program development as well as the key elements that were felt to be essential for sustained international programs.
RESULTS A total of 43 responses were received from the initial electronic survey. Another e-mail appeal was sent to nonresponder PDs in programs thought to have international rotations, which resulted in 48 responses (19% response rate). Overall, 34 general surgery residency programs were identified via this survey plus e-mail appeal as offering international surgery residency rotations of some type. Of these programs, 26 were located in university settings and 8 were in independent or affiliated institutions. A number of the programs offered more than one location choice, and all choices were captured in the count. In total, 23 of the programs included rotations in African countries, with the second most frequent area (11 programs) being South/ Central America/Caribbean; 3 programs offered European countries, 5 in Asian nations, and 2 programs allowed residents to work out their own sites (Table 2). Most residents rotating internationally were in their third or fourth clinical year. One program allowed residents from any level to use vacation time. These counts aggregate all the allowed years so will greatly exceed the 34 programs: postgraduate year (PGY) 4 (21); PGY 3 (20); PGY 2 (6); PGY 5 (2); PGY 1 (1); and research years—level varied (6). The international rotations are classified as “elective” at 31 institutions who responded. There were 2 programs that reported that every resident had an international rotation but did not use the word “required,” so it is not certain if it is required or just encouraged (Note: to be approved by the ACGME for general surgery, the rotation must be classified as “elective”). Many residents use either vacation or allocated research time for their international surgical experience. Only one of the respondents to this survey has a specific global surgery residency “track.” The majority of the current international rotations are clinically focused, but many include a research component as well. Overall, 41% (14) of respondents would be open to having a resident from another program participate in their international rotation, a finding of great importance to programs unable to establish a program of their own. Funding for international work proceeded from a number of sources, but at least 20% of the time the resident was responsible for some portion of the expense. Aggregated funding sources (Table 2) reveal the scope of sources with departmental and hospital funds contributed in 21
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TABLE 2. Description of Programs Number of Programs 1. Locations Africa Central/South America/ Caribbean Asia Europe Site worked out by resident 2. Program description Primarily clinical Research Combined clinical/research 3. Supervising faculty Home institution Host Institution Combined host/home 4. Funding sources (aggregated) Departmental funds Hospital funds Philanthropic contributions Resident Endowment Resident education fund “Various sources” Not yet funded 5. Allow outside resident to use slot Yes No Not sure/no response
23 11 5 3 2 20 4 10 8 16 10 11 10 10 7 3 1 3 1 14 17 3
programs, whereas 7 programs have managed to secure philanthropic support. No program listed external grant sources for surgical rotations, although the authors are aware that some institutions receive grants from the Fogarty International Institute at the National Institute of Health. Faculty supervision often is provided by the host surgeons (16) or a combination of host and home surgeons (10), with 8 programs exclusively using home surgeons. These figures may not give a totally clear picture of how many are ABS certified or have equivalent training because some of the host surgeons are US-trained persons who have worked in
the home institution or other US center before relocating to the international hospital. Of the 34 PDs with international rotations, 10 provided extensive insight into the key elements needed for success of programs and into the obstacles that were most challenging (Table 3). First, the needs and expectations of the host country must be considered; this is not about academic “tourism.” As such, many advocate for bidirectional exchanges and admonish that relationship building may take several years to accomplish. Second, having an empowered, enthusiastic, and dedicated faculty member at the home institution as well as at the host institution is considered essential. As noted in Table 3, obtaining approval for international rotations from the ACGMERRC in surgery is considered to be one of the important elements for a successful program. Going through the certification process with the ACGME-RRC and the ABS has not been an obstacle, and many regard this as an important element in gaining support for their international programs from the chair, dean, hospital Chief Medical Officer, etc. Those institutions that have global health programs/institutes have found that the training and support that they provide greatly enhance the global surgical program. The most important issue mentioned by almost every respondent was funding. Of the 10 PDs providing extensive insight, 5 considered funding a significant barrier to the rotation, with 1 respondent expressing uncertainty as to the sustainability of that program owing to reimbursement uncertainties. As noted previously, a number of residents are currently paying for some or most of their travel and lodging expenses. The ACGME-RRC guidelines for accreditation require that the sponsoring institution must provide salary, travel expenses, health insurance, and evacuation insurance.2 Competing with nongovernmental organizations for funding from philanthropic sources was noted as a challenge by some surgeons. Securing funding for faculty who travel to provide supervision is also a factor. Logistical difficulties include assuring safe housing in the host country, obtaining needed certificates (passports, visas, privileges,
TABLE 3. Key Elements for Success and Identified Challenges Elements for Success
Challenges
Relationship building with host country Supportive administration Bidirectional Programs Dedicated/empowered leader at the parent institution Dedicated/engaged leader at the host institution Early preparation Safe location Resident participating in fund-raising ACGME/ABS approval Established infrastructure for the resident Presence of a global health institute at the parent program
Securing long-term funding for the program Getting the time away from the parent institution Cultural differences Gaining support from chair, dean, CMO, etc. Meeting the needs of the host country Logistics: housing/certification etc. Local issues such as strikes, etc.
