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T HE J OURNAL
OF
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AND J OINT
S URGERY, I NCORPORATED
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Orthopaedic forum
International Elective During Orthopaedic Residency in North America: Perceived Barriers and Opportunities Bensen Fan, MD, Caixia Zhao, MD, and Sanjeev Sabharwal, MD, MPH Peer Review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors.
The prevalence of musculoskeletal trauma, including motor vehicle-related injuries, is increasing worldwide. It is estimated that global trauma will increase by 80% from 2010 to 20201, with a large number of these injuries occurring in regions with limited resources. In addition to neglected musculoskeletal trauma, other clinical entities such as untreated clubfoot, persistent bone and joint infections, and neuromuscular disorders add to the unmet burden in the daily lives of patients and caretakers who reside in such areas around the world. Various organizations have responded to this increasing health-care demand by providing volunteer opportunities for orthopaedic surgeons to teach and train overseas in regions with limited resources2-4. International volunteerism comes in many forms, including short-term surgical aid, disaster relief, and teaching and training local health-care providers2. It is well known that physicians who volunteer internationally during training are more likely to volunteer locally and internationally later in their careers5. Some orthopaedic residency programs in North America offer an international elective, and such an elective has been found to be beneficial2-4,6,7 (Table I). Aside from a few publications primarily resulting from experiences in a single orthopaedic residency program3,4,6, there is scant literature providing a detailed de-
scription of the barriers to setting up an international elective for orthopaedic residents. Given the variability in the size and characteristics of orthopaedic residency programs across North America, the challenges and opportunities for establishing such electives may vary among institutions. Furthermore, there is limited information on establishing such an international elective in residency programs that currently do not offer one. We surveyed U.S. and Canadian orthopaedic residency programs to ascertain the current status of such an international resident rotation and the goals and barriers perceived by various stakeholders. Our goal was to use a literature review and the results of our survey to identify barriers to, and potential solutions for, establishing global health electives for orthopaedic residents in North America. Materials and Methods The survey was approved by our institutional review board. Given the lack of existing surveys regarding barriers to international electives among orthopaedic residency programs, we incorporated some questions and themes that have 8-11 been used by investigators in other medical specialties . A web-based survey was formulated and sent to orthopaedic residency program directors and coordinators across North America. The respondents were asked whether or not their program offered an international elective. If the elective was offered, the
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
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TABLE I Perceived Benefits of an Overseas Orthopaedic Resident Elective in a Resource-Challenged Environment Exposure to musculoskeletal sequelae not commonly seen in North America (e.g., untreated osteomyelitis, tuberculosis, polio, neglected trauma, advanced stages of musculoskeletal tumors, and natural history of congenital deformities) Exposure to foreign health-care systems Greater cultural awareness Practice of professionalism in an unfamiliar setting Practice of resource-conscious treatment in a setting with limited resources Participation in training of local health-care providers
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Source of Funding No external funding was used for this study.
Results Fifty-six (31%) of 179 North American orthopaedic residency programs responded to the survey. The programs at the responding institutions varied in size from two to twelve residents (mean, five residents) per year (Table II). There were sixty respondents (thirty program directors and thirty program coordinators) at the fifty-six institutions; the responses for the four programs at which both the program director and coordinator responded were combined. Programs Offering an International Elective
Appreciation for global health
Overseas Location, Resident Year-in-Training, and Faculty Involvement (Table III)
Continued future volunteerism
purpose of the elective and its logistics (e.g., overseas location, duration, number of participating residents, number of participating faculty, and type of partner institution) were sought. All respondents were also asked fifteen closed-ended or openended questions to determine the motivation and perceived challenges and benefits in creating an international elective (see Appendix).
Statistics Analysis The survey results were analyzed with use of SAS software (version 9.2; SAS Institute, Cary, North Carolina). Frequencies and descriptive statistics were calculated to summarize the answers of the respondents. The chi-square test or Fisher exact test was used to assess relationships between categorical variables. The unpaired t test was used to compare the means of continuous variables between groups or subgroups. A p value of £0.05 was considered significant.
Eighteen (32%) of the fifty-six responding programs offered an international elective to their residents. The most common geographic regions were Africa and Central America (seven programs [39% of the eighteen] each), with some programs offering electives in multiple locations. In order to implement the international elective, residency programs partnered with academic institutions (eight programs [44%]), public hospitals (seven programs [39%]), and nongovernment organizations (NGOs; six programs [33%]) with already-established relationships in the host country. No programs reported working with a private hospital in a host country. Nine (50%) of the programs offered an international elective to orthopaedic residents in their fourth postgraduate year (PGY-4).
TABLE II Characteristics of the Programs Responding to the Survey (N = 56)* International Elective (no. [%]) Characteristic
No. (% of Respondents)
Yes
No
Northeast U.S.
10 (22)
3 (30)
7 (70)
Southern U.S.
9 (20)
3 (33)
6 (67)
13 (28) 9 (20)
2 (15) 3 (33)
11 (85) 6 (67)
5 (11)
4 (80)
1 (20)
Geographic region
Midwestern U.S. Western U.S. Canada No answer
10
No. of residents/yr 2
4 (9)
1 (25)
3 (75)
3
6 (13)
1 (17)
5 (83)
4
12 (26)
4 (33)
8 (67)
5
15 (33)
8 (53)
7 (47)
6 7
3 (7) 2 (4)
1 (33) 0 (0)
2 (67) 2 (100)
8
2 (4)
1 (50)
1 (50)
12
2 (4)
2 (100)
0 (0)
No answer *Not all programs responded to every question.
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TABLE III Selected Responses by Administrators of the Programs Offering an International Elective Question Preferred location of overseas elective*
Response (%) Central America (39%) Africa (39%) Europe (28%) South Asia, South America, Australia (11% each) East Asia (6%)
Year of elective*
PGY-4 (50%) PGY-5 (39%) PGY-3 (28%) PGY-1 or 2 (6%)
Proposed length of elective
4 weeks (33%) 2 weeks (22%) 1, 5, 6, or 12 weeks (6% each)
*More than one answer could be selected.
The administrators of one of the remaining programs reported that residents could select an international elective during their research rotation, but the year-in-training was not specified. Three (17%) of the programs sent one faculty member per year from the home program to the overseas elective site, four (22%) sent two, and three (17%) sent three or more. Faculty members spent a mean of two weeks (range, one week to two months) abroad. Four (22%) of the programs sent one resident per year for the international elective, three (17%) sent two, two (11%) sent three, and two (11%) sent four or more. Most of the responding program administrators believed that residents should spend two weeks (22%) or four weeks (33%) at the overseas location to get the most benefit.
Comparison Between Programs Offering and Not Offering an International Elective General Characteristics
No significant association was found between the number of residents in the program (p = 0.11) or geographic location of the residency program (p = 0.32) and the presence of an international elective (Table II). Perceived Barriers
All program administrators were given the same list of potential barriers to international electives and asked to select all options that applied to their program (Fig. 2). A greater percentage of those offering an international elective had concerns regarding safety compared with those not offering an elective (p = 0.004). A greater percentage of those not offering
Logistics and Coverage
When asked about coverage of the clinical duties of the traveling resident, most program administrators reported some form of cross-coverage or incorporation of the overseas rotation as an elective rotation without on-call responsibilities. Liability insurance for the traveling residents was covered by the home institution in nine programs (50%), the overseas host institution in four (22%), and a third party in one (6%). The administrators of four (22%) of the programs reported that separate liability insurance was not required for the overseas elective; another reported that insurance was provided through the partnering NGO. The administrators of twelve (67%) of the programs reported providing some financial assistance to the volunteering residents, and three (17%) reported providing no financial assistance. Goals
The administrators of thirteen (72%) of the programs reported that the purpose of the elective was to “increase cultural awareness among residents” (Fig. 1).
