Global Surgery & Anesthesia

Dear Colleagues

This is indeed a fascinating article and I take my hat off to the team who have carried this out in India and the SEARCH charity who endeavor to carry this philosophy forward across the developing world. This concept has also been shown to be effective in Uganda. Clarity needs to be made about levels of care that are needed to provide comprehensive health-care services in developing countries.
a) This article clearly reveals the value of local villagers providing very basic primary health care and education to their fellows - ideally as volunteers.
b) There is a need for trained primary health care nurses supervising and training these workers and acting in support of these village care-givers.
c) There need to be well placed clinics to provide clinical care to those who are sick. It is a fallacy that education and basic nutritional care eradicates medical illness. Once again these clinics need to be staffed by local villagers, but those who have received national specialist primary health nurse training.
d)There is a vital role for what we in Zambia call 'Clinical Officers' and 'Medical Licentiates'. These are 'technicians' who are trained to do what junior doctors would do ...

Dear Colleagues

This is indeed a fascinating article and I take my hat off to the team who have carried this out in India and the SEARCH charity who endeavor to carry this philosophy forward across the developing world. This concept has also been shown to be effective in Uganda. Clarity needs to be made about levels of care that are needed to provide comprehensive health-care services in developing countries.
a) This article clearly reveals the value of local villagers providing very basic primary health care and education to their fellows - ideally as volunteers.
b) There is a need for trained primary health care nurses supervising and training these workers and acting in support of these village care-givers.
c) There need to be well placed clinics to provide clinical care to those who are sick. It is a fallacy that education and basic nutritional care eradicates medical illness. Once again these clinics need to be staffed by local villagers, but those who have received national specialist primary health nurse training.
d)There is a vital role for what we in Zambia call 'Clinical Officers' and 'Medical Licentiates'. These are 'technicians' who are trained to do what junior doctors would do in more affluent countries e.g. emergency anaesthesia and surgery and running medical clinics. The key requirement for these workers is to receive i) adequate professional training by specialist doctors in their field, ii) adequate continuing medical education, and iii) adequate equipment to carry out their duties effectively and safely.
e) There need to be doctors working at each rural hospital ensuring the maintenance of clinical standards and representing their hospital to central government. Doctors should be providing advanced clinical care, training of their juniors and clinical management - it should NOT be the job of a doctor to be a hospital administrator. Business/hospital administration is a different field from school level onwards and it is a waste of very expensive and scarce resources for a clinician to take on these roles. The reason doctors end up in these roles is because these positions attract higher salaries and perks. This is appalling - it is far easier and cheaper to train an administrator than a doctor and the remuneration should reflect this fact.
f) There needs to be specialist consultants in all major specialties trained in-country. We have noticed how specialist fields who do not have an in-country training program lack the political influence to set and maintain standards in their field. This is evidenced in lack of drugs and equipment required by those fields available from central stores and a lack of clinical standards within their specialty.

In summary I want to strongly support the idea of using local villagers with basic skills to improve basic health education. It is essential that these workers have a voice as a village group to propose policy needs for their communities. This needs to be followed all the way up the chain of clinical expertise to the most senior consultants at the teaching centers. Each cadre of clinician is essential in order for the comprehensive health care to be available to the community. One cadre should not be developed at the expense of another.

For surgical care, I believe, a strong rebuttal is warranted.

I do not understand why a strong rebuttal is needed. I think these 'task shifting' initiatives are probably what is going to be the future of rural medicine including surgery.
In developing countries there is a serious dearth of health professionals. People suffer serious mortality and morbidity due to lack of access to health care.

Task shifting can work for some not all surgical diseases.But can be done for some important ones, I&Ds, chest tubes, hernias, appendectomies, C sections, wound debridement, can be done.

Also it is not necessary for the person performing the surgery to be totally untrained. Even general practitioners can be used for this, or OR technicians.

Indeed this is already being done in many parts of the world. GPs and OR techs and even 'quacks' informally perform surgeries. This is unchecked and thus dangerous.
By creating a system for this, some accountability can be added to it and training them can lead to better outcomes.

