How My Global Surgery Experience Helped Me Understand Reciprocal Innovation

Reciprocal innovation is defined as the bi-directional and iterative exchange of a technology, methodology, or process between at least two countries to address a common health challenge and provide mutual benefit to both sides. Lessons learned are continually shared throughout the process to suit the needs and infrastructure of each country. Prior to starting my global surgical experience, I believed “reciprocal innovation” needed to be relatively equal. If we were discussing a clinical problem, we should focus on exchange of clinical skills; if we were discussing a systems issue, we should focus on exchange of systemic improvements. One glaring challenge I saw within global surgical care was the limited disease-specific initiatives, including antibiotic stewardship for emergency general surgery procedures like appendicitis or cholecystitis or multidisciplinary care for complex wounds.

One limitation in involving surgeons in disease-specific initiatives like trauma registries or breast cancer care is the shortage of trained surgeons, leading to even fewer surgical subspecialists. In Kenya, many emergency general surgery procedures are completed by general physicians (GPs). These are doctors who have completed medical school and are practicing as GPs. In Kenya, they are called medical officers (MOs). MOs often work at community hospitals where there are few specialized physicians (a few pediatricians, a few internists, and a few surgeons). The MOs rotate through different specialties and are responsible for most of the child deliveries and emergency general surgery procedures. For the most part, the MOs care for the urgently sick patients whose surgical pathologies range from local abscesses to acute abdomens. They are mentored through the first few of each type of procedure, but after that, they are often left on their own due to limitations in the number of trained personnel.

For more complex surgical procedures like elective hernia repairs and oncologic resections, patients are referred to tertiary centers. At Moi Teaching and Referral Hospital (MTRH), the public hospital at which I am spending my global surgery year, there are a handful of trained general surgeons, each with particular interests in hepatobiliary or complex hernias, but none with official subspecialty training. This lack of sub-specialization has led to a shortage of surgical leaders willing to organize treatment protocols for acute general surgery or create a structure surgical oncology curriculum for the general surgery residents. However, it is this lack of sub-specialization that drew me into global general surgery because of the breadth of disease the general surgeon treats. When on a general surgery rotation, the Kenyan residents are responsible for completing Whipple procedures for pancreatic adenocarcinoma followed by placing setons for fistula-in-ano.

One of my primary projects during my research years was to assist in the development of a multi-disciplinary breast cancer program at Moi. The AMPATH Breast and Cervical Cancer Control Program has been funded by the Eli Lily Corporation since 2017. The program has developed breast and cervical cancer screening programs in the 22 counties served by Moi. This program has a strong local gynecologic oncologist spearheading the cervical cancer component and a medical oncologist interested in breast cancer helping with the breast cancer programming. Over the 5 years while the cervical cancer program rose, the breast cancer program lagged. In discussions with the lead gynecologic oncologist, he said the breast cancer program needed a champion to help develop the program further. My mentor, a US-trained breast surgical oncologist, was excited to help but knew she needed a Kenyan counterpart to navigate the cultural intricacies and to continue to lead the program when she left.

Initially, the plans for a breast cancer working group were discussed over a general oncology meeting where many stakeholders were present. However, the plans were not focused, ranging from improved diagnosis to introduction of artificial intelligence reading mammography results. At best, the ideas discussed were ambitious goals, and at worst, the grandiosity of the ideas might have provided a crumbling foundation on which to build the program.

Since this meeting, a small breast cancer working group has been formed. The members include clinicians, public health officials, and data managers who assisted in the day-to-day coordination of the AMPATH breast cancer screening. The team has identified delays in patient care while also implementing a multidisciplinary breast cancer clinic. This first-of-its-kind clinic in our setting reduced the number of times a patient needed to return to our hospital while also allowing all the doctors to discuss their plans, preventing any loss of treatment paths.

Although all the attending (consultant) surgeons have identified their desire to improve care for breast cancer patients, there is still not a local surgical leader ready to spearhead further development. One limitation to identifying a leader is surgeons are not explicitly trained to be leaders during residency.

I am a fixer. I love going down to the emergency department, assessing a patient for appendicitis, starting the preoperative antibiotics, removing the appendix, and watching the patient feel significantly better. But, I also chose surgery as my profession because I saw my surgical mentors in medical school take charge of a chaotic room. I have learned as a junior resident, standing at 5’2” and possessing a subjectively high-pitched voice, that it is my job, as the surgeon, to take control of a chaotic situation, whether that is a disorganized trauma resuscitation or a confusing patient presentation during tumor board. Of course, I model some of these skills from my mentors, but I have also been actively taught leadership skills in my residency. I have been trained to believe that surgeons should be running hospitals and communities because our perspectives on public health are significantly different, and our treatments could help develop a sustainable healthcare system.

Six months into my global experience, I am starting to understand the phrase “reciprocal innovation.” My Kenyan colleagues have taught me a lot about medicine in a setting with limited imaging, and for many months, I felt like it was a one-sided relationship benefitting me and educating me on the resources and infrastructure available to patients at MTRH. But, as I reflect on our breast cancer working group experience so far, I realize that, although I am “just” a junior resident, my education has taught me vital leadership and communication skills that I can share with my Kenyan peers.