Fig. 1
Goals in the eighteen residency programs with an international elective. (Program administrators could select multiple answers.)
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Fig. 2
Comparison of barriers perceived by residency programs offering and not offering an international elective.
an international elective were concerned about the financial cost compared with those offering an elective (p = 0.02). Discussion Our survey demonstrated that at least eighteen (10%) of the 179 North American orthopaedic residency programs currently offer an international elective to their residents, typically for two or four weeks in their final two years of training. The host institution is most commonly located in Africa or Central America (Table III). A review of the literature in other specialties shows that the majority of residency programs follow a similar pattern3,6,7,12-16. In a recently published survey of U.S. orthopaedic residency programs by Clement et al., fifty-five (61%) of ninety responding programs reported that at least one resident had a clinical experience in a developing country during residency7. Although eleven of the programs in that survey indicated having a “structured global health program” at that time, we were able to identify eighteen such programs, perhaps because of the inclusion of Canadian programs in our survey. Additionally, Clement et al. reported that fifteen residency programs (24%) without an international elective were planning to create one, and eleven (18%) were not in favor of creating such an elective. However, feedback from orthopaedic residents was not sought, and the opinions of Canadian residency program directors were not represented. Some of the perceived barriers to organizing an overseas elective for orthopaedic residents in resource-challenged environments, as well as potential solutions, are outlined in Table IV. Resident Expectations The purposes that were cited most frequently by program administrators offering an international elective were to “increase cultural awareness” and “develop resident professionalism” (Fig. 1). Survey results from other specialties indicate that some residents may have the misconception that they are going overseas primarily to improve their surgical skills11. Therefore, the goals of the international elective should be clearly elucidated
to the residents in order to maximize their experiential learning while minimizing the potential to harm the local population and jeopardize the sustainability of the overseas program. Prior to enrolling in an overseas elective, it should be specified to the interested residents that they are not participating in these clinical rotations to perform procedures that are beyond their abilities and level of training17-19, but rather to experience different cultures20, learn about physician-patient interactions in diverse settings, develop a greater appreciation for public health issues, be exposed to diagnoses and management of musculoskeletal entities not typically encountered in North America, experience working with limited resources, and improve basic skills such as physical examination, external fixation, and traction2,6,21 (Table I). Additionally, many NGOs have shifted their priorities from providing short-term overseas surgical aid to establishing sustainable relationships with various countries to educate and train the local physicians in treating musculoskeletal disorders and injuries2,4,21. Residents participating in an international elective far removed from their home program may encounter a number of ethical dilemmas. Steps should be taken to avoid unintended negative consequences of such clinical rotations. Underinvolved residents who spend more time as a “tourist” as well as overinvolved residents who perform procedures beyond their training may compromise patient outcomes and erode the trusting relationships with their local hosts and community. Volunteering residents must maintain a high level of professionalism and be flexible to a foreign health-care setting. Some residency program administrators have found that setting up interactive workshops and a structured orientation program outlining the goals and objectives of the rotation prior to embarkation on the international elective has been helpful12,13,16,17,22. This may be an important step in aligning the goals of the program directors, traveling residents, and host institution. Further insight will be needed to ensure that the needs of the host institution and the local community are served appropriately. In this way, the host community, sponsoring residency program, and visiting resident will all benefit, each in their own unique way.
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TABLE IV Perceived Barriers and Potential Solutions Barrier
Potential Solutions
Misalignment between goals of the rotation and goals perceived by the resident
Pre-elective orientation
Lack of funding
Scholarships and grants
Comments
Interactive workshops Application and screening process
Establish clear goals and expectations prior to the overseas experience
AAP offers scholarships for orthopaedic residents and pediatric orthopaedic fellows to travel with a mentor to treat children in resource-poor countries for 1-4 weeks The American Foundation for Surgery of the Hand and HVO partner to provide 2 types of scholarships for residents for a minimum of 4 weeks (a grant for senior residents and fellows to travel to a teaching site in a developing country and an orthopaedic traveling fellowship for senior residents to travel to an HVO teaching site)
Safety
Covering clinical duties when away
Build international network Avoid going to areas of political unrest
Establish and maintain international ties with politically stable countries to allow for safe and consistent volunteer opportunities benefiting both host countries and volunteers
Call-free elective block
Not all programs have a call-free elective block
During research rotation During pediatrics or trauma rotation with board-certified attending surgeon
International work in such environments is typically trauma or pediatrics-oriented
During vacation
Vacation time is limited to only 1-2 weeks
Lack of accreditation
Recognize ACGME core competencies in overseas electives
Collaborate with ACGME, RRC, and ABOS to recognize work done on international electives as fulfilling ACGME core competencies and toward fulfilling requirements for ABOS eligibility
Lack of faculty support
Support from department chair, program director, and hospital administration Mentors, including senior or semiretired board-certified orthopaedic surgeons from any North American residency program
Increase information and familiarity with overseas electives to assuage concerns and misconceptions
Lack of available opportunities
Online database listing opportunities, resources, educational material, trip reports, funding options
Links available at POSNA COUR, AAP, and ASSH web sites
Surgical residents traveling overseas as part of a disaster relief team (typically for one to two weeks) often provide assistance to more senior volunteering surgeons and share their knowledge and skills with local health-care workers in an acute setting. As was the case following the 2010 earthquake in Haiti, the most common surgical intervention in such a setting is typically external fixation, followed by traction and then intramedullary nailing23. In contrast, residents traveling overseas through an elective program as part of a teaching-oriented or service-oriented rotation may be in a more controlled environment, assist in lectures and clinics, and experience diverse orthopaedic pathology not typically encountered in North America. Currently, the international elective experience for residents varies greatly, depending on the participating host institution that they are visiting. Residency program administrators
who are considering allowing their residents to go abroad should evaluate the goals of this rotation and its potential benefits for supplementing their current curriculum. For example, residents from a program at a level-I trauma center may not benefit as much from a short-term disaster relief mission during which they perform a redundant amount of external fixation and traction that they already regularly perform at their home program. Such residents may benefit more from a four-week rotation in a more elective practice setting that allows for greater cultural immersion, increased contact with local patients and health providers, more longitudinal patient follow-up, and increased potential for learning and teaching. Financial Burden Despite a strong interest in international electives by residents in various medical specialties5,6,10,24, the majority (73%)
