Coalition for Global Clinical Surgical Education: The Alliance for Global Clinical Training

Jahanara Graf; Mackenzie Cook; Samuel Schecter; Karen Deveney; Paul Hofmann; Douglas Grey; Larry Akoko; Ali Mwanga; Kitembo Salum; William Schecter

doi:10.1016/j.jsurg.2017.08.019

Coalition for Global Clinical Surgical Education: The Alliance for Global Clinical Training

Jahanara Graf, Mackenzie Cook, Samuel Schecter, Karen Deveney, Paul Hofmann, Douglas Grey, Larry Akoko, Ali Mwanga, Kitembo Salum, William Schecter

Research output: Contribution to journal › Article › peer-review

3 Scopus citations

Abstract

Objective: Assessment of the effect of the collaborative relationship between the high-income country (HIC) surgical educators of the Alliance for Global Clinical Training (Alliance) and the low-income country surgical educators at the Muhimbili University of Health and Allied Sciences/Muhimbili National Hospital (MUHAS/MNH), Dar Es Salaam, Tanzania, on the clinical global surgery training of the HIC surgical residents participating in the program. Design: A retrospective qualitative analysis of Alliance volunteer HIC faculty and residents’ reports, volunteer case lists and the reports of Alliance academic contributions to MUHAS/MNH from 2012 to 2017. In addition, a survey was circulated in late 2016 to all the residents who participated in the program since its inception. Results: Twelve HIC surgical educators provided rotating 1-month teaching coverage at MUHAS/MNH between academic years 2012 and 2017 for a total of 21 months. During the same time period 11 HIC residents accompanied the HIC faculty for 1-month rotations. HIC surgery residents joined the MUHAS/MNH Department of Surgery, made significant teaching contributions, performed a wide spectrum of “open procedures” including hand-sewn intestinal anastomoses. Most had had either no or limited previous exposure to hand-sewn anastomoses. All of the residents commented that this was a maturing and challenging clinical rotation due to the complexity of the cases, the limited resources available and the ethical and emotional challenges of dealing with preventable complications and death in a resource constrained environment. Conclusions: The Alliance provides an effective clinical global surgery rotation at MUHAS/MNH for HIC Surgery Departments wishing to provide such an opportunity for their residents and faculty.

Original language	English (US)
Pages (from-to)	688-696
Number of pages	9
Journal	Journal of Surgical Education
Volume	75
Issue number	3
DOIs	https://doi.org/10.1016/j.jsurg.2017.08.019
State	Published - May 1 2018

Keywords

Interpersonal and Communication Skills
Medical Knowledge
Patient Care
Practice-Based Learning and Improvement
Professionalism
Systems-Based Practice
education
global surgery
training

ASJC Scopus subject areas

Surgery
Education

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Coalition for Global Clinical Surgical Education : The Alliance for Global Clinical Training. / Graf, Jahanara; Cook, Mackenzie; Schecter, Samuel; Deveney, Karen; Hofmann, Paul; Grey, Douglas; Akoko, Larry; Mwanga, Ali; Salum, Kitembo; Schecter, William.

In: Journal of Surgical Education, Vol. 75, No. 3, 01.05.2018, p. 688-696.

Research output: Contribution to journal › Article › peer-review

@article{4b5143b5100f4725925d8c4f82dcb4b3,

title = "Coalition for Global Clinical Surgical Education: The Alliance for Global Clinical Training",

abstract = "Objective: Assessment of the effect of the collaborative relationship between the high-income country (HIC) surgical educators of the Alliance for Global Clinical Training (Alliance) and the low-income country surgical educators at the Muhimbili University of Health and Allied Sciences/Muhimbili National Hospital (MUHAS/MNH), Dar Es Salaam, Tanzania, on the clinical global surgery training of the HIC surgical residents participating in the program. Design: A retrospective qualitative analysis of Alliance volunteer HIC faculty and residents{\textquoteright} reports, volunteer case lists and the reports of Alliance academic contributions to MUHAS/MNH from 2012 to 2017. In addition, a survey was circulated in late 2016 to all the residents who participated in the program since its inception. Results: Twelve HIC surgical educators provided rotating 1-month teaching coverage at MUHAS/MNH between academic years 2012 and 2017 for a total of 21 months. During the same time period 11 HIC residents accompanied the HIC faculty for 1-month rotations. HIC surgery residents joined the MUHAS/MNH Department of Surgery, made significant teaching contributions, performed a wide spectrum of “open procedures” including hand-sewn intestinal anastomoses. Most had had either no or limited previous exposure to hand-sewn anastomoses. All of the residents commented that this was a maturing and challenging clinical rotation due to the complexity of the cases, the limited resources available and the ethical and emotional challenges of dealing with preventable complications and death in a resource constrained environment. Conclusions: The Alliance provides an effective clinical global surgery rotation at MUHAS/MNH for HIC Surgery Departments wishing to provide such an opportunity for their residents and faculty.",

