GLOBAL HEALTH INITIATIVES
Training Surgical Residents for a Career in Academic Global Surgery: A Novel Training Model JaBaris D. Swain, MD,* Alexi C. Matousek, MD,* John W. Scott, MD,* Zara Cooper, MD,*,† Douglas S. Smink, MD,* Ralph Morton Bolman III, MD,‡ Samuel R.G. Finlayson, MD,§ Michael J. Zinner, MD,* and Robert Riviello, MD*,† *
Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; †Division of Trauma, Burns and Surgical Critical Care, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; ‡Division of Cardiac Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; and §Department of Surgery, University of Utah Health Care, Salt Lake City, Utah Academic global surgery is a nascent field focused on improving surgical care in resource-poor settings through a broad-based scholarship agenda. Although there is increasing momentum to expand training opportunities in low-resource settings among academic surgical programs, most focus solely on establishing short-term elective rotations rather than fostering research or career development. Given the complex nature of surgical care delivery and programmatic capacity building in the resource-poor settings, many challenges remain before global surgery is accepted as an academic discipline and an established career path. Brigham and Women’s Hospital has established a specialized global surgery track within the general surgery residency program to develop academic leaders in this growing area of need and opportunity. Here we describe our experience with the design and development of the program followed by practical applications and lessons learned from our early C 2015 Association of experiences. ( J Surg 72:e104-e110. J Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: global surgery, academic surgery, surgery
education, resident education COMPETENCIES: Professionalism, Interpersonal Communication Skills, Systems-Based Practice
and
Correspondence: Inquiries to Robert Riviello, MD, MPH, Brigham and Women’s Hospital, 75 Francis St., Boston, MA 02115; E-mail: [email protected], [email protected]
e104
INTRODUCTION Recently, there has been a well-documented surge of enthusiasm among medical students and surgical residents to incorporate international experience into their training, primarily in resource-poor settings.1-4 In response, several academic surgical programs have established opportunities for their trainees focused primarily on clinical electives.5-13 Although clinical care from visiting providers is needed in some contexts, in many poor countries there are local providers who can perform or be trained to perform the necessary surgical care. Therefore, many global surgery efforts focus on education, training, and research to address questions regarding care delivery, outcomes, and health equity at partner sites.6,8,14 This enhanced attention to measurement enables visitors to provide additional value, increase local clinical and research capacity, enable quality improvement, and avoid duplication of services that can already be provided in the host countries. However, many challenges need to be addressed before global surgery is accepted as an academic discipline and an established career path. Ensuring adequate mentorship, financial support, and stable partnerships with sites in resource-poor settings is necessary to respond to the unique logistic and ethical challenges that arise and to assure programmatic stability. Furthermore, trainees and faculty must convincingly demonstrate the value of their efforts within academic departments of surgery, public health institutions, nongovernmental organizations (NGOs), and host partners around the world through meaningful scholarship that advances surgical care delivery in resource-poor settings. To address these challenges, structured training programs in academic global surgery are needed to equip residents with the necessary clinical, research, and cultural-engagement skills unique to the field.
Journal of Surgical Education & 2015 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2015.01.007
Definition of Academic Global Surgery We conceptualize academic global surgery as an emerging discipline with the goal of improving surgical care delivery in resource-poor settings through a broad-based scholarship agenda. Global surgery training programs should be enacted through long-term collaborative partnerships with local stakeholders, with careful planning to ensure all parties realize meaningful benefits. We use the term global to include programs that serve resource-poor areas within the borders of high-income countries in addition to those based in low- and middle-income countries (LMICs).15 After the Resident Review Committee of the Accreditation Council for Graduate Medical Education approved international electives for credit, much of the recent literature has focused on the development and analysis of short-term clinical electives meant to expose trainees to the realities of surgical care delivery in resource-poor settings, but without an expressed focus on academically rigorous research development.11-13 Although clinical rotations, short- or long-term surgical missions, and disaster response efforts certainly contribute to surgical care in low-resource settings, we propose that the development of long-term academic partnerships should be the focal point of a formalized global surgery track for surgical residents.
THE BRIGHAM AND WOMEN’S HOSPITAL GLOBAL HEALTH EQUITY RESIDENCY IN GENERAL SURGERY Initial Planning To equip future leaders in academic Global Surgery, the leadership of the Brigham and Women’s Hospital (BWH) Department of Surgery created a formalized track within the existing general surgery residency program, entitled the Global Health Equity Residency in General Surgery (GHE-S). The initial design of the program was influenced by the BWH GHE Residency in Internal Medicine, which has been previously described.16,17 The BWH Center for Surgery and Public Health provides administrative, program management, and statistical support. The director of the GHE-S is a faculty surgeon with significant experience in global surgery and is supported by the Center for Surgery and Public Health and the BWH general surgery program director and department chairperson.