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of administrators of orthopaedic programs not offering such an elective cited financial concern as a barrier (Fig. 2). In contrast, financial concern was cited as a barrier by only 39% of responding administrators of programs offering an overseas elective (p = 0.02). Our results are consistent with those of another recent survey in which the most commonly reported barriers to international electives included lack of funding, limited faculty interest or time, and logistical planning7. One respondent in our survey reported, “Hospital does not want to pay salary while away.” In our survey, twelve (67%) of the eighteen programs offering an international elective provided their residents with some financial assistance. Funding from scholarships or grants to support such resident electives has been reported previously2,25,26. Organizations such as the AAP (American Academy of Pediatrics)25 and HVO (Health Volunteers Overseas)26 offer scholarships to interested senior orthopaedic residents and fellows for short-term overseas elective experience. International electives are a creative way to train culturally competent future orthopaedic surgeons who are interested in practicing in underserved communities6. If financial concerns are truly the principal difficulty in offering an international elective, then alternate sources of funding should be explored to make the elective more affordable. It may be useful to require the residents to fill out a “trip report” elaborating on their experience and providing insight to future volunteers and organizers as a precondition for their funding assistance (Table IV). Keeping track of resident case logs on international rotations may give more insight into the type of education that residents receive abroad, which may encourage more support from the host program and supporting institutions. Safety Concerns In 2004, the medical relief organization Doctors Without Borders withdrew its staff from Afghanistan and Iraq because the risk to their safety was too great. More recently, news reports have indicated the dangers to the volunteer medical staff in Syria27-29. Among programs in the present survey that did offer an international elective, personal safety was the barrier that was identified most frequently (by 61%). This finding is concerning, as those programs that have already established an international elective perceived safety as a barrier to volunteering overseas. Interestingly, all of the orthopaedic residents in a previously published survey who had already participated in an international elective stated that they would still include an international elective in their training if they could “do it all over.”6 Perhaps participants in the elective find the dangers of traveling abroad minor in comparison with the training experience gained. International volunteering often takes place in developing countries with social and cultural environments unfamiliar to the volunteers2. Establishing a network of orthopaedic volunteers with personal and institutional ties to overseas institutions in politically stable countries and avoiding travel to countries on the U.S. travel advisory list can be a helpful step toward ensuring the safety of the volunteering resident (Table IV). Additionally, having a central reporting agency through which participating residents and program co-
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ordinators could receive security alerts and share their specific experiences with other programs would help minimize such threats. Such a database could be maintained by a U.S. organization such as the AAOS (American Academy of Orthopaedic Surgeons) or AOA (American Orthopaedic Association) or perhaps by an international organization such as the SICOT (Soci´et´e Internationale de Chirurgie Orthop´edique et de Traumatologie) or WHO (World Health Organization), and it could be updated by individual residents and board-certified orthopaedic surgeons. Coverage Issues We asked administrators of programs with an international elective to describe how they manage clinical coverage at the home institution. Most frequently, the resident would participate in the overseas rotation during “elective” time without oncall responsibilities or cross-coverage of clinical services would be prearranged among residents. Some programs had a dedicated call-free elective rotation or had residents go overseas during their “research” rotation. Another potential solution involves traveling during a specific clinical rotation (e.g., trauma, pediatrics, or hand) that matches factors such as the anticipated types of clinical cases overseas and the clinical expertise of the faculty mentor willing to volunteer at the same site (Table IV)3,6. Residents also have the option of using a portion of their allotted vacation and conference time to travel abroad. At four of eighteen programs, only one resident participated in the international elective per year. Nevertheless, resident coverage may be a more substantial burden for programs with fewer residents and less flexibility in clinical rotations. This has become even more relevant with duty hour limitations for postgraduate trainees in the U.S. Some NGOs recommend that residents planning on an international elective obtain evacuation insurance to cover any unforeseen threats to personal health and security while abroad30. Volunteers should also be aware of the overseas coverage, if any, provided by their personal health insurance carriers. The volunteering resident should check with their training program and sponsoring organization to ascertain their medical liability insurance coverage, as such coverage may vary among institutions. Credentialing As international electives become an integral part of orthopaedic residency training in some programs, increasing collaboration is needed among residency programs, the ACGME (Accreditation Council for Graduate Medical Education), and the ABOS (American Board of Orthopaedic Surgery). The ABOS and other similar credentialing bodies may not provide credit for clinical work done by the resident while overseas5,31. This may result from a lack of a board-certified orthopaedic surgeon supervising the resident performance and the absence of standardized goals and objectives for the overseas rotation31. Mentorship by interested faculty, including those senior surgeons who are semiretired from active clinical practice, may be another possibility for providing supervision by board-certified orthopaedic surgeons for such electives (Table IV).
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The results of our survey show that North American orthopaedic residency programs of a variety of sizes do offer an elective international rotation in resource-challenged environments (Table II). As the international elective is offered but not mandated in certain programs, there is a potential for unequal educational exposure among residents of the same program and among residents nationwide. Development of a standardized international elective curriculum to provide a more uniform resident experience should involve aligning the elective with the six core competencies stipulated by the ACGME and the requirements for participating in the certification examination held by the ABOS32. Working with board-certified orthopaedic surgeons, gaining both an outpatient and operative experience, having a clearly outlined set of goals and objectives for the rotation, and providing evaluations of resident performance during the elective are some measures that the programs can incorporate33. Despite multiple obstacles, some other medical specialties incorporate accredited international electives into their curriculum. For example, the RRC (Residency Review Committee) for general surgery recently began accepting cases performed by residents overseas31,34. An international health elective is a valuable experience that has the potential to address all six ACGME core competencies5,6,8,9,13,16,32, especially those involving patient care, systems-based practice, professionalism, and interpersonal skills and communication. At the 2012 AOA Annual Meeting, it was suggested that “volunteerism” be included under “professionalism” as a core competency32. Formal guidelines can be developed to assist programs with an international elective to meet these targets. Hopefully, the residency programs, ACGME, RRC, and ABOS can soon formalize accreditation for orthopaedic international electives. Faculty Support Garnering faculty support for an international elective can be helpful in easing resident concerns about going overseas. Although previously published surveys have shown a general interest in international electives, there are still programs with no interest in incorporating such an elective7. Perhaps the growing information available about the benefits of overseas rotations and means of overcoming some of the barriers will make board-certified orthopaedic faculty members more likely to participate in such a program. Compiling an online database of the residency programs offering an international elective can yield another useful resource for interested residents and faculty members. Such a database can serve as a repository listing opportunities, educational materials, trip reports, online courses, and funding options. For instance, the COUR (Children’s Orthopedics for Underserved Regions) section of the POSNA (Pediatric Orthopaedic Society of North America) web site, the ASSH (American Society for Surgery of the Hand), and the AAP have started such sections for their members interested in overseas medical missions and teaching35-38. Ideally, a similar database serving as a repository for all possible opportunities for trainees should be established
