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Improving Surgical Care in Cambodia through American Surgical Resident Rotations

  • November 02, 2016
  • Medical Outreach Exchange, Surgical Focus

Elliott Brender, MD

In 2008 I joined a People to People’s Ambassador’s Tour of Vietnam and Cambodia with a group of other surgeons to evaluate surgical care and make associations with other surgeons from around the world. Because I had previously served in Vietnam I was interested in seeing what changed since 37 years ago.

We were asked to bring donations. Old medical journals, books, educational materials were suggested. I decided to bring an interactive CD I wrote called “Avoiding Complications during Laparoscopic Cholecystectomy” as my donation. Unfortunately when I got to Cambodia there was no laparoscopic surgery. There were no staplers. Everything was hand sewn. What I brought was of no real value although academically interesting.

So I inquired about mesh and that began multiple missions to Cambodia bringing supplies, teaching at their medical schools, attending their clinics, operating on patients with surgical problems, and doing public service announcements. Eventually laparoscopic equipment was obtained but no one knew how to use it. In 2009 I hooked it all up and did the first ever laparoscopic cholecystectomies in Cambodia. However more recently all the equipment was either broken or wore out and the program is now defunct. On my next mission I will restart the program. And therein lies the problem. I do a lot of good for those I can help and teach but once I leave things tend to revert back to the status quo.

How do we solve this? Is there a way to provide continuous surgical care? Can we provide a continuous influx of supplies? Can we replace what is broken? Can we teach the Cambodian doctors and nurses proper maintenance so things don’t get broken in the first place? We all have family and our visits can only be for a limited period of time. There is always so much more to do than we can possibly fix in our short visits. But maybe here is an answer.

In the United States surgical residents are complaining that on completion of training they do not feel adequately trained with confidence to handle practicing surgery in private practice. The American College of Surgeons has gone so far as to suggest adding an additional two years to an already five year program, a surgical preceptorship to get more responsibility. Whether this approach will work remains to be seen.

My idea is to rotate our American Surgical Residents to Cambodia. The rotation would be one month. We would also rotate a senior surgeon, retired or about to retire, with a lot of experience but who doesn’t quite want to quit yet. The surgical resident would have a surgical clinic, see and schedule patients, do ER & trauma call, and essentially would totally be in charge. Let’s also rotate a senior surgeon, someone either retired or near retirement age, with significant experience. Many are fed up with malpractice, billings, collections, electronic records, etc. They just want to practice surgery. The senior attending would be there to assist, to consult, to proctor and monitor the resident.

A win – win for everybody. So how does one accomplish this? The Residency Review Committee (RRC), a division of the American Board of Surgery (ABS) has strict regulations and a formal application process. The resident must be fully funded (which is why until now sponsorships were from individual residency programs). What this means is you must provide international airfare, local transportation (tuk-tuk personal driver), accommodations in a safe neighborhood, meals (usually breakfast), health insurance, evacuation insurance. A supervising physician is required who is approved by the ABS to monitor and proctor. Full documentation of the experience would be kept to meet requirements by the American College of Surgeons (ACS), the ABS, and the RRC.

On the Cambodian side, a license is not required. This may differ from country to country but in Cambodia no license is required as long as you are approved by the hospital director where you will be working and you provide all your services for free. A Memorandum of Understanding will be worked out with the involved hospital. The MOU should specify where, when, and what you plan to provide, i.e. cover clinics, operate in the OR, integrate into the existing system with ER backup, trauma call, etc., teaching and conference participation.

I envision the resident will arrive, get settled in, meet with the supervising physicians, and start in surgery clinic. All cases will be his or hers to treat appropriately which means going to the OR and operating where appropriate. The resident will integrate into ER/trauma call and provide support alongside Cambodian surgeons. The rotating resident and the attending would bring in donations so a continued supply of needed materials could be obtained.

American surgical residents get cases and confidence, Cambodia gets quality care on a continuous basis.