GLOBAL HEALTH INITIATIVES
Integrating Global Health Into Surgery Residency in the United States Anthony G. Charles, MD,* Jonathan C. Samuel, MD,* Robert Riviello, MD,† Melanie K. Sion, MD,‡ Margaret J. Tarpley, MLS,§ John L. Tarpley, MD,§ Oluyinka O. Olutoye, PhD,¶ Jeffrey R. Marcus, MDJ Department of Surgery, University of North Carolina, Chapel Hill, North Carolina, †Brigham and Women’s Hospital, Center for Surgery and Public Health, Boston, Massachusetts, ‡Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, §Department of Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee, ¶Texas Children’s Hospital, Baylor University, Houston, Texas; and J Department of Surgery, Duke University, Durham, North Carolina *
INTRODUCTION The increasing influence of globalization on health care has resulted in a greater awareness of health disparities within the millennial generation, some of who strive to ensure equity in the provision of health care services. Interest in global health among the surgical residency applicant pool is increasing.1 The ability to offer a global health opportunity is now considered a marker of a competitive surgical training program that improves resident recruitment. Furthermore, it motivates residents to serve local vulnerable communities and prepares them for a future career in global health. In 2011, the General Surgery Residency Review Committee (RRC) of the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Surgery approved international electives for credit toward residency graduation requirements. After extensive debate on the ways in which international electives could be standardized to ensure consistent educational experience for residents, the surgery RRC approved a set of requirements for such electives.2,3 Surgical training institutions (academic and community based) are beginning to explore ways to actualize international surgical rotations. We discuss inherent practicalities, challenges, and opportunities and emphasize that any such program must be bidirectional and fall within the educational pillars and the core competencies prescribed by the ACGME. All the authors are surgeons who are actively involved with a global surgical program, with resident participation at their respective institutions.
Correspondence: Inquiries to Anthony Charles, MD, MPH, FACS, Department of Surgery, UNC School of Medicine, Gillings School of Global Public Health, University of North Carolina, 4008 Burnett Womack Building, CB 7228, Chapel Hill, NC; fax: (919) 966-0369; e-mail: [email protected]
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FINDING A GLOBAL INSTITUTIONAL PARTNER Although the integration of global health into a surgery residency program may be focused on enhancing the experience of the surgery resident, it must fit into the overall global health mission of the institutions involved— the home institution and the host institution. There are a variety of reasons why an institution may be committed to global health, and the mechanism by which these efforts are actualized can be broadly categorized into clinical care, education, capacity building, and research, as well as, in some cases, business development.4 Most institutions are involved in several of these activities but there are typically 1 or 2 major thrusts that direct the overall mission. The home institution must clearly define how residency training specifically relates to the overall global health imperative. From the perspective of the host institution, the commitment to educational partnerships involving resident participation offers the opportunity to enhance patient care and build capacity through the education and training of the surgical trainees in the host countries in the developing world. The “global surgery experience,” from a resident standpoint, incorporates several elements to varying degrees. Surgery residents could have the opportunity to: (1) expand their surgical knowledge base by being exposed to a range or volume of pathology distinct from that in their home institutions, (2) understand system-based practice by learning to care for surgical patients in resource- and technologylimited environments, (3) contribute to the education of host health care providers, and (4) build international collaborations with their contemporaries in foreign countries. The choice of location and institution depends on what the expected outcomes are for the surgery residents. If the global surgery experience aims at least in part to augment the exposure to certain disease conditions, partnering with an institution that sees a large number of such diseases could
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.2014.05.005
be a compelling factor, e.g., thyroid disease, cleft lip, and cleft palate. For training programs in which conditionspecific educational exposure is not a primary motivating factor, the global surgery experience can be structured more creatively, focusing on the latter of the aforementioned elements. The structure of a resident-inclusive global health care program must be appropriately supervised; residents should be able to provide level-specific clinical care with guidance and accountability. Finally, such programs should seek to augment and should not compete with any clinical training programs or capacity building efforts aimed at the local trainees in the host institution. Operative volume should always be secondary or tertiary in the experience. The residents can also be involved in teaching and peer mentoring of their host country contemporaries. Where host-training efforts are in place, a superb opportunity exists for bidirectional exchange among the trainees. The duration and frequency of a global surgery elective for residents may be influenced by several factors. Prior experience with resident support at the host site and the presence of infrastructure, which