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by an entity (e.g., the AOA) that is not sponsoring any of the opportunities. Limitations of the Survey Our survey of North American orthopaedic residency programs has several limitations. First, the response rate was only 31%, which is less than the response rate of 40% preferred in this type of survey. However, we did receive responses from fifty-six different orthopaedic residency programs; these were well distributed throughout North America and ranged in size from two to twelve residents per year. Unfortunately, we did not ask about the presence or absence of global health programs in other departments at those same institutions, which could increase the likelihood of establishing a similar rotation in orthopaedics. Second, we did not use any objective measures to document the clinical experience of the residents who participated. Although detailed published data such as case logs during overseas electives may not be currently available for orthopaedic residency programs, such cases are well documented in the general surgery literature15,16,39. Finally, our survey did not examine the impact of visiting residents on the host institution and the local community. Although practicing orthopaedic surgeons traveling overseas can offer their surgical expertise, the role of residents in teaching and training local health-care professionals is unclear. Implications At least 10% (eighteen) of 179 North American orthopaedic residency programs currently offer an international elective to their residents, and more than half of those programs have some financial support available for the elective. However, despite a growing interest among orthopaedic residency programs in overseas clinical experience during the last two years of training, there are perceived barriers, including personal safety, cost, and administrative constraints. Further research is needed to analyze the experience of the orthopaedic training programs offering an international elective, as well as that of the overseas hosts, so that the impact of this clinical experience on all stakeholders, including the host community, can be fully assessed. Appendix An appendix containing the survey is available with the online version of this article as a data supplement at jbjs. org. n
Bensen Fan, MD Caixia Zhao, MD Sanjeev Sabharwal, MD, MPH Department of Orthopedics, UMDNJ-New Jersey Medical School, 90 Bergen Street, DOC 7300, Newark, NJ 07103. E-mail address for S. Sabharwal: [email protected]
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References 1. Gosselin RA, Gyamfi YA, Contini S. Challenges of meeting surgical needs in the developing world. World J Surg. 2011 Feb;35(2):258-61. 2. Dormans JP. Orthopaedic surgery in the developing world—can orthopaedic residents help? J Bone Joint Surg Am. 2002 Jun;84(6):1086-94. 3. Haskell A, Rovinsky D, Brown HK, Coughlin RR. The University of California at San Francisco international orthopaedic elective. Clin Orthop Relat Res. 2002 Mar; 396:12-8. 4. Rovinsky D, Brown HP, Coughlin RR, Paiement GD, Bradford DS. Overseas volunteerism in orthopaedic education. J Bone Joint Surg Am. 2000 Mar;82(3):433-6. 5. Drain PK, Holmes KK, Skeff KM, Hall TL, Gardner P. Global health training and international clinical rotations during residency: current status, needs, and opportunities. Acad Med. 2009 Mar;84(3):320-5. 6. Disston AR, Martinez-Diaz GJ, Raju S, Rosales M, Berry WC, Coughlin RR. The international orthopaedic health elective at the University of California at San Francisco: the eight-year experience. J Bone Joint Surg Am. 2009 Dec;91(12):29993004. 7. Clement RC, Ha YP, Clagett B, Holt GE, Dormans JP. What is the current status of global health activities and opportunities in US orthopaedic residency programs? Clin Orthop Relat Res. 2013 Nov;471(11):3689-98. Epub 2013 Jul 27. 8. Javidnia H, McLean L. Global health initiatives and electives: a survey of interest among Canadian otolaryngology residents. J Otolaryngol Head Neck Surg. 2011 Feb;40(1):81-5. 9. Jayaraman SP, Ayzengart AL, Goetz LH, Ozgediz D, Farmer DL. Global health in general surgery residency: a national survey. J Am Coll Surg. 2009 Mar;208(3):42633. Epub 2009 Jan 21. 10. 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, and volunteerism. J Am Coll Surg. 2009 Feb;208(2):304-12. Epub 2008 Dec 4. 11. Powell AC, Mueller C, Kingham P, Berman R, Pachter HL, Hopkins MA. International experience, electives, and volunteerism in surgical training: a survey of resident interest. J Am Coll Surg. 2007 Jul;205(1):162-8. Epub 2007 May 17. 12. Federico SG, Zachar PA, Oravec CM, Mandler T, Goldson E, Brown J. A successful international child health elective: the University of Colorado Department of Pediatrics’ experience. Arch Pediatr Adolesc Med. 2006 Feb;160(2):191-6. 13. Gladding S, Zink T, Howard C, Campagna A, Slusher T, John C. International electives at the University of Minnesota global pediatric residency program: opportunities for education in all Accreditation Council for Graduate Medical Education competencies. Acad Pediatr. 2012 May-Jun;12(3):245-50. Epub 2012 Apr 6. 14. Gupta AR, Wells CK, Horwitz RI, Bia FJ, Barry M. The International Health Program: the fifteen-year experience with Yale University’s Internal Medicine Residency Program. Am J Trop Med Hyg. 1999 Dec;61(6):1019-23. 15. Klaristenfeld 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 Jul;207(1):125-8. Epub 2008 Apr 24. 16. Sawatsky AP, Rosenman DJ, Merry SP, McDonald FS. Eight years of the Mayo International Health Program: what an international elective adds to resident education. Mayo Clin Proc. 2010 Aug;85(8):734-41. 17. Dharamsi S, Osei-Twum JA, Whiteman M. Socially responsible approaches to international electives and global health outreach. Med Educ. 2011 May;45(5):530-1. 18. Hayanga AJ. International surgical volunteerism electives and the rules. Surgery. 2008 Nov;144(5):839. Epub 2008 Aug 10. 19. Pherez FM, David PK. Re: Global health training and international clinical rotations during residency: current status, needs, and opportunities. Acad Med. 2009 Sep;84(9):1172; author reply 1172.
20. Campbell A, Sherman R, Magee WP. The role of humanitarian missions in modern surgical training. Plast Reconstr Surg. 2010 Jul;126(1):295-302. 21. Coughlin RR, Kelly NA, Berry W. Nongovernmental organizations in musculoskeletal care: Orthopaedics Overseas. Clin Orthop Relat Res. 2008 Oct;466(10): 2438-42. Epub 2008 Aug 7. 22. Sinha R. Ethical considerations in international health electives. Fam Med. 2011 Sep;43(8):592; author reply 592. 23. Teicher CL, Alberti K, Porten K, Elder G, Baron E, Herard P. M´edecins Sans Fronti`eres experience in orthopedic surgery in postearthquake Haiti in 2010. Prehosp Disaster Med. 2014 Feb;29(1):21-6. Epub 2014 Jan 15. 24. Jense RJ, Howe CR, Bransford RJ, Wagner TA, Dunbar PJ. University of Washington orthopedic resident experience and interest in developing an international humanitarian rotation. Am J Orthop (Belle Mead NJ). 2009 Jan;38(1):E18-20. 25. American Academy of Pediatrics. Section on orthopaedics. 2014. http://www2. aap.org/sections/ortho/. Accessed 2014 Mar 10. 26. Health Volunteers Overseas. The AFSH-HVO Young Surgeon Traveling Fellowship. http://www.hvousa.org/wp-content/uploads/2014/06/AFSH-YoungSurgeon-Fellowship-2014-Application-Updated.pdf. Accessed 2014 Jul 18. 27. Fieldstadt E. 5 members of Doctors Without Borders detained in northern Syria. World News: NBCNews.com. 2014 Jan 3. http://worldnews.nbcnews.com/_news/ 2014/01/03/22163582-5-members-of-doctors-without-borders-detained-in-northernsyria?lite. Accessed 2014 Mar 10. 28. NBC News. International medical aid group to leave Iraq. Conflict in Iraq on NBCNEWS.com. 2004 Nov 4. http://www.nbcnews.com/id/6406039/ns/world_newsmideast_n_africa/t/international-medical-aid-group-leave-iraq/#.UxzeeuddVEd. Accessed 2014 Mar 10. 29. BBCNews. Aid doctors to leave Afghanistan. 2004 Jul 28. http://news.bbc.co. uk/go/pr/fr/-/2/hi/south_asia/3931995.stm. Accessed 2014 Mar 10. 30. Health Volunteers Overseas. Travel resources. 2014 Apr 23. http://www. hvousa.org/resources/volunteer-toolkit/travel-resources/. Accessed 2014 Mar 10. 31. Mitchell KB, Tarpley MJ, Tarpley JL, Casey KM. Elective global surgery rotations for residents: a call for cooperation and consortium. World J Surg. 2011 Dec;35(12): 2617-24. 32. Weiner SD, DeRosa GP, Born CT, Wall LB, Weiner BK. On volunteerism and orthopaedics. AOA critical issues. J Bone Joint Surg Am. 2014 Jan 1;96(1):e5. 33. ACGME. International rotation application process: review committee for surgery. 2014. https://www.acgme.org/acgmeweb/Portals/0/PFAssets/ ProgramResources/440_Surgery_International_Rotation_Application_Process.pdf. Accessed 2014 Apr 30. 34. Parker AM, Petroze RT, Schirmer BD, Calland JF. Surgical residency market research-what are applicants looking for? J Surg Educ. 2013 Mar-Apr;70(2):232-6. Epub 2012 Oct 17. 35. Pediatric Orthopaedic Society of North America. Children’s orthopedics in underserved regions (COUR). 2014. http://www.posna.org/education/cour/cour.cfm. Accessed 2014 Mar 10. 36. American Society for Surgery of the Hand. International outreach opportunities. 2014. http://www.assh.org/Professionals/AboutASSH/OtherASSHConnections/ VolunteerServiceMap/Pages/default.aspx. Accessed 2014 Mar 10. 37. Health Volunteers Overseas. Orthopaedics. 2014. http://www.hvousa.org/ wherewework/orthopaedics.shtml. Accessed 2014 Mar 10. 38. American Academy of Pediatrics. AAP global. 2014. http://www2.aap.org/ international/. Accessed 2014 Mar 10. 39. Jarman BT, Cogbill TH, Kitowski NJ. Development of an international elective in a general surgery residency. J Surg Educ. 2009 Jul-Aug;66(4):222-4.
