From the Editor: In this section of Diseases of the Colon & Rectum, you will be able to read reports of individuals who have received travel scholarships from the International Committee of the American Society Colon & Rectal Surgeons. We hope that you will find this interesting reading. We have asked our scholarship recipients to list their greatest needs in the hope that some of our readers will be able to help them by volunteering their time and skills, by donating supplies, or hosting them on future trips in North America.
This is a report from Manuel Alejandro García Girón, M.D. (Fig. 1), a recipient of the 2017 International Travel Scholarship offered by the ASCRS.
Background, Training, and Current Position
I am 34 years old and live in Guatemala City. I obtained my medical degree in 2008 and my masters in general surgery in 2013, both from the Universidad de San Carlos de Guatemala. I completed my postgraduate studies (fellowship) in coloproctology under the auspices of Dr. Jorge Latif in 2016 at the Clínica Modelo de Lanús in Buenos Aires, Argentina, because there are no colorectal training programs in my country. Since my return to Guatemala in 2016, I have been working as deputy chief of the colorectal unit at the Hospital General San Juan de Dios in Guatemala City (Fig. 2). I was accepted into the Guatemalan Association of Surgeons, as well as the Guatemalan Association of Colon and Rectal Surgeons. I was elected to the Board of Directors as a spokesperson for the latter group.
Surgery Training in Guatemala and Specialty Training in Colon and Rectal Surgery
There are 10 hospitals with general surgery training programs in Guatemala. Of those 10 hospitals, only 3 are tertiary care hospitals, and all of these are located in Guatemala City. Two are part of the public health system and the other belongs to a semiprivate public health system. There are currently no colorectal training programs. If a Guatemalan surgeon wishes to pursue a career in coloproctology, he or she has to look for training opportunities abroad.
Health Care in Guatemala
Guatemala has a population of 16 million and ≈60% are poor, with access only to the public health system. The public health system is divided into 3 levels. The first level consists of health posts and health centers attended by general physicians or medical students. These are located in the most rural parts of the country. The second level consists of regional hospitals attended by specialized doctors (eg, general surgeons, pediatricians, obstetricians, and gynecologists) and are located in small cities. The third levels consists of 2 public hospitals (Hospital General San Juan de Dios and Hospital Roosevelt, which are part of the public health system; Fig. 3) with medical subspecialties (coloproctology, nephrology, cardiology, etc), both located in Guatemala City.
Challenges Treating Colon and Rectal Disease in Guatemala
The poverty of our population is perhaps the biggest challenge in treating colon and rectal disease in Guatemala. Sixty percent of our population is poor and only has access to the public health system. Our health system is underfunded; our equipment is outdated. We lack appropriate laparoscopic equipment. We do not have endorectal or endoanal ultrasound or manometry, and we lack the capacity to establish a colorectal cancer screening program. When it comes to treating colorectal cancer, we do not have MRI, and often our CT is out of order for weeks at a time. We sometimes will run out of chemotherapy medications. We do not have biologics or radiotherapy.
After visiting the United States and having the opportunity to attend the ASCRS annual meeting, I realized that the way in which we treat colorectal disease, especially colorectal cancer, at least in the public health system, is not at all adequate. The lack of funds and equipment directly affects the clinical outcome of our patients. That is why I have decided to create awareness of this situation at my institution, starting with the head of the department and the director of my institution.
The main differences between the United States and Guatemala when it comes to practicing colon and rectal surgery are the lack of data and original research, the lack of trained colorectal surgeons, and the extremely low salaries in the public health system. I was amazed at the amount of data that is collected at US institutions. It allows for great articles and posters to be published and for surgeons to accurately analyze their outcomes. In Guatemala there is no incentive to collect data or to publish scientific papers, and there is no access to public or private research funding. That is the reason why our biggest public health hospitals produce no research.
In addition, in Guatemala, a country of 16-million people, there are only 22 colorectal surgeons. Only 6 of us work in the public health system or in social security hospitals. The main reason for this is that the current salary for a public health doctor is the same as it was in 1984! We are hired as general surgeons, not as colorectal surgeons, and get paid between $550 and $1700 a month (depending on your contract). Most of us do not have the right to medical insurance, vacations, or even a pension.
Knowledge Gained From Attending Workshops
While in the United States, I had the opportunity to attend the Anal Intraepithelial Neoplasia (AIN) and High-Resolution Anoscopy (HRA) Workshop. It was excellent and I learned a lot. I believe that one of the most important parts of the workshop was the hands-on session and the fact that the professors shared amazing tips and tricks. It was a great experience for me, and I think that it is going to have the greatest impact in my practice, because we are planning to create an anal cancer screening program at my institution.
I also had the opportunity to learn about the benefits of laparoscopic and robotic surgery. I attended the debate on the “Optimal Approach for Treating Rectal Cancer.” It was very insightful, and it opened my eyes to the great benefits of minimally invasive surgery for rectal cancer. I had some previous experience with laparoscopic surgery, but this was the first time that I had the opportunity to see and have hands-on experience with a robot. From now on I will favor the use of minimally invasive surgery for all colorectal surgery in my institution.
Knowledge Gained From Attending the ASCRS Annual Scientific Meeting
Attending the ASCRS annual scientific meeting gave me the opportunity to learn a great deal about laparoscopic surgery, robotic surgery, AIN and HRA, and enhanced recovery after surgery. I learned a lot about these topics and will share this knowledge with my colleagues.
Enhanced recovery after surgery is perhaps the one thing that can be more easily be adopted at my institution, because it does not require a lot of funds and equipment. On the other hand, minimally invasive surgery requires a significant investment and might be more difficult to implement. Now, however, I have the opportunity to share what I have learned with others and help them realize that minimally invasive surgery is not a passing trend but a necessity for our institution. Last but not least is anal cancer screening and HRA. The chair of my department is interested in starting an anal cancer screening program at my institution. Because I had the opportunity to attend the AIN and HRA workshop, I believe that we are a little bit closer to achieving our goal–we just need to acquire the equipment.
Greatest Needs for Personal and Professional Development as a Surgeon?
My greatest needs for personal and professional development as a surgeon are training opportunities in endoscopic and laparoscopic surgery, as well as in anorectal physiology testing and therapeutic techniques (endoanal ultrasound, anorectal manometry, biofeedback, electrostimulation, etc).
My department’s and hospital’s greatest needs are:
- 1) Colonosocopes
- 2) Colposcope
- 3) Laparoscopic surgery equipment
- 4) Endoanal and endorectal ultrasound probes and machine
- 5) Anesthesia machines
- 6) Chemotherapy medications
- 7) Radiotherapy unit
- 8) Hospital beds