CMO, chief medical officer. e62
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credentialing, etc.), and finding the right time during residency to be away for relatively long periods of time (not shorting the program at home, not missing fellowship interviews, not missing time away from family, etc.). These obstacles were not found to be insurmountable, however, and the PDs who responded remain overwhelmingly supportive of global surgical rotations. In the words of one surgeon, “We believe the international surgical experience is invaluable for our residents in that it instills a sense of “thrift” in the practice of medicine and brings into focus the scarcity of health care resources across the globe and the innovative strategies that local surgeons use when forced to make do with what they have available.”
DISCUSSION If academic medical centers truly believe that training the future leaders of surgery is an integral part of their mission, then promoting awareness of the role for surgeons in improving health around the globe is imperative. One way to overcome the barriers to support for international rotations is through education concerning the vital role played by surgical intervention in global health. In 2014, at the 135th session of the World Health Assembly Executive Board (the governing body of the World Health Organization), the Assembly concluded that neglected surgical diseases represented a global health crisis, and it officially advocated for including access to surgical care as part of universal health coverage.3 Indeed, lack of basic surgical care contributes to 11%-15% of the burden of disease, affects 1 in 7 marginalized people in the world, and results in catastrophic economic, moral, and social consequences.4 It is estimated that 2 billion people currently have no access to surgical facilities.5 Lack of access to safe and timely surgical care results in more deaths and disabilities than HIV/AIDS or malaria, but this deficiency has thus far received little attention.6 In 2010, road traffic crashes alone accounted for 75.5 million disability-adjusted life years, a number up by 20 million since 1990.4 Thus, residents who intend to pursue careers in global surgery might be well advised to elect international rotations that provide trauma surgical experience. Since the term “global health” was coined in 1999, a whole new global health landscape has evolved7 with independent programs as well as the Consortium of Universities for Global Health that includes 100 North American universities and colleges. In a relatively recent survey of nearly 7000 resident members of the American College of Surgeons, more than 700 expressed an interest in an international rotation.8 Although that survey was limited by a poor response rate (11%), it is interesting to note that 95% of responders had experience as a volunteer either domestically or internationally. Elements identified by the residents as being important for an international rotation
included language training, the participation of a dedicated faculty member, and an opportunity to combine international work with laboratory research. Overall, 66% of the respondents reported that they would have selected programs with international training programs when going through the residency matching program. For PDs who are contemplating offering international/ global surgical exposure, it is worthwhile to consider the experience from some of the pioneer programs that have been documented in the literature. Surgeons from Alpert Medical School of Brown University collated the comments from 9 residents who had worked for a month at the Africa/ Tenwek Hospital (Kenya) under the direct supervision of a US board-certified faculty member permanently residing in Africa.9 During a typical 4-week rotation, these residents averaged 75 to 100 major operative procedures and 40 to 50 endoscopies. Interestingly, all of the participants thought that they were more likely to participate in volunteer opportunities in the future in both America and internationally after their experience in Africa. The fact that these missions were faith based did not affect negatively on the residents; however, they were cognizant of the fact that the “standard operating procedures” could be expected to be very different in their host country. Indeed culturesensitivity awareness is considered a vital part of prerotation orientation for the Vanderbilt University surgical program at Kijabe Hospital in Kenya.10 Another important point emphasized by the Vanderbilt group was the need to prepare the residents to maximize their experience in ways that would neither compete with the local surgery trainees nor place an undue burden on the hosts. In turn, the residents reported that they learned that good health care could be provided without expensive imaging, tests, and procedures considered “standard” in the United States and that they were subsequently much more cognizant of the amount of waste built into the US system of health care. They did report that they were emotionally challenged by the need for the African families to make medical decisions based on their available resources. It appears that both the briefing and debriefing sessions have been important to the success of that program. Leow et al.11 have developed an extensive preparation guide for surgical residents rotating to underserved regions that deserves consideration by PDs considering initiating such rotations. This guide includes practical lists of what to bring, what to read, and how to be a safe traveler as well as taking care of personal health. The authors also offer insight on other important topics such as ensuring adequate clinical supervision while on rotation, prioritizing the training of local personnel, and working within the local system and their protocols. The authors also address the very important issue of blogs and social media and the need to maintain professionalism and patient confidentiality no matter where one is located. It would seem that these practical guidelines perhaps together with some of the preparation tips outlined