Copyright of Journal of Bone & Joint Surgery, American Volume is the property of Journal of Bone & Joint Surgery, Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
BY
T HE J OURNAL
OF
B ONE
AND J OINT
S URGERY, I NCORPORATED
the
Orthopaedic forum
International Elective During Orthopaedic Residency in North America: Perceived Barriers and Opportunities Bensen Fan, MD, Caixia Zhao, MD, and Sanjeev Sabharwal, MD, MPH Peer Review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors.
The prevalence of musculoskeletal trauma, including motor vehicle-related injuries, is increasing worldwide. It is estimated that global trauma will increase by 80% from 2010 to 20201, with a large number of these injuries occurring in regions with limited resources. In addition to neglected musculoskeletal trauma, other clinical entities such as untreated clubfoot, persistent bone and joint infections, and neuromuscular disorders add to the unmet burden in the daily lives of patients and caretakers who reside in such areas around the world. Various organizations have responded to this increasing health-care demand by providing volunteer opportunities for orthopaedic surgeons to teach and train overseas in regions with limited resources2-4. International volunteerism comes in many forms, including short-term surgical aid, disaster relief, and teaching and training local health-care providers2. It is well known that physicians who volunteer internationally during training are more likely to volunteer locally and internationally later in their careers5. Some orthopaedic residency programs in North America offer an international elective, and such an elective has been found to be beneficial2-4,6,7 (Table I). Aside from a few publications primarily resulting from experiences in a single orthopaedic residency program3,4,6, there is scant literature providing a detailed de-
scription of the barriers to setting up an international elective for orthopaedic residents. Given the variability in the size and characteristics of orthopaedic residency programs across North America, the challenges and opportunities for establishing such electives may vary among institutions. Furthermore, there is limited information on establishing such an international elective in residency programs that currently do not offer one. We surveyed U.S. and Canadian orthopaedic residency programs to ascertain the current status of such an international resident rotation and the goals and barriers perceived by various stakeholders. Our goal was to use a literature review and the results of our survey to identify barriers to, and potential solutions for, establishing global health electives for orthopaedic residents in North America. Materials and Methods The survey was approved by our institutional review board. Given the lack of existing surveys regarding barriers to international electives among orthopaedic residency programs, we incorporated some questions and themes that have 8-11 been used by investigators in other medical specialties . A web-based survey was formulated and sent to orthopaedic residency program directors and coordinators across North America. The respondents were asked whether or not their program offered an international elective. If the elective was offered, the
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
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TABLE I Perceived Benefits of an Overseas Orthopaedic Resident Elective in a Resource-Challenged Environment Exposure to musculoskeletal sequelae not commonly seen in North America (e.g., untreated osteomyelitis, tuberculosis, polio, neglected trauma, advanced stages of musculoskeletal tumors, and natural history of congenital deformities) Exposure to foreign health-care systems Greater cultural awareness Practice of professionalism in an unfamiliar setting Practice of resource-conscious treatment in a setting with limited resources Participation in training of local health-care providers
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Source of Funding No external funding was used for this study.
Results Fifty-six (31%) of 179 North American orthopaedic residency programs responded to the survey. The programs at the responding institutions varied in size from two to twelve residents (mean, five residents) per year (Table II). There were sixty respondents (thirty program directors and thirty program coordinators) at the fifty-six institutions; the responses for the four programs at which both the program director and coordinator responded were combined. Programs Offering an International Elective
Appreciation for global health
Overseas Location, Resident Year-in-Training, and Faculty Involvement (Table III)
Continued future volunteerism
purpose of the elective and its logistics (e.g., overseas location, duration, number of participating residents, number of participating faculty, and type of partner institution) were sought. All respondents were also asked fifteen closed-ended or openended questions to determine the motivation and perceived challenges and benefits in creating an international elective (see Appendix).
Statistics Analysis The survey results were analyzed with use of SAS software (version 9.2; SAS Institute, Cary, North Carolina). Frequencies and descriptive statistics were calculated to summarize the answers of the respondents. The chi-square test or Fisher exact test was used to assess relationships between categorical variables. The unpaired t test was used to compare the means of continuous variables between groups or subgroups. A p value of £0.05 was considered significant.
Eighteen (32%) of the fifty-six responding programs offered an international elective to their residents. The most common geographic regions were Africa and Central America (seven programs [39% of the eighteen] each), with some programs offering electives in multiple locations. In order to implement the international elective, residency programs partnered with academic institutions (eight programs [44%]), public hospitals (seven programs [39%]), and nongovernment organizations (NGOs; six programs [33%]) with already-established relationships in the host country. No programs reported working with a private hospital in a host country. Nine (50%) of the programs offered an international elective to orthopaedic residents in their fourth postgraduate year (PGY-4).
TABLE II Characteristics of the Programs Responding to the Survey (N = 56)* International Elective (no. [%]) Characteristic
No. (% of Respondents)
Yes
No
Northeast U.S.
10 (22)
3 (30)
7 (70)
Southern U.S.
9 (20)
3 (33)
6 (67)
13 (28) 9 (20)
2 (15) 3 (33)
11 (85) 6 (67)
5 (11)
4 (80)
1 (20)
Geographic region
Midwestern U.S. Western U.S. Canada No answer
10
No. of residents/yr 2
4 (9)
1 (25)
3 (75)
3
6 (13)
1 (17)
5 (83)
4
12 (26)
4 (33)
8 (67)
5
15 (33)
8 (53)
7 (47)
6 7
3 (7) 2 (4)
1 (33) 0 (0)
2 (67) 2 (100)
8
2 (4)
1 (50)
1 (50)
12
2 (4)
2 (100)
0 (0)
No answer *Not all programs responded to every question.
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TABLE III Selected Responses by Administrators of the Programs Offering an International Elective Question Preferred location of overseas elective*
Response (%) Central America (39%) Africa (39%) Europe (28%) South Asia, South America, Australia (11% each) East Asia (6%)
Year of elective*
PGY-4 (50%) PGY-5 (39%) PGY-3 (28%) PGY-1 or 2 (6%)
Proposed length of elective
4 weeks (33%) 2 weeks (22%) 1, 5, 6, or 12 weeks (6% each)
*More than one answer could be selected.
The administrators of one of the remaining programs reported that residents could select an international elective during their research rotation, but the year-in-training was not specified. Three (17%) of the programs sent one faculty member per year from the home program to the overseas elective site, four (22%) sent two, and three (17%) sent three or more. Faculty members spent a mean of two weeks (range, one week to two months) abroad. Four (22%) of the programs sent one resident per year for the international elective, three (17%) sent two, two (11%) sent three, and two (11%) sent four or more. Most of the responding program administrators believed that residents should spend two weeks (22%) or four weeks (33%) at the overseas location to get the most benefit.
Comparison Between Programs Offering and Not Offering an International Elective General Characteristics
No significant association was found between the number of residents in the program (p = 0.11) or geographic location of the residency program (p = 0.32) and the presence of an international elective (Table II). Perceived Barriers
All program administrators were given the same list of potential barriers to international electives and asked to select all options that applied to their program (Fig. 2). A greater percentage of those offering an international elective had concerns regarding safety compared with those not offering an elective (p = 0.004). A greater percentage of those not offering
Logistics and Coverage
When asked about coverage of the clinical duties of the traveling resident, most program administrators reported some form of cross-coverage or incorporation of the overseas rotation as an elective rotation without on-call responsibilities. Liability insurance for the traveling residents was covered by the home institution in nine programs (50%), the overseas host institution in four (22%), and a third party in one (6%). The administrators of four (22%) of the programs reported that separate liability insurance was not required for the overseas elective; another reported that insurance was provided through the partnering NGO. The administrators of twelve (67%) of the programs reported providing some financial assistance to the volunteering residents, and three (17%) reported providing no financial assistance. Goals
The administrators of thirteen (72%) of the programs reported that the purpose of the elective was to “increase cultural awareness among residents” (Fig. 1).