keywords = "Interpersonal and Communication Skills, Medical Knowledge, Patient Care, Practice-Based Learning and Improvement, Professionalism, Systems-Based Practice, education, global surgery, training",

author = "Jahanara Graf and Mackenzie Cook and Samuel Schecter and Karen Deveney and Paul Hofmann and Douglas Grey and Larry Akoko and Ali Mwanga and Kitembo Salum and William Schecter",

note = "Funding Information: The global burden of surgical disease is significant, 6 access to surgical care is inequitable 1 and academic surgeons have a moral obligation to address the ensuing toll in human suffering. 5 Surgical residents as a group are interested in “global surgery” 7 but many departments do not offer a clinical experience. The reasons include expense, local competition for resident labor, regulations from the Residency Review Committee and in some cases, a perception that such clinical experiences are not particularly valuable. The Alliance for Global Clinical Training was established to link HIC faculty and surgical residents with LMIC academic surgery departments to improve the skill set of the local surgical educators and senior registrars in order to “train the trainers.” We chose MUHAS/MNH because there was an established surgical residency program and the MUHAS/MNH surgery faculty leaders were enthusiastic about collaborating with the Alliance and issued an invitation for a collaboration. In effect, Alliance volunteer faculty and residents join the MUHAS/MNH Department of Surgery for their month rotation. Like most successful educational endeavors, the HIC faculty and residents have learned as much from their MUHAS/MNH colleagues as they have taught. The positive effect on the MUHAS/MNH Surgery program has been documented in a previous study. 2 The purpose of this study was to assess the effect of the MUHAS/MNH rotation on the HIC surgery resident accompanying the volunteer HIC surgery faculty member. The Alliance offers HIC Surgery Departments an opportunity to integrate their faculty and residents into the MUHAS/MNH Department of Surgery and participate in all clinical and academic activities without start-up costs or the requirement to establish relationships which often take years to develop. Repeat visits by the HIC faculty members solidify the relationship with their Tanzanian colleagues and enhance the educational experience for all concerned. The cost of participation in the program for each volunteer is approximately $5000.00, which includes air fare from the West Coast of the United States, lodging and food. The cost of transportation from HIC Surgery Departments located closer to Tanzania is less. As the rotation occurred primarily during the resident research year and the cases were not counted as part of the American Board of Surgery case list ands the rules of the Residency Review Committee did not govern the rotation. Nevertheless, no volunteer surgery resident is accepted for a rotation without an accompanying supervising HIC faculty member. We prefer that the resident is accompanied by a faculty member from the same institution. However, 4 residents accompanied faculty members from other institutions with the consent of both their program director and the Alliance faculty member. Measurement of the effect of the MUHAS/MNH Global Clinical Surgery Rotation is a challenge. We know of no objective test that can adequately assess the effect of such an intense cultural, clinical, technical, and emotional experience. We have, therefore, used a retrospective qualitative analysis of resident reports and blogs written both during and immediately following the rotation. We also administered a standard survey to the residents between 4 years and 1 month following completion of the rotation. The results of the qualitative analysis indicate that the MUHAS/MNH Global Surgery clinical rotation provided through the Alliance has a positive effect on resident education as measured by the 6 competencies. There are many western university, missionary and nongovernmental agency (NGO) organizations providing medical care and education on the African continent. Two such organizations are the Rwanda's Human Resources for Health (HRH) Program 8 and the Pan-African Academy of Christian Surgeons (PAACS). 9 HRH is a 7-year program launched in 2012, the same year as the Alliance, on the initiative of the Rwandan Ministry of Health. Each year the program deploys close to 100 US faculty members from a consortium of medical, dental, and nursing schools for 1-year periods to partner with Rwandan faculty members working collaboratively on curriculum development, clinical teaching, patient care, and research. The Rwandan Ministry of Health estimated the cost of the 7-year program to be $152 million dollars. The cost of the initial phase of HRH was $33.6 million dollars. Funding was provided initially by reallocating funds provided to Rwanda by the US Presidents Emergency Plan for AIDS Relief (PEPFAR) and the US Agency for International Development (USAID). In contrast, the Alliance is a more modest program launched at the invitation of the MUHAS/MNH Department of Surgery which has been funded by a $25,000 loan from the Pacific Coast Surgical Association to cover administrative costs provided by the American College of Surgeons (2016 and 2017). The remainder of the program costs have been borne by the volunteer surgeons and residents as well as the Alliance Board members. The Israeli volunteer residents have been able to secure financial support for their travel and lodging through their home institutions and the Israel Surgical Association. However, as demonstrated by this study, the “twinning concept” for both faculty and residents is quite similar as is the focus on curriculum, didactic teaching, clinical care, and research. The PAACS, founded in 1997, trains African physicians as surgeons and disciples to share “the love of Christ” with their patients. 10 PAACS surgical residencies have spirituality as a major component of the curriculum with the goal of spreading Christianity. There are now nine general surgery programs in nine African countries with additional single programs in Orthopedic, Pediatric, and Head and Neck Surgery. The physician or surgeon must be Board-Qualified (or Board-Eligible), be a Christian and be vetted both medically and spiritually before participation in the residency program. The Alliance faculty are all Board-Eligible or Certified surgeons. Accompanying residents must be currently enrolled in an approved Residency Training Program. Alliance faculty and residents are eligible to participate regardless of race, religion, gender, sexual orientation, or national origin. The Alliance has no agenda other than a collaborative relationship with our Tanzanian colleagues aimed at improving surgical education and patient care. The faculty in the HRH and PAACS programs make longer term commitments than the Alliance faculty which is an advantage. However, many of the faculty members have returned for repeat visits. One of us (W.S.) has spent 10 months in direct teaching activities at MUHAS/MNH over the past 5 years. The Alliance faculty have maintained frequent contact by e-mail and phone with their MUHAS/MNH colleagues when not in country. Our study has a number of limitations. The assessment was retrospective and the survey was administered to residents at varying periods of time following completion of the rotation which may have affected the responses. There was a 55% response rate on the survey, which brings up the issue of nonresponse bias. However, 82% of the residents had blogs that were reviewed. The themes in the blogs correlate with the answers to the survey, therefore it is unlikely that the survey nonresponders had a drastically different experience than the survey responders. There was no defined curriculum or specific body of knowledge that the resident was asked to master during the rotation. There was a broad spectrum of advanced general surgery cases encountered during the rotation, which defined the specific experience of each resident. Nevertheless, the technical principles of anatomical dissection, manual ligation, and anastomosis unsupported by machines as well as the educational principles embodied in the 6 competencies were the same for all the residents. ",

