Kathleen M. Casey

Results of a national survey of surgical resident interest in international experience, electives, and volunteerism.

BACKGROUND Data are emerging about the essential nature of sustainable global surgical care and interest among North American surgeons. Currently, there is no formal mechanism for US surgical residents to participate in international training opportunities. A small, single-institution survey found that general surgery residents at New York University are highly motivated to pursue international training. But little research has addressed the attitudes of North American residents about international training. The goal of this study was to acquire a broader understanding of surgical resident interest in international training. STUDY DESIGN A structured questionnaire was administered anonymously and voluntarily to all American College of Surgeons resident members. RESULTS Seven hundred twenty-four residents completed surveys. Ninety-four percent of respondents planned careers in general surgery. Ninety-two percent of respondents were interested in an international elective, and 82% would prioritize the experience over all or some other electives. Fifty-four percent and 73% of respondents would be willing to use vacation and participate even if cases were not counted for graduation requirements, respectively. Educational indebtedness was high among respondents (50% of respondents carried >or=

Perioperative Mortality Rate (POMR): A Global Indicator of Access to Safe Surgery and Anaesthesia

100,000 debt). Despite debt, 85% of respondents plan to volunteer while in practice. The most frequent barriers identified by respondents were financial (61%) and logistic (66%). CONCLUSIONS American College of Surgeons resident members are highly motivated to acquire international training experience, with many planning to volunteer in the future. A consensus among stakeholders in North American surgical education is needed to further explore international training within surgical residency.

The Provision of Surgical Care by International Organizations in Developing Countries: A Preliminary Report

IntroductionThe unmet global burden of surgical disease is substantial. Currently, two billion people do not have access to emergency and essential surgical care. This results in unnecessary deaths from injury, infection, complications of pregnancy, and abdominal emergencies. Inadequately treated surgical disease results in disability, and many children suffer deformity without corrective surgery.MethodsA consensus meeting was held between representatives of Surgical and Anaesthetic Colleges and Societies to obtain agreement about which indicators were the most appropriate and credible. The literature and state of national reporting of perioperative mortality rates was reviewed by the authors.ResultsThere is a need for a credible national and/or regional indicator that is relevant to emergency and essential surgical care. We recommend introducing the perioperative mortality rate (POMR) as an indicator of access to and safety of surgery and anaesthesia. POMR should be measured at two time periods: death on the day of surgery and death before discharge from hospital or within 30 days of the procedure, whichever is sooner. The rate should be expressed as the number of deaths (numerator) over the number of procedures (denominator). The option of before-discharge or 30 days is practical for those low- to middle-income countries where postdischarge follow-up is likely to be incomplete, but it allows those that currently can report 30-day mortality rates to continue to do so. Clinical interpretation of POMR at a hospital or health service level will be facilitated by risk stratification using age, urgency (elective and emergency), procedure/procedure group, and the American Society of Anesthesiologists grade.ConclusionsPOMR should be reported as a health indicator by all countries and regions of the world. POMR reporting is feasible, credible, achieves a consensus of acceptance for reporting at national level. Hospital and Service level POMR requires interpretation using simple measures of risk adjustment such as urgency, age, the condition being treated or the procedure being performed and ASA status.

Elective Global Surgery Rotations for Residents: A Call for Cooperation and Consortium

ObjectiveEmerging data demonstrate that a large fraction of the global burden of disease is amenable to surgical intervention. There is a paucity of data related to delivery of surgical care in low- and middle-income countries, and no aggregate data describe the efforts of international organizations to provide surgical care in these settings. This study was designed to describe the roles and practices of international organizations delivering surgical care in developing nations with regard to surgical types and volume, outcomes tracking, and degree of integration with local health systems.MethodsBetween October 2008 and December 2008, an Internet-based confidential questionnaire was distributed to 99 international organizations providing humanitarian surgical care to determine their size, scope, involvement in surgical data collection, and integration into local systems.ResultsForty-six international organizations responded (response rate 46%). Findings reveal that a majority of organizations that provide surgery track numbers of cases performed and immediate outcomes, such as mortality. In general, these groups have mechanisms in place to track volume and outcomes, provide for postintervention follow-up, are committed to providing education, and work in conjunction with local health organizations and providers. Whereas most organizations surveyed provided fewer than 500 surgical procedures annually, more than half had the capacity to provide emergency services. In addition, a great diversity of specialized surgical care was provided, including obstetrics, orthopedic, plastic, and ophthalmologic surgery.ConclusionsInternational organizations providing surgical services are diverse in size and breadth of surgical services provided yet, with consistency, provide rudimentary analysis, postoperative follow-up care, and both education and integration of health services at the local level. The role of international organizations in the delivery of surgery is an important index, worthy of further evaluation.