global surgery. Programmatically, the overarching aim of the GHE-S is to foster long-term academic partnerships between our institution and academic centers in LMICs with a shared vision to promote global health equity through high-quality surgical care delivery. Our experiences to date have been focused on strengthening longitudinal partnerships in Haiti and Rwanda to build resources and relationships through successive collaborations. Program Design Candidates with career interest in global health are chosen from the postgraduate year 2 (PGY-2) class and paired with a research mentor through the department’s existing mentorship program. Selected individuals must complete 3 years of residency before entering the research experience in recognition of the clinical duties that are often required at partner sites. During their PGY-2 and PGY-3 years, the residents work with their faculty mentor and host collaborators to develop a research plan focused on host-country priorities and apply for competitive extradepartmental awards (Fig. 2). After completing 3 years of clinical training, GHE-S residents begin a 2-year research track. Formal classroom instruction or coursework (i.e., Masters in Public Health) is strongly encouraged to strengthen methodological research skills and the understanding of epidemiological, ethical, and social issues pertinent to global surgical care delivery. Measuring Success To date, 3 GHE-S residents have completed the 2-year program. They have collaborated with numerous researchers from multiple academic institutions, NGOs, and governments from around the world and contributed to significant academic scholarship. They have also obtained competitive external funding from a variety of sources. Although these
Program Goals The 2 major goals of the program are to improve resident training in academic global surgery and to strengthen longitudinal partnerships with institutions in low-resource settings (Fig. 1). The GHE-S is designed to provide residents with focused mentorship and the clinical and research skills necessary to become leaders in academic Journal of Surgical Education Volume 72/Number 4 July/August 2015
FIGURE 1. Goals of the GHE-S program. e105
Program Year
Summer
1
Spring
Standard General Surgery Curriculum (PGY-2) Apply to GHE-S
Accepted to GHE-S
Standard General Surgery Curriculum (PGY-3)
3
5*
Winter
Standard General Surgery Curriculum (PGY-1)
2
4
Fall
Work with mentor on research proposal, apply for funding
Site visit at host instuon
MPH Coursework
Field research, clinical work at host instuon
Project transion, academic wring
6
Standard General Surgery Curriculum (PGY-4)
7
Standard General Surgery Curriculum (PGY-5)
*Some trainees have opted for an alternate pathway which distributes equivalent me for course work throughout the 4th and 5th years amidst periodic field research and clinical research at the host instuon
FIGURE 2. Timeline of the Global Health Equity Curriculum for General Surgery Residents.
more traditional metrics of programmatic output demonstrate academic productivity, they do not capture the overall value of these global academic partnerships, which seek to advance research, policy making, and equity in surgical care delivery. Ultimately, success is measured by the GHE-S residents’ commitment to a career in academic global surgery and their career-long effect on the field.
PRACTICAL APPLICATIONS AND LESSONS LEARNED Engaging Diverse Stakeholders Global surgery is a field in its infancy, striving to establish value among at least 3 disparate stakeholders: academic departments of surgery, global health institutions, and care delivery organizations in low-resource settings (e.g., ministries of health, NGOs, faith-based organizations, university, private sector, and others). Surgical department leaders may be reluctant to acknowledge global surgery research as providing a sufficient scholarship experience for trainees.1 They are particularly circumspect regarding the support of projects that are perceived as purely clinical in nature. Therefore, a global surgery investigator must ensure that research efforts focused on improving care delivery in resource-poor settings are founded on sound methodology. GHE-S trainees are required to have their projects vetted by staff epidemiologists and statisticians during the application process and annual work-in-progress meetings. Despite concerted advocacy, surgical care continues to be perceived by many in public health as too expensive and specialized to be included as a global health priority.18,19 A global surgery specialist must be aware of this perception and demonstrate value accordingly. The growing evidence e106
base of surgical cost-effectiveness and the burden of trauma and injury are useful in illustrating these value propositions.20-24 In Rwanda, we found that presenting new data on prehospital injury patterns to both local governmental officials and interested international stakeholders led to renewed dialog between local policy makers and our host research colleagues. Local care delivery organizations in resource-poor settings are understandably reluctant to support research efforts that fail to demonstrate local value. This hesitation may be borne of the lack of institutional capacity for data gathering, overwhelming need for clinical service provision, and the concern that foreign researchers may be appropriating data to advance their own careers without creating local value. In Haiti, to address this concern, we specifically limited the scope of our research to quality improvement and adapted a proposed study to include measuring inpatient outcomes at the request of the host institution. Focusing Partnerships on Local Priorities and Values Global surgery research should promote the equitable distribution of the benefits derived from the work.25-29 Many host collaborators have overwhelming clinical responsibilities and typically lack protected time for research and writing. Therefore, it is imperative that the high-income country partners make research capacity building and true equity in authorship as a focus. Our Rwandan colleagues have established clear polices on equity in authorship and have ensured that research efforts are coupled with research didactics to ensure sustainability. Additionally, understanding the specific clinical and research desires of the host institution is paramount, as both are integral components of a global surgery partnership. For instance, some institutions
Journal of Surgical Education Volume 72/Number 4 July/August 2015
may place priority on improving the research capacity of their clinicians, whereas others may be more concerned with immediate improvement in the quality of surgical care delivery and education. However, this is not as simple as arriving and asking. Many hosting partners divulge their priorities only after a trusting relationship has been established. In Haiti, we spent multiple trips over several months providing clinical care and building trust before negotiating the presence of a research team. Even so, our success was only possible because of the nearly lifelong relationship our GHE-S trainee had with the host institution. The global surgery researcher must use a high degree of sensitivity when publishing research results that may affect a local partner organization’s reputation. Data integrity should be rigorously maintained, but if negative results are anticipated, it is important to allow for quality improvement before dissemination to avoid damaging the partnership. Practically, we share all results of our research and submit manuscripts for local review before any form of public dissemination. In addition, we have been careful to consider the potential positive effect of our research on the reputation of the hospital and have written blog posts, provided interviews, and helped write web pages to help enhance potential donations. Finally, the highest standards of scientific and ethical board review must be followed to ensure research does no harm to vulnerable populations. All GHE-S projects must receive ethical approval from both the partners’ health care institutional review board and the local ethics committee or institutional review board governing the host institution where the research will take place. We strongly believe that research that does not conform to local goals and standards or does not benefit the host population is an abuse of privileges granted by that population. Ensuring Appropriate Clinical Service at a Host Site Although academic global surgery is primarily a scholarly enterprise, clinical service at a host site is often appropriate, highly instructive, and even necessary for a global surgery specialist or trainee. The local clinical context and spectrum of disease certainly differ from the visitor’s experience at one’s home institution, which mandates that all care provided by the GHE-S trainee be supervised by a combination of locally accredited attending surgeons and those who are certified by the US board and are working at the partner sites. Importantly, even procedures that a resident can perform without supervision at his or her home institution should be approved by local providers. For example, at our partner institution in Haiti, tube thoracostomy is only performed in the operating room, and we comply with this requirement. Furthermore, the nature of clinical work in resource-poor settings is extremely demanding and must be balanced against time necessary for research. Clear expectations can be effective in ensuring