year = "2018",

month = may,

day = "1",

doi = "10.1016/j.jsurg.2017.08.019",

language = "English (US)",

volume = "75",

pages = "688--696",

journal = "Journal of Surgical Education",

issn = "1931-7204",

publisher = "Elsevier Inc.",

number = "3",

}

TY - JOUR

T1 - Coalition for Global Clinical Surgical Education

T2 - The Alliance for Global Clinical Training

AU - Graf, Jahanara

AU - Cook, Mackenzie

AU - Schecter, Samuel

AU - Deveney, Karen

AU - Hofmann, Paul

AU - Grey, Douglas

AU - Akoko, Larry

AU - Mwanga, Ali

AU - Salum, Kitembo

AU - Schecter, William

N1 - Funding Information: The global burden of surgical disease is significant, 6 access to surgical care is inequitable 1 and academic surgeons have a moral obligation to address the ensuing toll in human suffering. 5 Surgical residents as a group are interested in “global surgery” 7 but many departments do not offer a clinical experience. The reasons include expense, local competition for resident labor, regulations from the Residency Review Committee and in some cases, a perception that such clinical experiences are not particularly valuable. The Alliance for Global Clinical Training was established to link HIC faculty and surgical residents with LMIC academic surgery departments to improve the skill set of the local surgical educators and senior registrars in order to “train the trainers.” We chose MUHAS/MNH because there was an established surgical residency program and the MUHAS/MNH surgery faculty leaders were enthusiastic about collaborating with the Alliance and issued an invitation for a collaboration. In effect, Alliance volunteer faculty and residents join the MUHAS/MNH Department of Surgery for their month rotation. Like most successful educational endeavors, the HIC faculty and residents have learned as much from their MUHAS/MNH colleagues as they have taught. The positive effect on the MUHAS/MNH Surgery program has been documented in a previous study. 2 The purpose of this study was to assess the effect of the MUHAS/MNH rotation on the HIC surgery resident accompanying the volunteer HIC surgery faculty member. The Alliance offers HIC Surgery Departments an opportunity to integrate their faculty and residents into the MUHAS/MNH Department of Surgery and participate in all clinical and academic activities without start-up costs or the requirement to establish relationships which often take years to develop. Repeat visits by the HIC faculty members solidify the relationship with their Tanzanian colleagues and enhance the educational experience for all concerned. The cost of participation in the program for each volunteer is approximately $5000.00, which includes air fare from the West Coast of the United States, lodging and food. The cost of transportation from HIC Surgery Departments located closer to Tanzania is less. As the rotation occurred primarily during the resident research year and the cases were not counted as part of the American Board of Surgery case list ands the rules of the Residency Review Committee did not govern the rotation. Nevertheless, no volunteer surgery resident is accepted for a rotation without an accompanying supervising HIC faculty member. We prefer that the resident is accompanied by a faculty member from the same institution. However, 4 residents accompanied faculty members from other institutions with the consent of both their program director and the Alliance faculty member. Measurement of the effect of the MUHAS/MNH Global Clinical Surgery Rotation is a challenge. We know of no objective test that can adequately assess the effect of such an intense cultural, clinical, technical, and emotional experience. We have, therefore, used a retrospective qualitative analysis of resident reports and blogs written both during and immediately following the rotation. We also administered a standard survey to the residents between 4 years and 1 month following completion of the rotation. The results of the qualitative analysis indicate that the MUHAS/MNH Global Surgery clinical rotation provided through the Alliance has a positive effect on resident education as measured by the 6 competencies. There are many western university, missionary and nongovernmental agency (NGO) organizations providing medical care and education on the African continent. Two such organizations are the Rwanda's Human Resources for Health (HRH) Program 8 and the Pan-African Academy of Christian Surgeons (PAACS). 