We are entering a critical time in health care, when an increasing number of surgeons are becoming disillusioned with the practice of medicine. We are facing increasing patient-care demands with decreasing rewards. It has been shown that physicians who are involved in managed care, or who practice in areas with a high level of managed-care penetration, provide less charity care1. Encouraging early participation and decreasing the barriers are crucial to creating a culture of physician volunteerism5.
At the University of California, San Francisco, a program has been established to expose orthopaedic residents to an overseas volunteer experience during their training with the hope that they will continue involvement in such experiences throughout their careers. In this report, we discuss the need for increasing volunteerism in orthopaedic surgery and review the history of the overseas volunteer program at the University of California, San Francisco.
In a recent commentary, David Satcher, M.D., Ph.D., United States Surgeon General, underscored the global nature of health care by pointing out that increased international travel and trade have made the world's health problems our own7. He stated that the United States, with its economic and technological might, has a moral duty to improve the level of health care throughout the emerging world. Similarly, in his 1999 First Vice-President's Address to the American Academy of Orthopaedic Surgeons, Robert D'Ambrosia, M.D., challenged us to broaden our approach to the profession of orthopaedics: "Our partnership with our patients must extend to our [foreign] orthopaedic colleagues and their patients around the world. We must include all patients in all countries. We have a responsibility beyond the borders of our country because of what we have learned and developed and because of the unique educational opportunities that we have to offer."2 Dr. D'Ambrosia urged greater involvement by the orthopaedic community in programs such as Orthopaedics Overseas and the International Center for Orthopaedic Education. He also urged greater recognition of individual orthopaedists for their humanitarian efforts throughout the world.
Today, many volunteer programs are staffed by retiring or retired orthopaedic surgeons at the end of their careers. The challenges of establishing and building an orthopaedic practice, as well as heavy loan burdens, place constraints on young orthopaedists and thereby limit their ability and desire to contribute time toward volunteerism5,6. At the University of California, San Francisco, orthopaedic residents are introduced to overseas volunteerism early in their training with a hope to foster continuing participation in such activities throughout their professional lives.
The University of California, San Francisco, began incorporating overseas missions into its orthopaedic resident training program in 1992. From 1992 through 1998, fifteen of thirty-six graduating orthopaedic residents went on overseas volunteer missions. Of those fifteen residents, six went on additional volunteer missions after graduation. Of those six graduates, three have since led other volunteer missions that included University of California, San Francisco, residents.
The destinations of these missions included El Salvador, Guatemala, Honduras, Nicaragua, and Peru. These trips were conducted under the auspices of Operation Rainbow, a private, nongovernmental organization that focuses on short-term plastic and orthopaedic surgery service missions to Central and South America. These missions are structured such that patients are screened and evaluated during the first two days and operations are performed during the following five days. During a typical mission, a team may see as many as 300 patients and perform between fifty and sixty operations.
In the short seven days of the mission, the resident is exposed to a multitude of diagnostic and therapeutic challenges. A variety of third-world orthopaedic conditions such as poliomyelitis, tuberculosis, chronic oteomyelitis, delayed complex trauma, and late presentation of congenital deformity are encountered. The need to manage complex orthopaedic problems with increased independence helps to foster confidence in the young surgeons. In addition, residents learn to be creative and resourceful in less technologically advanced settings. These are excellent training opportunities, which improve surgical skills, versatility, and adaptability.
In our training and practice in the Western world, we often focus on highly specialized surgery requiring sophisticated implants and equipment. However, the latest revision hip prosthesis has little use in a country where sterile operating rooms are a rarity3. Residency training in the Western world takes place in a controlled environment, in which the foundations of orthopaedic knowledge and technique are built. Having the opportunity to function in a different environment, and to experience unusual pathology, allows for rapid expansion and growth from this base. Through these overseas missions, residents broaden their horizons and open their eyes to the larger world of orthopaedic care outside of United States tertiary medical centers. In overseas settings, it is more appropriate to train health-care providers in more conservative techniques such as traction or external fixation. Ideal operations in these situations include simple, reproducible procedures that require little equipment.
