Global Surgery Electives: A Strategy to Improve Care to Domestic Underserved Populations?

BACKGROUND: In the United States, a shortage of general surgeons exists, primarily in rural, poor, and minority communities. Identification of strategies that increase resident interest in underserved regions provides valuable information in understanding and addressing this shortage. In particular, surgical experience abroad exposes residents to practice in low-resource and rural settings. As residency programs increasingly offer global surgery electives, we explore whether the presence of an international surgical rotation affects graduates' future practice patterns in underserved communities domestically. METHODS: We surveyed general surgery residency graduates at a single academic institution. Those who finished general surgery residency from 2001 to 2018 were included. Participant demographics, current practice demographics, and perceptions related to global surgery and underserved populations were collected. Respondents were stratified based on whether they did ("after") or did not ("before") have the opportunity to participate in the Kijabe rotation (started in 2011), defined by graduation year. RESULTS: Out of 119 eligible program graduates, 64 (53.7%) completed the survey, and 33 (51.6%) of the respondents graduated following the implementation of the Kijabe rotation. Two participants defined their primary current practice location as international. Fifteen (45.5%) in the "After" group indicated an interest in working with underserved populations following residency, compared to 5 (17.8%) of the "Before" group (P = 0.074). Furthermore, 20 (60.6%) respondents in the "After" group expressed interest in working with underserved populations even if it meant making less money. In the "Before" group, only 13 (46.4%) responded similarly (P = 0.268). Eleven (9.2%) residents rotated at Kijabe. Those who participated in the Kijabe rotation reported an uninsured rate of 36.7% for their current patient population, compared to rate of 13.9% in those who did not rotate there (P = 0.22). CONCLUSIONS: At a single institution, our results suggest that participation in an international surgical rotation in a resource-constrained setting may be associated with increased care for underserved populations in future clinical practice. These results could be due to self-selection of residents who prioritize global surgery as part of their residency experience, or due to increased exposure to underserved patients through global surgery.

International Surgery Electives During General Surgery Residency: A 9-Year Experience at an Independent Academic Center.

OBJECTIVE: International experiences are an increasingly emphasized feature of general surgery residency programs. In 2008, an international elective (IE) was implemented for general surgery residents at our institution. This effort was augmented by the establishment of a pathway for formal approval of IEs by the American Board of Surgery and Accreditation Council for Graduate Medical Education in 2012. DESIGN: A retrospective review of Accreditation Council for Graduate Medical Education case logs was completed. IE operative volumes were compared to home institution general surgery service volumes. An electronic survey of IE participants was conducted to assess preresidency goals, prior international exposure, overall experience on IEs, and current or planned engagement with international experiences, volunteerism, or global philanthropy. SETTING: Independent Academic Medical Center. PARTICIPANTS: Fourteen general surgery residents who participated in IEs from 2008 to 2017. RESULTS: IE locations included the Dominican Republic (9), Ecuador (1), Ethiopia (3), and Nicaragua (1). IEs were a first-time international surgical experience for 10 (71%) residents. Nine (64%) reported that they would not or may not have participated in an IE during residency had established opportunities not been available. Ten residents had graduated at the time of this study and 3 of them have participated in international service. Median case volumes were 17 cases per week during IEs compared to 8 cases per week for residents on home institution rotations. Residents were exposed to a variety of first-time operations during IEs including open cholecystectomies, gynecologic procedures, thyroidectomies for goiter, and prostatectomies. CONCLUSIONS: Incorporation of IEs into our general surgery residency has demonstrated numerous benefits. IE participation provides valuable operative experience in both volume and variety, and can be especially impactful for those who may not have elected to pursue such opportunities independently. These experiences have the potential to empower general surgery residents to invest in similar practices and acts of generosity in their future careers.

Assessing Interest and Barriers for Resident and Faculty Involvement in Global Surgery.