that appropriate time and energy are dedicated to scholarship and that the boundaries and supervision of clinical activity are well established. The degree and duration of clinical exposure varies for each resident based on host institution needs and the amount of time available after attending to research-related obligations. In Haiti, we developed written guidelines with the medical director of the host institution, balancing clinical and research responsibilities before any clinical service by the GHE-S trainee. Although we encourage participation in the care of patients with advanced or interesting pathology that residents may not encounter at their home institution, it is equally important to assist in the not-so-glamorous work and avoid the appearance of medical adventurism. Occasionally, visitors may feel that they are the only ones who can provide a particular clinical service. In our experience, this is rarely the case. We have found that a position of humility, patience, and initial observation is generally more successful in producing collaboration. Unfortunately, we have been called to work with clinicians who have been cavalier and irresponsible at our host sites. In our experience, these unethical practices are most common among visiting practitioners rather than local providers. The need to avoid such behavior and carefully navigate these scenarios cannot be overemphasized, as vulnerable populations merit more rather than less stringent attention to ethical conduct owing to their powerless position. Finally, we had to be careful not to take training opportunities away from local residents, which can be more difficult than initially perceived, as they often defer to visitors. Frequent re-evaluations and adjustments may be necessary. When providing clinical service, a visitor must adapt to the local resources and practice patterns rather than assume that the approach taken in their home institution is the most appropriate. For example, risking re-expansion pulmonary edema by reinflating a collapsed lung from a longstanding pneumothorax with suction in the first hours after tube thoracostomy is more dangerous when there is no mechanical ventilation available. There are many ethical challenges that arise in these settings that require careful consideration, frequent processing with trusted mentors, and may prompt dialog with local colleagues regarding cases where deviation from otherwise established local norms may be necessary.29,30 In Rwanda, for instance, it is beneficial to periodically debrief the triage decisions made daily by faculty members as to which patients will have the opportunity to receive emergency surgical care and who will not, given the extremely limited operating room availability. Developing a Tailored Skill Set In addition to a strong foundation in clinical and research skills, the global surgery trainee must develop the ability to navigate a new social context with cultural humility. The candidate with extensive prior global health experience,
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particularly within the setting of the proposed project, is likely to be more versatile, adaptable, and skillful in negotiating across differences of language and culture. Predeparture didactic sessions focused on cultural awareness, regular check-in meetings with mentors, and onsite faculty supervision are critical to deepening these skills among residents. Generally, the GHE-S residents have had substantial experience in resource-poor settings before entering the program, which has greatly facilitated their success. Creating a Mentorship Paradigm At most US academic centers, the number of trainees seeking global surgery mentorship often exceeds the number of faculty with experience in resource-poor settings. In our program, we have modified the traditional model of academic mentorship and encourage residents to seek support from multiple sources. Senior academic surgeons may not feel equipped to mentor a global surgery trainee, but they can provide essential guidance with content expertise and research methodology and help demonstrate the value of the research to surgical leadership.1 However, because of the intense emotional nature of clinical work in austere environments and the high degree of relational skills required, we strongly encourage global surgery trainees to identify a mentor with experience in low-resource settings who can help them process these challenges. The mentorship team should meet regularly and be composed of faculty from any discipline with expertise needed by the mentee. As programs grow, trainees may be able to find a single global surgery mentor more easily as faculty resources increase. However, we have found it important to assemble diverse mentorship resources that can offer guidance in research methodology, context expertise, and career advice. In addition to the focused mentoring by US academic surgeons, mentors from the host institution play an important role in the development of the trainee. Host mentors are identified through relationships with US partners and are most often involved in teaching and training residents at their own institution. Host mentors help the trainee understand differences in local patterns of clinical care and decision making and are essential in adapting research proposals to the local context. In Rwanda, the academic head of surgery has connected GHE-S residents with specific Rwandan trainees to provide peerto-peer exchange of experience and understanding. Supporting the Emotional Health of the Trainee The taxing nature of working in health care within a resource-poor setting should not be underestimated. Adapting to a new environment, language, culture, burden of disease, and practice paradigm can challenge the coping skills of even the most seasoned trainee. The Peace Corps e108
recognizes the burden that overseas service puts on their volunteers and mandates 1-week periods of leave every 12 weeks.31 In our program, this also includes 1 day off in 7 days—keeping within the Accreditation Council for Graduate Medical Education–mandated residency workhour restrictions. Each of us has personally faced the death of our patients overseas, which could have been avoided at our home institutions. We have found that at a minimum, regularly scheduled contact with mentors is necessary to process these emotional challenges, maintain productivity, and avoid burnout.2 Furthermore, extending access to employee assistance services and mental health support should be considered a vital component of any global surgery program. Unsolved Problems and Limitations Despite concerted effort and the careful design described earlier, persistent challenges include robust mentorship, stable funding, and maintenance of a continuous chain of GHE-S trainees at our host sites. Each GHE-S resident develops a team of mentors who provide clinical, context, and research methodology expertise, led by the program director who is based in both Boston and Rwanda. Although this has been functional in the context of motivated residents, mentorship has also been fragmented, particularly when conducted across time zones and with variable Internet connections. Regarding financing, the BWH provided generous seed funding to launch the program; however, the GHE-S continues to seek stable programmatic financial support from grants and philanthropy. Currently, prospective trainees are still required to spend significant time securing funding for their personal and programmatic expenses. Finally, although building programs in 2 sites has been critical for focus and productivity for the trainees, this does not always align with individual resident’s geographic preferences. This trade-off has occasionally pit programmatic priorities and feasibilities against individual interests and goals. Thus, maintaining a pipeline of GHE-S trainees at each site is an ongoing challenge.