can be influenced by program maturity, are perhaps the most important factors. If the institution has existing infrastructure in the region to assist with local logistics, it would be helpful in coordinating housing, transportation, and advising about immunization and credentialing. For institutions that do not have such infrastructure on-site, partnering with other US institutions in the region or at the host institution would be beneficial. On an average, 2 or more US institutions providing services at a host institution can provide excellent synergy to coordinate services, avoid redundancy, and maximize effect. For example, faculty coverage for extended periods can be shared by the various institutions and reduce the burden on each individual institution while allowing more leeway for resident rotations. Other factors include presence of ACGME-approved faculty supervision, the breadth and volume of surgical scope, and the presence of other complimentary faculty and residents (e.g., anesthesia, obstetrics and gynecology (OB-GYN), and pathology). Geopolitical factors, as well as ease of access to the region of interest and to the medical facility, should also be
considered during site selection. Additional time for travel and recovery should be included in the rotations. Establishing prior relationships with the appropriate embassies and US consulates should be explored. Although it is desirable that there be personal relationships with a local champion from the program in the host institution, long-term commitments are best accomplished with relationships at the institutional or governmental levels. Formal agreements or memoranda of understanding are mandatory to clearly outline the goals and objectives and the expected outcomes beneficial to all parties.5 Although the areas with the most surgical need tend to be the regions fraught with political unrest, the safety of the residents and likelihood of maintaining a long-term relationship in the event of political changes must be considered. For this reason, consideration should be given to institutions with nongovernmental affiliations that are less susceptible to the ever-changing political climate, including faith-based institutions. Any rotation should be inclusive and open to all residents in the program. Behavioral guidelines, such as appropriate clothing or use or nonuse of alcohol on the host campus, are acceptable, but faith restrictions should not deny the opportunity to any eligible resident (Table). A striking characteristic of international surgical endeavors for resident trainees is the broad range of potential experiences available. Differences in local health care resources, disease patterns, languages, and cultures of the developing countries result in unique environments for each site. The home institution also contributes to this heterogeneity, as academic programs offering international experiences differ in many aspects—from the length of rotation and the expected outcomes for residents to the degree of formality employed in resident selection. A review of existing global surgery programs using the resources at Operation Giving Back combined with an Internet search of individual programs identified 19 programs with structured experiences for surgery residents.6 Among these programs, 4 offered an advanced degree (a Master in Public Health) as part of the experience. The duration of experiences ranged from
TABLE. The characteristics of the Home and the Host Institutions That Are Needed to Meet Resident Expectations Home Institution Mission Patient care Capacity building Education Research Business development
Resident Expectation Increased clinical and operative experience Exposure to diverse surgical pathology Systems-based practice in a resource-poor setting Teaching/educational opportunity Research opportunity
Ideal Host Institution Presence of high case volume and case mix Presence of local trainees Presence of qualified surgical faculty on-site Presence of other complementary faculty, e.g., anesthesia, OB-GYN, pathology, and radiology Existing infrastructure of the home institution in the host country Identified local champion Potential to foster a bidirectional relationship Stable geopolitical environment
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1 week to 2 years. Several commonly stated goals were surgical care and clinical service (N ¼ 19, 100%), research (N ¼ 9, 47%), and training and education of local providers (N ¼ 6, 32%). In selecting residents for global surgery rotations, one must carefully consider the individual’s capacity to function in a novel and foreign setting. The nature of the developing country environment may factor into the perceived challenges—a foreign culture and language, limited health care resources, and access to communication technology (i.e., separation from the usual social support networks). These factors imply the need for a resident who exhibits humility, self-sufficiency, psychosocial stability, strong work ethic, and importantly, cultural sensitivity. A demonstrated record of success during prior similar experiences is advantageous. More importantly, it should be emphasized that an international experience probably helps develop these traits in a surgical trainee, representing an invaluable contribution during the formative years of his or her professional development. Programs use differing criteria in selecting a resident for global surgical experiences to suit their institutional and departmental goals and objectives. Therefore, we cannot prescribe a universal method for candidate selection. A minimum expectation of adherence to the Hippocratic Oath and dedication to the profession and respect for local customs and beliefs in the host country are mandatory. More often than not, most residents interested in a global surgical experience self-select.