BACKGROUND: Multiple institutions have developed international electives and sustainable global surgery initiatives to facilitate clinical, research, and outreach opportunities with hospitals in resource-poor areas. Despite increasing interest among programs, many institutions have not successfully reached potential involvement. OBJECTIVE: This study evaluates the experiences of Yale residents and faculty, measures interest in the development of an international surgical elective, and enumerates barriers to developing or participating in these opportunities. This was performed to develop a formalized elective and assess interest and capacity for surgical global health initiatives, as a seemingly increasing number of trainee applicants and residents were expressing interest in working in resource-poor settings. METHODS: Electronic survey of Yale Surgery residents and faculty analyzed using SPSS and Graphpad Prism. RESULTS: Among residents, previous global experience correlates with current interest in international opportunities, with 100% remaining interested, and 78% of those without prior experience also expressing interest (p = 0.018). Barriers to pursuing these activities included the use of vacation time, funding, scheduling, family obligations, and concern for personal safety. Among faculty, 28% of respondents have been involved internationally, and most (86%) expressed interest in additional opportunities and all were willing to take residents. Barriers to faculty participation included funding, relative value unit target reduction, protected time, and the desire for institutional support for such activities. CONCLUSIONS: A substantial proportion of residents and faculty have experience in global health and motivation to pursue additional opportunities. The main barriers to participation are not a lack of interest, but rather needs for funding support, protected time, and institutional recognition of academic contributions. These findings are being used to develop a global surgery elective and establish long-term partnerships with international colleagues.

Smoking and attitudes towards its cessation among native and international dental students in Lithuania.

BACKGROUND: Dental professionals are uniquely positioned to discourage smoking among their patients. However, little is known about the role of cultural background and attitudes towards smoking in the education of these professionals. Our study aimed to compare native Lithuanian and international dental students' smoking habits, knowledge about the harmfulness of smoking and attitudes towards smoking cessation. METHODS: We conducted a cross-sectional survey of smoking and its cessation among dental students at the Lithuanian University of Health Sciences (Kaunas, Lithuania) in 2012. All Lithuanian and international dental students in each year of dental school were invited to participate in the survey during a compulsory practical class or seminar. Altogether 606 students participated in the survey with a response rate of 84.2%. Explanatory factorial analysis (EFA), multivariate Discriminant Analysis (DA) and Binary Logistic Regression (BLR) served for the statistical analyses. RESULTS: The percentages of occasional/current regular smokers were 41.1% and 55.7% (p = 0.068) among Lithuanian and international male students, and 22.7% and 22.9% (p = 0.776) among Lithuanian and international female students, respectively. The international dental students had a deeper knowledge of the harmfulness/addictiveness of smoking and held more positive attitudes towards smoking cessation among their patients than did the native Lithuanian dental students. CONCLUSIONS: The findings of the study underscored the need to properly incorporate tobacco cessation training into the curriculum of dental education. However, consideration of the cultural background of dental students in building up their capacity and competence for intervening against smoking is essential.

Loma Linda Global Surgery Elective: First 1000 Cases.

OBJECTIVE: To determine the nature and volume of surgical cases being performed by US general surgery residents during a global surgery elective. DESIGN: Retrospective review of case logs from 2012 to 2016. SETTING: Malamulo Mission Hospital is a rural hospital in southern Malawi. PARTICIPANTS: Rotating residents from a US-based general surgery residency program. RESULTS: Residents performed 12 cases per week from a variety of surgical disciplines. CONCLUSION: Global surgery rotations with dedicated faculty can provide excellent surgical variety and volume to enhance the training of residents.

[TUBERCULOSIS SCREENING BY CHEST RADIOGRAPHY AMONG INTERNATIONAL STUDENTS AT JAPANESE LANGUAGE SCHOOLS IN OSAKA CITY].