Burden of Surgical Disease: Strategies to Manage an Existing Public Health Emergency

BackgroundInternational elective experiences are becoming an increasingly important component of American general surgery education. In 2011, the Residency Review Committee (RRC) approved these electives for credit toward graduation requirements. Previous surveys of general surgery program directors have established strong interest in these electives but have not assessed the feasibility of creating a national and international database aimed at educational standardization. The present study was designed to gain in-depth information from program directors about features of existing international electives at their institution and to ascertain interest in national collaboration.MethodsThis cross-sectional study of 253 United States general surgery program directors was conducted using a web-based questionnaire program.ResultsOf the program directors who responded to the survey, twelve percent had a formal international elective in place at their institution, though 80% of these did not have a formal associated curriculum for the rotation. Sixty percent of respondents reported that informal international electives existed for their residents. The location, length, and characteristics of these electives varied widely. Sixty-eight percent of program directors would like to participate in a national and international database designed to facilitate standardization of electives and educational exchange.ConclusionsIn a world of increasing globalization, international electives are more important than ever to the education of surgery residents. However, a need for standardization of these electives exists. The creation of an educational consortium and database of international electives could improve the academic value of these electives, as well as provide increased opportunities for twinning and bidirectional exchange.

Consensus Statements Regarding the Multidisciplinary Care of Limb Amputation Patients in Disasters or Humanitarian Emergencies: Report of the 2011 Humanitarian Action Summit Surgical Working Group on Amputations Following Disasters or Conflict

The World Health Organization estimates that the burden of surgical disease due to war, self-inflicted injuries, and road traffic incidents will rise dramatically by 2020. During the 2009 Harvard Humanitarian Initiatives Humanitarian Action Summit (HHI/HAS),members of the Burden of Surgical Disease Working Group met to review the state of surgical epidemiology, the unmet global surgical need, and the role international organizations play in filling the surgical gap during humanitarian crises, conflict, and war. An outline of the groups findings and recommendations is provided.

Best Practice Guidelines on Surgical Response in Disasters and Humanitarian Emergencies: Report of the 2011 Humanitarian Action Summit Working Group on Surgical Issues within the Humanitarian Space

Limb amputations are frequently performed as a result of trauma inflicted during conflict or disasters. As demonstrated during the 2010 earthquake in Haiti, coordinating care of these patients in austere settings is complex. During the 2011 Humanitarian Action Summit, consensus statements were developed for international organizations providing care to limb amputation patients during disasters or humanitarian emergencies. Expanded planning is needed for a multidisciplinary surgical care team, inclusive of surgeons, anesthesiologists, rehabilitation specialists and mental health professionals. Surgical providers should approach amputation using an operative technique that optimizes limb length and prosthetic fitting. Appropriate anesthesia care involves both peri-operative and long-term pain control. Rehabilitation specialists must be involved early in treatment, ideally before amputation, and should educate the surgical team in prosthetic considerations. Mental health specialists must be included to help the patient with community reintegration. A key step in developing local health systems the establishment of surgical outcomes monitoring. Such monitoring can optimizepatient follow-up and foster professional accountability for the treatment of amputation patients in disaster settings and humanitarian emergencies.

A preparation guide for surgical resident and student rotations to underserved regions

The provision of surgery within humanitarian crises is complex, requiring coordination and cooperation among all stakeholders. During the 2011 Humanitarian Action Summit best practice guidelines were proposed to provide greater accountability and standardization in surgical humanitarian relief efforts. Surgical humanitarian relief planning should occur early and include team selection and preparation, appropriate disaster-specific anticipatory planning, needs assessment, and an awareness of local resources and limitations of cross-cultural project management. Accurate medical record keeping and timely follow-up is important for a transient surgical population. Integration with local health systems is essential and will help facilitate longer term surgical health system strengthening.

The impact of global anesthesia and surgery: professional partnerships and humanitarian outreach.

Interest in global health among surgical residents and medical students is growing. There are numerous opportunities worldwide for both short- and long-term experiences. In order to maximize the learning potential, the authors present a practical guide for residents and students to prepare for a surgical visit, elective, rotation, or mission to an underserved region. The following steps will be outlined:

Addressing the Global Burden of Surgical Disease: Proceedings from the 2nd Annual Symposium at the American College of Surgeons

Disparities in surgical services in low and middle income countries (LMICs) have long existed. Until recently however, the global health community did not appreciate the impact that inadequate access to surgical care had on public health. The lack of support for surgery as a public health intervention is likely the result of: (1) few sources of available surgical data, nonspecific health indicators related to surgery, and inadequate outcome measures, (2) limited surgical infrastructure, education and training, and (3) inaccurate assumptions regarding the cost effectiveness and sustainability of emergency and essential surgery. With this in mind, how is the case for surgical capacity best made? Limited infrastructure for record keeping makes it difficult to rely on cause of death statistics. And even if such records were reliable, most patients with surgical conditions such as trauma, obstructed labor, post-partum hemorrhage, coronary artery disease, neoplasm and bowel obstructions