FINANCIAL AND LOGISTICAL ASPECTS OF THE ELECTIVE INTERNATIONAL SURGICAL ROTATION In a time of shrinking revenue from governmental and other sources, funding the international surgical elective for a surgery resident presents some challenges. Approval by the surgery RRC-ACGME is contingent on the educational environment that requires the presence of a board-certified (or equivalent) surgeon to provide supervision, appropriate clinical experience, and safe living conditions. A highly recommended first expense might be a site visit by the program director or surgery education colleagues or both. For an international surgery elective, the RRC-ACGME guidelines require that regular salary and benefits be provided to the residents, as well as full financial coverage of expenses, including immunizations and medical necessities, airfare, local medical licenses, housing, and ground transportation; the only exceptions are food and recreation. Salary and benefits become the major financial commitment. Although resident training support at many hospitals already exceeds the capped Centers for Medicare and Medicaid Services payments, Centers for Medicare and Medicaid Services salary support cannot be used to e90
pay salaries for non-US rotations; therefore, the hospital or department must agree to absorb the costs. When electives are located in low- and middle-income countries, the largest single expense after salary and benefits is the airfare. For example, the total average cost including airfare for a 4-week rotation in rural Kenya is approximately $3000 for a person, with airfare costing approximately $2000. Unexpected natural or nonnatural situations may arise without a warning; therefore, purchasing airfare that is partially or fully refundable should be considered. Because funding from the large well-endowed global foundations is yet to materialize to address the global burden of surgical disease, seeking grant support from local and national foundations or agencies is recommended and is often encouraged—perhaps even required by the departmental and hospital leadership. Involving the institutional development office may reveal or perhaps create avenues of support. Any outside support raised decreases pressure on the departmental clinical dollars or hospital contribution or both. For example, fund-raising events may be organized. Although this is not a solution to the funding challenges, it certainly can augment the establishment of an international elective. Whenever fund-raising efforts of any type are under consideration, caution is advised, and approval should be sought from the proper institutional or university authority because some institutions may have strict guidelines for soliciting support and donations. Regarding personal safety and logistics, evacuation insurance is a mandatory responsibility of the program and should not be left up to the resident. Some institutions provide emergency evacuation coverage, but program directors and residents must read the small print to discover exclusions, such as those activities deemed risky by the carrier and not necessarily considered problematic by the traveler, e.g., caving, mountain or rock climbing, skydiving, bungee jumping, ballooning, hang gliding, and most types of racing. If the home institution has an evacuation partner in place, each trip should be registered to avoid possible loopholes if an emergency requiring evacuation arises. It is also important to ensure that the insurance carrier covers evacuations for nonmedical emergencies, such as natural disasters or political upheaval. The orientation for the international rotation must include personal safety rules and advice concerning the risks of road travel, including dangers of operating vehicles and riding motorcycles (with a proscription against either), traveling in the dark on any conveyance, or traveling at unsafe speeds at any time. A number of areas in the world are under a US State Department travelers advisory but might still be considered safe enough to visit if sensible precautions are taken. The program director should work closely with his or her institution’s international services office, if available, as well as the legal affairs office to be aware of any restrictions or liability waiver requirements, especially for areas of the
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world deemed to pose some degree of risk. No guideline or regulation should be assumed to be universal as tolerance for risk varies widely among educational institutions and possibly within various departments within a single institution. Sometimes, overly cautious persons must be reminded that even the United States is not immune to random violence and natural disasters. Most proponents of global surgical education experiences agree that the benefits far outweigh the risks.7
GLOBAL HEALTH AS AN ACADEMIC SURGICAL CAREER One of the greatest limitations of global surgery within a surgical training environment, which has hitherto been driven by the desires of surgery residents, is the lack of a clear career path for surgical faculty. A stipulation of the ACGME surgery RRC is the involvement of preferably an American Board of Surgery-certified surgeon with faculty appointment at a US program to provide oversight for the residents during their time abroad. As the field of academic global surgery evolves, it is critical that career paths are developed that match the needs of the young surgical faculty and academic departments. Academic global surgery appears to be developing a few different models of career paths. These patterns can be categorized by the protected allocated time available to be spent at the host institution, the individual global health emphasis (clinical care, education, and research), and the surgical specialty or subspecialty field. The most familiar model of time allocation is the use of the surgeon’s vacation time, allowing 2 to 4 weeks per year. This pattern is best suited to participate in focused clinical missions. This model has the advantage that it is not disruptive to a standard surgical practice, but the disadvantage is that it does relatively little to define the surgeon’s career trajectory or result in any academic advancement. Another model is the surgeon who is based full time at the host institution, with an academic appointment at the home institution. This paradigm allows the surgeon to invest undivided effort in global health work and may perhaps be the most effective model in delivering long-term benefit to the host institution, but it has the disadvantage of rarely being financially supported by the home institution, thus external funding needs to be identified. More recently, hybrid models have been developed, whereby surgeons variably split their time, spending several months in both settings. This has the advantage that the surgeon can act as a living link, bridging the home with the partnered host institution overseas while not sacrificing the home surgical networks and practice. This model gives the surgeon sufficient time abroad to coordinate research endeavors, build local research capacity, foster ongoing education and training relationships, and
