You are listening to The Operative Word, a podcast brought to you by the Journal of the American College of Surgeons. I'm Dr. Lillian Erdahl, and throughout this series, Dr. Tom Varghese and I will speak with recently published authors about the motivation behind their latest research and the clinical implications It has for the practicing surgeon. The opinions expressed in this podcast are those of the participants and not necessarily that of the American College of Surgeons.
Welcome to The Operative Word, the podcast of the Journal of the American College of Surgeons. I'm Dr. Lillian Erdahl and I'm here with Dr. Erin Scott, who is lead author on Practical and Ethical Guidelines for the Involvement of Trainees in Global Surgery. Consensus Statement and Recommendations from the Resident and Associate Society of the American College of Surgeons Global Surgery Working Group. So welcome, Dr. Scott. Thank you. I have no disclosures regarding this paper.
Okay. Well, I am really interested in hearing sort of how this consensus statement came about. If you can just take us through a little bit of the background of the need to have the statement and some guidance on trainees in global surgery. Sure. So, I mean, trainee interest in global surgery has really rise pretty steadily over the last several years.
It kind of goes back to 2015 with the Lancet Commission's initial paper on global surgery and targets for 2030 that stated about 5 billion people around the globe lack access to safe, timely and affordable surgical care. And that vast burden is concentrated in the world's low and middle income countries. So for the last decade or so since that paper came out, there's been a very, as I said, steadily rising interest from trainees in getting involved in global surgery.
Some of the needs as far as the Lancet Commission has addressed involved scaling up the global surgery workforce and infrastructure. And so I think it's kind of a natural fit for the rising trainees and the next generation of global surgeons to really kind of fit that, to fill that void. So providing access to care is kind of one of the concerns that's driving that.
The interest in global surgery and also the need to have consensus around how to approach that for the safety of patients and surgeons. Tell me a little bit about some of the ethical issues for involvement of trainees in global surgery. Sure. So there have been a lot of calls in the last year or so about the the colonialist thoughts behind global surgery and the unequal power dynamics in high income countries. And low to middle-income countries.
And so I think the fact that these conversations are still taking place and the fact that this is still such a hot topic suggests that these standards aren't consistently being met. So that was one of the driving forces, obviously, behind this paper. And in putting out a set of official guidelines from our group regarding trainee involvement.
Some of the specific ethical issues would involve things like a trainee traveling, a student or a trainee traveling to another country without the same kind of objectives or educational oversight that we might have here with our own training programs. Perhaps there are different scopes of practice in other countries with their trainees, so trainees in other countries might be allowed to do a wider variety of things than we would be here.
For instance, I'm a general surgery resident and if I were to maybe go to a different training program in a different country, those trainees might be doing more things such as caesarean sections, treatments of open fracture or orthopedic surgeries, urologic surgeries, things that I'm not necessarily trained to do here in my own program.
And without the same kind of oversight that I might have with one of my own attending surgeons, I might be expected to perform procedures that I'm quite frankly not trained to do. So there's you know, that's one of the ethical dilemmas as far as just scope of practice, really.
And some of the other things involve, you know, issues with informed consent, issues with people posting pictures online without consent from people that they're operating on in other countries and going on those kinds of lines, too. But a lot of the big ones have to do with really the scope of practice of the different trainees involved.
And when you touch on, you know, the the privacy issue, I mean, I think there may be different laws and policies around privacy, but I think the ethical concerns are the same. And we see that as a concern here in the United States as well. You know that with the rise of all of our digital technology and social media, we need extra attention to how we maintain patient privacy.
What what are some of the solutions or what are the, you know, kind of boundaries around how we then protect trainees and ensure that there's infrastructure in place so that we know what to expect. If you're someone traveling, you know, to participate in global surgery as a trainee or student. So one of the biggest parts of these domains that we set forth in our training guidelines obviously is preparedness. That's the first domain that we talk about.
