Are American Surgical Residents Prepared for Humanitarian Deployment?: A Comparative Analysis of Resident and Humanitarian Case Logs

  • Yihan Lin
  • James S. Dahm
  • Adam L. Kushner
  • John P. Lawrence
  • Miguel Trelles
  • Lynette B. Dominguez
  • David P. Kuwayama
Original Scientific Report

Abstract

Background

Effective humanitarian surgeons require skills in general surgery, OB/GYN, orthopedics, and urology. With increasing specialization, it is unclear whether US general surgery residents are receiving exposure to these disparate fields. We sought to assess the preparedness of graduating American surgical residents for humanitarian deployment.

Methods

We retrospectively analyzed cases performed by American College of Graduate Medical Education general surgery graduates from 2009 to 2015 and cases performed at select Médecins Sans Frontières (MSF) facilities from 2008 to 2012. Cases were categorized by specialty (general surgery, orthopedics, OB/GYN, urology) and compared with Chi-squared testing. Non-operative care including basic wound and drain care was excluded from both data sets.

Results

US general surgery residents performed 41.3% MSF relevant general surgery cases, 1.9% orthopedic cases, 0.1% OB/GYN cases, and 0.3% urology cases; the remaining 56.4% of cases exceeded the standard MSF scope of care. In comparison, MSF cases were 30.1% general surgery, 21.2% orthopedics, 46.8% OB/GYN, and 1.9% urology. US residents performed fewer OB/GYN cases (p < 0.01) and fewer orthopedic cases (p < 0.01). Differences in general surgery and urology caseloads were not statistically significant. Key procedures in which residents lacked experience included cesarean sections, hysterectomies, and external bony fixation.

Conclusion

Current US surgical training is poorly aligned with typical MSF surgical caseloads, particularly in OB/GYN and orthopedics. New mechanisms for obtaining relevant surgical skills should be developed to better prepare American surgical trainees interested in humanitarian work.

Introduction

Surgical humanitarianism has risen in popularity in recent years. Increased interest has been documented in surgeons, residents, and medical students from many high-income countries. After the 2010 earthquake in Haiti, more than 550 surgeons registered to volunteer through the American College of Surgeons (ACS) Operation Giving Back program [1]. A survey of ACS residents showed that 85% were interested in practicing internationally during their careers [2].

Because of geographical differences in the epidemiology of surgical disease and the relative lack of surgeons in most low- and middle-income countries (LMICs) [3], surgeons who practice internationally must be capable in many surgical specialties, including trauma, pediatrics, orthopedics, neurosurgery, urology, and obstetrics [4]. However, with increasing specialization in US surgical residencies and fellowships, many specialty fields are no longer a component of US general surgical training. A study on the change in general surgery chief resident operative experiences found that case mix has narrowed in the last two decades [5]. Residents perform an increasing number of alimentary tract and intra-abdominal cases, but exposure to other kinds of surgery is diminishing [5].

In contrast, surgical programs of medical humanitarian organizations such as Médecins Sans Frontières (MSF) typically provide a broad spectrum of care, though tailored to particular contexts [4]. For example, classic emergency surgical interventions (reacting to war, epidemics, or natural catastrophe) may be heavily focused on trauma in an urban or warzone environment. In contrast, choice interventions (responding to endemics, exclusion, and underserved populations) may require a surgical program to manage all surgical cases arriving in a district hospital, or to staff a maternity hospital focused on complicated obstetric interventions. Both types of programs require surgeons to possess a wide range of skills, some of which an American surgeon may not have accrued during his or her training.

The aim of this study was to assess the preparedness of American-trained general surgeons for humanitarian deployment. To do so, we compared ACGME case logs of graduating general surgery residents with MSF case logs from a wide array of surgical interventions, and identified specialty areas of mismatch.

Materials and methods

Two sets of data were used for the analysis: American College of Graduate Medical Education (ACGME) general surgery chief resident case logs spanning 2009–2015 [6], and previously published summary data of MSF-Brussels (MSF-OCB) case logs spanning June 2008 to December 2012 [7].