contribute to clinical care with the goal of increasing local surgical workforce capacity. Many surgeons are currently engaged in a mix of activities mentioned earlier, demonstrating that global surgery has evolved into a bona fide academic field.8 There are multiple surgical specialties building global programs. Certainly, some fields are obviously more amenable to a hybrid career path, allowing surgeons to split their time between the host and the home institutions. Specialties where team-based models are used for patient care certainly facilitate the development of global surgery careers. Acute care surgery/trauma and pediatric general surgery practices are often organized in this fashion. Several other fields are creating global practice models that work in their specific context. There are surgeons across many fields and specialties who have engaged in global work—orthopedic, cardiac surgery, neurosurgery, obstetrics and gynecology, thoracic surgery, urology, surgical oncology, plastics and reconstructive surgery, and acute care/burn/trauma surgery. Although almost any subspecialty has global applications, it is advisable for the aspiring academic global surgeon to consider the feasibility of global careers within one’s surgical disciplines. For many academic surgical chairpersons, the most obvious value of hiring global health faculty is to build global surgical programs that attract the best and brightest trainees, a large proportion of whom are now requesting substantial global health experience and training in their residency programs.9 These faculty members are also tasked to guide and mentor the global health–differentiated residents. Aspiring academic global surgeons should recognize the need for departments to stay financially solvent, as global health activity is not a revenuegenerating endeavor. This typically forms the basis for initial reluctance by departmental and institutional leadership. Conversely, it is important for chairpersons to acknowledge that global health faculty activity represents challenging work that supports the academic mission of their department. The global health faculty are the international ambassadors of their institutions’ brand. Thus, increasingly, young surgical faculty recruited with an academic focus in global health are being compensated with full salaries comparable to their nonglobal health counterparts and with protected time to engage in global health work.10 Finally, it is also advisable to negotiate with the chairperson and the hospital to secure funding for salary support and programmatic costs (Fig).
CONCLUSION As surgical residency programs contemplate the integration of global health partnerships, it must be recognized that the winds of change within global public health are now blowing in the direction of noncommunicable diseases, of
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Program and institutional commitment to integration of global health into surgery residency
Initiation of visit by faculty/ PD. Visit to Host site. Identiication of faculty mentors.
Identiication of ideal partner Host institution and surgeon champion
Ensure Initial inancial commitment by surgery department/institution
Sign memorandum of Understanding
Send application to ACGME for approval of rotation
Resident Selection
Start program with resident and US faculty
FIGURE. The steps for the integration of global health into surgery residency.
which surgical diseases are prominent. For surgical departments, prepositioning and addressing the global surgical burden through institutional partnerships built on a platform of clinical care, education and capacity building, and research are strongly encouraged. The exposure of current surgical trainees to global health portends the amelioration of future global disparities in surgical care. This endeavor celebrates the interconnectedness of the human spirit and e92
the innate need to respond to human suffering, which is emblematic of the medical profession.
REFERENCES 1. Powell AC, Casey K, Liewehr DJ, Hayanga A, James
TA, Cherr GS. Results of a national survey of surgical resident interest in international experience, electives,
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and volunteerism. J Am Coll Surg. 2009;208(2): 304-312. http://dx.doi.org/10.1016/j.jamcollsurg. 2008.10.025 [Epub 2008 Dec 4].
6. Operation giving back: resources for residents. Retrieved
2. Mitchell KB, Tarpley MJ, Tarpley JL, Casey KM. Elective
7. Tarpley M, Hansen E, Tarpley JL. Early experience
global surgery rotations for residents: a call for cooperation and consortium. World J Surg. 2011;35(12):2617-2624.
in establishing and evaluating an ACGMEapproved international general surgery rotation. J Surg Educ. 2013;70(6):709-714. http://dx.doi. org/10.1016/j.jsurg.2013.04.016 [Epub 2013 Jun 25].
3. Axt J, Nthumba PM, Mwanzia K, et al. Commentary:
the role of global surgery electives during residency training: relevance, realities, and regulations. Surgery. 2013;153(3):327-332. http://dx.doi.org/10.1016/j. surg.2012.09.014. 4. Riviello R, Ozgediz D, Hsia RY, Azzie G, Newton M,
Tarpley JL. Role of collaborative academic partnerships in surgical training, education, and provision. World J Surg. 2010;34(3):459-465. 5. Criteria for approved international rotations. Available
at: 〈http://www.acgme.org/acgmeweb/Portals/0/PFAs sets/ProgramResources/440_Surgery_International_Ro tation_Application_Process.pdf〉 Accessed 18.11.13.
November 14, 2013, from Available at: 〈http://www. operationgivingback.facs.org/content2271.html〉.
8. Leow JJ, Kingham TP, Casey KM, Kushner AL.
Global surgery: thoughts on an emerging surgical subspecialty for students and residents. J Surg Educ. 2010;67(3):143-148. 9. Calland JF, Petroze RT, Abelson J, Kraus E. Engaging
academic surgery in global health: challenges and opportunities in the development of an academic track in global surgery. Surgery. 2013;153(3):316-320. 10. Tarpley JL. Commentary: an academic track in global
surgery. Surgery. 2013;153(3):322-324.
