Global Surgery & Anesthesia

Great! The very popular Dr Cherian is on your team.
First question to her: Is there anyway that non-governmental entities can be involved in the WHO Essential and Emergency surgery training process for its members (for example Association of General & Private Medical Practitioners of Nigeria)?. If there is a way, what processes do you suggest ma?

Hello fellow GHD members. As it happens, this topic - Surgical Training in Resource-Limited Settings - is a major ongoing discussion topic on the HIFA2015 forum (Healthcare Information For All by 2015): www.hifa2015.org

I shall publicise this GHD Expert Online panel among HIFA2015 members, so that we can have the maximum input, collective expertise and experience during the focused week February 6-10.

Best wishes, Neil Pakenham-Walsh

Very glad to see this panel discussion and also note the panelists. Look forward to the discussions.

Exciting to see this discussion. There is a specific panel of experts discussing surgical education in resource poor areas during the "Extreme Affordability: Innovations for affordable surgical care conference sponsored by the Center for Global Surgery at the University of Utah March 22-23 in Salt Lake City. See the web site: http://medicine.utah.edu/globalsurgeryconference/

Emmanuel A. Ameh, FWACS, FACS is Professor of Surgery at the Ahmadu Bello University, Zaria, Nigeria and Consultant Paediatric Surgeon to the Ahmadu Bello University Teaching Hospital, Zaria, Nigeria Over the years, Dr. Ameh has been actively involved in the development of educational programmes and training activities of the West African College of Surgeons, Association of Paediatric Surgeons of Nigeria and Pan African Paediatric Surgical Association. He has been at the forefront of advocacy to elevate the profile of surgery and surgical specialties, including pediatric surgery in Nigeria and sub Saharan Africa. He has published widely on various aspects of paediatric surgery, surgery and surgical education, and has edited 3 books and written several book chapters on aspects of surgical care of children. Dr. Ameh is presently Chief of Pediatric Surgery at the Ahmadu Bello University Teaching Hospital, Zaria, Nigeria. He is also director for clinical services at the Ahmadu Bello University Teaching Hospital. . His present interests are in surgical education and training, as well as clinical paediatric surgery.

1. HOW TO IMPLEMENT CONTEXTUALLY APPROPRIATE SURGICAL TRAINING PROGRAMS?
There is need to first identify the surgical conditions encountered in the setting through analysis of publications and cumulative experiences of those ...

Emmanuel A. Ameh, FWACS, FACS is Professor of Surgery at the Ahmadu Bello University, Zaria, Nigeria and Consultant Paediatric Surgeon to the Ahmadu Bello University Teaching Hospital, Zaria, Nigeria Over the years, Dr. Ameh has been actively involved in the development of educational programmes and training activities of the West African College of Surgeons, Association of Paediatric Surgeons of Nigeria and Pan African Paediatric Surgical Association. He has been at the forefront of advocacy to elevate the profile of surgery and surgical specialties, including pediatric surgery in Nigeria and sub Saharan Africa. He has published widely on various aspects of paediatric surgery, surgery and surgical education, and has edited 3 books and written several book chapters on aspects of surgical care of children. Dr. Ameh is presently Chief of Pediatric Surgery at the Ahmadu Bello University Teaching Hospital, Zaria, Nigeria. He is also director for clinical services at the Ahmadu Bello University Teaching Hospital. . His present interests are in surgical education and training, as well as clinical paediatric surgery.

