February 15, 2024 • 22 mins
In this episode, Lillian Erdahl, MD, FACS, is joined by Erin M Scott, MD, MPH, from the University of Massachusetts Chan Medical School. They discuss Dr Scott’s recent study, which outlines recommendations of the American College of Surgeons Resident and Associate Society Global Surgery Work Group for involvement of trainees in global surgery, with an aim to support equitable, sustainable collaborations that center on improving access to safe, timely, and affordable surgical care for the global community.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:03):
You are listening to The Operative Word,
a podcast brought to you by the Journalof the American College of Surgeons.
I'm Dr.
Lillian Erdahl,and throughout this series, Dr.
Tom Vargheseand I will speak with recently
published authors about the motivationbehind their latest research
and the clinical implicationsIt has for the practicing surgeon.
The opinions expressed in this podcastare those of the participants
(00:26):
and not necessarilythat of the American College of Surgeons.
Welcome to The Operative Word,
the podcast of the Journalof the American College of Surgeons.
I'm Dr. Lillian Erdahland I'm here with Dr.
Erin Scott,who is lead author on Practical
and Ethical Guidelines for the Involvementof Trainees in Global Surgery.
(00:49):
Consensus Statement and Recommendationsfrom the Resident and Associate Society
of the American College of SurgeonsGlobal Surgery Working Group.
So welcome, Dr. Scott.
Thank you.
I have no disclosuresregarding this paper.
Okay.
Well, I am really interested
in hearing sort of how this consensusstatement came about.
If you can just take us througha little bit of the background of the need
(01:13):
to have the statement and some guidanceon trainees in global surgery.
Sure.
So, I mean, trainee interestin global surgery has really rise
pretty steadilyover the last several years.
It kind of goes back to 2015with the Lancet Commission's initial paper
on global surgery and targets for 2030that stated about 5 billion people
(01:34):
around the globe lack access to safe,timely and affordable surgical care.
And that vast burden is concentratedin the world's low
and middle income countries.
So for the last decadeor so since that paper came out,
there's been a very, as I said, steadily
rising interest from traineesin getting involved in global surgery.
(01:55):
Some of the
needs as far as the Lancet Commissionhas addressed involved
scaling up the global surgeryworkforce and infrastructure.
And so I think it's kind of a natural fitfor the rising trainees
and the next generation of global surgeonsto really kind of fit that,
to fill that void.
So providing access to care
(02:15):
is kind of one of the concernsthat's driving that.
The interest in global surgeryand also the need to have consensus around
how to approach that for the safety
of patients and surgeons.
Tell me a little bitabout some of the ethical issues
for involvement of traineesin global surgery.
(02:37):
Sure.
So there have been a lot of callsin the last year or so about the
the colonialist thoughtsbehind global surgery
and the unequal power dynamicsin high income countries.
And low to middle-income countries.
And so I think the fact thatthese conversations are still taking place
and the fact that this is still such a hot
topic suggests that these standardsaren't consistently being met.
(02:58):
So that was one of the driving forces,obviously, behind this paper.
And in putting out a set
of official guidelines from our groupregarding trainee involvement.
Some of the specific ethical issueswould involve things like
a trainee traveling, a studentor a trainee traveling to another country
without the same kind of objectivesor educational oversight
(03:19):
that we might have herewith our own training programs.
Perhaps there are different scopesof practice in other countries
with their trainees,so trainees in other countries
might be allowed to do a widervariety of things than we would be here.
For instance, I'ma general surgery resident
and if I were to maybe go to a differenttraining program in a different country,
those trainees might be doing more thingssuch as caesarean sections,
(03:42):
treatments of open fractureor orthopedic surgeries, urologic
surgeries, things that I'm not necessarilytrained to do here in my own program.
And without the same kind of oversightthat I might have
with one of my own attending surgeons,I might be expected
to perform proceduresthat I'm quite frankly not trained to do.
So there's you know,
that's one of the ethical dilemmasas far as just scope of practice, really.
(04:05):
And some of the other things involve,
you know,
issues with informed consent, issues
with people posting pictures onlinewithout consent
from people that they're operating onin other countries
and going on those kinds of lines, too.
But a lot of the big ones have to dowith really the scope of practice
of the different trainees involved.
(04:27):
And when you touch on, you know, thethe privacy issue,
I mean, I think there may be differentlaws and policies
around privacy, butI think the ethical concerns are the same.
And we see that as a concern herein the United States as well.
You know that with the rise of all of ourdigital technology and social media,
(04:47):
we need extra attention
to how we maintain patient privacy.