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previously by the Vanderbilt group could be incorporated into a standard predeployment course that could be used (and perhaps required) by all surgical programs that are seeking accreditation by the ACGME/RRC for their international rotations. The early experiences in surgical training and global health from the University of California at San Francisco (UCSF) were summarized by Ozgediz and others (including Knudson) in 2008.12 That report captured the activities of faculty and residents over a 10-year period. The global surgical program was greatly accelerated midway through the decade after a formal partnership was created between UCSF and Makerere University in Kampala, Uganda. During those 10 years, 10 surgical residents and 16 faculty members participated in international rotations. In total, 3 of the residents completed a university-based Global Health Clinical Scholars Program and 3 obtained master’s degrees in public health (MPH). A faculty member was based overseas for a prolonged period of time, and several residents contributed to mentored research projects in Uganda. With a grant from the Global Health Sciences Institute at UCSF, 2 surgical faculty members and 2 residents traveled to Kampala to provide trauma training and ultrasound instruction over a 1-week period. One surgical resident led a research project focusing on the development of a training program in basic prehospital trauma care for lay first responders in Kampala.13 Perhaps most importantly, however, was the ability to bring a member of the surgical faculty from Makerere to UCSF for several months, thus making the collaboration truly reciprocal. More recently, with the recognition that minimally invasive surgery in resource-poor settings might actually be cost-effective owing to shorter hospital stays and earlier return to work dates, 1 UCSF surgical resident designed and conducted a laparoscopic skills course using a low-cost box trainer for surgical residents in Dar es Salaam, Tanzania.14 In 2006, UCSF established the Institute for Global Orthopaedics and Traumatology, developing training sessions, exchange programs, and research projects with their colleagues in several African countries as well as Pakistan, Nepal, and Nicaragua.15 This Institute, which enjoys widespread support from the orthopedic chair, chiefs, and residents, is funded by both departmental coffers and foundations. Their training course that uses cadavers to teach orthopedic surgeons worldwide the basic techniques of flap coverage for open fractures has undoubtedly spared thousands of limbs by preventing the development of osteomyelitis and subsequent amputation. Eligibility criteria for an approved international rotation include several elements such as verification that the rotation is an elective.2 The PD must also receive ABS approval for the operative cases to count. As of mid-2014, 25 programs have been approved for international rotations (Cathy Ruiz, MA, Associate Executive Director, RRCs for Surgery, Plastic Surgery and Thoracic Surgery, ACGME; e64
personal communication). The total number of surgical cases performed internationally by rotating residents is currently unavailable at the national level because these cases are not segregated out at the ABS; however, these data may be compiled by individual programs. Several limitations of our study have been identified. This survey is limited by relying on the information provided to us via a survey. An apparently low response rate of (19%) may partly be explained by the survey instructions that requested responses only from PDs with international rotations; however, certainly there are surgical programs offering international experience that we are missing in this review. Because the credentials and training of the supervisors were not requested, another weakness is the lack of clarity of exactly who the supervisors are in a number of programs. Our using the phrase “interim report” in the title is an admission that there is constant flux in the number of programs. With funding cited as the most pervasive issue, whether a consideration or a barrier, some programs could cease to send residents even as other programs are becoming established.
CONCLUSION This study demonstrated that over the past 5 years, the number of identified programs providing international rotations has increased significantly from 23 (9%) to at least 34 (13%) of the 253 general surgery programs. A large number of these programs have applied for and were granted approval via the ACGME-RRC for these rotations, and this factor was considered by many to be important to the success of their program. We have also gathered information on the other key elements required for sustainment of these programs as well as the challenges (Table 3). It is estimated that more than half of the medical students entering general surgery training programs today are seeking exposure to resource-limited settings as a component of their training.16 How will the demands of this new generation of surgical residents be met? We propose, as suggested by Mitchell, Casey, and others, that collaborative efforts among programs are the key to sustainment.17 Collaboration would broaden opportunities for residents by allowing programs with unused slots to share with those programs unable to establish stand-alone partnerships (if the host institution were open to such an arrangement) with cost-saving potential for all involved. Collaborative efforts would also allow greater choice of location because the survey reported that a number of programs offered only 1 choice. Collaboration could potentially allow for the development of a standardized international curriculum, as well as a shared research agenda and integrated funding opportunities. Avenues for supporting collaboration include the American College of Surgeons Division of Education or even Operation Giving Back (http://www.operationgiving
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back.facs.org/), the Alliance for Surgery and Anesthesia Presence (http://asaptoday.org/), or the APDS. This survey offers only an interim report—or perhaps a snapshot—of the landscape following the ACGME-RRC approval for international surgery elective rotations. A primary goal of this report would be to encourage one of the surgical societies to create and maintain a public database of these rotations.