CONCLUSION Global surgery is an emerging academic field of both tremendous need and opportunity and yet, still faces the challenge of demonstrating value to disparate stakeholders. To become widely accepted into the academic mainstream, surgeons and trainees engaged in global surgery must demonstrate rigorous scholarship, successfully linking the needs and context of low-resource settings to questions of surgical care delivery, outcomes, and health equity. Trainees in global surgery must develop a diverse set of skills necessary for success in a cross-cultural context. Global
Journal of Surgical Education Volume 72/Number 4 July/August 2015
surgery training programs must assemble a diverse set of mentorship resources and sustain long-term partnerships with institutions in LMICs that provide mutual value. The result will be a well-developed academic field that combines rigorous scientific investigation with high-quality clinical care to generate innovative, sustained, and worldwide benefits in surgical care delivery.
8. Macfarlane SB, Jacobs M, Kaaya EE. In the name of
global health: trends in academic institutions. J Public Health Policy. 2008;29(4):383-401. 9. Qureshi JS, Samuel J, Lee C, Cairns B, Shores C,
Charles AG. Surgery and global public health: the UNC-Malawi surgical initiative as a model for sustainable collaboration. World J Surg. 2011;35(1):17-21. 10. Klaristenfeld DD, Chupp M, Cioffi WG, White RE.
ACKNOWLEDGMENTS We would like to acknowledge our colleagues and partners at Hôpital Albert Schweitzer in Haiti and at the Ministry of Health, the University of Rwanda, and Partners in Health in Rwanda. They have provided essential mentorship in the practice of surgery with constrained resources. We further acknowledge the leadership of the Center for Surgery and Public Health and the Department of Surgery at Brigham and Women’s Hospital in Boston, Massachusetts, for making this work possible.
An international volunteer program for general surgery residents at Brown Medical School: the Tenwek Hospital Africa experience. J Am Coll Surg. 2008;207 (1):125-128. 11. 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. 12. Tarpley M, Hansen E, Tarpley JL. Early experience in
establishing and evaluating an ACGME-approved international general surgery rotation. J Surg Educ. 2013;70(6):709-714. 13. Grigorian A, Sicklick JK, Kingham TP. International
REFERENCES 1. Finlayson SRG. How should academic surgeons
respond to enthusiasts of global surgery? Surgery. 2013;153(6):871-872. 2. Sullivan SR, Hughes CD, Raymonville M, Rogers SO,
surgical residency electives: a collaborative effort from trainees to surgeons working in low- and middleincome countries. J Surg Educ. 2014;71(5):694-700. 14. McQueen KA. Editorial perspective: global surgery:
measuring the impact. World J Surg. 2013;37(11): 2505-2506.
Steer ML, Meara JG. Training global surgery fellows. Bull Am Coll Surg. 2012;97(8):46-50.
15. Spechter WP. Commentary: charity begins at home.
3. Chin-Quee A, White L, Leeds I, MacLeod J, Master
16. Furin J, Paternek M, Katz JT. Global health equity as
VA. Medical student surgery elective in rural Haiti: a novel approach to satisfying clerkship requirements while providing surgical care to an underserved population. World J Surg. 2011;35(4):739-744.
the focus of graduate medical education. Med Educ. 2005;39(11):1161.
4. Jayaraman SP, Ayzengart AL, Goetz LH, Ozgediz D,
Farmer DL. Global health in general surgery residency: a national survey. J Am Coll Surg. 2009;208(3): 426-433. 5. Belyansky I, Williams KB, Gashti M, Heitmiller RF.
Surgical relief work in Haiti: a practical resident learning experience. J Surg Educ. 2011;68(3):213-217. 6. Riviello R, Ozgediz D, Hsia RY, Azzie G, Newton M,
Tarpley J. Role of collaborative academic partnerships in surgical training, education, and provision. World J Surg. 2010;34(3):459-465. 7. Ozgediz D, Wang J, Jayaraman S, et al. Surgical
training and global health: initial results of a 5-year partnership with a surgical training program in a lowincome country. Arch Surg. 2008;143(9):860-865.