Fig. 1
Goals in the eighteen residency programs with an international elective. (Program administrators could select multiple answers.)
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Fig. 2
Comparison of barriers perceived by residency programs offering and not offering an international elective.
an international elective were concerned about the financial cost compared with those offering an elective (p = 0.02). Discussion Our survey demonstrated that at least eighteen (10%) of the 179 North American orthopaedic residency programs currently offer an international elective to their residents, typically for two or four weeks in their final two years of training. The host institution is most commonly located in Africa or Central America (Table III). A review of the literature in other specialties shows that the majority of residency programs follow a similar pattern3,6,7,12-16. In a recently published survey of U.S. orthopaedic residency programs by Clement et al., fifty-five (61%) of ninety responding programs reported that at least one resident had a clinical experience in a developing country during residency7. Although eleven of the programs in that survey indicated having a “structured global health program” at that time, we were able to identify eighteen such programs, perhaps because of the inclusion of Canadian programs in our survey. Additionally, Clement et al. reported that fifteen residency programs (24%) without an international elective were planning to create one, and eleven (18%) were not in favor of creating such an elective. However, feedback from orthopaedic residents was not sought, and the opinions of Canadian residency program directors were not represented. Some of the perceived barriers to organizing an overseas elective for orthopaedic residents in resource-challenged environments, as well as potential solutions, are outlined in Table IV. Resident Expectations The purposes that were cited most frequently by program administrators offering an international elective were to “increase cultural awareness” and “develop resident professionalism” (Fig. 1). Survey results from other specialties indicate that some residents may have the misconception that they are going overseas primarily to improve their surgical skills11. Therefore, the goals of the international elective should be clearly elucidated
to the residents in order to maximize their experiential learning while minimizing the potential to harm the local population and jeopardize the sustainability of the overseas program. Prior to enrolling in an overseas elective, it should be specified to the interested residents that they are not participating in these clinical rotations to perform procedures that are beyond their abilities and level of training17-19, but rather to experience different cultures20, learn about physician-patient interactions in diverse settings, develop a greater appreciation for public health issues, be exposed to diagnoses and management of musculoskeletal entities not typically encountered in North America, experience working with limited resources, and improve basic skills such as physical examination, external fixation, and traction2,6,21 (Table I). Additionally, many NGOs have shifted their priorities from providing short-term overseas surgical aid to establishing sustainable relationships with various countries to educate and train the local physicians in treating musculoskeletal disorders and injuries2,4,21. Residents participating in an international elective far removed from their home program may encounter a number of ethical dilemmas. Steps should be taken to avoid unintended negative consequences of such clinical rotations. Underinvolved residents who spend more time as a “tourist” as well as overinvolved residents who perform procedures beyond their training may compromise patient outcomes and erode the trusting relationships with their local hosts and community. Volunteering residents must maintain a high level of professionalism and be flexible to a foreign health-care setting. Some residency program administrators have found that setting up interactive workshops and a structured orientation program outlining the goals and objectives of the rotation prior to embarkation on the international elective has been helpful12,13,16,17,22. This may be an important step in aligning the goals of the program directors, traveling residents, and host institution. Further insight will be needed to ensure that the needs of the host institution and the local community are served appropriately. In this way, the host community, sponsoring residency program, and visiting resident will all benefit, each in their own unique way.
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TABLE IV Perceived Barriers and Potential Solutions Barrier
Potential Solutions
Misalignment between goals of the rotation and goals perceived by the resident
Pre-elective orientation
Lack of funding
Scholarships and grants
Comments
Interactive workshops Application and screening process
Establish clear goals and expectations prior to the overseas experience
AAP offers scholarships for orthopaedic residents and pediatric orthopaedic fellows to travel with a mentor to treat children in resource-poor countries for 1-4 weeks The American Foundation for Surgery of the Hand and HVO partner to provide 2 types of scholarships for residents for a minimum of 4 weeks (a grant for senior residents and fellows to travel to a teaching site in a developing country and an orthopaedic traveling fellowship for senior residents to travel to an HVO teaching site)
Safety
Covering clinical duties when away
Build international network Avoid going to areas of political unrest
Establish and maintain international ties with politically stable countries to allow for safe and consistent volunteer opportunities benefiting both host countries and volunteers
Call-free elective block
Not all programs have a call-free elective block
During research rotation During pediatrics or trauma rotation with board-certified attending surgeon
International work in such environments is typically trauma or pediatrics-oriented
During vacation
Vacation time is limited to only 1-2 weeks
Lack of accreditation
Recognize ACGME core competencies in overseas electives
Collaborate with ACGME, RRC, and ABOS to recognize work done on international electives as fulfilling ACGME core competencies and toward fulfilling requirements for ABOS eligibility
Lack of faculty support
Support from department chair, program director, and hospital administration Mentors, including senior or semiretired board-certified orthopaedic surgeons from any North American residency program
Increase information and familiarity with overseas electives to assuage concerns and misconceptions
Lack of available opportunities
Online database listing opportunities, resources, educational material, trip reports, funding options
Links available at POSNA COUR, AAP, and ASSH web sites
Surgical residents traveling overseas as part of a disaster relief team (typically for one to two weeks) often provide assistance to more senior volunteering surgeons and share their knowledge and skills with local health-care workers in an acute setting. As was the case following the 2010 earthquake in Haiti, the most common surgical intervention in such a setting is typically external fixation, followed by traction and then intramedullary nailing23. In contrast, residents traveling overseas through an elective program as part of a teaching-oriented or service-oriented rotation may be in a more controlled environment, assist in lectures and clinics, and experience diverse orthopaedic pathology not typically encountered in North America. Currently, the international elective experience for residents varies greatly, depending on the participating host institution that they are visiting. Residency program administrators
who are considering allowing their residents to go abroad should evaluate the goals of this rotation and its potential benefits for supplementing their current curriculum. For example, residents from a program at a level-I trauma center may not benefit as much from a short-term disaster relief mission during which they perform a redundant amount of external fixation and traction that they already regularly perform at their home program. Such residents may benefit more from a four-week rotation in a more elective practice setting that allows for greater cultural immersion, increased contact with local patients and health providers, more longitudinal patient follow-up, and increased potential for learning and teaching. Financial Burden Despite a strong interest in international electives by residents in various medical specialties5,6,10,24, the majority (73%)