ACKNOWLEDGMENTS The authors would also like to express their gratitude to the general surgical program directors who supplied data for this project.
REFERENCES
7. Merson MH. University engagement in global health.
N Engl J Med. 2014;370(18):1676-1678. 8. Powell AC, Casey K, Liewehr DJ, et al. Results of a
national survey of surgical resident interest in international experience, electives and volunteerism. J Am Coll Surg. 2009;208(2):304-312. 9. Klatistenfeld DD, Chupp M, Cioffi WG, White RE.
An international volunteer program for general surgery residents at Brown Medical School: the Tenwek hospital Africa experience. J Am Coll Surg. 2008;207 (1):125-128. 10. 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.
1. Jayaraman SP, Ayzengart AL, Goetz LH, et al. Global
11. Leow JJ, Groen RS, Kingham P, et al. A preparation
health in general surgery residency: a national survey. J Am Coll Surg. 2009;208(3):426-433.
guide for surgical resident and student rotations to underserved regions. Surgery. 2012;151(6):770-778.
2. Accreditation Council for Graduate Medical Education.
12. Ozgediz D, Wang J, Jayaraman S, et al. Surgical
International rotation application process, Chicago. Available at: 〈http://www.acgme.org/acgmeweb/Por tals/0/PFAssets/ProgramResources/440_Surgery _Inter national_Rotation_Application_Process.pdf〉 Accessed 24.01.15.
training and global health: initial results of a 5-year partnership with a surgical training program in a lowincome country. Arch Surg. 2008;143(9):860-865.
3. Essential Surgery and the 135th session of World
Health Assembly Executive Board. Available at: 〈http://www.essentialsurgery.com/world-health-assem bly/〉 Accessed 24.01.15. 4. Murray CJ, Vos T, Lozano R, et al. Disability-adjusted
life years (DALYs) for 291 diseases and injuries in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859):2197-2223. 5. Funk LM, Weiser TG, Berry WR, et al. Global
operating theatre distribution and pulse oximetry supply: an estimation from reported data. Lancet. 2010;376(9746):1055-1061. 6. Lozano R, Naghavi M, Foreman K, et al. Global and
regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859):2095-2128.
13. Jayaraman S, Mabweijano JR, Lipnick MS, et al. First
things first: effectiveness and scalability of a basic prehospital trauma care program for lay first-responders in Kampala, Uganda. PLoS One. 2009;4(9):e6955. 14. Beard JH, Akoko L, Mwanga A, et al. Manual
laparoscopic skills development using a low-cost trainer box in Tanzania. J Surg Educ. 2014;71 (1):85-90. 15. Morshed S, Shearer DW, Coughlin RR. Collaborative
partnerships and the future of global orthopaedics. Clin Orthop Relat Res. 2013;471(10):3088-3092. 16. Riviello R, Ozgediz D, Hsia RY, et al. Role of
collaborative academic partnerships in surgical training, education, and provision. World J Surg. 2010;34 (3):459-465. 17. Mitchell KB, Tarpley MJ, Tarpley JL, Casey KM.
Elective global surgery rotations for residents: a call for cooperation and consortium. World J Surg. 2011;35 (12):2617-2624.
SUPPORTING INFORMATION Supplementary material cited in this article is available online at doi:10.1016/j.jsurg.2015.03.010.
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Global Surgery Opportunities for U.S. Surgical Residents: An Interim Report M. Margaret Knudson, MD,* Margaret J. Tarpley, MLS,† and Patricia J. Numann, MD‡ *
Department of Surgery, University of California, San Francisco General Hospital and Trauma Center, San Francisco, California; †Department of Surgery, Vanderbilt University, Nashville, Tennessee; and ‡ Department of Surgery Emerita, SUNY Upstate Medical University, Syracuse, New York INTRODUCTION: In 2011, the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Surgery developed guidelines that allowed time spent and cases performed outside of the United States by surgical residents from ACGME-accredited training programs to be applied toward program completion. We hypothesized that the number of programs with global surgical rotations would have increased after that important development. We also sought to determine the characteristics that led to sustainment of such programs. METHODS: An Institutional Review Board–approved elec-
tronic survey was sent to all 253 program directors of ACGME-approved general surgery residencies requesting information on international rotations available to residents. Responses were requested from program directors with extant rotations. Survey questions focused on locations, funding, nature of the rotations, faculty involvement, keys to success, and the barriers to overcome during program development and sustainment. RESULTS: The survey reported 34 surgery residency programs offering global surgery rotations, up from 23 just 5 years previously. Of these reporting programs, 25 have been approved by the ACGME. Most rotations occur in the postgraduate year 3 or 4 and are primarily clinical rotations. Africa is the main destination. Resident supervision is provided by a mixture of host and home surgeons. A dedicated faculty is considered to be the most important element for success while funding remains a major impediment.
