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

Joe Forrester Focuses on How to Develop Sustainable Overseas Collaborations

During my research years as an Epidemic Intelligence Service Officer with the Centers for Disease Control and Prevention, I saw firsthand how essential international collaboration was to combat the spread of Ebola. On the front lines in Liberia during July and August 2014, my team and I worked to restore basic health care services in the midst of a terrifying epidemic. Throughout this experience, I developed an appreciation for challenges faced by low- and middle-income countries in providing safe and accessible health care. And as the outbreak unfolded, the connection became clear—the health of people living in one continent has direct impact upon the health of us all.

Returning to my final clinical years in general surgery training at Stanford, I became convinced that surgery, and the infrastructure required to provide safe surgical care, can and should be an integral component of any essential health care package. Information and medical technology spread faster today than it did even 10 years ago, yet we as a species are still unable to provide surgical care for all 7.2 billion people in the world. I strongly believe that my generation of surgeons will be judged upon our ability to expand health care coverage to all those who need it. I know that one key to achieving this challenge will be through a series of international networks. The challenge is far too overwhelming for a single institution or country to accomplish alone, but through collaboration, I believe we can achieve this seemingly impossible goal.

Dr. Forrester with Professor Hyland at the RCSI Millin Meeting in Ireland

Founded in 1784 as a training and regulatory body for Irish surgeons, the Royal College of Surgeons of Ireland (RCSI) is one of the oldest surgical training organizations in the world. Located in Dublin, RCSI has grown to include a medical, physiotherapy, nursing, and pharmacy school. More recently RCSI has expanded, establishing training programs in Dubai and Malaysia. Given the geographical distribution of surgeons and trainees throughout Ireland and the European Union working-hour restrictions, RCSI has developed novel methods for ensuring adequate training of trainees, putting RCSI at the forefront of training surgeons both domestically and internationally.

On November 5, 2016 I flew to Dublin as one of this year’s ACS International Exchange Scholars. My goal was to try and understand how RCSI has become so successful in developing sustainable overseas collaborations. My first day was spent at Beaumont hospital with Debbie McNamara, a consultant colorectal surgeon. Throughout the day, I had the opportunity to learn more about the current Irish health care system in the setting of one of the nation’s largest public hospitals. This allowed me to put RCSI’s overseas collaborations into context with the Irish medical system.

Then, over the next three days I learned more about RCSI’s overseas programs. Eric O’Flynn and I discussed RCSI’s collaboration with the College of Surgeons of East, Central and Southern Africa (COSECSA), which began in 2007. To date, this successful partnership has resulted in the graduation of 158 specialist surgeons, 391 active surgical trainees, and 94 accredited hospitals. Professor Ruari Brugha talked with me at length about the challenges he faced, and successes he experienced, during the Clinical Officer Surgical Training in Africa (COST-Africa) trial. This trial, for which data collection ended just this year, underscores the potential for surgical care provided by supervised and trained non-physician clinicians. Professor Samuel McConkey and I discussed how Irish culture and the unique Irish surgical training environment have helped position RCSI to establish itself as a leader in international surgeon development. Finally, with Professor Sean Tierney we discussed the ethics and funding of international surgical programs.

Dr. Forrester and his fiancée at the Cliffs of Moher

I also had the pleasure of viewing the new systems and technology being used by RCSI to train its trainees throughout Ireland. Professor Oscar Traynor and Mr. Kieran Ryan showed me RCSI’s surgical trainee eLogbook which they use to track the surgical experience of a trainee. Mr. Donncha Ryan showed me the potential of full-immersion virtual reality training which could be applied to training complex laparoscopic procedures. Used for Irish trainees, it was quickly apparent that this technology could be scaled and used for long-distance, real-time training. Finally, my meetings culminated with Professor Hyland, president of RCSI, with whom I discussed some of the broader challenges facing the Irish health care system. The week finished with the Millin meeting, in which topics such as staffing level 3 hospitals and the changing surgical workforce were explored.

Surgical care is no longer effectively delivered in a silo, whether that silo be at the individual-, institution-, or country-level. Certainly, if we are to strive valiantly toward providing surgical care for all, we must do so in close collaboration with our colleagues overseas, both in Ireland and further abroad. Having exposure to the state-of-the-art training paradigms, programs, and international collaborations developed by RCSI was a truly wonderful experience. As I work to develop training programs capable of cultivating international surgical diplomats of the future, I will carry this experience and the friendships made with me. Together we can achieve the seemingly impossible goal of making surgical care available to all who are in need.

I would like to thank all the members of RCSI and the American College of Surgeons who provided me this opportunity. The hospitality I was shown in Dublin was truly wonderful. I also want to extend a warm thanks to Ger Conroy who helped organize and supervise my week in Ireland.

Joe Forrester, MD, MSc, is general surgery resident, department of surgery, Stanford University, Palo Alto, CA.