The ACGME is the accreditation body for medical residency and fellowship programs in the USA. The ACGME case logs analyzed in this study report the national average of procedures performed throughout general surgery residency training programs by graduating US general surgery residents, categorized by procedure type. While most ACGME procedure categories were operative in nature (e.g., “cholecystectomy,” “enterectomy”), some procedure categories involved perioperative or bedside care (e.g., “organ dysfunction,” “invasive line management/monitoring”). Such non-operative categories were considered irrelevant to this study and were excluded. With the remaining 114 procedure categories, case volumes were averaged over the 7 years of data.

MSF-Brussels is one of MSF’s five Operational Centers; the surgical logs used here covered operations performed at MSF-Brussels projects in 21 countries (14 in Africa, 1 in the Americas, 6 in the Middle East and South and East Asia) and comprised 93,385 procedures [7]. These were categorized into 28 procedure categories (6 obstetric/gynecologic, 1 urologic, 5 visceral, 10 orthopedic, 6 other). Three categories, “Wound debridement, abscess drainage, circumcision,” “Drain insertion, chest tube insertion, dressing change,” and “Dressing change (burns),” were excluded from analysis, as they were either not captured by ACGME case logs or were technically basic enough to assume surgical trainee proficiency.

In instances where multiple ACGME procedure categories corresponded to a single MSF procedure category (e.g., ACGME: “Open reduction of open/closed fracture,” “Closed reduction of fracture”; MSF: “Fracture reduction”), the ACGME categories were summed into a single data point for purposes of comparative analysis. The category groupings and equivalencies used to generate comparable data are delineated in Table 1.
Table 1

Procedure classifications

MSF category

ACGME category

General surgery

 

 Herniorrhaphy, other anogenital

Hemorrhoidectomy (all)

Sphincterotomy/sphincteroplasty

Drainage proc for anorectal abscess

Repair anorectal fistula

Other operations for anal incontinence

Repair rectal prolapse

Other major anorectal

Inguinal-femoral (all)-open

Inguinal-femoral (all)-laparos

Ventral

Other major hernias

Herniorrhaphy, inguinal/umbilical

Define op for Hirschsprungs/Imperf anus

 Minor tumor resection

Remove skin moles, small tumors, etc

Removal subcut small tumors, cysts, fbs

 

 Exploratory laparotomy

Gastric trauma-closure/resect/exclusion

Duodenal trauma-closure/resect/exclusion

Sm bowel trauma-closure/resect/exclusion

Colon trauma-closure/resect/exclusion

Explor laparotomy-open

Drainage pancreatic injury

Resection of pancreatic injury

Repair of abdominal aorta/vena cava

Exp lap exclusive of trauma-open

Drainage intra-abdominal abscess

Maj retroperit/pelvic node dissec-open

Other major ab-general-lap complex

Esophago-gastrectomy

Antireflux proc-open

Gastrostomy (all types)-open

Gastric resect, partial-open

Gastric resect, total

Vagotomy, trun/sel w/drainage/res-open

Repair perf-gastric dis

Prox gast vagotomy, highly select-open

Gastric reduc for morbid obesity (all)

Enterolysis - open

Repair perf-duodenal dis

Repair perf-small bowel dis

Ileostomy (not assoc w/colectomy)-open

Diverticulectomy

Appendectomy-open

Colostomy (all types)

Repair perf-colon dis Lobectomy or segmentectomy

Wedge resection/open biopsy

Drainage liver abscess

Cholecystostomy

Cholecystectomy w/wo oper grams-open

Common bile duct explor-open

Choledochoenteric anastomosis

Sphincteroplasty (oddi)

Drainage pancreatic abscess

Resection for pancreatic necrosis

Panc resection, distal

Panc resection, whipple

Panc resection, total

Drainage pseudocyst (all types)

Pancreaticojejunostomy

Open repair infrarenal a-i aneurysm, ruptured

Open repair infrarenal a-i aneurysm, elective

Repair suprarenal aortic aneurysm

Celiac/sma endarterectomy, bypass

Renal endarterectomy, bypass

Embolectomy/thrombectomy, renal

Antireflux procedure-open (peds)