Surgery. 2013;153(3):326-327.
17. Furin J, Farmer P, Wolf M, et al. A novel training
model to address health problems in poor and underserved populations. J Health Care Poor Underserved. 2006;17(1):17-24. 18. Ozgediz D, Chu K, Ford N, et al. Surgery in global
health delivery. Mt Sinai J Med. 2011;78(3):327-341. 19. Farmer PE, Kim JY. Surgery and global health: a view
from beyond the OR. World J Surg. 2008;32(4): 533-536. 20. Royston G. Meeting global health challenges through
operational research and management science. Bull World Health Organ. 2011;89(9):683-688. 21. Bozorgmehr K. Rethinking the ‘global’ in global health: a
dialectic approach. Global Health. 2010;6:19. 22. Johnson WD. Surgery as a global health issue. Surg
Neurol Int. 2013;4:47.
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23. Weiser TG, Regenbogen SE, Thompson KD, et al. An
estimation of the global volume of surgery: a modeling strategy based on available data. Lancet. 2008;372 (9633):139-144. 24. Ozgediz D, Jamison D, Cherian M, McQueen K. The
burden of surgical conditions and access to surgical care in low- and middle-income countries. Bull World Health Organ. 2008;86(8):646-647. 25. Kushner AL, Cherian MN, Noel L, Spiegel DA, Groth
S, Etienne C. Addressing the Millennium Development Goals from a surgical perspective: essential surgery and anesthesia in 8 low- and middle-income countries. Arch Surg. 2010;145(2):154-159. 26. Hunt MR, Godard B. Beyond procedural ethics:
foregrounding questions of justice in global health research ethics training for students. Glob Public Health. 2013;8(6):713-724. 27. Lairumbi GM, Parker M, Fitzpatrick R, English MC.
Forms of benefit sharing in global health research undertaken in resource poor settings: a qualitative
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study of stakeholders’ views in Kenya. Philos Ethics Humanit Med. 2012;7:7. 28. Lairumbi GM, Michael P, Fitzpatrick R, English MC.
Ethics in practice: the state of the debate on promoting the social value of global health research in resource poor settings particularly Africa. BMC Med Ethics. 2011;12:22. 29. Simon C, Mosavel M. Getting personal: ethics and
identity in global health research. Dev World Bioeth. 2011;11(2):82-92. 30. Crump JA, Sugarman J. The Working Group on
Ethics Guidelines for Global Health Training (WEIGHT). Ethics and best practice guidelines for training experiences in Global Health. Am J Trop Med Hyg. 2010;83(6):1178-1182. 31. Peace Corps Manual. Financial management—mainte-
nance of employee time and leave records. Available at: 〈http://www.peacecorps.gov/about/policies/docs /manual/〉; 2013 Accessed 03.11.13 [internet].
Journal of Surgical Education Volume 72/Number 4 July/August 2015
Training Surgical Residents for a Career in Academic Global Surgery: A Novel Training Model JaBaris D. Swain, MD,* Alexi C. Matousek, MD,* John W. Scott, MD,* Zara Cooper, MD,*,† Douglas S. Smink, MD,* Ralph Morton Bolman III, MD,‡ Samuel R.G. Finlayson, MD,§ Michael J. Zinner, MD,* and Robert Riviello, MD*,† *
Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; †Division of Trauma, Burns and Surgical Critical Care, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; ‡Division of Cardiac Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; and §Department of Surgery, University of Utah Health Care, Salt Lake City, Utah Academic global surgery is a nascent field focused on improving surgical care in resource-poor settings through a broad-based scholarship agenda. Although there is increasing momentum to expand training opportunities in low-resource settings among academic surgical programs, most focus solely on establishing short-term elective rotations rather than fostering research or career development. Given the complex nature of surgical care delivery and programmatic capacity building in the resource-poor settings, many challenges remain before global surgery is accepted as an academic discipline and an established career path. Brigham and Women’s Hospital has established a specialized global surgery track within the general surgery residency program to develop academic leaders in this growing area of need and opportunity. Here we describe our experience with the design and development of the program followed by practical applications and lessons learned from our early C 2015 Association of experiences. ( J Surg 72:e104-e110. J Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: global surgery, academic surgery, surgery
education, resident education COMPETENCIES: Professionalism, Interpersonal Communication Skills, Systems-Based Practice
and
Correspondence: Inquiries to Robert Riviello, MD, MPH, Brigham and Women’s Hospital, 75 Francis St., Boston, MA 02115; E-mail: [email protected], [email protected]
e104
INTRODUCTION Recently, there has been a well-documented surge of enthusiasm among medical students and surgical residents to incorporate international experience into their training, primarily in resource-poor settings.1-4 In response, several academic surgical programs have established opportunities for their trainees focused primarily on clinical electives.5-13 Although clinical care from visiting providers is needed in some contexts, in many poor countries there are local providers who can perform or be trained to perform the necessary surgical care. Therefore, many global surgery efforts focus on education, training, and research to address questions regarding care delivery, outcomes, and health equity at partner sites.6,8,14 This enhanced attention to measurement enables visitors to provide additional value, increase local clinical and research capacity, enable quality improvement, and avoid duplication of services that can already be provided in the host countries. However, many challenges need to be addressed before global surgery is accepted as an academic discipline and an established career path. Ensuring adequate mentorship, financial support, and stable partnerships with sites in resource-poor settings is necessary to respond to the unique logistic and ethical challenges that arise and to assure programmatic stability. Furthermore, trainees and faculty must convincingly demonstrate the value of their efforts within academic departments of surgery, public health institutions, nongovernmental organizations (NGOs), and host partners around the world through meaningful scholarship that advances surgical care delivery in resource-poor settings. To address these challenges, structured training programs in academic global surgery are needed to equip residents with the necessary clinical, research, and cultural-engagement skills unique to the field.