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of administrators of orthopaedic programs not offering such an elective cited financial concern as a barrier (Fig. 2). In contrast, financial concern was cited as a barrier by only 39% of responding administrators of programs offering an overseas elective (p = 0.02). Our results are consistent with those of another recent survey in which the most commonly reported barriers to international electives included lack of funding, limited faculty interest or time, and logistical planning7. One respondent in our survey reported, “Hospital does not want to pay salary while away.” In our survey, twelve (67%) of the eighteen programs offering an international elective provided their residents with some financial assistance. Funding from scholarships or grants to support such resident electives has been reported previously2,25,26. Organizations such as the AAP (American Academy of Pediatrics)25 and HVO (Health Volunteers Overseas)26 offer scholarships to interested senior orthopaedic residents and fellows for short-term overseas elective experience. International electives are a creative way to train culturally competent future orthopaedic surgeons who are interested in practicing in underserved communities6. If financial concerns are truly the principal difficulty in offering an international elective, then alternate sources of funding should be explored to make the elective more affordable. It may be useful to require the residents to fill out a “trip report” elaborating on their experience and providing insight to future volunteers and organizers as a precondition for their funding assistance (Table IV). Keeping track of resident case logs on international rotations may give more insight into the type of education that residents receive abroad, which may encourage more support from the host program and supporting institutions. Safety Concerns In 2004, the medical relief organization Doctors Without Borders withdrew its staff from Afghanistan and Iraq because the risk to their safety was too great. More recently, news reports have indicated the dangers to the volunteer medical staff in Syria27-29. Among programs in the present survey that did offer an international elective, personal safety was the barrier that was identified most frequently (by 61%). This finding is concerning, as those programs that have already established an international elective perceived safety as a barrier to volunteering overseas. Interestingly, all of the orthopaedic residents in a previously published survey who had already participated in an international elective stated that they would still include an international elective in their training if they could “do it all over.”6 Perhaps participants in the elective find the dangers of traveling abroad minor in comparison with the training experience gained. International volunteering often takes place in developing countries with social and cultural environments unfamiliar to the volunteers2. Establishing a network of orthopaedic volunteers with personal and institutional ties to overseas institutions in politically stable countries and avoiding travel to countries on the U.S. travel advisory list can be a helpful step toward ensuring the safety of the volunteering resident (Table IV). Additionally, having a central reporting agency through which participating residents and program co-
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ordinators could receive security alerts and share their specific experiences with other programs would help minimize such threats. Such a database could be maintained by a U.S. organization such as the AAOS (American Academy of Orthopaedic Surgeons) or AOA (American Orthopaedic Association) or perhaps by an international organization such as the SICOT (Soci´et´e Internationale de Chirurgie Orthop´edique et de Traumatologie) or WHO (World Health Organization), and it could be updated by individual residents and board-certified orthopaedic surgeons. Coverage Issues We asked administrators of programs with an international elective to describe how they manage clinical coverage at the home institution. Most frequently, the resident would participate in the overseas rotation during “elective” time without oncall responsibilities or cross-coverage of clinical services would be prearranged among residents. Some programs had a dedicated call-free elective rotation or had residents go overseas during their “research” rotation. Another potential solution involves traveling during a specific clinical rotation (e.g., trauma, pediatrics, or hand) that matches factors such as the anticipated types of clinical cases overseas and the clinical expertise of the faculty mentor willing to volunteer at the same site (Table IV)3,6. Residents also have the option of using a portion of their allotted vacation and conference time to travel abroad. At four of eighteen programs, only one resident participated in the international elective per year. Nevertheless, resident coverage may be a more substantial burden for programs with fewer residents and less flexibility in clinical rotations. This has become even more relevant with duty hour limitations for postgraduate trainees in the U.S. Some NGOs recommend that residents planning on an international elective obtain evacuation insurance to cover any unforeseen threats to personal health and security while abroad30. Volunteers should also be aware of the overseas coverage, if any, provided by their personal health insurance carriers. The volunteering resident should check with their training program and sponsoring organization to ascertain their medical liability insurance coverage, as such coverage may vary among institutions. Credentialing As international electives become an integral part of orthopaedic residency training in some programs, increasing collaboration is needed among residency programs, the ACGME (Accreditation Council for Graduate Medical Education), and the ABOS (American Board of Orthopaedic Surgery). The ABOS and other similar credentialing bodies may not provide credit for clinical work done by the resident while overseas5,31. This may result from a lack of a board-certified orthopaedic surgeon supervising the resident performance and the absence of standardized goals and objectives for the overseas rotation31. Mentorship by interested faculty, including those senior surgeons who are semiretired from active clinical practice, may be another possibility for providing supervision by board-certified orthopaedic surgeons for such electives (Table IV).
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The results of our survey show that North American orthopaedic residency programs of a variety of sizes do offer an elective international rotation in resource-challenged environments (Table II). As the international elective is offered but not mandated in certain programs, there is a potential for unequal educational exposure among residents of the same program and among residents nationwide. Development of a standardized international elective curriculum to provide a more uniform resident experience should involve aligning the elective with the six core competencies stipulated by the ACGME and the requirements for participating in the certification examination held by the ABOS32. Working with board-certified orthopaedic surgeons, gaining both an outpatient and operative experience, having a clearly outlined set of goals and objectives for the rotation, and providing evaluations of resident performance during the elective are some measures that the programs can incorporate33. Despite multiple obstacles, some other medical specialties incorporate accredited international electives into their curriculum. For example, the RRC (Residency Review Committee) for general surgery recently began accepting cases performed by residents overseas31,34. An international health elective is a valuable experience that has the potential to address all six ACGME core competencies5,6,8,9,13,16,32, especially those involving patient care, systems-based practice, professionalism, and interpersonal skills and communication. At the 2012 AOA Annual Meeting, it was suggested that “volunteerism” be included under “professionalism” as a core competency32. Formal guidelines can be developed to assist programs with an international elective to meet these targets. Hopefully, the residency programs, ACGME, RRC, and ABOS can soon formalize accreditation for orthopaedic international electives. Faculty Support Garnering faculty support for an international elective can be helpful in easing resident concerns about going overseas. Although previously published surveys have shown a general interest in international electives, there are still programs with no interest in incorporating such an elective7. Perhaps the growing information available about the benefits of overseas rotations and means of overcoming some of the barriers will make board-certified orthopaedic faculty members more likely to participate in such a program. Compiling an online database of the residency programs offering an international elective can yield another useful resource for interested residents and faculty members. Such a database can serve as a repository listing opportunities, educational materials, trip reports, online courses, and funding options. For instance, the COUR (Children’s Orthopedics for Underserved Regions) section of the POSNA (Pediatric Orthopaedic Society of North America) web site, the ASSH (American Society for Surgery of the Hand), and the AAP have started such sections for their members interested in overseas medical missions and teaching35-38. Ideally, a similar database serving as a repository for all possible opportunities for trainees should be established
