© Springer International Publishing Switzerland 2016
Mamta Swaroop and Sanjay Krishnaswami (eds.)Academic Global SurgerySuccess in Academic Surgery10.1007/978-3-319-14298-2_1111. Developing Educational Opportunities for Trainees on Both Sides
(1)
Division of Pediatric Surgery, Department of Surgery, College of Health Sciences, University of Abuja, Abuja, Nigeria
(2)
Division of Paediatric Surgery, Hospital for Sick Children, Toronto, ON, M5G 1X8, Canada
(3)
Department of Surgery, University of Toronto, Toronto, ON, Canada
(4)
Department of Surgery and Pediatrics, Nationalwide Children’s Hospital, The Ohio State University, Columbus, OH 43205, USA
Keywords
Surgical EducationGlobal Surgery ElectivesGlobal RotationsInternational RotationsResident educationEducational CollaborationExchange visitsInstitutional TwinningIdeally, the development of educational opportunities in global surgery addresses learning objectives for participants from both High Income Countries (HIC) and Low-Middle Income Countries (LMIC). Historically speaking, HIC have offered some undergraduate and postgraduate training opportunities to individuals from LMIC. However, in the context of “medical missions”, trainees from HIC typically gain easier access to LMIC, with little reciprocal benefit for trainees from their host countries. Also, given that many doctors from LMIC have not returned home after training in HIC, the overall benefits of training has been heavily weighted in favor of participants from HIC.
Trainees from LMIC often face a highly regulated set of conditions when visiting HIC. These regulations tend to focus on patient safety and liability protection for the HIC host institution. Consequently, the participation of visiting trainees from LMIC is usually limited to observation only, with few opportunities for practical experience. Therefore, when planning visits for participants from LMIC, consideration should be given to optimizing their experience. While the environment may not allow full participation in clinical activities, other valuable educational opportunities can be planned and instituted.
In designing new educational partnerships between HIC and LMIC, there exists the risk to perpetuate the inequity and imbalance in medical workforce that underlies many existing arrangements. While complete equity may not be possible at this juncture, there is a growing movement to shift the paradigm, and seek greater transparency, clearer objectives, and ultimately, programs that address educational wants and needs for interested parties from both resource rich and resource restricted environments.
While we strongly advocate truly bilateral exchange visits in which trainees from both sides participate fully in clinical activities, such arrangements are limited at present. Rigid licensing requirements, accreditation agencies, and medico-legal norms in HIC effectively check the activities of visiting LMIC trainees. However, such protections are not always available to the vulnerable patients and local trainees from LMIC when they receive trainees from HIC. The following discussion assumes that the visiting trainee is from a HIC while the host site is in a LMIC, and focuses on how such visits can provide meaningful benefits to both sides.
Educational Opportunities for Trainees from HIC
(i)
Learning surgery in an environment with a different teaching system, training pattern and ethical considerations
The participants from HIC will experience the host country’s models for teaching and training. They look to focus on and learn what they perceive as most important: acquisition of traditional cognitive knowledge and psychomotor skills. They may recognize that these differ from those in their home country, but are most apt to concentrate on what they feel will transfer to their resource rich context. This acquisition of traditional knowledge and skill may occur in clinical conferences and meetings, on the wards, in the operating theatre or in a multitude of clinical settings. However, not least important is the learning which reflects the local culture and ethical values. These insights into systems-based issues and differences in practice are perhaps the most important lessons learned during such experiences.
Depending on the environment, the emphasis may be more on ensuring patient survival than on improving the quality of life. This reality in certain resource restricted environments needs to be highlighted. The local trainers who serve as mentors to the trainees will provide insight based on the same body of knowledge available to colleagues in HIC, but tempered by personal experiences and preferences in the management of surgical conditions in their resource restricted environment. The trainee will also have peer learning opportunities while interacting with the local residents at various clinical/academic forums.
Complementary formal teaching sessions could further improve the overall capacity of the visiting trainee to understand the processes from a new perspective of limited manpower and limited resources. Many stakeholders from HIC recognize that well established bedside teaching methods that are utilized in LMIC are becoming extinct in resource rich environments. Formal efforts are being made to re-establish traditional bedside teaching rounds in many resource rich environments, largely based on experience from time spent in a LMIC. Another change in behavior by the trainee from HIC may be a shift in attitude towards greater resource efficiency. This is often the result of experiencing the constraints imposed by limited resources in LMIC, and may impact their practice upon return to their home country.
There is a growing awareness that while formal learning objectives may focus on the previously mentioned traditional criteria based on knowledge and skill, some of the most valuable lessons are learned in realms of communication, collaboration, professionalism, health advocacy and systems-based practice. Recognition of this concept as a whole, and the focus on tailored preparation will assist in appropriately sensitizing and preparing the trainee for the new context in which they will find themselves, and will help focus and maximize the learning experience.
Point of Caution
An overseas rotation may not be ideal for every resident. Residents from both HIC and LMIC are more likely to thrive in a foreign setting if they exhibit the cultural sensitivity and situational awareness necessary to facilitate a smooth transition from one environment to another. Therefore, in selecting residents for these rotations, especially early on, program directors should prioritize those with these qualities. A formalized preparation should be considered prior to arrival at the host site.
(ii)
Opportunity to exchange knowledge and skills with trainees in the host country
The expectation is that the trainee from a HIC will integrate fully into the training structure of the host institution and therefore will readily provide information about perspectives in their own country. The presumption here is that the visiting trainees from HIC will be sufficiently advanced in training to participate more effectively in clinical care at the host site. The acceptable level of training is a matter to be carefully considered during the planning stages. In some situations, visiting trainees will encounter host LMIC peers with superior knowledge and skills. It is not unusual to find trainees from LMIC who have unique insights into local diseases, honed through reliance on clinical skills and adaptation to the scarcity of modern technology. For instance, trainees from HIC, accustomed to minimally invasive procedures, could have much to learn from their LMIC counterparts who may have more advanced open surgical skills. In many situations, both the visiting and host trainees and faculty can scrub together and learn from each other. These opportunities to exchange knowledge and skills with local trainees may also bring to the fore previously undeveloped leadership skills of the visitor, and help foster a spirit of collaboration and understanding. A sense of both humility and camaraderie on both sides can foster a positive learning environment for all. The exchange of knowledge can take place in the operating theatre as above, or through planned presentations made during formal clinical meetings and rounds, or even during informal bedside teaching. Careful planning, adequate supervision and close monitoring from a dedicated local stakeholder and a thoughtful HIC organizer are therefore imperative.