Rethinking Global Health Education during Plastic Surgery Residency

Brian Christie, MD, MPH

Stanford Hand and Upper Extremity Fellow

ACAPS Winter Retreat

February 22, 2020

What are the goals of resident involvement in global health?

Residency Training• ACGME Resident Education:

• “The mission of institutions participating in graduate medical education is to improve the health of the public.”

• RRC and ABPS allow 12 weeks of elective rotations

• Current models improve all core competencies1

• Short term trips predict future involvement2

• So why rethink global health education?

Global Health

Professionalism

Patient Care

Interpersonal Skills

Practiced-Based Learning

Medical Knowledge

Systems-Based Practice

1. Yao CA, Swanson J, McCullough M, et al. The Medical Mission and Modern Core Competency Training: A 10-Year Follow-Up of Resident Experiences in Global Plastic Surgery. Plastic and Reconstructive Surgery. 2016;138(3):531e-538e.

2. Tannan SC, Gampper TJ. Resident Participation in International Surgical Missions is Predictive of Future Volunteerism in Practice. Arch Plast Surg. 2015;42(2):159.

3 Evolving Contexts

• Residency training

• Academic surgery

• Global surgery

1. Residency Training has Evolved• Work-hour restrictions

• Competency-based education

• “Unprecedented, pervasive, and passionate” interest in global surgery1,2

1. Merson MH. University Engagement in Global Health. N Engl J Med. 2014;370(18):1676-1678. 2. Calland JF, Petroze RT, Abelson J, Kraus E. Engaging academic surgery in global health: Challenges and opportunities in the development of an academic track in global surgery. Surgery.

2013;153(3):316-320.

2. Academic Surgery has Evolved

• Global Surgery emerging as validated academic track1

• Multiple models for career paths2

• Academic surgery and global health3:• “Win-win situation”

• Addresses three current realities:

Unprecedented interest of trainees and young faculty

Diminishing clinical experience 2/2 work hour limitations

Terrible condition of medical science in LMICs

1. Tarpley JL. An academic track in global surgery. Surgery. 2013;153(3):322-324.2. Charles AG, Samuel JC, Riviello R, et al. Integrating Global Health Into Surgery Residency in the United States. Journal of Surgical Education. 2015;72(4):e88-e93. 3. Debas HT. Academic Surgery and Global Health. Surgery. 2013;153(3):324-326.

3. Global Surgery has Evolved

• Self-limited “mission” style trips

• Vertical models

• Self-contained

• Limited efficacy

• Non-sustainable

• Questionable cultural competency

• Convenient for guest

• Sustained presence

• Diagonal models

• Local partnerships

• Wider efficacy

• Focus on sustainability

• Accompaniment

• Convenient for host

Past/Present Future

The Need to Evolve

•Current models provide residents with1:• Introduction to skills to function in limited-resource settings

• Exposure to a wider variety of operative pathology

• Limited immersion in a foreign culture

• Temporary relationships with local counterparts

• Are these models optimized for the modern global surgical context?

1. Henry JA, Groen RS, Price RR, et al. The benefits of international rotations to resource-limited settings for U.S. surgery residents. Surgery. 2013;153(4):445-454.

Are Current Models Preparing Residents?

• How successful is current model?• 76% of residents want to incorporate

global surgery into their career1

• Only 17% continue to provide surgical care in LMICs after graduation2

1. Johnston PF, Scholer A, Bailey JA, Peck GL, Aziz S, Sifri ZC. Exploring residents’ interest and career aspirations in global surgery. Journal of Surgical Research. 2018;228:112-117. 2. Harfouche M, Krowsoski L, Goldberg A, Maher Z. Global surgical electives in residency: The impact on training and future practice. The American Journal of Surgery. ;215(1):200-203.

Interest

No interest

Plans

Practice

No Practice

Reality

The Need for a Better Experience• Teaching the next generation of global surgeons

• Does global health education ethically/optimally necessitate follow up?• Most resident experiences are singular and lack follow up

• How does this experience set expectations for the future?• How does it prepare them for modern global surgical practice?

• Future models need to evolve in tandem with changes in:• Residency training

• Global surgery

• Academic surgery

Evolution in Tandem• Longitudinal opportunities for global health involvement

• Structured opportunities in preparation for global surgery career1,2:• Research

• Education

• Clinical work

• Development of specific global surgery tracks within residency

• Emphasis on capacity building

• Development of resident research/QI project with local partners

• Cultural exchange/true reciprocity1. Chao TE, Riesel JN, Anderson GA, et al. Building a Global Surgery Initiative Through Evaluation, Collaboration, and Training: The Massachusetts General Hospital Experience. Journal of

Surgical Education. 2015;72(4):e21-e28.2. Swain JD, Matousek AC, Scott JW, et al. Training Surgical Residents for a Career in Academic Global Surgery: A Novel Training Model. Journal of Surgical Education. 2015;72(4):e104-e110.

Competing Priorities

• Service vs Education• US Model LMIC model

• Can the training environment be optimized for more efficient resident education?

• Operating Rooms vs Clinics• Teaching residents to do more with less

• Exposure to pathology

• Technical Skills vs Cultural Competency• Exposure to resource-limited environments

• Exposure to challenges of truly rationed medical care

• LMIC medical education

• Cultural exchange/accompaniment

Where is Field Experience Unnecessary?• Is there a role for global surgery taught in residency outside of an outreach trip?

• Pre-education• Global burden of surgical disease

• Experience of practicing medicine in LMIC

• Specific cultural context

• Professionalism/ethical social media

• Efficiency of on-site experience• Resources available

• Expected curriculum/schedule

• Briefing and debriefing sessions

GLOBAL BURDEN OF SURGICAL DISEASE

Financing• Major challenge1

• Grants support from local/national foundations/agencies2

• Institutional/Departmental buy-in2

• Attract top residency candidates

• Supports academic mission of department/institution

• International brand ambassadors

• Reverse innovation: reducing waste/cost-savings3

• Involve institutional development office

1. Hau DK, Smart LR, DiPace JI, Peck RN. Global health training among U.S. residency specialties: a systematic literature review. Medical Education Online. 2017;22(1):1270020.2. Charles AG, Samuel JC, Riviello R, et al. Integrating Global Health Into Surgery Residency in the United States. Journal of Surgical Education. 2015;72(4):e88-e93.3. LeCompte MT, Goldman C, Tarpley JL, et al. Incorporation of a Global Surgery Rotation into an Academic General Surgery Residency Program: Impact and Perceptions. World J Surg. 2018;42(9):2715-2724.

Next Steps• RRC-PS and ABPS are permissive

• More optimized experiences are necessary to prepare the next generation

• PS training programs should develop:• Long term relationships with teaching institutions in LMIC

• Structured, longitudinal experiences for residents

• Consideration of dedicated tracks/local (US-based) education/training

• An educational curriculum that balances multiple priorities

• Working with NGOs and fostering institutional/departmental support is crucial for financial sustainability

“If academic medical centers truly believe that training the

future leaders of surgery is an integral part of their mission,

then promoting awareness of the role for surgeons in

improving health around the globe is imperative.“

Knudson MM, Tarpley MJ, Numann PJ. Global Surgery Opportunities for U.S. Surgical Residents: An Interim Report. Journal of Surgical Education. 2015;72(4):e60-e65.