There will always be a severe dearth of surgeons in remote and completely rural areas of developing countries.

That is what I feel

Good example of task shifting in Utah is development of our Physician/ Nurse Practitioner program on our trauma service. They now do almost all the care and procedures previously done by the chief and junior surgical residents. We reviewed some examples of task shifting in developed countries and developing countries in our book: Global Surgery and Public Health. Other examples are Shuldice clinic in Canada, Fistula hospital in Ethiopia. However, task shifting needs to be done in an appropriate manner with still a realization that without more advanced surgical access, basic surgical care remains just basic and denies many access to more advanced needed care. Developing a continuum of care is needed. Great discussion.

I don't know that a strong rebuttal on either side is actually warranted. There are dangers (and relatively obvious ones) inherent in task shifting, but there are also significant dangers (and equally obvious ones) in maintaining the status quo and insisting on surgery only being performed by fully trained physicians.

It goes without saying that surgical task shifting risks an overstepping of bounds, but insisting that the sorts of diseases which Nabeel has already mentioned be treated by attending-level surgeons only preferences strongly against the treatment of surgical disease in the developing world.

I think, like all significant paradigm shifts, the idea of task shifting deserves cautious (but optimistic) examination.

I indeed agree with Mark Shrime on the need for serious caution in surgical task
shifting. As a Surgeon practicing in developing country, I had found out that
most people find it difficult to operate within their limit. It is also
extremely difficult to effect laws on the limit on the offenders. As it was seen
with the traditional birth attendant (TBA) introduced sometime ago in O&G, the
outcome may be worse than before. My suggestion will be to maximize the few
General Practitioners found in the remote part through continous medical
training on safe surgical technique. Also, as in Nigeria, the Doctors on
National Service programme should be trained to supplement the effort of the GPs
on ground.

Great discussion. An important component of any program involved with task shifting is being sure these new providers have thorough training and are also taught to recognize when they need to not provide care- to seek out assistance from providers with more expertise. No one is advocating for people without proper skills/training to be providing care- but by task shifting the more repetitive/routine services, the "specialists" are freed up to treat those in need of their advanced skills/expertise. This better leverages the skilled providers expertise to treat a larger population.

> The fact of the matter is that a large component of health care, including surgical care, is delivered by non physicians in SSA. There is not the capacity to make a meaningful impact on the surgeon to population ratio in the near to mid future within the current surgical training programs. So it seems to me that the non physician training programs should be encouraged and optimised to provide the best skills possible within the limits of these training programs. This includes first evaluation, resuscitation and safe transfer.
> In Western countries we are already well down the road with task shifting, e.g. endoscopy, trauma evaluation and resuscitation, OR assist, PAs, advanced nurse practitioners, pharmacists taking more responsibility for renewing and in some case prescribing drugs. For the betterment of our health care systems.

As an anesthesiologist, I have worked with many well-trained non-physician
surgeons who routinely perform a small spectrum of procedures with great
skill. Training and monitoring is obviously key, and physician oversight
(for anesthesia and surgery) is essential in LIC settings. I agree that to
endourse physician only surgery, would be an endorsement for *very
limited*emergency and essential surgery in most LICs. C-sections,
D&Cs,
Appendectomy and some trauma interventions are very appropriate for a
physician-trained, skilled provider. I understand the concern for "skill
creep" but truly believe that establishing a set of minimum standards,
recommendations on numbers of supervised cases, and a method for monitoring
outcomes would help prevent inappropriate extension into other surgical
interventions.

Kelly

--
K A Kelly McQueen, MD, MPH

I think there is no question that task shifting is a must, the challenge remains that it most be done in such a way that care provision is increased without compromising on patient safety. One of the key issues in task shifting is to provide a solid back up to the non-physician provider. Working within a strong referral system with a two-way feedback mechanism in place is often the best way to build the confidence of the non physician provider in handling increasingly challenging procedures over time, with a surety that he/she has a responsive port of call in case to turn to for support.

A lot to be said for investing in networks rather than in individuals.

I absolutely agree! Is anyone interested in putting together an opinion or
consensus paper on this?