So the importance of adequate preparation of global surgery trainees prior to any kind of rotation abroad really can't be overstated. And that involves things such as being familiar with the language, the customs, the standards of their destination. It also involves setting forth educational objectives and their role when they travel abroad and having that kind of in place so that everyone knows what to expect.
The ACGME does actually have an approval process for international rotations, and the reason why I bring this up is sometimes residents might travel abroad with the thought that they will be operating and working with other surgeons. But the ACGME put out this statement before ours, and it is much more practically focused regarding oversight.
And if you're going to be operating in other countries and you're going to be logging those cases and it's going to be an approved ACGME official rotation, you really need to have an ACCME or an ACS-verified surgeon with you to and for proper oversight, essentially. And that's based on our kinds of standards and for rotation objectives that we have here in the States with our training programs as well.
Well, I think it strengthens any consensus statement to have another governing body agree with you or, you know, at least touch on some of the same principles and the way that our training programs are structured. There certainly is quite a bit of oversight and a lot of attention to oversight and safe surgery and supervision, which I think again protects the patient and the trainee both to ensure that the standard of care is being protected.
How how do people go about enacting these guidelines from a practical standpoint or, you know, and maybe this is outside of the scope of your paper, but, you know, what have you seen in terms of what infrastructure does or doesn't exist as you review what's been done in the past?
Yeah, I think that these guidelines, although they are practical in some respects and they can be seen as some sort of a checklist in terms of, you know, researching the site ahead of time, making sure that you have safe lodging when you're there and that kind of thing that falls under preparedness.
I really think it's more of a document for trainees and students to to consider and to really, really hone in on before they travel while they're traveling and also when they come back in terms of sustainability and handing over the project to someone else.
And so while it can be seen, like I said, as an objective checklist, I think it's more so of kind of a culture that they should really practice when they're engaging in global surgery and thinking about all of these different domains, being prepared before they go, thinking about sustainability when they come back, thinking about collaboration in terms of longitudinal research with other parties and different countries.
And, you know, I think from there the nitty gritty is something that we can the nitty gritty details is something that surgical trainees I think are good at and they can figure those things out based on people that have traveled to those countries before. But I think it's a good reminder of the the expectations and the standards that we expect for our trainees when they're traveling. Well, so we talked a little bit about preparedness.
And as you said, I think surgeons are particularly focused on how to prepare. And, you know, making a plan. I was always taught that you shouldn't be making the plan for surgery in the operating room. You should really be setting that out in advance and you should have contingency plans. You know what?
If I get there and this arrangement falls through, you know, but what about when we are thinking about the bigger picture, sort of how do we ensure that what we're doing is respectful of the country or traveling to the patients there, their medical community? I think that falls under sort of the reciprocity and collaboration. How do we think about our partners in this global surgery effort?
I think one of the biggest things that you could prepare for in terms of either starting a project, taking over a project, or even just traveling for an operative rotation is something that we do in all of our projects that I've been involved in, which is a needs assessment and the importance of a needs assessment before you get started on anything is to make sure that everyone's needs kind of align and really prioritizing the local needs of the host community that you're traveling to.
And so I think that that's always important to start with some sort of needs assessment to prioritize local needs to make sure that it's not, you know, my research desires and my ideas and plans that I'm prioritizing that maybe would work here in the United States; a certain plan or a certain idea, but it might not work somewhere else that I'm not used to. And I think also part of that has to do with what you're talking about in terms of demonstrating flexibility.
And there have been plenty of times that we've been involved in projects and you you get there and you do the needs assessment. You figure out what you know, what local stakeholders, local surgeons, local academics or focused on. And you get there and you find out it's just not going to work. You both have the best of intentions and you just really have to have, I think, an open mind for change.