Journal of Surgical Education & 2015 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2015.01.007
Definition of Academic Global Surgery We conceptualize academic global surgery as an emerging discipline with the goal of improving surgical care delivery in resource-poor settings through a broad-based scholarship agenda. Global surgery training programs should be enacted through long-term collaborative partnerships with local stakeholders, with careful planning to ensure all parties realize meaningful benefits. We use the term global to include programs that serve resource-poor areas within the borders of high-income countries in addition to those based in low- and middle-income countries (LMICs).15 After the Resident Review Committee of the Accreditation Council for Graduate Medical Education approved international electives for credit, much of the recent literature has focused on the development and analysis of short-term clinical electives meant to expose trainees to the realities of surgical care delivery in resource-poor settings, but without an expressed focus on academically rigorous research development.11-13 Although clinical rotations, short- or long-term surgical missions, and disaster response efforts certainly contribute to surgical care in low-resource settings, we propose that the development of long-term academic partnerships should be the focal point of a formalized global surgery track for surgical residents.
THE BRIGHAM AND WOMEN’S HOSPITAL GLOBAL HEALTH EQUITY RESIDENCY IN GENERAL SURGERY Initial Planning To equip future leaders in academic Global Surgery, the leadership of the Brigham and Women’s Hospital (BWH) Department of Surgery created a formalized track within the existing general surgery residency program, entitled the Global Health Equity Residency in General Surgery (GHE-S). The initial design of the program was influenced by the BWH GHE Residency in Internal Medicine, which has been previously described.16,17 The BWH Center for Surgery and Public Health provides administrative, program management, and statistical support. The director of the GHE-S is a faculty surgeon with significant experience in global surgery and is supported by the Center for Surgery and Public Health and the BWH general surgery program director and department chairperson.
global surgery. Programmatically, the overarching aim of the GHE-S is to foster long-term academic partnerships between our institution and academic centers in LMICs with a shared vision to promote global health equity through high-quality surgical care delivery. Our experiences to date have been focused on strengthening longitudinal partnerships in Haiti and Rwanda to build resources and relationships through successive collaborations. Program Design Candidates with career interest in global health are chosen from the postgraduate year 2 (PGY-2) class and paired with a research mentor through the department’s existing mentorship program. Selected individuals must complete 3 years of residency before entering the research experience in recognition of the clinical duties that are often required at partner sites. During their PGY-2 and PGY-3 years, the residents work with their faculty mentor and host collaborators to develop a research plan focused on host-country priorities and apply for competitive extradepartmental awards (Fig. 2). After completing 3 years of clinical training, GHE-S residents begin a 2-year research track. Formal classroom instruction or coursework (i.e., Masters in Public Health) is strongly encouraged to strengthen methodological research skills and the understanding of epidemiological, ethical, and social issues pertinent to global surgical care delivery. Measuring Success To date, 3 GHE-S residents have completed the 2-year program. They have collaborated with numerous researchers from multiple academic institutions, NGOs, and governments from around the world and contributed to significant academic scholarship. They have also obtained competitive external funding from a variety of sources. Although these
Program Goals The 2 major goals of the program are to improve resident training in academic global surgery and to strengthen longitudinal partnerships with institutions in low-resource settings (Fig. 1). The GHE-S is designed to provide residents with focused mentorship and the clinical and research skills necessary to become leaders in academic Journal of Surgical Education Volume 72/Number 4 July/August 2015
FIGURE 1. Goals of the GHE-S program. e105
Program Year
Summer
1
Spring
Standard General Surgery Curriculum (PGY-2) Apply to GHE-S
Accepted to GHE-S
Standard General Surgery Curriculum (PGY-3)
3
5*
Winter
Standard General Surgery Curriculum (PGY-1)
2
4
Fall
Work with mentor on research proposal, apply for funding
Site visit at host instuon
MPH Coursework
Field research, clinical work at host instuon
Project transion, academic wring
6
Standard General Surgery Curriculum (PGY-4)
7
Standard General Surgery Curriculum (PGY-5)
*Some trainees have opted for an alternate pathway which distributes equivalent me for course work throughout the 4th and 5th years amidst periodic field research and clinical research at the host instuon
FIGURE 2. Timeline of the Global Health Equity Curriculum for General Surgery Residents.
more traditional metrics of programmatic output demonstrate academic productivity, they do not capture the overall value of these global academic partnerships, which seek to advance research, policy making, and equity in surgical care delivery. Ultimately, success is measured by the GHE-S residents’ commitment to a career in academic global surgery and their career-long effect on the field.