Rep intestinal atresia/stenosis

Repair pyloric stenosis

Operation for malrotation/intussuscept

Proc for meconium ileus/nec enterocolit

Exc wilms tumor/neuroblastoma

Rep omphalocele/gastroschisis

 Bowel resection

Enterectomy - open

Colectomy/proctectomy-open

Colectomy/proctectomy-laparoscopic Colectomy w/ileoanal pull-thru

Colectomy w/continent reconstruct

Abdomino-perineal resection

 Skin/muscle graft

Skin-grafting, non-burn (all)

Composite tissue transfer

Burn debridement and/or grafting

 Repair/resection of spleen, liver, kidney

Lobectomy or segmentectomy

Wedge resection/open biopsy

Splenectomy for disease-open

Splenectomy for disease-lapar

Splenectomy/splenorrhaphy-open Repair/drainage hepatic lacs-open

Hepatic resection for injury

Repair/resect for kidney trauma

Lobectomy or segmentectomy

Obstetrics and gynecology

 

 Cesarean delivery

  

 Complex delivery, episiotomy, perineal laceration repair

  

 Curettage

  

 Hysterectomy, oophorectomy, pelvic tumorectomy

Hysterectomy (all)

Salpingo-oophorectomy

Other major gynecology

Other major gynecology - laparoscopic

Orthopedics

 Fasciotomy, amputation

Fasciotomy

Fasciotomy for injury

Amputation, digit

 Fracture reduction

Closed reduction of fracture

  

 Internal fixation of fracture

Open reduction of open/closed fracture

  

 Limb amputation

Amputation, transmetatarsal

Amputation, below knee

Amputation, above knee

Amputation, upper extremity

 Debridement of osteomyelitis

  

Urology

 Urological procedures

Hydrocelectomy

Cystostomy

Cystectomy

Ileal urinary conduit

Other major genito-urinary

Other major genito-urinary - lap basic

Other major genito-urinary - lap complex

Repair epi- and hypo-spadias

Orchiopexy

Compiled procedure category data were grouped into five specialty categories: general surgery, obstetrics and gynecology, orthopedics, urology, and other procedures. Specialty category volumes in each data set were converted to percentages of total operative volume to facilitate comprehension of case distribution across specialties and to enable comparison between the two data sets. Differences across specialty categories were assessed for statistical significance using Chi-squared testing (RStudio Version 0.99.903).

Results

From 2008 to 2012, MSF-OCB performed a total of 93,385 procedures. Of these, 21.9% were minor cases and excluded from further analysis. Of major cases, 46.8% were obstetrics and gynecology, 30.1% were general surgery, 21.2% were orthopedics, and 1.9% were urology (Table 2). The most common general surgery cases were herniorrhaphy (13.5%), bowel resection (6.8%), and minor tumor resection (4.5%). The most common obstetrics and gynecology cases included cesarean delivery (33.1%), complex delivery (4.1%), dilation and curettage (3.4%), and hysterectomy (3.1%). The most common orthopedic procedures included fasciotomy or amputation of fingers and toes (11.7%), fracture reduction (4.0%), and external fixation of fracture (1.3%).
Table 2

Comparison of ACGME case logs with MSF case logs

Specialty

MSF

ACGME

Procedures

Number of procedures

%

Number of procedures

%

General surgery

 Herniorrhaphy, other anogenital

9873

13.5

163.38

16.6

 Bowel resection

4949

6.8

78.63

8.0

 Minor tumor resection

3316

4.5

11.17

1.1

 Exploratory laparotomy

2498

3.4

125.60

12.7

 Skin/muscle graft

789

1.1

14.00

1.4

 Repair or resection of spleen, liver, kidney

570

0.8

14.78

1.5

Total

21,995

30.1

407.38

41.3

Obstetrics and gynecology

 Cesarean delivery

24,182

33.1

0

0.0

 Complex delivery, episiotomy, or perineal laceration repair

3002

4.1

0

0.0

 Curettage (obstetric)

