Alex Campbell

The Medical Mission and Modern Cultural Competency Training

BACKGROUND Culture has increasingly appreciated clinical consequences on the patient-physician relationship, and governing bodies of medical education are widely expanding educational programs to train providers in culturally competent care. A recent study demonstrated the value an international surgical mission in modern surgical training, while fulfilling the mandate of educational growth through six core competencies. This report further examines the impact of international volunteerism on surgical residents, and demonstrates that such experiences are particularly suited to education in cultural competency. METHODS Twenty-one resident physicians who participated in the inaugural Operation Smile Regan Fellowship were surveyed one year after their experiences. RESULTS One hundred percent strongly agreed that participation in an international surgical mission was a quality educational experience and 94.7% deemed the experience a valuable part of their residency training. In additional to education in each of the ACGME core competencies, results demonstrate valuable training in cultural competence. CONCLUSIONS A properly structured and proctored experience for surgical residents in international volunteerism is an effective instruction tool in the modern competency-based residency curriculum. These endeavors provide a unique understanding of the global burden of surgical disease, a deeper appreciation for global public health issues, and increased cultural sensitivity. A surgical mission experience should be widely available to surgery residents.

The role of humanitarian missions in modern surgical training.

Background: Surgical trainees have participated in international missions for decades and are now seeking out these experiences in record numbers. Resident participation in humanitarian service has been highly controversial in the academic plastic surgery community, and little evidence exists elucidating the value of these experiences. This report examines the impact of international volunteerism on surgical training. Methods: Twenty-one resident physicians who participated in the inaugural Operation Smile Regan Fellowship were surveyed 1 year after their experiences. Results: One hundred percent responded that participation in an international surgical mission had an overall positive impact on their lives, and 94.7 percent reported that they had achieved marked personal growth. Results demonstrate significant education in each of the Accreditation Council for Graduate Medical Education core competencies and insights into global health and cultural competency. One hundred percent “strongly agreed” that the Regan Fellowship was a quality educational experience, and 94.7 percent deemed the experience a valuable part of their residency training. Conclusions: Resident physicians are calling for more international health opportunities, and they should be generously supported. A properly structured and proctored experience for surgical residents in international volunteerism is an effective instruction tool in the modern competency-based residency curriculum. These endeavors provide a unique understanding of the global burden of surgical disease, a deeper appreciation for global public health issues, and increased cultural sensitivity. Plastic surgery training programs can contribute mightily to global health and improved resident education by embracing and fostering the development of international humanitarian opportunities. A surgical mission experience should be widely available to plastic surgery residents.

Early complications after cleft palate repair: a multivariate statistical analysis of 709 patients.

Abstract This study presents a large consecutive institutional experience with primary cleft palate repairs. The purpose of this study was to determine the incidence of early complications after cleft palate surgery in a series of nonsyndromic children treated at the authors’ comprehensive cleft center. This retrospective analysis includes 709 consecutive patients with cleft palate treated by 6 different staff surgeons at Guwahati Comprehensive Cleft Care Center between April 2011 and December 2012. Secondary cases were excluded from this study. The patients were initially followed up between 1 week and 1 month after surgery. The overall incidence of early complications was determined, and the effect of the extent of clefting, the type of repair, the age at repair, and the operating surgeon were analyzed. Early complications in this study include dehiscence of the wound, fistula formation, hanging palate, and total or partial flap necrosis. There was a 2.4% rate (17/709) of take-back to the operating room in the immediate postoperative period for control of bleeding, although no blood transfusions were required. The incidence of postoperative fistulas in this series was 3.9% (20/512). There was a statistically significant increase in the incidence of cleft palatal fistula for Veau IV clefts, but there were no significant differences with respect to operating surgeon, patient sex, patient age, and type of palatoplasty. The complication and fistula rate is consistent with other published reports from developed countries and provides evidence for the value of this model for surgical delivery in the developing world.

Early Surgical Complications After Primary Cleft Lip Repair: A Report of 3108 Consecutive Cases

Objective To analyze short term surgical complications after primary cleft lip repair. Patients and Design A total of 3108 consecutive lip repairs with 2062 follow-ups were reviewed retrospectively through medical records. Patients were aged 3 months to 75 years at the time of surgery, with a median of 7 years. Setting Guwahati Comprehensive Cleft Care Center, Assam, India. Intervention Primary cleft lip repair. Main Outcome Measures Documented complications in terms of dehiscence, necrosis, infection, and suture granuloma were compiled. Logistic regression was used with dehiscence (yes/no) or infection (yes/no) as binary dependant variables. Age, cleft type, and surgeon (visiting/long term) were used as covariates. Results Among the 2062 patients who returned for early follow-up, 90 (4.4%) had one or more complications. Dehiscence (3.2%) and infection (1.1%) were the most common types of complication. Visiting surgeon, complete cleft, and bilateral cleft were significantly associated with wound dehiscence, and complete cleft was associated with wound infection according to the logistic regression analysis. Of patients with bilateral complete clefts, 6.9% suffered from some degree of wound dehiscence. Conclusion In a setting where presurgical molding is unavailable and patients present at all ages, lip wound dehiscence is a relatively common complication in patients with bilateral complete clefts. The risk of dehiscence, however, is reduced when these cases are assigned to surgeons with experience with these types of clefts. We also found that the incidence of wound infection can be kept relatively low, even without the use of postoperative antibiotics.