And the idea that iterative review is absolutely essential and a lot of these processes and being able to adapt and being humble about it and saying, you know what, this isn't working for either party. Whoever whoever brings up the concerns and being able to pivot and restart or refocus I think is incredibly important. Well, you bring up a point that in all research we might start out with an idea or a hypothesis or a way to test that hypothesis and find out, you know, that's not going to work.
And we maybe don't always talk about those because they sound like failures as opposed to part of this iterative process to get to something that is going to be successful and, you know, is going to work for everyone involved. And maybe, you know, even when we try to be we're unrealistic about what we can do in a given time frame or with given resources. What have you learned in terms of that? I mean, is there a way to set yourself up for success in advance?
Do you spend a lot of time communicating back and forth before you travel? How do you kind of approach that to make sure that all parties are involved in making a plan that will work? I think that obviously communication is absolutely essential, and I would say that it's essential before, during and after, really.
And that's the key to these global surgery collaborations is building a relationship that's going to stand not only the stress, the test of distance, but like the test of time, something that I learned actually doing a lot of this research during the pandemic was that maintaining those relationships are absolutely essential is the core to any project.
We spent two years on one of my projects meeting virtually over Zoom during COVID because we couldn't travel and those relationships by the time we got to the host site in person, it felt like we had worked with them. I mean, obviously we had worked with them for several years, but it felt like we knew each other just by meeting virtually. But I think establishing that trust is incredibly important because it allows both parties to be honest when something isn't working.
And there were there was a time actually in one of my last projects where something to do with our needs assessment really just wasn't working. And I think that if we didn't have that trust in that established relationship of working really well together, I think that the project probably would have just fallen flat and they would have said, You know what, I'm not interested. This isn't working, we’re out.
But I think the fact that we had a really good relationship going and allowed them to bring their concerns to us and we pivoted and we worked on a solution that was going to work for everybody. And then in terms of communication, moving forward, I think that these these global surgery collaborations really depend on these long lasting partnerships.
There's a reason why people sign memoranda of understanding and contracts and all of this kind of stuff because everyone wants it to work and to last a long time. And I think recognizing that building those relationships takes respect on both sides. It takes time.
It takes continued investment over and over really explains a lot of the longitudinal side of global surgery in terms of trainees taking over projects from each other and setting up the next person that's going to go after you for success and continuing communication both with the people that are going to follow you.
So trainees that are going to take over my projects, but also making sure that they have the contacts that they need in the host site as well to continue that relationship moving forward.
That gives me a view into what you're talking about when you talk about sustainability, really that that again, it's setting things up in advance, but taking the time to build a team, to build communication and that open communication, you know, and I think even just going in with the intent of sustainability made a lot of sense to me, but also I think is something that I don't hear people thinking about when they're first getting into global surgery or when they
you know, when I hear especially from students who are hoping to make that part of their training or part of their career, that they just haven't thought about the fact that this is most of these relationships end up being long term, and particularly if there's going to be a reciprocal benefit from the investment of time on the side of both parties that, you know, doing a short project in most cases doesn't really meet the needs, at least on one side. It's not on both sides.
And I wanted to come back to, you know, how do we then use these principles or the focus on global surgery to really make a long term impact on the lack of access to care? How can we invest in global surgery or in addressing this lack of access to surgical care? I think that your point on sustainability really is the crux here. And when I was first getting started in global surgery, one of my mentors explained it very beautifully to me that I still think about quite often.
And the goal when you're you're starting and developing these long term relationship is to always keep in the back of your mind that the goal is that hopefully someday you're no longer needed, right? These short-term mission trips are wonderful and they can offload a lot of surgical volume for places.
But I think that honing in on sustainability and keeping in mind that the goal is to serve the whole local system, serve the serve the infrastructure, build the workforce for the long term by teaching skills, setting up registries that trainees and different academics in other places can help manage, providing education, improving access to resources.
These are all important things so that hopefully the goal is that, you know, eventually the local surgeons and local trainees can take this stuff over on their own. And just as an example, if you're getting involved in a place where let's say, for instance, the first meet off the bat based in the home site is that maybe they want additional training. With laparoscopy, you have over a period of a couple of years building their system for training, for laparoscopy.