What what are some of the solutionsor what are the, you know,
kind of boundaries aroundhow we then protect trainees and ensure
that there's infrastructure in placeso that we know what to expect.
If you're someone traveling, you know, to
(05:09):
participate in global surgeryas a trainee or student.
So one of the biggest partsof these domains that we set forth
in our training guidelinesobviously is preparedness.
That's the first domainthat we talk about.
So the importance of adequate preparationof global surgery trainees
prior to any kind of rotationabroad really can't be overstated.
And that involves thingssuch as being familiar with the language,
(05:31):
the customs,the standards of their destination.
It also involves setting forth
educational objectives and their rolewhen they travel abroad
and having that kind of in placeso that everyone knows what to expect.
The ACGMEdoes actually have an approval process
for international rotations,and the reason why I bring this up is
(05:51):
sometimesresidents might travel abroad with
the thought that they will be operatingand working with other surgeons.
But the ACGME put out this statementbefore ours,
and it is much more practically focusedregarding oversight.
And if you're going to be operatingin other countries
and you're going to be logging those casesand it's going to be an approved ACGME
(06:13):
official rotation,you really need to have an ACCME
or an ACS-verified surgeon with you toand for proper oversight, essentially.
And that's based on our kinds of standardsand for rotation objectives
that we have here in the Stateswith our training programs as well.
Well, I think it strengthens any consensus
statement to have another governing bodyagree with you or,
(06:37):
you know, at leasttouch on some of the same principles
and the way that our training programsare structured.
There certainly is quitea bit of oversight and a lot of attention
to oversightand safe surgery and supervision, which
I think again protects thepatient and the trainee both
to ensure
(06:57):
that the standard of careis being protected.
How how do people goabout 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 termsof what infrastructure does
or doesn't exist as you reviewwhat's been done in the past?
(07:20):
Yeah, I think that these guidelines,although they are practical
in some respects and they can be seenas some sort of a checklist in terms of,
you know, researching the siteahead of time, making sure that you have
safe lodging when you're there
and that kind of thingthat falls under preparedness.
I really think it's more of a documentfor trainees and students to to consider
and to really,
(07:42):
really hone in on before they travelwhile they're traveling
and also when they come backin terms of sustainability
and handing over the projectto 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
practicewhen they're engaging in global surgery
(08:02):
and thinking about all of these differentdomains, being prepared before they go,
thinking about sustainabilitywhen they come back,
thinking about collaborationin terms of longitudinal research
with other partiesand different countries.
And, you know, I think from therethe nitty gritty is something that we can
the nitty gritty details is somethingthat surgical trainees I think are good at
(08:23):
and they can figure those things out
based on people that have traveledto those countries before.
But I think it's a good reminder of thethe expectations
and the standards that we expectfor our trainees when they're traveling.
Well, so we talked a little bit about
preparedness.
And as you said, I think surgeons are
(08:43):
particularly focused on how to prepare.
And, you know, making a plan.
I was always taught that you shouldn'tbe making the plan
for surgery in the operating room.
You should really be settingthat out in advance
and you should have contingency plans.You know what?
If I get there and this arrangementfalls through, you know,
but what about when we are thinking
(09:06):
about the bigger picture, sort ofhow do we ensure that what we're doing
is respectful of the country
or traveling to the patientsthere, their medical community?
I think that falls under sortof the reciprocity and collaboration.
How do we think about our partners
in this global surgery effort?
(09:26):
I think one of the biggest thingsthat you could prepare for
in terms of eitherstarting a project, taking over a project,
or even just traveling for an operativerotation
is something that we doin all of our projects
that I've been involved in,which is a needs assessment
and the importance of a needs assessmentbefore you get started on
anything is to make sure that everyone'sneeds kind of align
(09:48):
and really prioritizing the local needs
of the host communitythat you're traveling to.
And so I think thatthat's always important to start with
some sort of needs assessmentto 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 herein the United States; a certain plan
(10:11):
or a certain idea, but it might not worksomewhere else that I'm not used to.
And I think also part of that
has to do with what you're talking aboutin terms of demonstrating flexibility.
And there have been plenty of timesthat we've been involved in projects
and you you get there and you dothe needs assessment.
You figure out what you know,
what local stakeholders, local surgeons,local academics or focused on.
(10:31):
And you get there and you find outit's just not going to work.
You both have the best of intentionsand you just really have to have,
I think, an open mind for change.