1. HOW TO IMPLEMENT CONTEXTUALLY APPROPRIATE SURGICAL TRAINING PROGRAMS?
There is need to first identify the surgical conditions encountered in the setting through analysis of publications and cumulative experiences of those already working in the setting. A goal-oriented curriculum should be drawn up to focus on a) common/regular diseases; b) diseases that are uncommon but have severe consequences; c) rare diseases. The training time should be proportioned based on a, b, and c. Important to emphasize here that trauma and rural surgery are important aspects in many resource-limited settings.
At the West African College of Surgeons (which coordinates postgraduate surgical training in West Africa), the curriculum is being revised along with trainee operative logbook, to make the training more appropriate and more robust.
Providing appropriate surgical training resources that addresses local needs is important in the long-term as most regular surgical texts (published in western countries) do not adequately address the range of surgical problems in resource-limited settings. An example is the “Surgery in tropics and sub tropics by Badoe EA et al” which has been in West Africa for over a decade and is presently being revised. The recent “Paediatric surgery: a comprehensive text for Africa” and “Surgical care for children: a guide for primary referral centres” have also tried to address this aspect.

2. HOW TO ENSURE LOCAL TRAINING NEEDS ARE PRIORITIZED ABOVE EXPATRIATE TRAINING NEEDS?
I feel that once there’s a goal-oriented curriculum, it would help to focus on and ensure local training needs are priority over expatriate training needs. The training director/coordinator would need to continuously emphasize and remind both local and expatriate trainers on the need to meet give the local trainee adequate attention. However, expatriate training needs should not be completely downplayed, as this may blunt the interest and commitment of expatriate collaborators and supporters.

3.WHAT ARE THE CHALLENGES OF PROVIDING SURGICAL TRAINING FOR NON-PHYSICIANS?
My comments here will be specific about Nigeria. Although we don’t any experience with providing surgical training to non-physicians, there have been much debate on whether this should be done or not, particularly considering that most doctors would not want to work in the rural areas and remote villages. In the last few weeks, this debate has been quite passionate on HIFA2015!
The main concern and challenge in Nigeria has been the apprehension regarding regulation of the practice on non-physicians if they are trained to provide surgery. This is based on the fact that the medical terrain in Nigeria is that in which the medical and dental council only regulates the practice of doctors, and even doing this has proved most difficult. A situation where non-physicians provide surgical services but cannot be regulated by any surgical body then becomes quite frightening. Even medical doctors who have had little or no training in surgery go far beyond what they can do in the rural areas and villages and produce much complications and mortality. Also, community health officers (CHOs) have been trained in Nigeria for several decades to provide primary ...

3.WHAT ARE THE CHALLENGES OF PROVIDING SURGICAL TRAINING FOR NON-PHYSICIANS?
My comments here will be specific about Nigeria. Although we don’t any experience with providing surgical training to non-physicians, there have been much debate on whether this should be done or not, particularly considering that most doctors would not want to work in the rural areas and remote villages. In the last few weeks, this debate has been quite passionate on HIFA2015!
The main concern and challenge in Nigeria has been the apprehension regarding regulation of the practice on non-physicians if they are trained to provide surgery. This is based on the fact that the medical terrain in Nigeria is that in which the medical and dental council only regulates the practice of doctors, and even doing this has proved most difficult. A situation where non-physicians provide surgical services but cannot be regulated by any surgical body then becomes quite frightening. Even medical doctors who have had little or no training in surgery go far beyond what they can do in the rural areas and villages and produce much complications and mortality. Also, community health officers (CHOs) have been trained in Nigeria for several decades to provide primary health care but some of them often go beyond what they are trained to do and then produce complications and mortality. I must say that Nigeria is a rather large country and so much goes on in the remote rural areas which is difficult to regulate at the moment.
Another challenge would be deciding on the appropriate content of the training, but it does appear that countries like Malawi may have already been able to address this aspect.
Some countries in West Africa have actually requested WACS to train middle level surgical manpower (i.e. below level of specialist but beyond general duty doctor) to help address the surgical manpower needs. This has been successfully done for Ophthalmology and Anesthesia but it appears that the entrance into this training remains low.