Paper presented at the 2014 Clinical Congress of the American College of Surgeons. Vanderbilt Institute for Clinical and Translational Research provided grant support (UL1TR000445 from NCATS/NIH, USA) by providing REDCap (Research Electronic Data Capture) that is hosted at Vanderbilt for study data collection and management. Correspondence: Inquiries to Margaret J. Tarpley, MLS, Department of Surgery, Vanderbilt University, D-4314 Medical Center North, 1161 21st Avenue South, Nashville, TN 37232-2730; e-mail: [email protected]
e60
CONCLUSIONS: The interest in global surgery continues
to increase, and general surgical programs will strive to meet the expectations of residents looking for international exposure. Collaboration could facilitate resident opportunities and potentially be more cost-effective. ( J Surg 72:e60C 2015 Association of Program Directors in Surgery. e65. J Published by Elsevier Inc. All rights reserved.) KEY WORDS: international surgical rotations, surgery
education, global surgery, surgery electives, international medical education, graduate medical education COMPETENCIES: Patient Care, Medical Knowledge, Professionalism, Interpersonal and Communication Skills, PracticeBased Learning and Improvement, Systems-Based Practice
INTRODUCTION In 2008, a national survey regarding opportunities for U.S. surgical residents in global surgery revealed that only 23 of 253 accredited general surgery programs offered educational activities in global surgery.1 One of the barriers for international program development identified in that survey was the lack of approval from the Accreditation Council for Graduate Medical Education (ACGME) and the Residency Review Committee (RRC) for time spent working in underserved areas outside of the parent institution. In 2011, in response to the growing interest in global surgery among residents, the ACGME-RRC together with the American Board of Surgery (ABS) developed guidelines for international general surgery elective rotations that would allow cases performed and time spent abroad to be officially credited toward program completion.2 The purpose of this current study was to compile an updated list of programs offering international rotations for general surgery residents. We postulated that after the historic ACGME/ABS validation decision, the number of such programs would have increased in number from the survey 5 years before. We further sought to identify the
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.2015.03.010
TABLE 1. Survey Questions With Instructions International Rotations Short Survey Dear Program Director: As you are aware, surgical trainees are seeking out opportunities to gain experience in global surgery. However, identifying international rotations with accredited faculty and providing funding for such rotations presents unique challenges for surgical training programs. Members of the American Surgical Association are compiling a list of programs that have already embarked on international surgical work and can provide leadership and share experience with other programs as they develop in this area. If your program has an international rotation, we would very much appreciate it if you could respond to this e-mail by answering the following questions: 1. What is the name of your program? 2. Who is the program director? 3. What countries are included in your international surgical rotations? 4. What year(s) of surgical residency is/are considered eligible for the rotation? 5. Are these rotations primarily clinical or research focused? 6. Is the rotation required or elective? 7. How is the program funded? 8. Who supervises the residents during the rotation? 9. Do you have a global surgery “track” in your program? 10. Would you allow a resident from another program to participate? 11. What is the name of your program? 12. Who is the program director? 13. What countries are included in your international surgical rotations? 14. What year(s) of surgical residency is/are considered eligible for the rotation? 15. Are these rotations primarily clinical or research focused? 16. Is the rotation required or elective? 17. How is the program funded? 18. Who supervises the residents during the rotation? 19. Do you have a global surgery “track” in your program? 20. Would you allow a resident from another program to participate?
essential components that resulted in successful international efforts.
METHODS The survey questions (Table 1) were developed by the authors and approved by the Vanderbilt Institutional Review Board. The e-mail addresses used to reach the program directors (PDs) were copied from the publicly available Association of Program Directors in Surgery (APDS) directory found on the APDS website (www.apds. org). The survey was distributed electronically to the 253 ACGME general surgery PDs via e-mail containing a link to the REDCap survey instrument. Reminders were sent to the
nonresponders. Results of the survey were entered into the REDCap secured database at Vanderbilt University. Those PDs who responded to this nonanonymous survey affirmatively as to the availability of international rotations through their institutions were contacted again via e-mail and asked to provide insight on the barriers to program development as well as the key elements that were felt to be essential for sustained international programs.