And the idea
that iterative review is absolutelyessential and a lot of these processes
and being able to adaptand being humble about it and saying,
you know what,this isn't working for either party.
(10:52):
Whoever whoever brings up the concernsand being able to pivot
and restart or refocusI think is incredibly important.
Well,you bring up a point that in all research
we might start out with an ideaor 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 thosebecause they sound like failures
(11:17):
as opposed to partof this iterative process
to get to somethingthat is going to be successful and,
you know, is going to workfor everyone involved.
And maybe, you know,even when we try to be we're unrealistic
about what we can do in a given timeframe or with given resources.
(11:39):
What have you learned in terms of that?
I mean, is there a way to set yourself upfor success
in advance?
Do you spend a lot of time communicatingback and forth before you travel?
How do you kind of approachthat to make sure that all parties
are involved in making a planthat will work?
(12:01):
I think that obviously communicationis absolutely essential,
and I would say that it's essentialbefore, during and after, really.
And that's the key to these global surgerycollaborations is building
a relationshipthat's going to stand not only the stress,
the test of distance,but like the test of time,
something that I learned actuallydoing a lot of this research
(12:22):
during the pandemic was that maintaining
those relationships are absolutelyessential is the core to any project.
We spent two years on one of my projectsmeeting
virtually over Zoom during COVIDbecause 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.
(12:45):
I mean, obviouslywe had worked with them for several years,
but it felt like we knew each otherjust by meeting virtually.
But I think establishing that trust
is incredibly important
because it allows both partiesto be honest when something isn't working.
And there were there was a time actuallyin one of my last projects
where something to do with our needsassessment really just wasn't working.
And I think that if we didn'thave that trust
(13:06):
in that established relationshipof working really well together,
I think that the project probablywould 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 hada really good relationship going
and allowed themto bring their concerns to us
and we pivoted and we worked on a solutionthat was going to work for everybody.
(13:27):
And then in terms of communication,moving forward, I think that these
these global surgerycollaborations really depend
on these long lasting partnerships.
There's a reason why people sign
memoranda of understanding and contractsand all of this kind of stuff
because everyone wants it towork and to last a long time.
And I think recognizing
that building those relationshipstakes respect on both sides.
(13:49):
It takes time.
It takes continued investmentover and over
really explainsa lot of the longitudinal side
of global surgery in terms of traineestaking over projects from each other
and setting up the next personthat's going to go after you for success
and continuing communication both withthe people that are going to follow you.
(14:10):
So traineesthat are going to take over my projects,
but also making sure that they havethe contacts that they need in the host
site as well to continue that relationshipmoving forward.
That gives me a viewinto 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
(14:30):
a team, to build communicationand that open communication,
you know, and I think
even just going inwith the intent of sustainability
made a lot of sense to me, but alsoI think is something that I don't hear
people thinking about when they're firstgetting into global surgery or when they
(14:51):
you know, when I hearespecially from students who are hoping
to make that part of their trainingor part of their career, that they just
haven't thought about the factthat this is most of these relationships
end up being long term, and particularlyif there's going to be
a reciprocal benefit
from the investment of timeon the side of both parties
(15:13):
that, you know, doing a short projectin 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 principlesor the focus on global surgery
(15:35):
to really make a long term impacton the lack of access to care?
How can we invest
in global surgery or in
addressingthis lack of access to surgical care?
I think that your point on sustainabilityreally is the crux here.
And when I was first getting startedin global surgery, one of my mentors
(15:58):
explained it very beautifully to methat I still think about quite often.
And the goal when you're you're startingand developing these long term
relationship is to always keepin the back of your mind that the goal is
that hopefully someday you're no longerneeded, right?
These short-termmission trips are wonderful
and they can offloada lot of surgical volume for places.
(16:22):
But I think that honing inon sustainability
and keeping in mindthat the goal is to serve the whole local
system, serve the servethe infrastructure, build the workforce
for the long termby teaching skills, setting up registries
that trainees and different academicsin other places can help manage,
providing education,improving access to resources.
(16:43):
These are all important thingsso that hopefully the goal is that,
you know, eventually the local surgeons
and local traineescan 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 thatmaybe they want additional training.
(17:04):
With laparoscopy, you have over a periodof a couple of years
building their systemfor training, for laparoscopy.
You send a couple of surgeons down,
help the attending surgeonslearn laparoscopic skills.
You help them maybe provide
a couple of laparoscopic box trainersso that the trainees can start learning.