Dr. David Spiegel works as a pediatric orthopaedic surgeon at the Children’s Hospital of Philadelphia, specializing in neuromuscular diseases, trauma, and spinal deformities and is an Associate Professor of Orthopaedic Surgery at the University of Pennsylvania School of Medicine. He attended Duke University for college, medical school, and orthopaedic surgical residency training, and then completed both a research and a clinical fellowship in pediatric orthopaedics at the Children's Hospital of Philadelphia and the University of Pennsylvania School of Medicine. He serves as a Consultant in Orthopaedics and Rehabilitation at the Hospital & Rehabilitation Centre for Disabled Children in Banepa, Nepal. He served seven years on the Committee on Childrens Orthopaedics in Underdeveloped Regions of the Pediatric Orthopaedic Society of North America (POSNA), serving as chairman the last 3 years. He has been on the Board of Orthopaedics Overseas, Global-HELP, the Ponseti International Association, and Miracle Feet. He has received the President's Call to Service Award (2006), by the Presidents Council on Service and Civic Participation, for 4000 hours of community service, and the Golden Apple Award by Health Volunteers Overseas (2009). He has served as a consultant for the World Health Organization, and has been involved in the ...

Dr. David Spiegel works as a pediatric orthopaedic surgeon at the Children’s Hospital of Philadelphia, specializing in neuromuscular diseases, trauma, and spinal deformities and is an Associate Professor of Orthopaedic Surgery at the University of Pennsylvania School of Medicine. He attended Duke University for college, medical school, and orthopaedic surgical residency training, and then completed both a research and a clinical fellowship in pediatric orthopaedics at the Children's Hospital of Philadelphia and the University of Pennsylvania School of Medicine. He serves as a Consultant in Orthopaedics and Rehabilitation at the Hospital & Rehabilitation Centre for Disabled Children in Banepa, Nepal. He served seven years on the Committee on Childrens Orthopaedics in Underdeveloped Regions of the Pediatric Orthopaedic Society of North America (POSNA), serving as chairman the last 3 years. He has been on the Board of Orthopaedics Overseas, Global-HELP, the Ponseti International Association, and Miracle Feet. He has received the President's Call to Service Award (2006), by the Presidents Council on Service and Civic Participation, for 4000 hours of community service, and the Golden Apple Award by Health Volunteers Overseas (2009). He has served as a consultant for the World Health Organization, and has been involved in the Global Initiative for Emergency and Essential Surgical Care.

How to implement contextually appropriate surgical training programs? (Please feel free to share country-specific examples)

This will depend of course on the local pathology (regional, national), the resources available to deliver interventions (district versus secondary versus tertiary level), and the background and expectations of the trainees (surgeons, paraprofessionals). Programs for surgical training may vary considerably even within an economically developing country , for example the training of an orthopaedic surgeon in Malawi versus an orthopaedic clinical officer, as both will be complementary/interlinked aspects of the provision of orthopaedic care, working in different environments (primary level versus tertiary), yet communicating and interacting to orchestrate the delivery of services.

How to ensure local training needs are prioritized above expatriate training needs?

We need to understand the local disease burden, based on audits or formal epidemiologic studies, to determine which surgical conditions are seen with frequency in a given environment. The training needs would thus be defined by what conditions are seen with frequency in the environment, which skills would be required to address the burden, and how those required skills overlap with the expatriate community. Thus the expatriates must adapt their knowledge base and approach to problem solving and treatment.

What are the challenges of providing surgical training for non-physicians?

Determining which conditions or procedures are most appropriate for the local environment, ensuring that the resources are available to deliver this level of care, and then to determine which providers will be delivering the service. A curriculum would then need to be developed (contextually relevant) with a well defined scope of services or skills. Accreditation standards would also need to be formalized. A mechanism for continuing education and recertification would be important.

How to create incentives for clinicians to train in surgery?