You send a couple of surgeons down, help the attending surgeons learn laparoscopic skills. You help them maybe provide a couple of laparoscopic box trainers so that the trainees can start learning. You train the trainer, you train the attending surgeon, then how to train their trainees, and then hopefully over the period of a couple of years you have enough attending surgeons that are skilled in laparoscopy. They have the resources that they need.
Hopefully by that time with some additional assistance and they're training their own trainees on laparoscopy. And so within a couple of years you have hopefully completed that circle of now they can continue training their own. And then maybe by that point you have such a well-established relationship that you've established another need. Maybe the, you know, maybe there's something else going on and they would like better support in managing a trauma registry.
And so hopefully with these well-established collaborations, the the goal post is always moving, I think. And so I think that that's one of the important things to think about sustainability is that this isn't 10 years of just coming down to operate for a week at a time and then leaving. This is years and years of investment in a relationship and a collaboration where, as I said, the goalpost is always moving.
You have different goals every time and hopefully you're checking the boxes and and helping get people set up for success for the long term. I love the look at the long term and again, look at, you know, what is it that I can provide of value to a community, to a group of surgeons if I'm taking the time and they're, you know, taking the time to host people coming or to collaborate.
And I think a lot about surgical disease when we talk about access to care and the global burden of surgical disease, you know, it's not always a one-time visit or, you know, the the 60 days of recovery after your surgery. Patients who have abdominal surgeries can have obstructive symptoms in the future and need additional surgeries or need follow up.
And I think that sometimes those outside of the surgical community forget that surgical diseases are not always acute, you know, requiring a single treatment. So having a having access to long term surgical care is really the goal. The last thing that I wanted to end on, Dr. Scott, is what is your advice to surgeons who are interested or students who are interested in getting involved in global surgery? I understand you pursued a master's in public health as part of your training.
How can people start if they want to get involved in this area? I think that there are certainly a lot more resources now than when I started getting involved in global surgery, which is right around the time of the Lancet paper, really around 2015, as many of the current trainees and current attendings can probably attest to. I think the biggest thing for me that I can suggest to others would be to find a mentor. And that mentor can be an attending surgeon or it can be another resident.
Finding a mentor to help kind of guide you in that process. Someone who shares the same passions that you have, someone who's been there before, who can help you kind of navigate navigate that field, I think is really crucial. And I think one of the beautiful things that did come out of the pandemic is our ability to network virtually. Your mentor no longer has to be someone at your own medical school, in your own program.
I have mentors all over the country that I that I consider as part of my network, and that's based off of, you know, getting involved on different kind of social media and things like that. I think the other thing that you can do is that there are quite a few groups that are very well established now that are involved in global surgery. The one that I led the task force for for this paper is the Resident and Associate Society of the American College of Surgeons.
We have a global surgeon workgroup that's actually now on its way to becoming its own committee, but it is accessible to trainees all over the country and actually international trainees as well. You become a member of the RAS ACS and you can just ask to be involved in the mailing list and you can join anyone can join the meetings. And I think that that really opened a huge world for me in terms of being involved in global surgery.
I joined one of the meetings and people were working on projects all over the country, all over the world, different trainees, as I said, here in the United States and internationally, and just joining the meetings and reaching out to people and people asking for volunteers to help with things really helped expand my network and certainly expand my experience in global surgery. And so I think a lot of that is much more accessible now than even it was probably a decade ago.
And the fact that your network can open up a huge world for you virtually, to be quite honest. And so I think in finding a mentor and getting involved in some of those organizations and some of those smaller committees really can help and they can help you find a mentor as well. So wonderful. Thank you, Dr. Scott, for taking the time to tell us a little bit more about the research and the ideas behind your consensus statement and for the work that you do. Thank you so much for having me.
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