You train the trainer,you train the attending surgeon,
then how to train their trainees,
(17:25):
and then hopefully over the periodof a couple of years
you have enough attending surgeonsthat are skilled in laparoscopy.
They have the resources that they need.
Hopefully by that timewith some additional assistance
and they're training their own traineeson laparoscopy.
And so within a couple of yearsyou have hopefully completed that circle
of nowthey can continue training their own.
And then maybe by that point you have sucha well-established relationship
(17:49):
that you've established another need.
Maybe the, you know,maybe there's something else going on
and they would like better supportin managing a trauma registry.
And so hopefully with thesewell-established collaborations,
the the goal post is always moving,I think.
And so I think that that'sone of the important things
to think about sustainabilityis that this isn't 10 years
(18:11):
of just coming down to operatefor a week at a time and then leaving.
This is years and years of investmentin a relationship
and a collaboration where, as I said,the goalpost is always moving.
You have different goals every time andhopefully you're checking the boxes and
and helping get people set up for successfor the long term.
I love the look at the long termand again, look at, you know,
(18:34):
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 timeto host people coming or to collaborate.
And I think a
lot about surgical disease
when we talk about access to careand the global burden of surgical disease,
(18:54):
you know, it's not always a one-timevisit or,
you know, the the 60 days of recoveryafter your surgery.
Patients who have abdominalsurgeries can have obstructive
symptoms in the future and needadditional surgeries or need follow up.
And I think that sometimes
those outside of the surgical communityforget that surgical diseases
(19:16):
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 endon, Dr.
Scott, is what is your adviceto surgeons who are interested
(19:37):
or students who are interestedin getting involved in global surgery?
I understand you pursued a master'sin public health as part of your training.
How can people startif they want to get involved in this area?
I think that there are certainlya lot more resources
now than when I started getting involvedin global surgery, which is right around
(19:59):
the time of the Lancet paper,really around 2015, as many of the current
trainees and currentattendings can probably attest to.
I think the biggest thing for methat I can suggest to others
would be to find a mentor.
And that mentor can be an attendingsurgeon or it can be another resident.
Finding a mentor to helpkind of guide you in that process.
Someone who shares the same passionsthat you have, someone
(20:22):
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 thingsthat did come out of
the pandemic is our ability to networkvirtually.
Your mentor
no longer has to be someone at your ownmedical school, in your own program.
I have mentors all over the country that Ithat I consider as part of my network,
(20:44):
and that's based off of,you know, getting involved on
different kind of social mediaand things like that.
I think the other thing that you can dois that there are quite a few groups
that are very well establishednow that are involved in global surgery.
The one that I led the task force forfor this paper
is the Resident and Associate Societyof the American College of Surgeons.
(21:05):
We have a global surgeon
workgroup that's actually now on its wayto becoming its own committee,
but it is accessible to trainees
all over the country and actuallyinternational trainees as well.
You become a member of the RAS ACSand you can just ask to be involved
in the mailing list and you can joinanyone can join the meetings.
And I think that that really openeda huge world for me in terms of
(21:28):
being involved in global surgery.
I joined one of the meetingsand people were working on projects
all over the country,all over the world, different trainees,
as I said, here in the United Statesand internationally,
and just joining the meetingsand reaching out to people
and people asking for volunteersto help with things really helped
expand my network and certainly expandmy experience in global surgery.
(21:49):
And so I think a lot of
that is much more accessible now than evenit was probably a decade ago.
And the fact that your networkcan open up a huge world
for you virtually, to be quite honest.
And so I think in
finding a mentor and getting involvedin some of those organizations
and some of those smallercommittees really can help
(22:10):
and theycan help you find a mentor as well.
So wonderful.
Thank you, Dr.
Scott, for taking the time to tell usa little bit more about the research
and the ideas behind your consensusstatement and for the work that you do.
Thank you so much for having me.
Thanks for your time.
Thank you for listening
to the Journal of the American Collegeof Surgeons Operative Word podcast.
(22:34):
If you enjoyed today's episode,spread the word on social media
by using the hashtag #JACSOperativeWord.
Subscribe to the operative wordwherever podcasts are available
or listen on the American Collegeof Surgeons website at FACS.org/podcast.
You are listening to The Operative Word,
a podcast brought to you by the Journalof the American College of Surgeons.
I'm Dr.
Lillian Erdahl,and throughout this series, Dr.
Tom Vargheseand I will speak with recently
published authors about the motivationbehind their latest research
and the clinical implicationsIt has for the practicing surgeon.
The opinions expressed in this podcastare those of the participants
(00:26):
and not necessarilythat of the American College of Surgeons.