Kelly


--
K A Kelly McQueen, MD, MPH

As we advocate for task-shifting in surgery, I feel it can be efficient and effective if specific packages of procedures are well defined at each level of the health system.
In the Ugandan health system, one would expect all incision and drainage of abscesses forexample to be done either at the Health centre III or IV. In that case nurses at that level should be trained to perform the procedure safely.
What happens in most cases is that a doctor in a general hospital and a surgeon in a Regional referral hospital have to do minor procedures at the expense of the referred major procedures. sometimes this is due to lack of resources and expertise at the lower level health unit and unfortunately due to lack of appropriate resources at a general hospital and regional referral hospital. I would strongly suggest that we conduct an audit and be sure that where doctors and surgeons are available there are appropriate resources for them to do the work, then on a case-to-case basis do the task-shifting. We need also to operationalize our referral system to ensure that different levels are enabled to perform the duties prescibed in the National health policy. This ...

As we advocate for task-shifting in surgery, I feel it can be efficient and effective if specific packages of procedures are well defined at each level of the health system.
In the Ugandan health system, one would expect all incision and drainage of abscesses forexample to be done either at the Health centre III or IV. In that case nurses at that level should be trained to perform the procedure safely.
What happens in most cases is that a doctor in a general hospital and a surgeon in a Regional referral hospital have to do minor procedures at the expense of the referred major procedures. sometimes this is due to lack of resources and expertise at the lower level health unit and unfortunately due to lack of appropriate resources at a general hospital and regional referral hospital. I would strongly suggest that we conduct an audit and be sure that where doctors and surgeons are available there are appropriate resources for them to do the work, then on a case-to-case basis do the task-shifting. We need also to operationalize our referral system to ensure that different levels are enabled to perform the duties prescibed in the National health policy. This will not only motivate the health workers at that level but also help define provide the right answers for the right question.
As a surgeon who has worked in rural Uganda all my medical life, I have not heard anyone caught stealing surgical equipment or sundries but many have been caught stealing anti malarials and anti-TB medicines. This to me is an indication that actually surgical equipment and sundries are either inadequate or misplaced. we need a system that supplies complete packages with resources. For Ugandans you know very well that at one time nurses were trained to give anaesthesia but because they could not be deployed due to finantial issues, majority of them continued with their nursing career.

Dr. Mcqueen, I would be very interested in helping write a consensus paper on this topic. I am a student, but I have done a lot of research on the cold chain and similar health systems issues.

Given the state of the world's needs (resource constraints included), surgical task shifting in predefined common, essential, life saving procedures is something that can be or have already been embraced by LICs. Assuming that we provide quality and safe standards for these procedures.

We have to remember the issue at large is the ongoing necessity for surgical management, and the time to make a change is not tomorrow it is this moment - patients are waiting and dying unserved.

Would be happy to participate. 

Ray

Good discussion about task shifting. While we talk about it as a solution for LIC's, we already have a fairly comprehensive system for rural task shifting here in the States, as well as tertiary centers. In Utah, for example, many community health centers (which do minor surgery, L&D, etc. and a lot of diagnostic and other procedures) are staffed entirely by nonsurgeons, and in many cases, by PAs. In the tertiary hospitals, procedures such as bone marrow biopsy and central line placement are done by nurses. Training doctors is simply too expensive and takes too long to cover the needs of populations in both poor and wealthy countries. Furthermore, there has been an evolution of tasks assigned to mid-levels to include most of the management of surgical patients for cardiac surgery, neurosurgery, trauma and critical care, with supervising MDs in wealthier countries. Whereas we have not relinquished as much surgical freedom to midlevels here as surgical Technicos have in Mozambique, we may get there in the foreseeable future, as our own residents have increasing work hour restrictions and are not available to staff the public hospitals as they have in the past.

Catherine deVries, M.D., FACS, FAAP ...