2462

3.4

0

0.0

 Hysterectomy, oophorectomy, pelvic tumorectomy

2228

3.1

1.32

0.1

 Obstetrical fistula repair

1585

2.2

0

0.0

 Ectopic pregnancy

663

0.9

0

0.0

 Total

34,122

46.8

1.32

0.1

Orthopedics

 Fasciotomy, amputation of fingers or toes

8566

11.7

4.53

0.5

 Fracture reduction

2945

4.0

0.37

0.0

 External fixation of fracture

974

1.3

0

0.0

 Limb amputation

841

1.2

11.72

1.2

 Internal fixation of fracture

803

1.1

0.30

0.0

 Other (corrective procedure, ortho)

624

0.9

0.97

0.1

 Internal fixation removal

464

0.6

0

0.0

 Curettage for osteomyelitis

193

0.3

0

0.0

 Joint procedure

35

0.0

0

0.0

 Bone graft

35

0.0

0

0.0

 Nerve repair

18

0.0

0.30

0.0

 Total

15,498

21.2

18.18

1.9

Urology

 Urological procedures

1354

1.9

3.12

0.3

 Total

1354

1.9

3.12

0.3

Total for analysis

72,969

78.1

430.00

43.6

From 2009 to 2015, general surgery residents performed an average of 1328 cases by the completion of their residency. Of these, 25.8% were non-major cases, endoscopic, or perioperative management, and excluded from further analysis (Table 3). Of the remaining 985 cases, 430 (43.6%) corresponded to surgeries done at MSF facilities, and the remaining 555 (56.4%) had no corollary in the MSF case logs. The majority of cases that corresponded to MSF surgeries were general surgery procedures (41.3%), followed by orthopedics (1.9%), obstetrics and gynecology (0.1%), and urology (0.3%). The most common general surgery procedures included herniorrhaphy (16.6%), exploratory laparotomy (12.7%), and bowel resection (8.0%). The only recorded obstetrics and gynecology procedure was hysterectomy (0.1%). The only recorded orthopedic procedures included major amputation (1.2%) and fasciotomy or amputation of fingers and toes (0.5%).
Table 3

Excluded non-major and perioperative procedure categories

MSF

ACGME

Wound debridement, abscess drainage, circumcision

Drain insertion, chest tube insertion, dressing change

Dressing change (burns)

Laryngoscopy

Bronchoscopy

Sclerotherapy/banding esoph varices

Esophago-gastro-duodenoscopy

Percutan endo gastrostomy (peg)

ERCP w/wo papillotomy

Sigmoidoscopy, rigid/flexible

Flexible colonoscopy w/wo bx/polypect

Choledochoscopy

Cysto/urethroscopy

Other endoscopy

Repair minor wounds and grafts

Banding/incision thrombosed hemorrhoid

Endorectal ultrasound [miscellaneous]

Other endorectal procedures

Non-operative trauma

Ventilatory management

Bleed (non-trauma) >3 units

Hemodynamic instability

Organ dysfunction

Dysrhythmias

Invasive line manage/monitoring

Parenteral/enteral nutrition

In comparison with MSF surgeons, residents of ACGME programs performed fewer orthopedic procedures (1.9 vs. 21.2%, p < 0.01) and fewer obstetric and gynecologic procedures (0.1 vs. 46.8%, p < 0.01). US residents performed relatively more general surgery procedures (41.3 vs. 30.1%, p = 0.10) and fewer urology procedures (0.3 vs. 1.9%, p = 0.29), although these differences were not statistically significant (Fig. 1).
Fig. 1

Comparison of MSF and ACGME surgical cases

Discussion

Our study found that less than one-half of cases performed in ACGME general surgical residencies are directly relevant to surgical practice in MSF projects. Furthermore, only one-third of major surgery performed in MSF projects corresponds to typical ACGME general surgical training.

ACGME general surgery residents spend a majority of their training (56%) engaged in advanced general surgical or specialty procedures with no direct corollary in MSF projects. Furthermore, they receive minimal exposure to orthopedic surgery (2% of cases), even though orthopedic procedures comprise a significant portion of the surgical work in MSF facilities (21%). The discrepancy is even greater in obstetrics and gynecology, while obstetric and gynecologic case volume totaled 47% of MSF cases, it totaled less than 1% of ACGME cases. Most striking, while the single most commonly performed surgery in MSF projects is cesarean section, the average graduating general surgery resident reported never having participated in a single one.