RESULTS A total of 43 responses were received from the initial electronic survey. Another e-mail appeal was sent to nonresponder PDs in programs thought to have international rotations, which resulted in 48 responses (19% response rate). Overall, 34 general surgery residency programs were identified via this survey plus e-mail appeal as offering international surgery residency rotations of some type. Of these programs, 26 were located in university settings and 8 were in independent or affiliated institutions. A number of the programs offered more than one location choice, and all choices were captured in the count. In total, 23 of the programs included rotations in African countries, with the second most frequent area (11 programs) being South/ Central America/Caribbean; 3 programs offered European countries, 5 in Asian nations, and 2 programs allowed residents to work out their own sites (Table 2). Most residents rotating internationally were in their third or fourth clinical year. One program allowed residents from any level to use vacation time. These counts aggregate all the allowed years so will greatly exceed the 34 programs: postgraduate year (PGY) 4 (21); PGY 3 (20); PGY 2 (6); PGY 5 (2); PGY 1 (1); and research years—level varied (6). The international rotations are classified as “elective” at 31 institutions who responded. There were 2 programs that reported that every resident had an international rotation but did not use the word “required,” so it is not certain if it is required or just encouraged (Note: to be approved by the ACGME for general surgery, the rotation must be classified as “elective”). Many residents use either vacation or allocated research time for their international surgical experience. Only one of the respondents to this survey has a specific global surgery residency “track.” The majority of the current international rotations are clinically focused, but many include a research component as well. Overall, 41% (14) of respondents would be open to having a resident from another program participate in their international rotation, a finding of great importance to programs unable to establish a program of their own. Funding for international work proceeded from a number of sources, but at least 20% of the time the resident was responsible for some portion of the expense. Aggregated funding sources (Table 2) reveal the scope of sources with departmental and hospital funds contributed in 21
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TABLE 2. Description of Programs Number of Programs 1. Locations Africa Central/South America/ Caribbean Asia Europe Site worked out by resident 2. Program description Primarily clinical Research Combined clinical/research 3. Supervising faculty Home institution Host Institution Combined host/home 4. Funding sources (aggregated) Departmental funds Hospital funds Philanthropic contributions Resident Endowment Resident education fund “Various sources” Not yet funded 5. Allow outside resident to use slot Yes No Not sure/no response
23 11 5 3 2 20 4 10 8 16 10 11 10 10 7 3 1 3 1 14 17 3
programs, whereas 7 programs have managed to secure philanthropic support. No program listed external grant sources for surgical rotations, although the authors are aware that some institutions receive grants from the Fogarty International Institute at the National Institute of Health. Faculty supervision often is provided by the host surgeons (16) or a combination of host and home surgeons (10), with 8 programs exclusively using home surgeons. These figures may not give a totally clear picture of how many are ABS certified or have equivalent training because some of the host surgeons are US-trained persons who have worked in
the home institution or other US center before relocating to the international hospital. Of the 34 PDs with international rotations, 10 provided extensive insight into the key elements needed for success of programs and into the obstacles that were most challenging (Table 3). First, the needs and expectations of the host country must be considered; this is not about academic “tourism.” As such, many advocate for bidirectional exchanges and admonish that relationship building may take several years to accomplish. Second, having an empowered, enthusiastic, and dedicated faculty member at the home institution as well as at the host institution is considered essential. As noted in Table 3, obtaining approval for international rotations from the ACGMERRC in surgery is considered to be one of the important elements for a successful program. Going through the certification process with the ACGME-RRC and the ABS has not been an obstacle, and many regard this as an important element in gaining support for their international programs from the chair, dean, hospital Chief Medical Officer, etc. Those institutions that have global health programs/institutes have found that the training and support that they provide greatly enhance the global surgical program. The most important issue mentioned by almost every respondent was funding. Of the 10 PDs providing extensive insight, 5 considered funding a significant barrier to the rotation, with 1 respondent expressing uncertainty as to the sustainability of that program owing to reimbursement uncertainties. As noted previously, a number of residents are currently paying for some or most of their travel and lodging expenses. The ACGME-RRC guidelines for accreditation require that the sponsoring institution must provide salary, travel expenses, health insurance, and evacuation insurance.2 Competing with nongovernmental organizations for funding from philanthropic sources was noted as a challenge by some surgeons. Securing funding for faculty who travel to provide supervision is also a factor. Logistical difficulties include assuring safe housing in the host country, obtaining needed certificates (passports, visas, privileges,
TABLE 3. Key Elements for Success and Identified Challenges Elements for Success
Challenges
Relationship building with host country Supportive administration Bidirectional Programs Dedicated/empowered leader at the parent institution Dedicated/engaged leader at the host institution Early preparation Safe location Resident participating in fund-raising ACGME/ABS approval Established infrastructure for the resident Presence of a global health institute at the parent program
Securing long-term funding for the program Getting the time away from the parent institution Cultural differences Gaining support from chair, dean, CMO, etc. Meeting the needs of the host country Logistics: housing/certification etc. Local issues such as strikes, etc.