Early exposure in medical school would be helpful. The prospects for better job opportunities and better remuneration would help incentivize pursuit of a career in surgical care. These might be present for those who can secure a job in the private sector, or perhaps even the public sector in an urban environment. The greater challenge is how to entice those with surgical training to practice in a more rural environment, where challenges such as a limitation in resources available make it difficult to effectively deliver the training and skills that they have acquired. In this situation, one incentive might to be upgrade the infrastructure and physical resources available to more rural facilities. Another would be to provide for continuing education and career advancement for those individuals who are willing to take on the challenges of practicing in the rural setting.

How to generate and sustain political commitment to surgical training?

First we need to understand what the barriers are at the political level. It is a great challenge to market basic surgical care in environments with limited financial resources for health and multiple competing interests. This would begin with collecting regional epidemiologic data on burden of surgical diseases, in order to characterize the magnitude of the problem. Next would be to take stock of the availability of surgical services, at this point the published material suggests large shortfalls in the availability of surgery at the district level in LMICs. One possibility would be to evaluate Shiffman’s model for gaining political priority, and how it might help us to understand how to move forward. The “thought process” illustrated in his scheme might help us to define a concrete action plan to move the agenda forward at the national or even global level.

I prefer team from USA, as example Eduplast from Wisconsin, you write
maybe visits Nigeria

4. HOW TO CREATE INCENTIVES FOR CLINICIANS TO TRAIN IN SURGERY?
In Nigeria, the present challenge really is that of lack of enough training posts for clinicians who want to train in surgery as the available training posts are limited and there appear to be several young doctors ‘roaming’ around trying to get admitted into a surgical training program.
However, some of the concerns of practicing surgeons and young doctors with interest in surgical training include:
a) Concerns about supervision: given that most surgical trainers are overburdened with large clinical work load and some also have to cope with their private practices, adequate supervision of the trainee becomes a problem. This is a concern often expressed by young graduating doctors and has to be addressed to attract these doctors.
b) Limited personal time: surgical training is demanding and personal time may be small. This means that there’s often not enough time to devote to family and other non-clinical pursuits. The current demography and generational desires of prospective surgical trainees means that the training program has to be structured in a way that gives the trainee some time for family and private pursuits. Without this, surgical training would be unattractive ...

4. HOW TO CREATE INCENTIVES FOR CLINICIANS TO TRAIN IN SURGERY?
In Nigeria, the present challenge really is that of lack of enough training posts for clinicians who want to train in surgery as the available training posts are limited and there appear to be several young doctors ‘roaming’ around trying to get admitted into a surgical training program.
However, some of the concerns of practicing surgeons and young doctors with interest in surgical training include:
a) Concerns about supervision: given that most surgical trainers are overburdened with large clinical work load and some also have to cope with their private practices, adequate supervision of the trainee becomes a problem. This is a concern often expressed by young graduating doctors and has to be addressed to attract these doctors.
b) Limited personal time: surgical training is demanding and personal time may be small. This means that there’s often not enough time to devote to family and other non-clinical pursuits. The current demography and generational desires of prospective surgical trainees means that the training program has to be structured in a way that gives the trainee some time for family and private pursuits. Without this, surgical training would be unattractive to many clinicians.
c) Remuneration: in Nigeria at the moment, remuneration for doctors is similar irrespective of the specialty and workload. This means that a surgeon gets the same pay as other clinicians of the same level. Many young graduating doctors argue that it is not worthwhile putting in so much long hours. This has made many of them to go into public health (there’s not so much difficult work and many NGOs and much money) and other less time-demanding specialties. Some financial incentive would need to be introduced into surgical training and surgical practice.
d) Additional training opportunities: providing additional training opportunities (usually in a more developed setting) would also help to attract clinicians into surgical training.