While these data suggest a significant mismatch between US surgical training and surgical needs abroad, they fail to capture yet another layer of training deficiency. Even with common surgical procedures such as inguinal herniorrhaphy, the approach and technique utilized in limited-resource environments may differ dramatically from that taught to residents at tertiary training facilities in the USA. The lack of access to mesh, laparoscopic equipment, surgical staplers, and at times electric dermatomes, requires that surgeons be familiar with alternative, low-technology methods for completing the same general surgical procedures one may perform routinely at home. Furthermore, diagnostic tools upon which US surgeons rely routinely, such as CT scans and interventional radiology services, are notably absent in humanitarian environments. Although ultrasound is widely available, few general surgery residents graduate with advanced familiarity in utilizing ultrasound technology for either diagnostic or therapeutic purposes.

Given such training disparities, US surgeons in humanitarian contexts may find themselves incompletely prepared to meet the broad demands made of them. To address key deficiencies and augment essential skills, several focused training courses are available to surgeons preparing for humanitarian missions. For its own volunteers, MSF offers a 4-day cadaver-based surgical skills workshop in Düsseldorf, Germany. The Royal College of Surgeons (London) offers its Surgical Training in Austere Environments (STAE) course, an intensive 5-day cadaver-based course open to civilian and military surgeons. Other courses include Stanford University’s Continuing Medical Education (CME)-accredited International Humanitarian Aid Skills Course, and the American College of Surgeons’ (ACS) International Humanitarian Aid Surgery course offered during the annual ACS Clinical Conference. For surgical and obstetrical residents interested in global health careers following graduation, the University of Colorado holds its annual Humanitarian Surgical Skills Workshop, a 2-day cadaver-based course focused exclusively on training senior-level residents.

Efforts are also being made to create more integrated training in global health within the structure of surgical residency. Vanderbilt University has created a global acute care surgery fellowship, a 2-year experience for residents to gain technical and research skills to practice in underserved settings [8]. Numerous surgical residencies throughout the country are adding formal global health tracks to their curricula, designed to augment interest in and exposure to the science and research aspects of global surgical care delivery. As of 2015, 34 general surgery residency programs had incorporated international rotations into their curricula [9]. Residents may alternatively seek training through one of the ten rural surgery residency tracks recognized by the ACS; these programs generally expose trainees to a wider spectrum of surgical specialties, notably including obstetrics, gynecology, and orthopedics [10].

The disparities identified here may suggest that organizations like MSF ought to focus on expanding its portfolio of specialist surgeons in its many surgical projects across the globe. While seemingly a straight forward solution, this approach fails to take account of the multiple other constraints facing MSF humanitarian interventions, including the logistics of inserting, housing, and extracting practitioners in potentially tenuous security contexts, and human resources issues such as the reliable availability of desired practitioner types. Rather, our belief is that the most flexible, durable, and efficient solution to this issue remains a focus on expanding the portfolio of procedures performable by the cadre of current and future MSF general surgeons.

There are several limitations to this study. First, the primary data set relies on the reporting accuracy of both ACGME and MSF surgical case logs. ACGME case reporting is closely monitored by surgical program directors, and studies suggest case log reporting accuracy of more than 95% among chief residents [11]. MSF case log generation involves a chain of information transfer from surgical theater to project office to MSF Operational Center headquarters, a multi-step process that may be comparatively more prone to error. To our knowledge, external auditing of the fidelity of this process has either not been performed or not been made public.

A second limitation pertains to the granularity of our data sets. The ACGME data set was de-identified and did not permit us to subgroup analyze case logs by urban or rural training programs. Possibly, case log data from rural programs would have been more on par with MSF data, particularly with respect to critical procedures such as cesarean section and bony external fixation. However, we were unable to assess this possibility. With respect to the MSF data set, we were unable to subgroup analyze cases by type of surgical practitioner. MSF projects occasionally employ specialist surgeons; in such projects, specialists are more likely to perform the bulk of procedures germane to their specialty, thereby reducing or obviating the burden of such cases on general surgeons. Our inability to remove case log data pertaining to specialists may have resulted in overestimating the true orthopedic, obstetric, and gynecologic operative burden on MSF general surgeons. However, the presence of specialists in MSF missions remains the exception, and, in the authors’ experience, the case log data remain a qualitatively accurate reflection of the overall demands placed upon MSF general surgeons.

