by Harry Nayar, MD, MBE
I recently had the opportunity to attend the spring retreat of the American Council of Academic Plastic Surgeons (ACAPS) in Miami, Florida. The subject of this years meeting was global health opportunities in plastic surgery residency. I listened as chairmen and program directors recounted their experiences with global surgery. Whether they were presenting epidemiologic data, offering ideas on finding time in busy clinical schedules to travel abroad, describing philanthropic efforts to secure funding, or simply sharing their life stories in international service, the tone was positive and the gaze was decidedly forward. However, amid this spirited exchange between the academic leaders of our field, I couldn’t help but think that the one voice missing from the room was the catalyst for the entire movement- the resident.
Formal global surgery training, both for domestic and foreign practitioners, is gaining momentum in the academic community, although it has traditionally been considered as a post-residency pursuit. The Paul Farmer fellowship in Global Surgery, through a trinity of education, research, and clinical care is often held up as the standard of structured training in underserved settings. The American Association for Hand Surgery (AAHS) supports a reverse fellowship program in Kumasi, Ghana, whereby U.S. hand surgeons travel abroad to train foreign providers, thus advancing local capabilities and infrastructure. While these programs have undoubtedly moved us towards addressing many of the unmet needs of the world’s indigent by producing culturally competent, capable global surgeons, formal global surgery training during residency has thus far been lacking.
There are three major obstacles to implementing global health training in residency: time, money, and accreditation. There were plenty of creative strategies presented at the retreat to overcoming issues of time and money, but the latter, the issue of accreditation, was effectively solved. The process of applying for accreditation of cases performed abroad was once considered too daunting and cumbersome to even consider, but it has been streamlined and demystified by Dr. Rohrich and the rest of the residency review committee (RRC). Furthermore, the ACGME, which was also represented at the meeting, considers these initiatives to be unique and important components of resident surgical education. What does this all mean for you? Your time abroad is not taken from vacation time and the cases you perform can count towards your plastic surgery operative log. Facilitating the pathway to accreditation is a necessary incentive to pursue global health curricula, but to maximize the uptake of global surgery programs the motivation must come from the resident body.
Every year for more than a decade, the chief residents at my program, the University of Wisconsin, have travelled to Nicaragua. There, they collaborate with local practitioners to provide surgical services including clinics and didactics to one of the world’s poorest populations. However, our training to think globally starts long before we arrive to the hospitals of Nicaragua. Our chairman, Michael Bentz, has fostered an environment of mindful resource conservation. Pans are left closed until it is absolutely necessary to open them, operating room time is minimized, and every suture is used to the hilt, not only because we know that what we save could be utilized abroad, but also to challenge us to operate outside of our comfort zone. This pervasive philosophy has left us as better surgeons, domestically and abroad.
I feel confident in saying that all plastic surgeons, in some form or the other, have an affinity to global health. Whether that is participating in humanitarian missions or forging a career in academic global surgery, we could all benefit from structured training. Our chairmen, program directors, and regulatory commissions have made laudable strides to making these experiences possible, but it all starts with us, the residents. So, have you asked about global surgery?
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2. Farmer, P. E., Kim, J. Y. Surgery and global health: a view from beyond the OR. World Journal Surg. 2008; 32: 533-536.
3. Hughes, C. D., Babigian, A., McCormack, S., et al. The clinical and economic impact of a sustained program in global plastic surgery: valuing cleft care in resource-poor settings. Plast Reconstr Surg. 2012; 87e-94e.