Welcome to The Operative Word,
the podcast of the Journalof the American College of Surgeons.
I'm Dr. Lillian Erdahland I'm here with Dr.
Erin Scott,who is lead author on Practical
and Ethical Guidelines for the Involvementof Trainees in Global Surgery.
(00:49):
Consensus Statement and Recommendationsfrom the Resident and Associate Society
of the American College of SurgeonsGlobal Surgery Working Group.
So welcome, Dr. Scott.
Thank you.
I have no disclosuresregarding this paper.
Okay.
Well, I am really interested
in hearing sort of how this consensusstatement came about.
If you can just take us througha little bit of the background of the need
(01:13):
to have the statement and some guidanceon trainees in global surgery.
Sure.
So, I mean, trainee interestin global surgery has really rise
pretty steadilyover the last several years.
It kind of goes back to 2015with the Lancet Commission's initial paper
on global surgery and targets for 2030that stated about 5 billion people
(01:34):
around the globe lack access to safe,timely and affordable surgical care.
And that vast burden is concentratedin the world's low
and middle income countries.
So for the last decadeor so since that paper came out,
there's been a very, as I said, steadily
rising interest from traineesin getting involved in global surgery.
(01:55):
Some of the
needs as far as the Lancet Commissionhas addressed involved
scaling up the global surgeryworkforce and infrastructure.
And so I think it's kind of a natural fitfor the rising trainees
and the next generation of global surgeonsto really kind of fit that,
to fill that void.
So providing access to care
(02:15):
is kind of one of the concernsthat's driving that.
The interest in global surgeryand also the need to have consensus around
how to approach that for the safety
of patients and surgeons.
Tell me a little bitabout some of the ethical issues
for involvement of traineesin global surgery.
(02:37):
Sure.
So there have been a lot of callsin the last year or so about the
the colonialist thoughtsbehind global surgery
and the unequal power dynamicsin high income countries.
And low to middle-income countries.
And so I think the fact thatthese conversations are still taking place
and the fact that this is still such a hot
topic suggests that these standardsaren't consistently being met.
(02:58):
So that was one of the driving forces,obviously, behind this paper.
And in putting out a set
of official guidelines from our groupregarding trainee involvement.
Some of the specific ethical issueswould involve things like
a trainee traveling, a studentor a trainee traveling to another country
without the same kind of objectivesor educational oversight
(03:19):
that we might have herewith our own training programs.
Perhaps there are different scopesof practice in other countries
with their trainees,so trainees in other countries
might be allowed to do a widervariety of things than we would be here.
For instance, I'ma general surgery resident
and if I were to maybe go to a differenttraining program in a different country,
those trainees might be doing more thingssuch as caesarean sections,
(03:42):
treatments of open fractureor orthopedic surgeries, urologic
surgeries, things that I'm not necessarilytrained to do here in my own program.
And without the same kind of oversightthat I might have
with one of my own attending surgeons,I might be expected
to perform proceduresthat I'm quite frankly not trained to do.
So there's you know,
that's one of the ethical dilemmasas far as just scope of practice, really.
(04:05):
And some of the other things involve,
you know,
issues with informed consent, issues
with people posting pictures onlinewithout consent
from people that they're operating onin other countries
and going on those kinds of lines, too.
But a lot of the big ones have to dowith really the scope of practice
of the different trainees involved.
(04:27):
And when you touch on, you know, thethe privacy issue,
I mean, I think there may be differentlaws and policies
around privacy, butI think the ethical concerns are the same.
And we see that as a concern herein the United States as well.
You know that with the rise of all of ourdigital technology and social media,
(04:47):
we need extra attention
to how we maintain patient privacy.
What what are some of the solutionsor what are the, you know,
kind of boundaries aroundhow we then protect trainees and ensure
that there's infrastructure in placeso that we know what to expect.
If you're someone traveling, you know, to
(05:09):
participate in global surgeryas a trainee or student.
So one of the biggest partsof these domains that we set forth
in our training guidelinesobviously is preparedness.
That's the first domainthat we talk about.
So the importance of adequate preparationof global surgery trainees
prior to any kind of rotationabroad really can't be overstated.
And that involves thingssuch as being familiar with the language,
(05:31):
the customs,the standards of their destination.
It also involves setting forth
educational objectives and their rolewhen they travel abroad
and having that kind of in placeso that everyone knows what to expect.
