American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

How to Establish an Overseas Surgical Rotation: Lessons from the Mount Sinai Experience

Introduction

Volunteerism in the surgical field in not a new concept. Many medical groups, such as Operation Smile,1 Orthopedics Overseas,2 international health organizations,3 and missions have been functioning for years in the spirit of humanitarianism, sending surgical personnel to areas around the globe. These programs occasionally include surgical residents on a rotational basis but often are conducted sporadically and lack the sustainability that should represent the foundation of collaborative work.

We proposed developing an ongoing clinical rotation for surgical residents at a hospital we selected in a developing country. The local population would benefit from the residents’ presence, and, simultaneously, the surgical residents would benefit from working in an environment with limited resources distinctly different from their own. This type of ongoing rotation would allow residents to continuously evaluate the true needs of the hospital in order to possibly provide future assistance in other fields such as well-needed equipment, books, videos, and senior staff, thus strengthening the bond between the institutions. We believe this program to be the first of its kind.

Rotation Aims

The rotation should be developed to meet the following criteria:

  • Provide valuable service to a developing community and assist with teaching and training
  • Acquire operative experience in a setting with limited resources
  • Experience living and working in a different cultural environment
  • Develop a sense of volunteerism

The rotation is suitable for senior surgical residents in their postgraduate third or fourth year and would occur during the last four weeks of their training. Preferably, the residents should follow each other consecutively, which would both foster a sense of confidence in the residents on the part of the local physicians and allow the local administration to incorporate the house staff into their daily work schedule. The rotation should not be mandatory but highly encouraged.

Methods

Seeking a Location

The process of locating an ideal site for this type of surgical rotation is complex and time consuming. For this purpose, a small search committee of attendings and residents should be formed in order to establish initial contacts. Over a period of six months, our search committee contacted 22 hospitals in 14 countries and multiple health organizations in order to locate a potential site.

Initial Contact

Initial contacts between the organizing institution and potential sites can be made in several ways:

International Health Organizations: There are many global health organizations that deal with sending medical staff to developing countries. Some of these organizations offer information about hospitals in need. Others offer names of missions. Information on most of these organizations can be found on websites such as IMVA, the International Medical Volunteers Association.3 Many of these organizations, such as Médecins Sans Frontières, prefer to hire fully trained surgeons for their missions and require obligatory time commitments from their field members. Other locations appear to require medical or surgical assistance for a limited period of time but are not looking to commit to an ongoing surgical rotation.

American College of Surgeons (ACS): The ACS Operation Giving Back program is designed to serve as a comprehensive resource center where surgeons can find the information they need to investigate and participate in national and international volunteer opportunities. Many of the locations listed on the organization’s website4 can be contacted through a mission center, and others can be reached by directly contacting the hospital at the site.

Direct Approach: Letters were sent to several hospitals inquiring about the needs for surgical staff. This approach proved to be grossly ineffective. Many such hospitals demonstrated an obvious need for volunteer assistance, but perhaps organizational failures at the administrative level resulted in limited and delayed responses.

Personal Contacts: This method involved directly contacting a colleague who practices in a developing country. In our experience, it proved to be the most effective in terms of making the initial contact for the program. Designating a reliable contact person or liaison facilitates the process of acquiring basic information about the hospital (size, needs, safety), assists in connecting to relevant surgical staff within the hospital, and aids in organizational issues ranging from logistics to integration into an unfamiliar political municipality.

Special Considerations

Safety

Perhaps the most important issue to consider when planning an overseas rotation is the residents’ safety. Hospitals located in areas with a high crime rate should not be considered as potential sites. Political instability is an additional consideration. Places that are either actively engaged in a war state with neighboring countries or suffering from internal socio-political instability should not be considered.

Case Volume

In order for the overseas program to be beneficial for the residents, the operative experience in terms of volume and variety of cases must be sufficient. We gave preference to sites that boast a large number of combined elective and emergency cases.

Independence

In situations where senior residents will be doing the rotation, some consideration should be given to the residents who have a certain degree of independence in the operating room. Obviously, we must avoid the extreme in which residents are operating without supervision.

Clinical Experience

The chosen location should provide the residents with a variety of unusual pathology and expose them to different and unfamiliar surgical techniques.

Humanitarian Need

The proposed hospital must be in need of surgical staff. A hospital that does not have its own resident house staff is preferable. The communities served by the hospital under consideration should be in underdeveloped and under-resourced places where inhabitants lack the means to obtain advanced health care.

Cost

No financial burden should fall on the designated hospital. All costs, including travel, food, accommodations, medications, vaccinations, insurance, and visas should be the responsibility of the organizing hospital. This consideration is fundamental to avoid future obstacles regarding expenses.

Housing

Three different types of accommodations should be considered.

  1. Renting: This option works well, particularly if there will be residents living in the apartment year-round. If the apartment will be empty for a large portion of the year, alternative housing should be explored.
  2. Local families: In many locations, families may offer to rent a small living quarter on their property or a room in their house. These families would be paid by the organizing hospital. This arrangement avoids the need for a contract, and there would be no problem leaving the area unoccupied for parts of the year when there is no resident.
  3. Hotels: Inexpensive hotels can be found in almost any city. Prices are often negotiable depending on the length of stay. Hotels are best for itinerant residents or programs that do not have a recurring commitment.