5. HOW TO GENERATE AND SUSTAIN POLITICAL COMMITMENT TO SURGICAL TRAINING?
We need to generate convincing data to show that surgical diseases are an important cause of morbidity and mortality as well as long term disability and that this has long term economic consequences. Policy makers need to be convinced that providing surgical services would significantly impact on the well being of large populations and not just a selected few ‘unfortunate individuals’. Trauma very easily comes to mind and this could serve as the launching pad for surgical advocacy. In Nigeria, there has been a recent interest in trauma care by government and policy makers due to increasing traffic accidents and terror-related events.
We need to get out of the operating room and move into the community and political arena in order to generate and sustain political commitment to surgical training. We should not stop at simply presenting our data and thoughts to colleagues at surgical meetings

David, could you provide a link or reference for "Shiffman’s model for gaining political priority"? I listened to the talk in San Diego in November and it sounded quite interesting. I feel that it needs to be made more widely available to participants to help in this discussion.

Eric Borgstein is Professor of Surgeryat the College of Medicine (University of Malawi) and Consultant Paediatric surgeon at the Queen Elizabeth Central Hospital in Blantyre, Malawi.
He has been working there since 1992. He hascarried out district hospital outreach for many years and is involved in medical student teaching, clinical officer teaching, training of intern doctors and surgical registrars
As Head of Department in surgery and later as Postgraduate Dean of the COM he has been instrumental in setting up the postgraduate specialist training programmes in particular in surgery. He is on council of the College of Surgeons of east, central and southern africa (COSECSA) and directs one of the few training units in Paediatric surgery in sub saharan africa.
He is also currently working on the COST-africa project which is an EU FP7 research grant looking at surgical training of non physician clinicians in Malawi and Zambia.
1. HOW TO IMPLEMENT CONTEXTUALLY APPROPRIATE SURGICAL TRAINING PROGRAMS?
of course the practical aspects of surgical training will always conform to the prevailing surgical conditions; however the training institutions need to adopt regional standards. In COSECSA we are looking at analyzing the trainee logbooks to as a basis for developing these regional ...

Eric Borgstein is Professor of Surgeryat the College of Medicine (University of Malawi) and Consultant Paediatric surgeon at the Queen Elizabeth Central Hospital in Blantyre, Malawi.
He has been working there since 1992. He hascarried out district hospital outreach for many years and is involved in medical student teaching, clinical officer teaching, training of intern doctors and surgical registrars
As Head of Department in surgery and later as Postgraduate Dean of the COM he has been instrumental in setting up the postgraduate specialist training programmes in particular in surgery. He is on council of the College of Surgeons of east, central and southern africa (COSECSA) and directs one of the few training units in Paediatric surgery in sub saharan africa.
He is also currently working on the COST-africa project which is an EU FP7 research grant looking at surgical training of non physician clinicians in Malawi and Zambia.
1. HOW TO IMPLEMENT CONTEXTUALLY APPROPRIATE SURGICAL TRAINING PROGRAMS?
of course the practical aspects of surgical training will always conform to the prevailing surgical conditions; however the training institutions need to adopt regional standards. In COSECSA we are looking at analyzing the trainee logbooks to as a basis for developing these regional standards.

2. HOW TO ENSURE LOCAL TRAINING NEEDS ARE PRIORITIZED ABOVE EXPATRIATE TRAINING NEEDS?

in our hospital this has not really been an issue mainly because we still have very few surgical trainees. The trainers need to monitor the logbooks carefully and this topic should be openly brought up in the 6 monthly appraisal discussions.

3.WHAT ARE THE CHALLENGES OF PROVIDING SURGICAL TRAINING FOR NON-PHYSICIANS?
This will certainly vary from country to country.
In malawi, with a relatively young medical school and only very recent specialist training it is not difficult to accept the reality that there are not going to be enough surgical specialists for at least another generation.
The role of NPC in the health service here is already well established and specialist NPC training programmes have existed since the 1980s in orthopaedics and anaesthesia.
The challenge is to link the training to a qualification that confers recognized advancement in the career path and so keeps the trainee actively engaged in the specialty. For this it will be necessary to offer a university degree at completion of the training.

I would like to add to the conversation the deep experience of PAACS - the Pan-African Academy of Christian Surgeons. I've invited the directors to participate in the discussion. I've attached here a recent publication on their experience.