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Integrating Global Health Into Surgery Residency in the United States Anthony G. Charles, MD,* Jonathan C. Samuel, MD,* Robert Riviello, MD,† Melanie K. Sion, MD,‡ Margaret J. Tarpley, MLS,§ John L. Tarpley, MD,§ Oluyinka O. Olutoye, PhD,¶ Jeffrey R. Marcus, MDJ Department of Surgery, University of North Carolina, Chapel Hill, North Carolina, †Brigham and Women’s Hospital, Center for Surgery and Public Health, Boston, Massachusetts, ‡Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, §Department of Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee, ¶Texas Children’s Hospital, Baylor University, Houston, Texas; and J Department of Surgery, Duke University, Durham, North Carolina *
INTRODUCTION The increasing influence of globalization on health care has resulted in a greater awareness of health disparities within the millennial generation, some of who strive to ensure equity in the provision of health care services. Interest in global health among the surgical residency applicant pool is increasing.1 The ability to offer a global health opportunity is now considered a marker of a competitive surgical training program that improves resident recruitment. Furthermore, it motivates residents to serve local vulnerable communities and prepares them for a future career in global health. In 2011, the General Surgery Residency Review Committee (RRC) of the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Surgery approved international electives for credit toward residency graduation requirements. After extensive debate on the ways in which international electives could be standardized to ensure consistent educational experience for residents, the surgery RRC approved a set of requirements for such electives.2,3 Surgical training institutions (academic and community based) are beginning to explore ways to actualize international surgical rotations. We discuss inherent practicalities, challenges, and opportunities and emphasize that any such program must be bidirectional and fall within the educational pillars and the core competencies prescribed by the ACGME. All the authors are surgeons who are actively involved with a global surgical program, with resident participation at their respective institutions.
Correspondence: Inquiries to Anthony Charles, MD, MPH, FACS, Department of Surgery, UNC School of Medicine, Gillings School of Global Public Health, University of North Carolina, 4008 Burnett Womack Building, CB 7228, Chapel Hill, NC; fax: (919) 966-0369; e-mail: [email protected]
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FINDING A GLOBAL INSTITUTIONAL PARTNER Although the integration of global health into a surgery residency program may be focused on enhancing the experience of the surgery resident, it must fit into the overall global health mission of the institutions involved— the home institution and the host institution. There are a variety of reasons why an institution may be committed to global health, and the mechanism by which these efforts are actualized can be broadly categorized into clinical care, education, capacity building, and research, as well as, in some cases, business development.4 Most institutions are involved in several of these activities but there are typically 1 or 2 major thrusts that direct the overall mission. The home institution must clearly define how residency training specifically relates to the overall global health imperative. From the perspective of the host institution, the commitment to educational partnerships involving resident participation offers the opportunity to enhance patient care and build capacity through the education and training of the surgical trainees in the host countries in the developing world. The “global surgery experience,” from a resident standpoint, incorporates several elements to varying degrees. Surgery residents could have the opportunity to: (1) expand their surgical knowledge base by being exposed to a range or volume of pathology distinct from that in their home institutions, (2) understand system-based practice by learning to care for surgical patients in resource- and technologylimited environments, (3) contribute to the education of host health care providers, and (4) build international collaborations with their contemporaries in foreign countries. The choice of location and institution depends on what the expected outcomes are for the surgery residents. If the global surgery experience aims at least in part to augment the exposure to certain disease conditions, partnering with an institution that sees a large number of such diseases could
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.2014.05.005
be a compelling factor, e.g., thyroid disease, cleft lip, and cleft palate. For training programs in which conditionspecific educational exposure is not a primary motivating factor, the global surgery experience can be structured more creatively, focusing on the latter of the aforementioned elements. The structure of a resident-inclusive global health care program must be appropriately supervised; residents should be able to provide level-specific clinical care with guidance and accountability. Finally, such programs should seek to augment and should not compete with any clinical training programs or capacity building efforts aimed at the local trainees in the host institution. Operative volume should always be secondary or tertiary in the experience. The residents can also be involved in teaching and peer mentoring of their host country contemporaries. Where host-training efforts are in place, a superb opportunity exists for bidirectional exchange among the trainees. The duration and frequency of a global surgery elective for residents may be influenced by several factors. Prior experience with resident support at the host site and the presence of