PRACTICAL APPLICATIONS AND LESSONS LEARNED Engaging Diverse Stakeholders Global surgery is a field in its infancy, striving to establish value among at least 3 disparate stakeholders: academic departments of surgery, global health institutions, and care delivery organizations in low-resource settings (e.g., ministries of health, NGOs, faith-based organizations, university, private sector, and others). Surgical department leaders may be reluctant to acknowledge global surgery research as providing a sufficient scholarship experience for trainees.1 They are particularly circumspect regarding the support of projects that are perceived as purely clinical in nature. Therefore, a global surgery investigator must ensure that research efforts focused on improving care delivery in resource-poor settings are founded on sound methodology. GHE-S trainees are required to have their projects vetted by staff epidemiologists and statisticians during the application process and annual work-in-progress meetings. Despite concerted advocacy, surgical care continues to be perceived by many in public health as too expensive and specialized to be included as a global health priority.18,19 A global surgery specialist must be aware of this perception and demonstrate value accordingly. The growing evidence e106
base of surgical cost-effectiveness and the burden of trauma and injury are useful in illustrating these value propositions.20-24 In Rwanda, we found that presenting new data on prehospital injury patterns to both local governmental officials and interested international stakeholders led to renewed dialog between local policy makers and our host research colleagues. Local care delivery organizations in resource-poor settings are understandably reluctant to support research efforts that fail to demonstrate local value. This hesitation may be borne of the lack of institutional capacity for data gathering, overwhelming need for clinical service provision, and the concern that foreign researchers may be appropriating data to advance their own careers without creating local value. In Haiti, to address this concern, we specifically limited the scope of our research to quality improvement and adapted a proposed study to include measuring inpatient outcomes at the request of the host institution. Focusing Partnerships on Local Priorities and Values Global surgery research should promote the equitable distribution of the benefits derived from the work.25-29 Many host collaborators have overwhelming clinical responsibilities and typically lack protected time for research and writing. Therefore, it is imperative that the high-income country partners make research capacity building and true equity in authorship as a focus. Our Rwandan colleagues have established clear polices on equity in authorship and have ensured that research efforts are coupled with research didactics to ensure sustainability. Additionally, understanding the specific clinical and research desires of the host institution is paramount, as both are integral components of a global surgery partnership. For instance, some institutions
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may place priority on improving the research capacity of their clinicians, whereas others may be more concerned with immediate improvement in the quality of surgical care delivery and education. However, this is not as simple as arriving and asking. Many hosting partners divulge their priorities only after a trusting relationship has been established. In Haiti, we spent multiple trips over several months providing clinical care and building trust before negotiating the presence of a research team. Even so, our success was only possible because of the nearly lifelong relationship our GHE-S trainee had with the host institution. The global surgery researcher must use a high degree of sensitivity when publishing research results that may affect a local partner organization’s reputation. Data integrity should be rigorously maintained, but if negative results are anticipated, it is important to allow for quality improvement before dissemination to avoid damaging the partnership. Practically, we share all results of our research and submit manuscripts for local review before any form of public dissemination. In addition, we have been careful to consider the potential positive effect of our research on the reputation of the hospital and have written blog posts, provided interviews, and helped write web pages to help enhance potential donations. Finally, the highest standards of scientific and ethical board review must be followed to ensure research does no harm to vulnerable populations. All GHE-S projects must receive ethical approval from both the partners’ health care institutional review board and the local ethics committee or institutional review board governing the host institution where the research will take place. We strongly believe that research that does not conform to local goals and standards or does not benefit the host population is an abuse of privileges granted by that population. Ensuring Appropriate Clinical Service at a Host Site Although academic global surgery is primarily a scholarly enterprise, clinical service at a host site is often appropriate, highly instructive, and even necessary for a global surgery specialist or trainee. The local clinical context and spectrum of disease certainly differ from the visitor’s experience at one’s home institution, which mandates that all care provided by the GHE-S trainee be supervised by a combination of locally accredited attending surgeons and those who are certified by the US board and are working at the partner sites. Importantly, even procedures that a resident can perform without supervision at his or her home institution should be approved by local providers. For example, at our partner institution in Haiti, tube thoracostomy is only performed in the operating room, and we comply with this requirement. Furthermore, the nature of clinical work in resource-poor settings is extremely demanding and must be balanced against time necessary for research. Clear expectations can be effective in ensuring
that appropriate time and energy are dedicated to scholarship and that the boundaries and supervision of clinical activity are well established. The degree and duration of clinical exposure varies for each resident based on host institution needs and the amount of time available after attending to research-related obligations. In Haiti, we developed written guidelines with the medical director of the host institution, balancing clinical and research responsibilities before any clinical service by the GHE-S trainee. Although we encourage participation in the care of patients with advanced or interesting pathology that residents may not encounter at their home institution, it is equally important to assist in the not-so-glamorous work and avoid the appearance of medical adventurism. Occasionally, visitors may feel that they are the only ones who can provide a particular clinical service. In our experience, this is rarely the case. We have found that a position of humility, patience, and initial observation is generally more successful in producing collaboration. Unfortunately, we have been called to work with clinicians who have been cavalier and irresponsible at our host sites. In our experience, these unethical practices are most common among visiting practitioners rather than local providers. The need to avoid such behavior and carefully navigate these scenarios cannot be overemphasized, as vulnerable populations merit more rather than less stringent attention to ethical conduct owing to their powerless position. Finally, we had to be careful not to take training opportunities away from local residents, which can be more difficult than initially perceived, as they