All of Dr. Ameh's thoughts very insightful especially from the developing country perspective. Similar concerns facing surgery in all countries.

Despite the significant clinical demands on surgeons time, surgeons must become involved in advocacy issues to promote surgery as a central component of public health, a viable option for academic pursuit, and for increasing funding to address surgical issues. Surgeons need to become integral to the public health organizations, become active in Ministries of Health, and be innovative in "marketing" the cause of surgical diseases in a way that others can understand the issues in an active way that leads to action. (Poignant short video clips, movies, television shows, newspaper and magazine articles, facebook, twitter, and others are all necessary.) The time for formal acceptance of global surgery as a multidisciplinary multinational specialty may be needed to fully understand the problem and find sustainable solutions.

Ray Price

Here are 3 of Shiffman's references, very interesting perspective. When reviewing his scheme for evaluating political priority, we can see that global surgery and anaesthesia has many challenges to confront

As an advocate for women's health and with the developing world carrying the burden of disease related to gynecologic cancers, I would love to see a discussion about the successful models of surgical training related specifically to GYN ONCOLOGY. Why is Obstetrical training a necessary first step in the development of a GYN Oncologist? Is a 5 year surgical track after medical school focusing specifically on Advanced Pelvic Surgery not a better choice? How does one include in such a program training in Radiation and Medical Oncology?

Thanks for the panelists and community members for sharing your insights - please continue to comment and ask questions. Unfortunately due to a timing conflict, Dr. Cherian may not be able to join us for this discussion, but we hope she will be able to share her thoughts on these important issues in a few weeks.

Thanks Robert. It will be interest and informative to see the comments from PAACS directors on their experiences.

Thanks David. These Shiffmann documents are quite useful and we should perhaps adopt the principles in planning our advocacy and political action course.

I think that some significant numbers of surgeons really have to commit to surgical public health to help in the profile of surgical diseases as public health concern. Unfortunately, this has proved difficult especially in resource limited settings. Even getting the WHO's emergency and essential surgical care programme implemented is proving problematic.

Good morning, and thank you for convening this panel.

I work for the Lifebox Foundation, a safe surgery/safe anaesthesia initiative that provides essential equipment and training (www.lifebox.org) and we're very glad of the opportunity to listen, learn, and play a part in supporting this critical healthcare priority.

The WHO checklist is an evidence based intervention reducing complications and mortality in surgery and anaesthesia. Does the panel support its adoption internationally? Or have thoughts about its implementation in resource-limited settings?

Thanks and best wishes,

Sarah Kessler

At the Ahmadu Bello University Teaching Hospital, Zaria, Nigeria, we implemented the use of WHO safe surgery checklist sometime last year, after a sensitization workshop. Although fully supported by the hospital's administration and accepted by most stakeholders with much enthusiasm, we still face some difficulties with compliance. What has become obvious is that we do need to have follow up workshops and continuously remind stakeholders.
I also find that given the very limited operating time in our setting, some stakeholders remain apprehensive that time is being wasted even though this is not the case in practice. Although we are yet to evaluate the impact of use of the checklist, personal experience shows that several adverse events have been prevented.

I would support adopting the safety checklist, and we use it faithfully at our institution. I believe it is useful.....but in order for it to be useful there has to be the capacity to deliver surgical services! Work with another simple WHO questionnaire for surgical availability or capacity has revealed glaring deficiencies in infrastructure, physical resources, and human resources for surgery at district hospitals.....there are now about 8 publications supporting this theme. The call to action is that while surgery can be cost effective, and the burden of surgical diseases is significant, we have to take the most basic steps to ensure availability of safe and timely surgery. This of course involves having a health provider with surgical training, not necessarily a surgeon in many cases, but they need to have running water, dressings, safe anaesthesia, etc.