Short-term missions are advantageous in that they make the volunteer experience more accessible. Most practicing orthopaedic surgeons cannot afford to take a month or more to volunteer their service abroad, whereas an absence of a week or ten days can be both feasible and attractive. However, short-term trips have limitations. Despite the intensity of the effort and the large individual case volume, these circumscribed interventions have relatively minimal lasting impact on the host country's health-care system. Members of the team participate in education within the local medical system during their stay. Upon leaving, however, there is no formal organization in place to continue to implement and maintain change. In addition, limited follow-up is available, and there is an absence of continuity of care. Often, good results are dependent on the use of casts and braces postoperatively. A successful clubfoot operation can be ruined by inadequate postoperative treatment. Another danger is creating complications that the local physicians or medical system cannot handle.
Orthopaedics Overseas seeks to address these issues through a combination of education and longer-term service. Now celebrating its fortieth year, Orthopaedics Overseas is a private, nonprofit organization under the larger umbrella of Health Volunteers Overseas. The goal of this organization is to improve the quality and availability of health care in developing countries through education and training4.
Orthopaedics Overseas has established long-term missions in eleven host countries, including Bhutan, Ethiopia, Indonesia, Kenya, Malawi, Peru, St. Lucia, South Africa, Tanzania, Uganda, and Vietnam. A Western-trained physician program director actively directs development and activities at the overseas sites. The local overseas programs, which are maintained by local volunteers, work to improve the overall level of care delivered to the population and to involve the community in the function of the hospital and the delivery of that care.
The programs present a challenging environment in which to work, as they often lack the vast array of resources that are available in the Western world. They also provide opportunities to teach and to effect long-term change, by working within an established system. One analogy used is, "Give a man a fish, and he has food for a day. Teach a man to fish, and he will have food for a lifetime."4 The local sites host volunteer physicians and other health-care professionals from the United States for periods from two to eight weeks. This strategy enables multiple-physician participation while providing continuity of care and education through the program directors. Local personnel, including "orthopaedic officers," technicians, nurse-practitioners, and residents, are trained in the management of musculoskeletal conditions utilizing local equipment and resources.
Recently, the Orthopaedic Research and Education Foundation earmarked funds to sponsor a pilot program for a resident rotation at an Orthopaedics Overseas site. Holly Brown, M.D. (University of California, San Francisco, Class of 1999) was the first American resident to be selected. She spent two and a half weeks at the Bedford Orthopaedic Center in Umtata, located on the eastern coast of South Africa in the former Transkei homeland. The heavy caseload there consists of a variety of general orthopaedic problems with an emphasis on fracture management. A considerable amount of the trauma is subacute in nature due to the delay in initial presentation to the hospital. In addition to trauma, there are many tuberculous infections and pediatric cases, with only one orthopaedic center to care for more than three million people (Fig. 1). The orthopaedic cases undergo initial evaluation at Umtata General Hospital and are then transferred to the Bedford Orthopaedic Center for definitive management. To appreciate the impact of one of these trips, we offer here an excerpt from Dr. Brown's report of her posting in Umtata:
In the environment of managed care and social negativism toward medicine that permeates the current American mind-set, it is extremely refreshing and inspiring to work in an environment where patients are so grateful for, and appreciative of, the care that they receive. Places do exist where physicians can do what they do best, be good doctors and take good care of patients, without having to answer to insurance companies, managed-care organizations, or lawyers. Experiences like these remind us of why we entered the field of medicine.
In light of the previous experience of the University of California, San Francisco, with short-term missions through Operation Rainbow, and the recent interaction with an established overseas site directed by Orthopaedics Overseas, the University of California, San Francisco, has developed a formal overseas rotation. All fourth-year orthopaedic residents will have the opportunity to take a one-month elective at an Orthopaedics Overseas site. Just as with any new rotation during residency, time is required both for the resident to learn a new medical system and for the members of the host team to learn the resident's capabilities. A one-month duration appropriately balances the time required to optimize the learning experience and to minimize the impact on the individual and on the orthopaedic program in the resident's absence. This is a purely elective rotation, and the resident response has been overwhelmingly positive. In the fourth year, the resident has reached a level of training to both take maximal advantage of the learning opportunity of the overseas experience and be a contributing member of the team at the host site.