9 HRH is a 7-year program launched in 2012, the same year as the Alliance, on the initiative of the Rwandan Ministry of Health. Each year the program deploys close to 100 US faculty members from a consortium of medical, dental, and nursing schools for 1-year periods to partner with Rwandan faculty members working collaboratively on curriculum development, clinical teaching, patient care, and research. The Rwandan Ministry of Health estimated the cost of the 7-year program to be $152 million dollars. The cost of the initial phase of HRH was $33.6 million dollars. Funding was provided initially by reallocating funds provided to Rwanda by the US Presidents Emergency Plan for AIDS Relief (PEPFAR) and the US Agency for International Development (USAID). In contrast, the Alliance is a more modest program launched at the invitation of the MUHAS/MNH Department of Surgery which has been funded by a $25,000 loan from the Pacific Coast Surgical Association to cover administrative costs provided by the American College of Surgeons (2016 and 2017). The remainder of the program costs have been borne by the volunteer surgeons and residents as well as the Alliance Board members. The Israeli volunteer residents have been able to secure financial support for their travel and lodging through their home institutions and the Israel Surgical Association. However, as demonstrated by this study, the “twinning concept” for both faculty and residents is quite similar as is the focus on curriculum, didactic teaching, clinical care, and research. The PAACS, founded in 1997, trains African physicians as surgeons and disciples to share “the love of Christ” with their patients. 10 PAACS surgical residencies have spirituality as a major component of the curriculum with the goal of spreading Christianity. There are now nine general surgery programs in nine African countries with additional single programs in Orthopedic, Pediatric, and Head and Neck Surgery. The physician or surgeon must be Board-Qualified (or Board-Eligible), be a Christian and be vetted both medically and spiritually before participation in the residency program. The Alliance faculty are all Board-Eligible or Certified surgeons. Accompanying residents must be currently enrolled in an approved Residency Training Program. Alliance faculty and residents are eligible to participate regardless of race, religion, gender, sexual orientation, or national origin. The Alliance has no agenda other than a collaborative relationship with our Tanzanian colleagues aimed at improving surgical education and patient care. The faculty in the HRH and PAACS programs make longer term commitments than the Alliance faculty which is an advantage. However, many of the faculty members have returned for repeat visits. One of us (W.S.) has spent 10 months in direct teaching activities at MUHAS/MNH over the past 5 years. The Alliance faculty have maintained frequent contact by e-mail and phone with their MUHAS/MNH colleagues when not in country. Our study has a number of limitations. The assessment was retrospective and the survey was administered to residents at varying periods of time following completion of the rotation which may have affected the responses. There was a 55% response rate on the survey, which brings up the issue of nonresponse bias. However, 82% of the residents had blogs that were reviewed. The themes in the blogs correlate with the answers to the survey, therefore it is unlikely that the survey nonresponders had a drastically different experience than the survey responders. There was no defined curriculum or specific body of knowledge that the resident was asked to master during the rotation. There was a broad spectrum of advanced general surgery cases encountered during the rotation, which defined the specific experience of each resident. Nevertheless, the technical principles of anatomical dissection, manual ligation, and anastomosis unsupported by machines as well as the educational principles embodied in the 6 competencies were the same for all the residents.