The surgical burden of disease is often unaddressed and remains a burden in the shadows of other programs capable of community intervention. Rural surgery is an attempt to address this by equipping and positioning surgeon capable of a wide range of procedures in rural areas. Despite recent attention and recognition, the word rural is a relative term dependant on context and geography. Rather than focus on training half baked workers to attempt surgery with its potential for complications, i would like to see a reverse movement in medical colleges fortifying the all round training of the general surgeon. How can we resurrect this interest in the context of our tertiary hospitals today producing progressively specialised surgeons capable of more and more about less and less?

Thanks to everyone for joining this discussion! We'd like to hear your thoughts on this panel and invite you to submit your comments and suggestions by visiting:
http://bit.ly/surgerypanel

Your feedback will help us improve the Expert Panel experience and let us know what topics to focus on in the future, so we hope you'll take a few minutes to share your thoughts!

I deeply understand Phillip concerns and i agree with him perfectly. It is not only in surgical training that tertiary institutions must go beyond the Ivory Tower. The whole issue must be tackled wholistically. Education, training and service in medicine and health must be extended into the community. The Medical University of Northern Ontario is blazing the trail and what an innovative trail!
All its faculty members, laboratories, medical students are all in the community! In a blockbuster conference in Thunder Bay In Nothern Ontario this year, the University in collaboration with 4 other global organizations (including WONCA rural health & TUFH)
are sharing with the whole world their over 10 years experience in educating post-graduate and undergraduate students of the health professions for retention in the rural areas of Northern Ontario. The impact of the medical school has been phenomenal. Kindly visit their website for more info

The comment by Philip is interesting. In Nigeria and West Africa, the General surgery programme of the training colleges is quite robust and on completion of training, that surgeon is able to handle a wide range of surgical problems that are encountered in rural settings. The challenges are however:
1) Once they complete training, hardly any of these surgeons wants to practice in the rural setting for several important and understandable reason. Finding a way and incentive to attract trained surgeons to practice in rural settings appear to have remained elusive.
2) Although the number of medical schools training and graduating doctors has more than doubled in the last 2 decades, there simply are not enough surgical training posts available.
It is partly for these reasons that some of the countries of West Africa have been considering the training of middle level surgical manpower to help in addressing the shortage of surgical manpower in rural settings. 'Middle Level Surgical Manpower' happens to be one of the themes for the Annual Meeting of West African College of Surgeons taking place in Monrovia, Liberia later this month.

Emmanuel--I have enjoyed the comments over the last couple of weeks, and your points are well taken. For those of us unable to attend the WACS meeting, will you bring back the highlights for this forum? Many thanks in advance.

Despite all the insights the experienced panel has provided, the pursuit of adequate surgical services in most of rural Africa seems hopeless, at least in the short term. I agree that the surgical community needs make more noise about the necessity of basic surgical services in rural communities. However, top policy makers will find it heard to listen since they can usually afford the well trained local surgeons or travel abroad for treatment. Since politicians are likely to be unreliable, could rural communities develop self-help programs to provide surgical services? I would certainly appreciate a comment on what rural communities can do or are doing in some places to recruit surgeons. For example, could they raise a scholarship for a son of the soil to do surgical training in exchange for a promise to practice in the community for a number of years?

A wonderful example exists In South Kivu province, Democratic Republic of Congo. The General Reference Hospital in Bukavu is trying to build surgical capacity by identifing trainees who are both interested in advanced surgical specialty training and want to remain in the community long-term. The hospital then provides support during this additional training process (which usually is done outside of the country). Now the hospital has surgeons with advanced training in orthopedics, neurosurgery, urology, and head/neck surgery and are working towards sponsoring trainees in plastic surgery, pediatric surgery, and other specialties. And it is being done essentially without assistance from the government.

Nadine
Thanks for sharing this great example. For others that would like to learn more about how to replicate their work, where do they get their support? What is their model?