CMO, chief medical officer. e62
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credentialing, etc.), and finding the right time during residency to be away for relatively long periods of time (not shorting the program at home, not missing fellowship interviews, not missing time away from family, etc.). These obstacles were not found to be insurmountable, however, and the PDs who responded remain overwhelmingly supportive of global surgical rotations. In the words of one surgeon, “We believe the international surgical experience is invaluable for our residents in that it instills a sense of “thrift” in the practice of medicine and brings into focus the scarcity of health care resources across the globe and the innovative strategies that local surgeons use when forced to make do with what they have available.”
DISCUSSION If academic medical centers truly believe that training the future leaders of surgery is an integral part of their mission, then promoting awareness of the role for surgeons in improving health around the globe is imperative. One way to overcome the barriers to support for international rotations is through education concerning the vital role played by surgical intervention in global health. In 2014, at the 135th session of the World Health Assembly Executive Board (the governing body of the World Health Organization), the Assembly concluded that neglected surgical diseases represented a global health crisis, and it officially advocated for including access to surgical care as part of universal health coverage.3 Indeed, lack of basic surgical care contributes to 11%-15% of the burden of disease, affects 1 in 7 marginalized people in the world, and results in catastrophic economic, moral, and social consequences.4 It is estimated that 2 billion people currently have no access to surgical facilities.5 Lack of access to safe and timely surgical care results in more deaths and disabilities than HIV/AIDS or malaria, but this deficiency has thus far received little attention.6 In 2010, road traffic crashes alone accounted for 75.5 million disability-adjusted life years, a number up by 20 million since 1990.4 Thus, residents who intend to pursue careers in global surgery might be well advised to elect international rotations that provide trauma surgical experience. Since the term “global health” was coined in 1999, a whole new global health landscape has evolved7 with independent programs as well as the Consortium of Universities for Global Health that includes 100 North American universities and colleges. In a relatively recent survey of nearly 7000 resident members of the American College of Surgeons, more than 700 expressed an interest in an international rotation.8 Although that survey was limited by a poor response rate (11%), it is interesting to note that 95% of responders had experience as a volunteer either domestically or internationally. Elements identified by the residents as being important for an international rotation
included language training, the participation of a dedicated faculty member, and an opportunity to combine international work with laboratory research. Overall, 66% of the respondents reported that they would have selected programs with international training programs when going through the residency matching program. For PDs who are contemplating offering international/ global surgical exposure, it is worthwhile to consider the experience from some of the pioneer programs that have been documented in the literature. Surgeons from Alpert Medical School of Brown University collated the comments from 9 residents who had worked for a month at the Africa/ Tenwek Hospital (Kenya) under the direct supervision of a US board-certified faculty member permanently residing in Africa.9 During a typical 4-week rotation, these residents averaged 75 to 100 major operative procedures and 40 to 50 endoscopies. Interestingly, all of the participants thought that they were more likely to participate in volunteer opportunities in the future in both America and internationally after their experience in Africa. The fact that these missions were faith based did not affect negatively on the residents; however, they were cognizant of the fact that the “standard operating procedures” could be expected to be very different in their host country. Indeed culturesensitivity awareness is considered a vital part of prerotation orientation for the Vanderbilt University surgical program at Kijabe Hospital in Kenya.10 Another important point emphasized by the Vanderbilt group was the need to prepare the residents to maximize their experience in ways that would neither compete with the local surgery trainees nor place an undue burden on the hosts. In turn, the residents reported that they learned that good health care could be provided without expensive imaging, tests, and procedures considered “standard” in the United States and that they were subsequently much more cognizant of the amount of waste built into the US system of health care. They did report that they were emotionally challenged by the need for the African families to make medical decisions based on their available resources. It appears that both the briefing and debriefing sessions have been important to the success of that program. Leow et al.11 have developed an extensive preparation guide for surgical residents rotating to underserved regions that deserves consideration by PDs considering initiating such rotations. This guide includes practical lists of what to bring, what to read, and how to be a safe traveler as well as taking care of personal health. The authors also offer insight on other important topics such as ensuring adequate clinical supervision while on rotation, prioritizing the training of local personnel, and working within the local system and their protocols. The authors also address the very important issue of blogs and social media and the need to maintain professionalism and patient confidentiality no matter where one is located. It would seem that these practical guidelines perhaps together with some of the preparation tips outlined