often defer to visitors. Frequent re-evaluations and adjustments may be necessary. When providing clinical service, a visitor must adapt to the local resources and practice patterns rather than assume that the approach taken in their home institution is the most appropriate. For example, risking re-expansion pulmonary edema by reinflating a collapsed lung from a longstanding pneumothorax with suction in the first hours after tube thoracostomy is more dangerous when there is no mechanical ventilation available. There are many ethical challenges that arise in these settings that require careful consideration, frequent processing with trusted mentors, and may prompt dialog with local colleagues regarding cases where deviation from otherwise established local norms may be necessary.29,30 In Rwanda, for instance, it is beneficial to periodically debrief the triage decisions made daily by faculty members as to which patients will have the opportunity to receive emergency surgical care and who will not, given the extremely limited operating room availability. Developing a Tailored Skill Set In addition to a strong foundation in clinical and research skills, the global surgery trainee must develop the ability to navigate a new social context with cultural humility. The candidate with extensive prior global health experience,
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particularly within the setting of the proposed project, is likely to be more versatile, adaptable, and skillful in negotiating across differences of language and culture. Predeparture didactic sessions focused on cultural awareness, regular check-in meetings with mentors, and onsite faculty supervision are critical to deepening these skills among residents. Generally, the GHE-S residents have had substantial experience in resource-poor settings before entering the program, which has greatly facilitated their success. Creating a Mentorship Paradigm At most US academic centers, the number of trainees seeking global surgery mentorship often exceeds the number of faculty with experience in resource-poor settings. In our program, we have modified the traditional model of academic mentorship and encourage residents to seek support from multiple sources. Senior academic surgeons may not feel equipped to mentor a global surgery trainee, but they can provide essential guidance with content expertise and research methodology and help demonstrate the value of the research to surgical leadership.1 However, because of the intense emotional nature of clinical work in austere environments and the high degree of relational skills required, we strongly encourage global surgery trainees to identify a mentor with experience in low-resource settings who can help them process these challenges. The mentorship team should meet regularly and be composed of faculty from any discipline with expertise needed by the mentee. As programs grow, trainees may be able to find a single global surgery mentor more easily as faculty resources increase. However, we have found it important to assemble diverse mentorship resources that can offer guidance in research methodology, context expertise, and career advice. In addition to the focused mentoring by US academic surgeons, mentors from the host institution play an important role in the development of the trainee. Host mentors are identified through relationships with US partners and are most often involved in teaching and training residents at their own institution. Host mentors help the trainee understand differences in local patterns of clinical care and decision making and are essential in adapting research proposals to the local context. In Rwanda, the academic head of surgery has connected GHE-S residents with specific Rwandan trainees to provide peerto-peer exchange of experience and understanding. Supporting the Emotional Health of the Trainee The taxing nature of working in health care within a resource-poor setting should not be underestimated. Adapting to a new environment, language, culture, burden of disease, and practice paradigm can challenge the coping skills of even the most seasoned trainee. The Peace Corps e108
recognizes the burden that overseas service puts on their volunteers and mandates 1-week periods of leave every 12 weeks.31 In our program, this also includes 1 day off in 7 days—keeping within the Accreditation Council for Graduate Medical Education–mandated residency workhour restrictions. Each of us has personally faced the death of our patients overseas, which could have been avoided at our home institutions. We have found that at a minimum, regularly scheduled contact with mentors is necessary to process these emotional challenges, maintain productivity, and avoid burnout.2 Furthermore, extending access to employee assistance services and mental health support should be considered a vital component of any global surgery program. Unsolved Problems and Limitations Despite concerted effort and the careful design described earlier, persistent challenges include robust mentorship, stable funding, and maintenance of a continuous chain of GHE-S trainees at our host sites. Each GHE-S resident develops a team of mentors who provide clinical, context, and research methodology expertise, led by the program director who is based in both Boston and Rwanda. Although this has been functional in the context of motivated residents, mentorship has also been fragmented, particularly when conducted across time zones and with variable Internet connections. Regarding financing, the BWH provided generous seed funding to launch the program; however, the GHE-S continues to seek stable programmatic financial support from grants and philanthropy. Currently, prospective trainees are still required to spend significant time securing funding for their personal and programmatic expenses. Finally, although building programs in 2 sites has been critical for focus and productivity for the trainees, this does not always align with individual resident’s geographic preferences. This trade-off has occasionally pit programmatic priorities and feasibilities against individual interests and goals. Thus, maintaining a pipeline of GHE-S trainees at each site is an ongoing challenge.
CONCLUSION Global surgery is an emerging academic field of both tremendous need and opportunity and yet, still faces the challenge of demonstrating value to disparate stakeholders. To become widely accepted into the academic mainstream, surgeons and trainees engaged in global surgery must demonstrate rigorous scholarship, successfully linking the needs and context of low-resource settings to questions of surgical care delivery, outcomes, and health equity. Trainees in global surgery must develop a diverse set of skills necessary for success in a cross-cultural context. Global
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surgery training programs must assemble a diverse set of mentorship resources and sustain long-term partnerships with institutions in LMICs that provide mutual value. The result will be a well-developed academic field that combines rigorous scientific investigation with high-quality clinical care to generate innovative, sustained, and worldwide benefits in surgical care delivery.
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ACKNOWLEDGMENTS We would like to acknowledge our colleagues and partners at Hôpital Albert Schweitzer in Haiti and at the Ministry of Health, the University of Rwanda, and Partners in Health in Rwanda. They have provided essential mentorship in the practice of surgery with constrained resources. We further acknowledge the leadership of the Center for Surgery and Public Health and the Department of Surgery at Brigham and Women’s Hospital in Boston, Massachusetts, for making this work possible.
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