Good discussion about task shifting. While we talk about it as a solution for LIC's, we already have a fairly comprehensive system for rural task shifting here in the States, as well as tertiary centers. In Utah, for example, many community health centers (which do minor surgery, L&D, etc. and a lot of diagnostic and other procedures) are staffed entirely by nonsurgeons, and in many cases, by PAs. In the tertiary hospitals, procedures such as bone marrow biopsy and central line placement are done by nurses. Training doctors is simply too expensive and takes too long to cover the needs of populations in both poor and wealthy countries. Furthermore, there has been an evolution of tasks assigned to mid-levels to include most of the management of surgical patients for cardiac surgery, neurosurgery, trauma and critical care, with supervising MDs in wealthier countries. Whereas we have not relinquished as much surgical freedom to midlevels here as surgical Technicos have in Mozambique, we may get there in the foreseeable future, as our own residents have increasing work hour restrictions and are not available to staff the public hospitals as they have in the past.

Catherine deVries, M.D., FACS, FAAP
Clinical Professor of Surgery (Urology)
University of Utah

President, IVUmed
www.ivumed.org
801-641-5444

Dr. McQueen

I would be interested in working with you on a position paper. I am a nurse anesthetist, university faculty as well as clinical, and have been teaching in the anesthesia programs in Niger ( for many years) and Rwanda ( recently) while working with a volunteer surgical team. Both anesthesia programs utilize both a nursing and non nursing model . Using clinicians in areas that are appropriate to their skills and training and providing on going education , and I have some ideas about this, is a key. Available consults is another important adjunct.

Janet A. Dewan
Please include me if you take the lead on this.

Dear Janet,

It is interesting to learn that there are nurse anesthetists in various parts of the world. We don't have such a system in India. Only medical practitioners who have specialized in anesthesia are authorized here. We have paucity of anesthetists and moreover some anesthetists especially in public hospitals are not very positive in getting surgeries done. In the garb of ensuring safety, sometimes patients who can be helped surgically are denied the help. I have a feeling that anesthesiologists tend to behave in this manner out of a pure professional jealousy with surgeons.

Ravindra Dewan
Thoracic Surgeon,
LRS Institute of TB & Respiratory Diseases,
New Delhi-110030,
India
Ph: 91-11-26517826-30, Fax: 91-11-26517834

Mobile: 09810324635
Res: 91-11-26030011

I think there are really a couple of questions in play here. First, is task shifting appropriate? I think when you look at the data regarding volume of surgical and anesthesia providers in LICs, it becomes difficult to argue against task shifting. Thus, the extension of that question becomes -- what's the safest and best way to implement task shifting? That is certainly open for debate, but there are a number of models in various disciplines that could be explored. Aside from those mentioned above, I would throw out the Integrated Management of Childhood Illness (IMCI) program the WHO has implemented. It is a system of utilizing local, village level non-physician providers to help promote general child health, but also to identify illnesses early that need to be managed at a higher level of care. I see no reason why such a system could not be used for surgical patients. This would hopefully funnel a population of patients to actual surgical providers at district or referral hospitals, thus improving access to surgical care. This is just one example of utilizing non-physicians to improve surgical care delivery.

The other major question to me is how to devote resources to improve care ...

I think there are really a couple of questions in play here. First, is task shifting appropriate? I think when you look at the data regarding volume of surgical and anesthesia providers in LICs, it becomes difficult to argue against task shifting. Thus, the extension of that question becomes -- what's the safest and best way to implement task shifting? That is certainly open for debate, but there are a number of models in various disciplines that could be explored. Aside from those mentioned above, I would throw out the Integrated Management of Childhood Illness (IMCI) program the WHO has implemented. It is a system of utilizing local, village level non-physician providers to help promote general child health, but also to identify illnesses early that need to be managed at a higher level of care. I see no reason why such a system could not be used for surgical patients. This would hopefully funnel a population of patients to actual surgical providers at district or referral hospitals, thus improving access to surgical care. This is just one example of utilizing non-physicians to improve surgical care delivery.

The other major question to me is how to devote resources to improve care. If you go for all short term accomplishments and move heavily towards a task shifting model, you run the risk of making surgery and anesthesiology even less attractive for medical students. I believe the solution is a balanced investment in each path in order to help the immediate situation while building the future.

Dr Dewan, with all due respect, that's just incorrect.

Kelly, I'd be happy to work with you. I think it would be quite interesting.