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 “It is the norm - not the exception - that when we go abroad, the
non-American surgeons are teaching the American surgeons how to do
numerous things,” said Kuwayama, who regularly serves on
humanitarian missions for the medical aid group Medecins Sans
Frontieres (MSF), known in the U.S. as Doctors Without Borders.
Kuwayama and other American surgeons who volunteer overseas have
faced a consistent and growing mismatch between their training and
the basic surgical needs of people they treat outside the U.S.
A new study confirms their suspicions: ever-more specialized
American surgical training programs fail to teach young surgeons how
to deliver babies by C-section, how to repair broken bones or many
of the other skills frequently needed in areas stricken by wars,
earthquakes and other disasters.
Two-thirds of major surgeries performed in MSF projects were
procedures that most general surgical residents never learn in the
U.S., according to the report in the World Journal of Surgery,
online August 4.
Cesarean sections, for example, were the most common surgery in MSF
projects, the study found. But the average general surgery resident
reported graduating without ever having delivered a baby by
C-section.
“C-sections, the single most life-saving operation performed in most
humanitarian missions, is never performed - not even once - by
American graduates,” said Kuwayama, the study’s senior author and a
professor at the University of Colorado Denver in Aurora. “That
number is shocking.”
Kuwayama and his team compared logs of cases performed by U.S.
surgical residents with cases performed at MSF facilities. Fewer
than half of the procedures U.S. surgical trainees performed were
relevant to surgical practice in MSF projects.
American general surgery residents are critically deficient in
exposure to obstetrical, gynecological and orthopedic care -
essential skills in humanitarian operations, the study found.
Dr. Sherry Wren, professor of surgery at Stanford University School
of Medicine in California, has witnessed the mismatch while working
as a surgeon in sub-Saharan Africa.
“This mismatch has been accelerated over the last 20-plus years,”
Wren, who was not involved with the study, said by email.
Sub-specialization has exacerbated the problem, she said, along with
American surgeons’ use of high-tech devices absent from MSF clinics.
A power tool used to perform a skin graft in the U.S. won’t be
available in South Sudan, Kuwayama said.
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“You’re not going to have power tools to do an array of things like
a skin graft,” he said in a phone interview. “The tools may be lower
tech. It doesn’t mean they’re easier to use. They may be more
difficult to use.”
Pediatric surgeon Dr. John Lawrence, president of the board of
directors of MSF-USA, has been working with a group exploring ways
to better prepare newly trained surgeons to work in austere
settings.
His group is considering establishing MSF training programs, lasting
from three weeks to three months, to expose surgeons to procedures
identified as absent from their training, Lawrence, a co-author of
the study, said by email.
Short, one- to three-day, courses, like one Wren runs at Stanford to
prepare surgeons for humanitarian missions, can help address the
problem, Wren and Kuwayama said.
But the demand for short courses far outstrips their availability,
and short courses can only pack in so much.
“There is no easy fix as surgeons become more specialized,” Wren
said.
“The definition of general surgery has continued to narrow over the
years,” Kuwayama said. “Pretty much every organ system has been
co-opted by specialists.”
While that benefits American patients who need a specialist like
Kuwayama to perform complicated endovascular thoracic surgery, when
U.S. surgeons work overseas, they come up short, he said.
Despite their lack of training, most U.S. medical students and
surgical residents say they want to work abroad, he said.
“But the problem is we are not training people to be fully
functioning participants in the kinds of projects they’ve expressed
a desire to participate in,” he said.
SOURCE: http://bit.ly/2xlraGE
World J Surg 2017.
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