infrastructure, which can be influenced by program maturity, are perhaps the most important factors. If the institution has existing infrastructure in the region to assist with local logistics, it would be helpful in coordinating housing, transportation, and advising about immunization and credentialing. For institutions that do not have such infrastructure on-site, partnering with other US institutions in the region or at the host institution would be beneficial. On an average, 2 or more US institutions providing services at a host institution can provide excellent synergy to coordinate services, avoid redundancy, and maximize effect. For example, faculty coverage for extended periods can be shared by the various institutions and reduce the burden on each individual institution while allowing more leeway for resident rotations. Other factors include presence of ACGME-approved faculty supervision, the breadth and volume of surgical scope, and the presence of other complimentary faculty and residents (e.g., anesthesia, obstetrics and gynecology (OB-GYN), and pathology). Geopolitical factors, as well as ease of access to the region of interest and to the medical facility, should also be
considered during site selection. Additional time for travel and recovery should be included in the rotations. Establishing prior relationships with the appropriate embassies and US consulates should be explored. Although it is desirable that there be personal relationships with a local champion from the program in the host institution, long-term commitments are best accomplished with relationships at the institutional or governmental levels. Formal agreements or memoranda of understanding are mandatory to clearly outline the goals and objectives and the expected outcomes beneficial to all parties.5 Although the areas with the most surgical need tend to be the regions fraught with political unrest, the safety of the residents and likelihood of maintaining a long-term relationship in the event of political changes must be considered. For this reason, consideration should be given to institutions with nongovernmental affiliations that are less susceptible to the ever-changing political climate, including faith-based institutions. Any rotation should be inclusive and open to all residents in the program. Behavioral guidelines, such as appropriate clothing or use or nonuse of alcohol on the host campus, are acceptable, but faith restrictions should not deny the opportunity to any eligible resident (Table). A striking characteristic of international surgical endeavors for resident trainees is the broad range of potential experiences available. Differences in local health care resources, disease patterns, languages, and cultures of the developing countries result in unique environments for each site. The home institution also contributes to this heterogeneity, as academic programs offering international experiences differ in many aspects—from the length of rotation and the expected outcomes for residents to the degree of formality employed in resident selection. A review of existing global surgery programs using the resources at Operation Giving Back combined with an Internet search of individual programs identified 19 programs with structured experiences for surgery residents.6 Among these programs, 4 offered an advanced degree (a Master in Public Health) as part of the experience. The duration of experiences ranged from
TABLE. The characteristics of the Home and the Host Institutions That Are Needed to Meet Resident Expectations Home Institution Mission Patient care Capacity building Education Research Business development
Resident Expectation Increased clinical and operative experience Exposure to diverse surgical pathology Systems-based practice in a resource-poor setting Teaching/educational opportunity Research opportunity
Ideal Host Institution Presence of high case volume and case mix Presence of local trainees Presence of qualified surgical faculty on-site Presence of other complementary faculty, e.g., anesthesia, OB-GYN, pathology, and radiology Existing infrastructure of the home institution in the host country Identified local champion Potential to foster a bidirectional relationship Stable geopolitical environment
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1 week to 2 years. Several commonly stated goals were surgical care and clinical service (N ¼ 19, 100%), research (N ¼ 9, 47%), and training and education of local providers (N ¼ 6, 32%). In selecting residents for global surgery rotations, one must carefully consider the individual’s capacity to function in a novel and foreign setting. The nature of the developing country environment may factor into the perceived challenges—a foreign culture and language, limited health care resources, and access to communication technology (i.e., separation from the usual social support networks). These factors imply the need for a resident who exhibits humility, self-sufficiency, psychosocial stability, strong work ethic, and importantly, cultural sensitivity. A demonstrated record of success during prior similar experiences is advantageous. More importantly, it should be emphasized that an international experience probably helps develop these traits in a surgical trainee, representing an invaluable contribution during the formative years of his or her professional development. Programs use differing criteria in selecting a resident for global surgical experiences to suit their institutional and departmental goals and objectives. Therefore, we cannot prescribe a universal method for candidate selection. A minimum expectation of adherence to the Hippocratic Oath and dedication to the profession and respect for local customs and beliefs in the host country are mandatory. More often than not, most residents interested in a global surgical experience self-select.