A third limitation has to do with the narrow scope of our comparison: case logs of surgical trainees from a single country, and one wing of a large humanitarian non-governmental organization. With respect to case logs of trainees, we did make attempts to obtain similar case log data from other national training systems, including those of the College of Surgeons of East, Central and Southern Africa; the Royal Australasian College of Surgeons; the United Kingdom’s Joint Committee on Surgical Training, and the Royal College of Surgeons in Ireland. However, despite our efforts, we were unable to convince these organizations to share proprietary data. While such data would have been useful to explore the variability in training across national health systems, our impression is that the advanced degree of specialization in American surgical training likely represents a “worst case” comparison with respect to the needs of humanitarian organizations. With respect to the MSF data, there is some variability in surgical projects across MSF’s six Operational Centers; our data pertained only to the case logs of MSF OC-Brussels. The generalizability of this data to the broader context of humanitarian surgery is difficult to verify. However, the high burden of orthopedic and obstetric cases identified here is not unique to MSF projects and has been reported in other humanitarian and austere surgical contexts. A systematic literature review on surgical care during humanitarian crises found that the most common procedures were soft tissue surgery, orthopedic surgery, cesarean sections, hernia repairs, and appendectomies [12]. In a military context, US Forward Surgical Teams (FSTs) in Afghanistan reported that 17% of all cases were orthopedic and 23% were subspecialty in nature, while only 20% were classic general surgery [13]. Still, future research comparing surgical trainee experience from multiple national health systems with case logs of other international aid agencies or standardized criteria such as the DCP-3 Essential Surgery [14] categories may be useful.

Conclusion

A rising generation of American surgical trainees is increasingly expressing interest in global surgical volunteerism and humanitarian work. However, our study raises serious questions about the ability of current US surgical training to adequately prepare graduates to be effective in such environments. Graduates of US general surgical training programs spend a majority of their time in advanced general surgery and specialty care impractical in most humanitarian settings. US trainees are also critically deficient in exposure to basic and essential obstetrical, gynecological, and orthopedic care. New mechanisms for obtaining relevant surgical skills must be developed to better prepare the many American surgical trainees who now express a profound interest in humanitarian work as part of their professional careers.

Notes

Acknowledgements

The following individuals participated in a previously published paper on MSF case volumes. This analysis relied heavily upon their prior work: Evan Wong MD, Shailvi Gupta MD, and Gilbert Burnham MD PhD.

Compliance with ethical standards

Conflicts of interest

There are no financial or personal relationships which could potentially and inappropriately influence this work and conclusions.

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Copyright information

© Société Internationale de Chirurgie 2017

Authors and Affiliations

  • Yihan Lin
    • 1
    • 2
  • James S. Dahm
    • 2
    • 3
  • Adam L. Kushner
    • 4
    • 5
  • John P. Lawrence
    • 6
    • 7
  • Miguel Trelles
    • 8
  • Lynette B. Dominguez
    • 8
  • David P. Kuwayama
    • 1
  1. 1.Department of SurgeryUniversity of Colorado DenverAuroraUSA
  2. 2.Program in Global Surgery and Social ChangeHarvard Medical SchoolBostonUSA
  3. 3.University of Wisconsin School of Medicine and Public HealthMadisonUSA
  4. 4.Surgeons OverSeasNew YorkUSA
  5. 5.Center for Humanitarian Health, Johns Hopkins Bloomberg School of Public HealthBaltimoreUSA
  6. 6.Maimonides Medical CenterBrooklynUSA
  7. 7.Médecins Sans Frontières (MSF-USA)New YorkUSA
  8. 8.Médecins Sans Frontières (MSF), Operational Center - BrusselsBrusselsBelgium

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