There are many obstacles to the establishment of an overseas resident elective rotation. It is only through the commitment of the university and the department that this type of rotation can become a reality. Specific challenges include loss of service to the institutions, potential loss of educational experience for the resident, and inequality of resident experience.
The overseas rotation is a four-week block that is inserted between two regular clinical rotations. In this way, no hospital is deprived of a resident's services for more than two weeks. To account for the time away from the hospital, one week is taken from the resident's personal vacation, one week is granted by the department as educational leave, and one week is granted by each of the teaching hospitals. Taking time from the resident, the department, and the hospitals ensures commitment from all involved parties to this volunteer experience.
At the University of California, San Francisco, the time is taken from the two pediatric orthopaedic rotations. The overseas rotation is heavily weighted toward pediatric orthopaedics and provides an experience that has comparable educational value to that which the resident would have at home. The overseas rotation may be better in some respects because the residents have more responsibility and are exposed to a greater diversity of pathologies.
All rotations take place at an already established Orthopaedics Overseas site affiliated with a local medical school that is recognized by the World Health Organization. Each Orthopaedics Overseas site is staffed by a board-certified orthopaedic surgeon from the United States, Canada, the United Kingdom, Australia, or New Zealand. Residents are sent to sites where English is the language of education at the local medical school and is used in the medical center.
To give the experience formal educational structure, residents are provided with a specific set of goals and objectives for the rotation that they formally acknowledge. Residents keep a journal of all of their operative cases, listing the diagnosis, treatment, and level of supervision by the program director. In addition, the resident records data concerning the patients seen in consultation in outpatient, inpatient, and emergency department settings. Residents are expected to teach the local staff of health-care providers and to document the audience, setting, and topic of all formal education that they provide. Before the resident's departure, the journal is reviewed and validated by the on-site program director. These measures help to ensure that the residents have a quality educational experience.
Because participation in the overseas program is voluntary, some residents may choose not to participate. This may result in an unequal educational experience among the residents. The measures that we have mentioned and the constant supervision by a board-certified orthopaedic surgeon help to ensure that the overseas rotation is a valid educational experience. Through this elective, residents gain a unique learning opportunity that complements and consolidates their orthopaedic residency training. This experience gives them broader overall training and ultimately allows them to provide better patient care, creating a clear win-win situation for everyone involved.
An additional concern is funding. At most sites, housing is provided and local food is inexpensive and often provided free of charge. The major expense, therefore, is the airfare to the location. The Orthopaedic Research and Education Foundation has provided some initial seed money for this program. At the University of California, San Francisco, additional funding has been arranged through contributions from orthopaedic equipment vendors, manufacturers, faculty, and individual donors. To date, these sources have proven adequate to support the program.
There are health risks to volunteers, which include the general risks of travel to such areas as well as the specific risks to health-care workers. General risks vary by location but may include malaria, hepatitis A, cholera, and yellow fever. Occupational risks include human immunodeficiency virus, hepatitis C, and tuberculosis. All Orthopaedics Overseas sites employ modern infectious disease precautions and have educational programs in place.
Bringing adult family members on volunteer missions may be possible depending on the local site accommodations and settings. Some sites actually provide accommodations for spouses and adult family members. Bringing young children obviously complicates the logistics and increases expenses and risks.
Our commitment is to foster the lifelong spirit of volunteerism in our orthopaedic residents. We have seen that these early overseas volunteer experiences have a positive lasting impact. We hope that the overseas training program developed at the University of California, San Francisco, will be considered favorably by other orthopaedic programs, which may be interested in developing and implementing similar rotations. By decreasing the barriers to volunteerism and encouraging early participation in overseas volunteer activities, we hope to nurture a culture of physician involvement within the United States orthopaedic community.
David Rovinsky, M.D.Holly P. Brown, M.D.R. Richard Coughlin, M.D.Guy D. Paiement, M.D.David S. Bradford, M.D.
Department of Orthopaedic Surgery,
University of California, San Francisco,
500 Parnassus Avenue (MU-320W),
San Francisco, California 94143-0728
E-mail address for David Rovinsky:
davidrovinsky@hotmail.com
E-mail address for G. D. Paiement:
paiement@orthosurg.ucsf.edu
E-mail address for R. R. Coughlin:
coughlin@orthosurg.ucsf.edu