FINANCIAL AND LOGISTICAL ASPECTS OF THE ELECTIVE INTERNATIONAL SURGICAL ROTATION In a time of shrinking revenue from governmental and other sources, funding the international surgical elective for a surgery resident presents some challenges. Approval by the surgery RRC-ACGME is contingent on the educational environment that requires the presence of a board-certified (or equivalent) surgeon to provide supervision, appropriate clinical experience, and safe living conditions. A highly recommended first expense might be a site visit by the program director or surgery education colleagues or both. For an international surgery elective, the RRC-ACGME guidelines require that regular salary and benefits be provided to the residents, as well as full financial coverage of expenses, including immunizations and medical necessities, airfare, local medical licenses, housing, and ground transportation; the only exceptions are food and recreation. Salary and benefits become the major financial commitment. Although resident training support at many hospitals already exceeds the capped Centers for Medicare and Medicaid Services payments, Centers for Medicare and Medicaid Services salary support cannot be used to e90
pay salaries for non-US rotations; therefore, the hospital or department must agree to absorb the costs. When electives are located in low- and middle-income countries, the largest single expense after salary and benefits is the airfare. For example, the total average cost including airfare for a 4-week rotation in rural Kenya is approximately $3000 for a person, with airfare costing approximately $2000. Unexpected natural or nonnatural situations may arise without a warning; therefore, purchasing airfare that is partially or fully refundable should be considered. Because funding from the large well-endowed global foundations is yet to materialize to address the global burden of surgical disease, seeking grant support from local and national foundations or agencies is recommended and is often encouraged—perhaps even required by the departmental and hospital leadership. Involving the institutional development office may reveal or perhaps create avenues of support. Any outside support raised decreases pressure on the departmental clinical dollars or hospital contribution or both. For example, fund-raising events may be organized. Although this is not a solution to the funding challenges, it certainly can augment the establishment of an international elective. Whenever fund-raising efforts of any type are under consideration, caution is advised, and approval should be sought from the proper institutional or university authority because some institutions may have strict guidelines for soliciting support and donations. Regarding personal safety and logistics, evacuation insurance is a mandatory responsibility of the program and should not be left up to the resident. Some institutions provide emergency evacuation coverage, but program directors and residents must read the small print to discover exclusions, such as those activities deemed risky by the carrier and not necessarily considered problematic by the traveler, e.g., caving, mountain or rock climbing, skydiving, bungee jumping, ballooning, hang gliding, and most types of racing. If the home institution has an evacuation partner in place, each trip should be registered to avoid possible loopholes if an emergency requiring evacuation arises. It is also important to ensure that the insurance carrier covers evacuations for nonmedical emergencies, such as natural disasters or political upheaval. The orientation for the international rotation must include personal safety rules and advice concerning the risks of road travel, including dangers of operating vehicles and riding motorcycles (with a proscription against either), traveling in the dark on any conveyance, or traveling at unsafe speeds at any time. A number of areas in the world are under a US State Department travelers advisory but might still be considered safe enough to visit if sensible precautions are taken. The program director should work closely with his or her institution’s international services office, if available, as well as the legal affairs office to be aware of any restrictions or liability waiver requirements, especially for areas of the
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world deemed to pose some degree of risk. No guideline or regulation should be assumed to be universal as tolerance for risk varies widely among educational institutions and possibly within various departments within a single institution. Sometimes, overly cautious persons must be reminded that even the United States is not immune to random violence and natural disasters. Most proponents of global surgical education experiences agree that the benefits far outweigh the risks.7
GLOBAL HEALTH AS AN ACADEMIC SURGICAL CAREER One of the greatest limitations of global surgery within a surgical training environment, which has hitherto been driven by the desires of surgery residents, is the lack of a clear career path for surgical faculty. A stipulation of the ACGME surgery RRC is the involvement of preferably an American Board of Surgery-certified surgeon with faculty appointment at a US program to provide oversight for the residents during their time abroad. As the field of academic global surgery evolves, it is critical that career paths are developed that match the needs of the young surgical faculty and academic departments. Academic global surgery appears to be developing a few different models of career paths. These patterns can be categorized by the protected allocated time available to be spent at the host institution, the individual global health emphasis (clinical care, education, and research), and the surgical specialty or subspecialty field. The most familiar model of time allocation is the use of the surgeon’s vacation time, allowing 2 to 4 weeks per year. This pattern is best suited to participate in focused clinical missions. This model has the advantage that it is not disruptive to a standard surgical practice, but the disadvantage is that it does relatively little to define the surgeon’s career trajectory or result in any academic advancement. Another model is the surgeon who is based full time at the host institution, with an academic appointment at the home institution. This paradigm allows the surgeon to invest undivided effort in global health work and may perhaps be the most effective model in delivering long-term benefit to the host institution, but it has the disadvantage of rarely being financially supported by the home institution, thus external funding needs to be identified. More recently, hybrid models have been developed, whereby surgeons variably split their time, spending several months in both settings. This has the advantage that the surgeon can act as a living link, bridging the home with the partnered host institution overseas while not sacrificing the home surgical networks and practice. This model gives the surgeon sufficient time abroad to coordinate research endeavors, build local research capacity, foster ongoing education and training relationships, and