PURPOSE: With a broader aim of controlling pulmonary tuberculosis (TB) among foreigners, here, we have reported the findings of chest radiography screening for TB among international students at Japanese language schools in Osaka city. METHODS: Between April 2011 and December 2013, 4,529 international students from 19 Japanese language schools in Osaka city underwent chest radiography for TB screening. The chest radiographs were studied in reference to the student's sex, age, nationality, and date of entry to Japan as well as any health conditions present at the time of screening. We further analyzed the bacterial information and pulmonary TB classification based on chest radiography findings of students who were identified to be positive for TB. Information on the implementation of health education was also gathered. RESULTS: The results revealed that 52.5% of the students who underwent chest radiography came from China, 20.3 % from South Korea, and 16.3% from Vietnam. Of the students, 52.9% were male and 47.1% were female. The median age of students was 23 years (range: 14-70 years). The median number of days from the first date of entry to Japan up until the radiography screening was 63 days. Based on the chest radiography findings, 71 students (1.6%) were suspected to have TB; however, further detailed examination confirmed that 19 students (0.4%) had active TB. This percentage is significantly higher than the 0.1% TB identification rate among residents in Osaka city of the same time period (P<0.001), which was also determined by chest radiography. The median age of the 19 TB positive patients was 23 years. Among them, 14 (73.7%) were male. The median time from the date of entry to Japan to the date of the chest radiography screening was 137 days. For 16 of those students, the entry to Japan was within 1 year of the radiography. Of the 19 TB positive patients, 16 (84.2%) did not have respiratory symptoms, 15 (79.0%) had sputum smear negative results, and 17 (89.5%) had no cavity. Health education was conducted in 11 schools (for a total of 12 times) in the 3-year period. A total of 257 language school staff and students attended the health education seminars. DISCUSSION: The identification rate of TB positive students in Japanese language schools was higher than that of the general residents in Osaka city. In addition, most of these students came to Japan within 1 year. It is also important to note that the majority of TB positive students had sputum smear negative results. This study proves that medical examination after entry to Japan would be useful for early detection of TB positive patients. Furthermore, it would be beneficial to conduct chest radiography screenings among students at language schools on a continuous basis. It is also necessary to provide health education to the staff and students in Japanese language schools. Effective methods of disseminating health education, especially on the topic of TB, should be considered.

Surgical residency training and international volunteerism: a national survey of residents from 2 surgical specialties.

BACKGROUND: Many low- and middle-income countries (LMICs) lack basic surgical resources, resulting in avoidable disability and mortality. Recently, residents in surgical training programs have shown increasing interest in overseas elective experiences to assist surgical programs in LMICs. The purpose of this study was to survey Canadian surgical residents about their interest in international volunteerism. METHODS: We sent a web-based survey to all general and orthopedic surgery residents enrolled in surgical training programs in Canada. The survey assessed residents' interests, attitudes and motivations, and perceived barriers and aids with respect to international volunteerism. RESULTS: In all, 361 residents completed the survey for a response rate of 38.0%. Half of the respondents indicated that the availability of an international surgery elective would have positively influenced their selection of a residency program. Excluding the 18 residents who had volunteered during residency, 63.8% of the remaining residents confirmed an interest in international volunteering with "contributing to an important cause," "teaching" and "tourism/cultural enhancement" as the leading reasons for their interest. Perceived barriers included "lack of financial support" and "lack of available organized opportunities." All (100%) respondents who had done an international elective during residency confirmed that they would pursue such work in the future. CONCLUSION: Administrators of Canadian surgical programs should be aware of strong resident interest in global health care and accordingly develop opportunities by encouraging faculty mentorships and resources for global health teaching.

Do international rotations make surgical residents more resource-efficient? A preliminary study.

OBJECTIVE: Interest in international surgery among general surgery residents in the United States has been shown in several publications. Several general surgery residency programs have reported their experiences with international surgery rotations (ISRs). Learning to use limited resources more efficiently is often cited as a benefit of such rotations. We hypothesized that general surgery residents become more resource efficient after they have completed an ISR. STUDY DESIGN: Laboratory, radiologic, and diagnostic studies ordered on 2900 patients by 21 general surgery residents over 65 months at a single institution were analyzed retrospectively. The patient populations they wrote orders on were assessed for similarity in age, gender, and diagnoses. The outcomes in those patient populations were assessed by duration of stay and in-hospital mortality. Six (29%) of these residents (ISR residents) completed a 1-month ISR during their third year of residency. Their orders were compared with their classmates who did not participate in an ISR (NISR residents). The results were compared between the 2 cohorts from both before and after their international rotations. An analysis focused on comparing the changes from pre-ISR to post-ISR. A survey was also sent after objective data were collected to all residents and alumni involved in the study to assess their subjective perception of changes in their resource efficiency and to characterize their ISRs. RESULTS: Patient populations were similar in terms of demographics and diagnoses. ISR residents generated an average of $122 less in orders per patient per month after their ISR compared with before. NISR residents generated an average of $338 more in orders per patient per month after the ISRs compared with before (p = 0.04). Pre-ISR order charges were statistically similar. Similar results were observed when radiologic/diagnostic study orders were analyzed independently. Differences in outcomes were statistically insignificant. The survey revealed that most of the ISR residents perceived that their attitude toward ordering tests and laboratories was influenced greatly by their ISR, and all the ISR residents perceived that they became more resource efficient than their peers after their ISRs. CONCLUSION: These preliminary findings seem to indicate increased resource efficiency among general surgery residents who completed an ISR. However, the sample size of residents was small, and we could not establish conclusively a causal relationship to their ISRs. A more extensive study is needed if reliable conclusions are to be drawn regarding the effect of ISRs on the resource efficiency of residents.