Initial Survey

After establishing the initial contact, the next step is to send a representative to each of the potential locations. The purpose of these visits is to evaluate the proposed site, establish contacts with local administration and hospital staff, and evaluate housing options. Preferably, the person conducting these visits should be a resident or attending with some experience traveling in developing countries. He or she should also have a moderate degree of operative experience in order to participate in surgical procedures if doing so is permitted. This approach allows for a more “hands-on” experience and affords an actual assessment of available surgical equipment and practiced techniques, an opportunity that might not be achieved by inquiry alone.

A rudimentary scoring system based on relevant parameters (that is, regional safety, case volume) should be developed by the program. This is not a scientifically based decision. Although the scoring system may suggest that a certain location would provide the ultimate experience, certain information can be obtained only from a site visit and hands-on experience with the staff and patients. Other aspects should be investigated. For example, how friendly is the staff? Are American residents rotating at their hospital wanted and/or needed? How many of the staff and patients speak English? What are the true needs of the population in terms of medical aid? What cultural and social experiences can be best assessed by a site visit with direct interaction with the local staff and patients?

Rotation Evaluation

Goals and objectives must exist for every rotation, including any overseas rotation. Then, upon returning to the home program, residents should complete a rotation evaluation form relating to all aspects of their rotation.

The Mount Sinai Hospital Experience

The hospital chosen for our program was Juan Pablo Pina, a 250-bed public hospital serving a small urban population in the Dominican Republic. The facility provides health care to a large catchment basin of underprivileged persons, both from urban and greater surrounding rural areas. Furthermore, the site selected offers sufficient operative experience with an optimal balance between emergent and elective cases. The hospital is located in a safe and tenable environment. The hospital has very limited resources (no radiology department or intensive care unit). The initial surgical experience acquired by six of our senior residents who performed the rotation was highly favorable. During their visit they performed many elective and emergent cases in the fields of general surgery and trauma, gynecology, orthopedics, urology, and head and neck specialties. Residents performed 50 to 90 cases during their one-month rotation, and they were generally involved with preoperative selection and elective scheduling, which is done through free, daily, public clinics.

We set up a family stay for the residents that included a private room. Food and other necessities were provided for the residents’ health and comfort. The residents were supplied with reading materials, Internet access, and telephone contacts. Additionally, they were supplied with a highly secured call room on the hospital premises. By ensuring the residents’ safety and basic comfort, they were able to perform in the local hospital efficiently and reported a great satisfaction level. The residents reported a high degree of independence and autonomy with appropriate supervision. Cases were generally performed utilizing minimal equipment. Basic ancillary studies such as basic laboratory values were typically available, but the availability of radiographic evaluation was limited and often became the financial responsibility of the patient, whereas all surgical care was rendered either free of charge or at minimal cost. The residents became largely responsible for managing most of the clinical issues pertaining to the patients on whom they operated. Furthermore, residents organized an academic lecture series. Translators were available to non-Spanish speakers in all clinical settings. A Spanish teaching program for the residents was also initiated as an after-work activity.

The rotation abroad also exposed our residents to distinct cultural correlates, including unique family and social situations, as well as important experiences associated with the socioeconomic and political evolution of a foreign country and how such elements related to the current state of social welfare and health care in general.

Resident Satisfaction

The resident consensus was that the average case load per resident should be about 60 major cases per month combined with the clinical and academic experiences. All were satisfied with local family accommodations. The positive home stay also helped the residents avoid isolation and depression. Suggestions for change and improvement included allowing the residents to perform the most challenging parts of the procedures with supervision. Not all attendings allowed for the same level of autonomy, which residents felt should be a critical part of this rotation.

Language barriers were not cited as a major problem, and all residents were able to learn and communicate effectively in the operating room and clinics regardless of Spanish-language proficiency. Negotiating some of the cultural and language difference barriers was a lesson in and of itself. All residents expressed the desire to learn Spanish; consequently, a language-teaching program has been established. Other resident suggestions for improvement included the proposal to donate equipment such as ventilators and basic operative equipment to Juan Pablo Pina as an evolving facet of the program.

It is important to note that the resident cases performed as a part of this international rotation were not considered admissible to the Accreditation Council for Graduate Medical Education (ACGME) or to case logs required for American Board of Surgery (ABS) eligibility.

Summary

The arrangement of a resident surgical rotation in a third-world country is complex and time-consuming. It must be approached in an organized fashion, taking into account multiple factors such as specific needs of the country, workload and resources of the host hospital, and personal issues regarding the well-being of the participating residents. We believe that such a rotation would be beneficial to the residents, the local population being served, and the organizing surgery program. We hope our experience in organizing such a program can serve as a template for similar programs.

References

  1. Operation Smile homepage. Available at: http://www.operationsmile.org. Accessed March 15, 2005.
  2. Derkash RS, Kelly N. The history of orthopaedics overseas. Clin Orthop Relat Res. March 2002;(396):30-35.
  3. International Medical Volunteers Association homepage. Available at: http://www.imva.org. Accessed February 10, 2005.
  4. Operation Giving Back, American College of Surgeons homepage. Available at: http:// www.operationgivingback.facs.org. Accessed February 20, 2005.
About the Authors

Rachel Wellner, MD, MPH, FACS
Department of Surgery
Mount Sinai School of Medicine, New York

Lester Silver, MD, FACS
Department of Surgery
Mount Sinai School of Medicine, New York

Celia M. Divino, MD, FACS
Department of Surgery
Mount Sinai School of Medicine, New York