contribute to clinical care with the goal of increasing local surgical workforce capacity. Many surgeons are currently engaged in a mix of activities mentioned earlier, demonstrating that global surgery has evolved into a bona fide academic field.8 There are multiple surgical specialties building global programs. Certainly, some fields are obviously more amenable to a hybrid career path, allowing surgeons to split their time between the host and the home institutions. Specialties where team-based models are used for patient care certainly facilitate the development of global surgery careers. Acute care surgery/trauma and pediatric general surgery practices are often organized in this fashion. Several other fields are creating global practice models that work in their specific context. There are surgeons across many fields and specialties who have engaged in global work—orthopedic, cardiac surgery, neurosurgery, obstetrics and gynecology, thoracic surgery, urology, surgical oncology, plastics and reconstructive surgery, and acute care/burn/trauma surgery. Although almost any subspecialty has global applications, it is advisable for the aspiring academic global surgeon to consider the feasibility of global careers within one’s surgical disciplines. For many academic surgical chairpersons, the most obvious value of hiring global health faculty is to build global surgical programs that attract the best and brightest trainees, a large proportion of whom are now requesting substantial global health experience and training in their residency programs.9 These faculty members are also tasked to guide and mentor the global health–differentiated residents. Aspiring academic global surgeons should recognize the need for departments to stay financially solvent, as global health activity is not a revenuegenerating endeavor. This typically forms the basis for initial reluctance by departmental and institutional leadership. Conversely, it is important for chairpersons to acknowledge that global health faculty activity represents challenging work that supports the academic mission of their department. The global health faculty are the international ambassadors of their institutions’ brand. Thus, increasingly, young surgical faculty recruited with an academic focus in global health are being compensated with full salaries comparable to their nonglobal health counterparts and with protected time to engage in global health work.10 Finally, it is also advisable to negotiate with the chairperson and the hospital to secure funding for salary support and programmatic costs (Fig).
CONCLUSION As surgical residency programs contemplate the integration of global health partnerships, it must be recognized that the winds of change within global public health are now blowing in the direction of noncommunicable diseases, of
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Program and institutional commitment to integration of global health into surgery residency
Initiation of visit by faculty/ PD. Visit to Host site. Identiication of faculty mentors.
Identiication of ideal partner Host institution and surgeon champion
Ensure Initial inancial commitment by surgery department/institution
Sign memorandum of Understanding
Send application to ACGME for approval of rotation
Resident Selection
Start program with resident and US faculty
FIGURE. The steps for the integration of global health into surgery residency.
which surgical diseases are prominent. For surgical departments, prepositioning and addressing the global surgical burden through institutional partnerships built on a platform of clinical care, education and capacity building, and research are strongly encouraged. The exposure of current surgical trainees to global health portends the amelioration of future global disparities in surgical care. This endeavor celebrates the interconnectedness of the human spirit and e92
the innate need to respond to human suffering, which is emblematic of the medical profession.
REFERENCES 1. Powell AC, Casey K, Liewehr DJ, Hayanga A, James
TA, Cherr GS. Results of a national survey of surgical resident interest in international experience, electives,
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and volunteerism. J Am Coll Surg. 2009;208(2): 304-312. http://dx.doi.org/10.1016/j.jamcollsurg. 2008.10.025 [Epub 2008 Dec 4].
6. Operation giving back: resources for residents. Retrieved
2. Mitchell KB, Tarpley MJ, Tarpley JL, Casey KM. Elective
7. Tarpley M, Hansen E, Tarpley JL. Early experience
global surgery rotations for residents: a call for cooperation and consortium. World J Surg. 2011;35(12):2617-2624.
in establishing and evaluating an ACGMEapproved international general surgery rotation. J Surg Educ. 2013;70(6):709-714. http://dx.doi. org/10.1016/j.jsurg.2013.04.016 [Epub 2013 Jun 25].
3. Axt J, Nthumba PM, Mwanzia K, et al. Commentary:
the role of global surgery electives during residency training: relevance, realities, and regulations. Surgery. 2013;153(3):327-332. http://dx.doi.org/10.1016/j. surg.2012.09.014. 4. Riviello R, Ozgediz D, Hsia RY, Azzie G, Newton M,
Tarpley JL. Role of collaborative academic partnerships in surgical training, education, and provision. World J Surg. 2010;34(3):459-465. 5. Criteria for approved international rotations. Available
at: 〈http://www.acgme.org/acgmeweb/Portals/0/PFAs sets/ProgramResources/440_Surgery_International_Ro tation_Application_Process.pdf〉 Accessed 18.11.13.
November 14, 2013, from Available at: 〈http://www. operationgivingback.facs.org/content2271.html〉.
8. Leow JJ, Kingham TP, Casey KM, Kushner AL.
Global surgery: thoughts on an emerging surgical subspecialty for students and residents. J Surg Educ. 2010;67(3):143-148. 9. Calland JF, Petroze RT, Abelson J, Kraus E. Engaging
academic surgery in global health: challenges and opportunities in the development of an academic track in global surgery. Surgery. 2013;153(3):316-320. 10. Tarpley JL. Commentary: an academic track in global
surgery. Surgery. 2013;153(3):322-324.
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