Hospital-based plastic surgery volunteerism: a resident's international experience.

The purpose of this presentation is to describe an American plastic surgery resident's experience working for an academic year in a district-level general hospital in rural Kenya. The operative experience, educational value, and cultural adaptation over the custom-designed year are discussed. Furthermore, the logistics and ethics of picking a location, adjusting to the milieu, and treating patients are evaluated. The importance of a qualified, supportive, and perceptive mentor is emphasized. International volunteerism in plastic surgery beyond the more typical 1- or 2-week short-term trips can be extremely beneficial to a resident's experience, although long-term benefit to the served population should not be overestimated. A careful understanding of plastic surgery in relation to the global burden of disease highlights the fact that plastic surgery, although valuable, is limited in its role within international medical volunteerism. Not unexpectedly, obstetric, orthopedic, and general surgical skills are vital in the management of the most common surgical maladies.

The medical education of United States citizens who train abroad.

BACKGROUND: Graduates of international medical schools (IMGs) make up approximately one quarter of the physician workforce in the United States. Among IMGs are a number of US citizens (USIMGs) who take graduate training positions and ultimately practice in the United States. Compared with graduates of US medical schools (USMGs), relatively little is known about the undergraduate educational experiences of these US citizens. The objective of this study was to identify the schools that produce the most USIMGs and to describe the educational experiences and examination performance of graduates of these schools. METHODS: The 10 largest schools were identified based on the number of USIMGs who were certified by the Educational Commission for Foreign Medical Graduates between 2001 and 2004. Information about the institutions was collected from the International Medical Education Directory; educational experience information was gathered from 100 randomly selected transcripts and from a survey that was completed by 418 graduates of the schools. These data were compared with information about USMGs from the curriculum management and information tool and the graduation questionnaire of the Association of American Medical Colleges. Performance on steps 1 and 2CK of the United States Medical Licensing Examination were also analyzed. RESULTS: Some differences existed between USIMGs and USMGs in the required clinical clerkships, the sites where educational experiences occurred, and the special topics that were covered. USMGs and non-US citizen IMGs had better examination scores than USIMGs. CONCLUSION: There are many similarities; however, there are some noteworthy differences between the educational experiences of USIMGs and USMGs. Further work is needed to better understand the educational experiences of USIMGs, particularly in the clinical clerkships.

Thai medical graduates in the United States residency training programs: 1988-2003.

In the past 2 decades, international medical graduates (IMG) were needed to fill graduate medical education (GME) positions in the United States (U.S.). The author built a database of Thai medical graduates in accredited U.S. residency systems between 1988-2003, and analyzed the trend and opportunity for Thai IMG. During the 16-year study period, there were 281 Thai medical graduates who successfully entered residency in the U.S., with a rising trend that reached a peak between 1993-1994, and subsequently declined to about 10-15 per year Thai physicians entered U.S. residency program 4.2 +/- 3.3 years after medical school graduation. Thai IMGs were mostly in internal medicine (N=153, 54.4%) and pediatric residency programs (N=76, 27.1%), with much fewer in psychiatry (N=10), surgery (N=9), neurology (N=8), anesthesiology (N=7), and other specialties (N=18). Thai medical graduates tended to be clustered in a few residency programs. Half of the Thai graduates in the U.S. internal medicine residency were accepted in 9 programs; the largest were Texas Tech (Lubbock, N=18), Albert Einstein University (Philadelphia, N=14), and University of Hawaii (Honolulu, N=13). For pediatric residency, about half of the Thai graduates (56.6%) were in 6 programs; the largest were Christ Hospital (Oaklawn, N=11), University of Illinois at Chicago (N=11), and Jersey City Medical Center (N=9). After residency training, most Thais (94.5%) chose to do subspecialty training. The most popular medical subspecialties were cardiology, nephrology, and hematology-oncology. The most popular pediatric subspecialties were allergy-immunology, endocrinology, and cardiology. In conclusion, there are too few Thais in the U.S. residency system. This information may be helpful for Thai medical graduates who seek residency abroad.