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by an entity (e.g., the AOA) that is not sponsoring any of the opportunities. Limitations of the Survey Our survey of North American orthopaedic residency programs has several limitations. First, the response rate was only 31%, which is less than the response rate of 40% preferred in this type of survey. However, we did receive responses from fifty-six different orthopaedic residency programs; these were well distributed throughout North America and ranged in size from two to twelve residents per year. Unfortunately, we did not ask about the presence or absence of global health programs in other departments at those same institutions, which could increase the likelihood of establishing a similar rotation in orthopaedics. Second, we did not use any objective measures to document the clinical experience of the residents who participated. Although detailed published data such as case logs during overseas electives may not be currently available for orthopaedic residency programs, such cases are well documented in the general surgery literature15,16,39. Finally, our survey did not examine the impact of visiting residents on the host institution and the local community. Although practicing orthopaedic surgeons traveling overseas can offer their surgical expertise, the role of residents in teaching and training local health-care professionals is unclear. Implications At least 10% (eighteen) of 179 North American orthopaedic residency programs currently offer an international elective to their residents, and more than half of those programs have some financial support available for the elective. However, despite a growing interest among orthopaedic residency programs in overseas clinical experience during the last two years of training, there are perceived barriers, including personal safety, cost, and administrative constraints. Further research is needed to analyze the experience of the orthopaedic training programs offering an international elective, as well as that of the overseas hosts, so that the impact of this clinical experience on all stakeholders, including the host community, can be fully assessed. Appendix An appendix containing the survey is available with the online version of this article as a data supplement at jbjs. org. n
Bensen Fan, MD Caixia Zhao, MD Sanjeev Sabharwal, MD, MPH Department of Orthopedics, UMDNJ-New Jersey Medical School, 90 Bergen Street, DOC 7300, Newark, NJ 07103. E-mail address for S. Sabharwal: [email protected]
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References 1. Gosselin RA, Gyamfi YA, Contini S. Challenges of meeting surgical needs in the developing world. World J Surg. 2011 Feb;35(2):258-61. 2. Dormans JP. Orthopaedic surgery in the developing world—can orthopaedic residents help? J Bone Joint Surg Am. 2002 Jun;84(6):1086-94. 3. Haskell A, Rovinsky D, Brown HK, Coughlin RR. The University of California at San Francisco international orthopaedic elective. Clin Orthop Relat Res. 2002 Mar; 396:12-8. 4. Rovinsky D, Brown HP, Coughlin RR, Paiement GD, Bradford DS. Overseas volunteerism in orthopaedic education. J Bone Joint Surg Am. 2000 Mar;82(3):433-6. 5. Drain PK, Holmes KK, Skeff KM, Hall TL, Gardner P. Global health training and international clinical rotations during residency: current status, needs, and opportunities. Acad Med. 2009 Mar;84(3):320-5. 6. Disston AR, Martinez-Diaz GJ, Raju S, Rosales M, Berry WC, Coughlin RR. The international orthopaedic health elective at the University of California at San Francisco: the eight-year experience. J Bone Joint Surg Am. 2009 Dec;91(12):29993004. 7. Clement RC, Ha YP, Clagett B, Holt GE, Dormans JP. What is the current status of global health activities and opportunities in US orthopaedic residency programs? Clin Orthop Relat Res. 2013 Nov;471(11):3689-98. Epub 2013 Jul 27. 8. Javidnia H, McLean L. Global health initiatives and electives: a survey of interest among Canadian otolaryngology residents. J Otolaryngol Head Neck Surg. 2011 Feb;40(1):81-5. 9. Jayaraman SP, Ayzengart AL, Goetz LH, Ozgediz D, Farmer DL. Global health in general surgery residency: a national survey. J Am Coll Surg. 2009 Mar;208(3):42633. Epub 2009 Jan 21. 10. 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, and volunteerism. J Am Coll Surg. 2009 Feb;208(2):304-12. Epub 2008 Dec 4. 11. Powell AC, Mueller C, Kingham P, Berman R, Pachter HL, Hopkins MA. International experience, electives, and volunteerism in surgical training: a survey of resident interest. J Am Coll Surg. 2007 Jul;205(1):162-8. Epub 2007 May 17. 12. Federico SG, Zachar PA, Oravec CM, Mandler T, Goldson E, Brown J. A successful international child health elective: the University of Colorado Department of Pediatrics’ experience. Arch Pediatr Adolesc Med. 2006 Feb;160(2):191-6. 13. Gladding S, Zink T, Howard C, Campagna A, Slusher T, John C. International electives at the University of Minnesota global pediatric residency program: opportunities for education in all Accreditation Council for Graduate Medical Education competencies. Acad Pediatr. 2012 May-Jun;12(3):245-50. Epub 2012 Apr 6. 14. Gupta AR, Wells CK, Horwitz RI, Bia FJ, Barry M. The International Health Program: the fifteen-year experience with Yale University’s Internal Medicine Residency Program. Am J Trop Med Hyg. 1999 Dec;61(6):1019-23. 15. Klaristenfeld 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 Jul;207(1):125-8. Epub 2008 Apr 24. 16. Sawatsky AP, Rosenman DJ, Merry SP, McDonald FS. Eight years of the Mayo International Health Program: what an international elective adds to resident education. Mayo Clin Proc. 2010 Aug;85(8):734-41. 17. Dharamsi S, Osei-Twum JA, Whiteman M. Socially responsible approaches to international electives and global health outreach. Med Educ. 2011 May;45(5):530-1. 18. Hayanga AJ. International surgical volunteerism electives and the rules. Surgery. 2008 Nov;144(5):839. Epub 2008 Aug 10. 19. Pherez FM, David PK. Re: Global health training and international clinical rotations during residency: current status, needs, and opportunities. Acad Med. 2009 Sep;84(9):1172; author reply 1172.
20. Campbell A, Sherman R, Magee WP. The role of humanitarian missions in modern surgical training. Plast Reconstr Surg. 2010 Jul;126(1):295-302. 21. Coughlin RR, Kelly NA, Berry W. Nongovernmental organizations in musculoskeletal care: Orthopaedics Overseas. Clin Orthop Relat Res. 2008 Oct;466(10): 2438-42. Epub 2008 Aug 7. 22. Sinha R. Ethical considerations in international health electives. Fam Med. 2011 Sep;43(8):592; author reply 592. 23. Teicher CL, Alberti K, Porten K, Elder G, Baron E, Herard P. M´edecins Sans Fronti`eres experience in orthopedic surgery in postearthquake Haiti in 2010. Prehosp Disaster Med. 2014 Feb;29(1):21-6. Epub 2014 Jan 15. 24. Jense RJ, Howe CR, Bransford RJ, Wagner TA, Dunbar PJ. University of Washington orthopedic resident experience and interest in developing an international humanitarian rotation. Am J Orthop (Belle Mead NJ). 2009 Jan;38(1):E18-20. 25. American Academy of Pediatrics. Section on orthopaedics. 2014. http://www2. aap.org/sections/ortho/. Accessed 2014 Mar 10. 26. Health Volunteers Overseas. The AFSH-HVO Young Surgeon Traveling Fellowship. http://www.hvousa.org/wp-content/uploads/2014/06/AFSH-YoungSurgeon-Fellowship-2014-Application-Updated.pdf. Accessed 2014 Jul 18. 27. Fieldstadt E. 5 members of Doctors Without Borders detained in northern Syria. World News: NBCNews.com. 2014 Jan 3. http://worldnews.nbcnews.com/_news/ 2014/01/03/22163582-5-members-of-doctors-without-borders-detained-in-northernsyria?lite. Accessed 2014 Mar 10. 28. NBC News. International medical aid group to leave Iraq. Conflict in Iraq on NBCNEWS.com. 2004 Nov 4. http://www.nbcnews.com/id/6406039/ns/world_newsmideast_n_africa/t/international-medical-aid-group-leave-iraq/#.UxzeeuddVEd. Accessed 2014 Mar 10. 29. BBCNews. Aid doctors to leave Afghanistan. 2004 Jul 28. http://news.bbc.co. uk/go/pr/fr/-/2/hi/south_asia/3931995.stm. Accessed 2014 Mar 10. 30. Health Volunteers Overseas. Travel resources. 2014 Apr 23. http://www. hvousa.org/resources/volunteer-toolkit/travel-resources/. Accessed 2014 Mar 10. 31. Mitchell KB, Tarpley MJ, Tarpley JL, Casey KM. Elective global surgery rotations for residents: a call for cooperation and consortium. World J Surg. 2011 Dec;35(12): 2617-24. 32. Weiner SD, DeRosa GP, Born CT, Wall LB, Weiner BK. On volunteerism and orthopaedics. AOA critical issues. J Bone Joint Surg Am. 2014 Jan 1;96(1):e5. 33. ACGME. International rotation application process: review committee for surgery. 2014. https://www.acgme.org/acgmeweb/Portals/0/PFAssets/ ProgramResources/440_Surgery_International_Rotation_Application_Process.pdf. Accessed 2014 Apr 30. 34. Parker AM, Petroze RT, Schirmer BD, Calland JF. Surgical residency market research-what are applicants looking for? J Surg Educ. 2013 Mar-Apr;70(2):232-6. Epub 2012 Oct 17. 35. Pediatric Orthopaedic Society of North America. Children’s orthopedics in underserved regions (COUR). 2014. http://www.posna.org/education/cour/cour.cfm. Accessed 2014 Mar 10. 36. American Society for Surgery of the Hand. International outreach opportunities. 2014. http://www.assh.org/Professionals/AboutASSH/OtherASSHConnections/ VolunteerServiceMap/Pages/default.aspx. Accessed 2014 Mar 10. 37. Health Volunteers Overseas. Orthopaedics. 2014. http://www.hvousa.org/ wherewework/orthopaedics.shtml. Accessed 2014 Mar 10. 38. American Academy of Pediatrics. AAP global. 2014. http://www2.aap.org/ international/. Accessed 2014 Mar 10. 39. Jarman BT, Cogbill TH, Kitowski NJ. Development of an international elective in a general surgery residency. J Surg Educ. 2009 Jul-Aug;66(4):222-4.
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