PY - 2018/5/1

Y1 - 2018/5/1

N2 - Objective: Assessment of the effect of the collaborative relationship between the high-income country (HIC) surgical educators of the Alliance for Global Clinical Training (Alliance) and the low-income country surgical educators at the Muhimbili University of Health and Allied Sciences/Muhimbili National Hospital (MUHAS/MNH), Dar Es Salaam, Tanzania, on the clinical global surgery training of the HIC surgical residents participating in the program. Design: A retrospective qualitative analysis of Alliance volunteer HIC faculty and residents’ reports, volunteer case lists and the reports of Alliance academic contributions to MUHAS/MNH from 2012 to 2017. In addition, a survey was circulated in late 2016 to all the residents who participated in the program since its inception. Results: Twelve HIC surgical educators provided rotating 1-month teaching coverage at MUHAS/MNH between academic years 2012 and 2017 for a total of 21 months. During the same time period 11 HIC residents accompanied the HIC faculty for 1-month rotations. HIC surgery residents joined the MUHAS/MNH Department of Surgery, made significant teaching contributions, performed a wide spectrum of “open procedures” including hand-sewn intestinal anastomoses. Most had had either no or limited previous exposure to hand-sewn anastomoses. All of the residents commented that this was a maturing and challenging clinical rotation due to the complexity of the cases, the limited resources available and the ethical and emotional challenges of dealing with preventable complications and death in a resource constrained environment. Conclusions: The Alliance provides an effective clinical global surgery rotation at MUHAS/MNH for HIC Surgery Departments wishing to provide such an opportunity for their residents and faculty.

AB - Objective: Assessment of the effect of the collaborative relationship between the high-income country (HIC) surgical educators of the Alliance for Global Clinical Training (Alliance) and the low-income country surgical educators at the Muhimbili University of Health and Allied Sciences/Muhimbili National Hospital (MUHAS/MNH), Dar Es Salaam, Tanzania, on the clinical global surgery training of the HIC surgical residents participating in the program. Design: A retrospective qualitative analysis of Alliance volunteer HIC faculty and residents’ reports, volunteer case lists and the reports of Alliance academic contributions to MUHAS/MNH from 2012 to 2017. In addition, a survey was circulated in late 2016 to all the residents who participated in the program since its inception. Results: Twelve HIC surgical educators provided rotating 1-month teaching coverage at MUHAS/MNH between academic years 2012 and 2017 for a total of 21 months. During the same time period 11 HIC residents accompanied the HIC faculty for 1-month rotations. HIC surgery residents joined the MUHAS/MNH Department of Surgery, made significant teaching contributions, performed a wide spectrum of “open procedures” including hand-sewn intestinal anastomoses. Most had had either no or limited previous exposure to hand-sewn anastomoses. All of the residents commented that this was a maturing and challenging clinical rotation due to the complexity of the cases, the limited resources available and the ethical and emotional challenges of dealing with preventable complications and death in a resource constrained environment. Conclusions: The Alliance provides an effective clinical global surgery rotation at MUHAS/MNH for HIC Surgery Departments wishing to provide such an opportunity for their residents and faculty.

KW - Interpersonal and Communication Skills

KW - Medical Knowledge

KW - Patient Care

KW - Practice-Based Learning and Improvement

KW - Professionalism

KW - Systems-Based Practice

KW - education

KW - global surgery

KW - training

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AN - SCOPUS:85028572013

VL - 75

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JO - Journal of Surgical Education

JF - Journal of Surgical Education

SN - 1931-7204

IS - 3

ER -

Coalition for Global Clinical Surgical Education: The Alliance for Global Clinical Training

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