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previously by the Vanderbilt group could be incorporated into a standard predeployment course that could be used (and perhaps required) by all surgical programs that are seeking accreditation by the ACGME/RRC for their international rotations. The early experiences in surgical training and global health from the University of California at San Francisco (UCSF) were summarized by Ozgediz and others (including Knudson) in 2008.12 That report captured the activities of faculty and residents over a 10-year period. The global surgical program was greatly accelerated midway through the decade after a formal partnership was created between UCSF and Makerere University in Kampala, Uganda. During those 10 years, 10 surgical residents and 16 faculty members participated in international rotations. In total, 3 of the residents completed a university-based Global Health Clinical Scholars Program and 3 obtained master’s degrees in public health (MPH). A faculty member was based overseas for a prolonged period of time, and several residents contributed to mentored research projects in Uganda. With a grant from the Global Health Sciences Institute at UCSF, 2 surgical faculty members and 2 residents traveled to Kampala to provide trauma training and ultrasound instruction over a 1-week period. One surgical resident led a research project focusing on the development of a training program in basic prehospital trauma care for lay first responders in Kampala.13 Perhaps most importantly, however, was the ability to bring a member of the surgical faculty from Makerere to UCSF for several months, thus making the collaboration truly reciprocal. More recently, with the recognition that minimally invasive surgery in resource-poor settings might actually be cost-effective owing to shorter hospital stays and earlier return to work dates, 1 UCSF surgical resident designed and conducted a laparoscopic skills course using a low-cost box trainer for surgical residents in Dar es Salaam, Tanzania.14 In 2006, UCSF established the Institute for Global Orthopaedics and Traumatology, developing training sessions, exchange programs, and research projects with their colleagues in several African countries as well as Pakistan, Nepal, and Nicaragua.15 This Institute, which enjoys widespread support from the orthopedic chair, chiefs, and residents, is funded by both departmental coffers and foundations. Their training course that uses cadavers to teach orthopedic surgeons worldwide the basic techniques of flap coverage for open fractures has undoubtedly spared thousands of limbs by preventing the development of osteomyelitis and subsequent amputation. Eligibility criteria for an approved international rotation include several elements such as verification that the rotation is an elective.2 The PD must also receive ABS approval for the operative cases to count. As of mid-2014, 25 programs have been approved for international rotations (Cathy Ruiz, MA, Associate Executive Director, RRCs for Surgery, Plastic Surgery and Thoracic Surgery, ACGME; e64
personal communication). The total number of surgical cases performed internationally by rotating residents is currently unavailable at the national level because these cases are not segregated out at the ABS; however, these data may be compiled by individual programs. Several limitations of our study have been identified. This survey is limited by relying on the information provided to us via a survey. An apparently low response rate of (19%) may partly be explained by the survey instructions that requested responses only from PDs with international rotations; however, certainly there are surgical programs offering international experience that we are missing in this review. Because the credentials and training of the supervisors were not requested, another weakness is the lack of clarity of exactly who the supervisors are in a number of programs. Our using the phrase “interim report” in the title is an admission that there is constant flux in the number of programs. With funding cited as the most pervasive issue, whether a consideration or a barrier, some programs could cease to send residents even as other programs are becoming established.
CONCLUSION This study demonstrated that over the past 5 years, the number of identified programs providing international rotations has increased significantly from 23 (9%) to at least 34 (13%) of the 253 general surgery programs. A large number of these programs have applied for and were granted approval via the ACGME-RRC for these rotations, and this factor was considered by many to be important to the success of their program. We have also gathered information on the other key elements required for sustainment of these programs as well as the challenges (Table 3). It is estimated that more than half of the medical students entering general surgery training programs today are seeking exposure to resource-limited settings as a component of their training.16 How will the demands of this new generation of surgical residents be met? We propose, as suggested by Mitchell, Casey, and others, that collaborative efforts among programs are the key to sustainment.17 Collaboration would broaden opportunities for residents by allowing programs with unused slots to share with those programs unable to establish stand-alone partnerships (if the host institution were open to such an arrangement) with cost-saving potential for all involved. Collaborative efforts would also allow greater choice of location because the survey reported that a number of programs offered only 1 choice. Collaboration could potentially allow for the development of a standardized international curriculum, as well as a shared research agenda and integrated funding opportunities. Avenues for supporting collaboration include the American College of Surgeons Division of Education or even Operation Giving Back (http://www.operationgiving
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back.facs.org/), the Alliance for Surgery and Anesthesia Presence (http://asaptoday.org/), or the APDS. This survey offers only an interim report—or perhaps a snapshot—of the landscape following the ACGME-RRC approval for international surgery elective rotations. A primary goal of this report would be to encourage one of the surgical societies to create and maintain a public database of these rotations.
ACKNOWLEDGMENTS The authors would also like to express their gratitude to the general surgical program directors who supplied data for this project.
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SUPPORTING INFORMATION Supplementary material cited in this article is available online at doi:10.1016/j.jsurg.2015.03.010.
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