Catherine deVries, M.D., FACS, FAAP

Director, Center for Global Surgery
Clinical Professor of Surgery (Urology)
University of Utah

President, IVUmed

www.ivumed.org
801-641-5444

The hospital is supported by the Catholic Church- but funding is very tight. The primary catalysts are the local physicians- surgeons and medicine doctors who have remained in Bukavu during very difficult and dangerous times and want to provide care for their people of their community. They are an inspiring group who manages to make professional connections to help them achieve their goal.

Catherine et al,

Thank you very much for the multitude of contributions to this panel discussion, it's been a pleasure following the conversation.

I can share a model that we at Global Emergency Care Collaborative (GECC) www.globalemergencycare.org have been using to sustainably staff a rural Ugandan District Hospital's Emergency Department. Essentially GECC has embraced both a task-shifting approach (now advocated for by the Ugandan Ministry of Health) as well as a train-the-trainer model. GECC created the 2-year Emergency Care Provider (ECP) program that primarily teaches the basic didactic lectures during the first year, while the ECP students worked full time in the ED and during the second year the students become teachers of the material with mentorship by Board Certified/Eligible Emergency Physicians volunteering with GECC. By the time the students graduate, they no longer function as nurses. They function at a much higher clinical level, having learned and practiced medical stabilization, diagnosis using labs, xrays and bedside ultrasound, clinical decision making, medical and basic surgical/orthopedic treatment, and disposition...all in a mentored environment. Additionally, they are learning how to be effective educators and are now being introduced to program management and even basic surveillance ...

Catherine et al,

Thank you very much for the multitude of contributions to this panel discussion, it's been a pleasure following the conversation.

I can share a model that we at Global Emergency Care Collaborative (GECC) www.globalemergencycare.org have been using to sustainably staff a rural Ugandan District Hospital's Emergency Department. Essentially GECC has embraced both a task-shifting approach (now advocated for by the Ugandan Ministry of Health) as well as a train-the-trainer model. GECC created the 2-year Emergency Care Provider (ECP) program that primarily teaches the basic didactic lectures during the first year, while the ECP students worked full time in the ED and during the second year the students become teachers of the material with mentorship by Board Certified/Eligible Emergency Physicians volunteering with GECC. By the time the students graduate, they no longer function as nurses. They function at a much higher clinical level, having learned and practiced medical stabilization, diagnosis using labs, xrays and bedside ultrasound, clinical decision making, medical and basic surgical/orthopedic treatment, and disposition...all in a mentored environment. Additionally, they are learning how to be effective educators and are now being introduced to program management and even basic surveillance and outcomes research. We have found the model to work well for both surgical and medical emergencies and GECC is currently in discussions with the regional science and technology university to create a formal diploma program as well as with the Ministry of Health to develop a formal place for this new cadre of health providers in the MOH's Human Resources structure. If interested, I would be happy to discuss GECC's ECP Train-the-Trainer model for Emergency Care with those interested, as we feel it is one that has potential for both sustainability and scalability for the resource limited setting, particularly in the rural district hospital setting. I am planning to attend at least part of University of Utah's Extreme Affordability Conference: Innovative Solutions for Surgical Care, organized by the Center for Global Surgery, and look forward to discussing sustainable and scalable models for providing Emergency and Surgical care in the resource limited setting.

Bradley Dreifuss, MD
International Emergency Medicine Fellow
University of Utah Division of Emergency Medicine


Global Emergency Care Collaborative
Member of the Board of Directors
Research Co-Director
http://globalemergencycare.org
http://vimeo.com/17141360

Well so where do we do from here, especially in Nigeria? The Association of General and Private Medical Practitioners of Nigeria is planning to start a training programme in Emergency Surgery using the WHO training toolkit and the Mission hospitals, for its members nationwide
Any comments? Any volunteers?

Thanks again for participating in this discussion surgical training. We've summarized the discussion into a two-page brief available here: http://bit.ly/surgicaltraining

If you come across additional resources related to surgical training that the community would find useful, please post them in the community.