Measuring and Comparing the Cost-Effectiveness of Surgical Care Delivery in Low-Resource Settings: Cleft Lip and Palate as a Model.

AbstractCleft lip and palate (CLP) care is the longest sustained global effort in humanitarian surgical care. However, the relative cost-effectiveness of surgical delivery approaches remains largely unknown. We assessed the cost-effectiveness of two strategies of CLP surgical care delivery in low resource settings: medical mission and comprehensive care center.We evaluated the medical records and costs for 17 India-based medical missions and a Comprehensive Cleft Care Center in Guwahati, India, from Operation Smile, a humanitarian nongovernmental organization. Age, sex, diagnosis, and procedures were extracted and cost/Disability-Adjusted Life Year (DALY) averted was calculated using a providers perspective. The disability weights for CLP from the Global Burden of Disease (GBD) 2010 update were used as the reference case. Sensitivity analysis was performed using various disability weights, age-weighting, discounting, and cost perspective.The medical missions treated 3503 patients for first-time cleft procedures and averted 6.00 DALYs per intervention with a cost-effectiveness of

Scalable, Sustainable Cost-effective Surgical Care: A Model for Safety and Quality in the Developing World, Part Iii

247.42/DALY. The care center cohort included 2778 patients with first-time operations for CLP and averted a mean of 5.96 DALYs per intervention with a cost-effectiveness of

Improving patient follow-up in developing regions.

189.81/DALY. The Incremental Cost-Effectiveness Ratio (ICER) of choosing medical mission over care center is

Providing more than health care: the dynamics of humanitarian surgery efforts on the local microeconomy.

462.55.The care center provides cleft care with a higher cost-effectiveness, although both models are highly cost-effective in India, in accordance with WHO guidelines. Compared to other global health interventions, cleft care is very cost-effective and investment in cleft surgery might be realistic and achievable in similar resource-constrained environments.

Scalable, sustainable cost-effective surgical care: a model for safety and quality in the developing world, part I: challenge and commitment.

Background The Guwahati Comprehensive Cleft Care Center (GCCCC) utilizes a high-volume, subspecialized institution to provide safe, quality, and comprehensive and cost-effective surgical care to a highly vulnerable patient population. Methods The GCCCC utilized a diagonal model of surgical care delivery, with vertical inputs of mission-based care transitioning to investments in infrastructure and human capital to create a sustainable, local care delivery system. Over the first 2.5 years of service (May 2011–November 2013), the GCCCC made significant advances in numerous areas. Progress was meticulously documented to evaluate performance and provide transparency to stakeholders including donors, government officials, medical oversight bodies, employees, and patients. Results During this time period, the GCCCC provided free operations to 7,034 patients, with improved safety, outcomes, and multidisciplinary services while dramatically decreasing costs and increasing investments in the local community. The center has become a regional referral cleft center, and governments of surrounding states have contracted the GCCCC to provide care for their citizens with cleft lip and cleft palate. Additional regional and global impact is anticipated through continued investments into education and training, comprehensive services, and research and outcomes. Conclusion The success of this public private partnership demonstrates the value of this model of surgical care in the developing world, and offers a blueprint for reproduction. The GCCCC experience has been consistent with previous studies demonstrating a positive volume-outcomes relationship, and provides evidence for the value of the specialty hospital model for surgical delivery in the developing world.

Scalable, sustainable cost-effective surgical care: a model for safety and quality in the developing world, part II: program development and quality care.

Background Cleft surgery follow-up in developing regions is challenging. This study evaluated rates, costs, and satisfaction of 2 follow-up programs at the Guwahati Comprehensive Cleft Care Centre (GC4) in Assam, India. Methods For this study, 10,582 postoperative visits were analyzed from May 2011 to November 2013. A questionnaire was administered to subsets of follow-up patients at both locations. Costs were calculated. Results Eighty-five percent of patients had follow-up at GC4, and 15% were seen in the patients’ local districts. One hundred ninety-five questionnaires were completed (122 at GC4, 73 in local districts). Patients with local follow-up had fewer accompanying family members (mean, 1.95 vs 0.99; P = 0.00), fewer days off work (mean, 1.84 vs 1.15; P = 0.19), less lost income (Indian rupees 367 vs 143, P = 0.00), and lower direct costs (mean Rs, 911 vs 299; P = 0.00). The financial burden of local follow-up was significantly lower (P = 0.003). No significant differences were seen for convenience, likelihood of attending follow-up, or satisfaction. Follow-ups increased after revising programs from a mean of 139 monthly visits (follow-up to surgery ratio of 0.722) to a mean of 363 visits (ratio of 1.57). The center’s mean cost for local follow-up was Rs 303 per patient, whereas the estimated costs would have been Rs 1100 for follow-up at the center. Conclusions This study demonstrates potential improvements in costs and outcomes by changing the model of care. Despite significant follow-up challenges, much progress can be achieved through process changes and outreach follow-up programs. The results have important applications across the developing world.