The ACGMEdoes actually have an approval process
for international rotations,and the reason why I bring this up is
(05:51):
sometimesresidents might travel abroad with
the thought that they will be operatingand working with other surgeons.
But the ACGME put out this statementbefore ours,
and it is much more practically focusedregarding oversight.
And if you're going to be operatingin other countries
and you're going to be logging those casesand it's going to be an approved ACGME
(06:13):
official rotation,you really need to have an ACCME
or an ACS-verified surgeon with you toand for proper oversight, essentially.
And that's based on our kinds of standardsand for rotation objectives
that we have here in the Stateswith our training programs as well.
Well, I think it strengthens any consensus
statement to have another governing bodyagree with you or,
(06:37):
you know, at leasttouch on some of the same principles
and the way that our training programsare structured.
There certainly is quitea bit of oversight and a lot of attention
to oversightand safe surgery and supervision, which
I think again protects thepatient and the trainee both
to ensure
(06:57):
that the standard of careis being protected.
How how do people goabout 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 termsof what infrastructure does
or doesn't exist as you reviewwhat's been done in the past?
(07:20):
Yeah, I think that these guidelines,although they are practical
in some respects and they can be seenas some sort of a checklist in terms of,
you know, researching the siteahead of time, making sure that you have
safe lodging when you're there
and that kind of thingthat falls under preparedness.
I really think it's more of a documentfor trainees and students to to consider
and to really,
(07:42):
really hone in on before they travelwhile they're traveling
and also when they come backin terms of sustainability
and handing over the projectto 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
practicewhen they're engaging in global surgery
(08:02):
and thinking about all of these differentdomains, being prepared before they go,
thinking about sustainabilitywhen they come back,
thinking about collaborationin terms of longitudinal research
with other partiesand different countries.
And, you know, I think from therethe nitty gritty is something that we can
the nitty gritty details is somethingthat surgical trainees I think are good at
(08:23):
and they can figure those things out
based on people that have traveledto those countries before.
But I think it's a good reminder of thethe expectations
and the standards that we expectfor our trainees when they're traveling.
Well, so we talked a little bit about
preparedness.
And as you said, I think surgeons are
(08:43):
particularly focused on how to prepare.
And, you know, making a plan.
I was always taught that you shouldn'tbe making the plan
for surgery in the operating room.
You should really be settingthat out in advance
and you should have contingency plans.You know what?
If I get there and this arrangementfalls through, you know,
but what about when we are thinking
(09:06):
about the bigger picture, sort ofhow do we ensure that what we're doing
is respectful of the country
or traveling to the patientsthere, their medical community?
I think that falls under sortof the reciprocity and collaboration.
How do we think about our partners
in this global surgery effort?
(09:26):
I think one of the biggest thingsthat you could prepare for
in terms of eitherstarting a project, taking over a project,
or even just traveling for an operativerotation
is something that we doin all of our projects
that I've been involved in,which is a needs assessment
and the importance of a needs assessmentbefore you get started on
anything is to make sure that everyone'sneeds kind of align
(09:48):
and really prioritizing the local needs
of the host communitythat you're traveling to.
And so I think thatthat's always important to start with
some sort of needs assessmentto 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 herein the United States; a certain plan
(10:11):
or a certain idea, but it might not worksomewhere else that I'm not used to.
And I think also part of that
has to do with what you're talking aboutin terms of demonstrating flexibility.
And there have been plenty of timesthat we've been involved in projects
and you you get there and you dothe needs assessment.
You figure out what you know,
what local stakeholders, local surgeons,local academics or focused on.
(10:31):
And you get there and you find outit's just not going to work.
You both have the best of intentionsand you just really have to have,
I think, an open mind for change.
And the idea
that iterative review is absolutelyessential and a lot of these processes
and being able to adaptand being humble about it and saying,
you know what,this isn't working for either party.
(10:52):
Whoever whoever brings up the concernsand being able to pivot
and restart or refocusI think is incredibly important.
Well,you bring up a point that in all research
we might start out with an ideaor 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 thosebecause they sound like failures
(11:17):
as opposed to partof this iterative process
to get to somethingthat is going to be successful and,
you know, is going to workfor everyone involved.
And maybe, you know,even when we try to be we're unrealistic
about what we can do in a given timeframe or with given resources.
(11:39):
What have you learned in terms of that?
I mean, is there a way to set yourself upfor success
in advance?
Do you spend a lot of time communicatingback and forth before you travel?
How do you kind of approachthat to make sure that all parties
are involved in making a planthat will work?
(12:01):
I think that obviously communicationis absolutely essential,
and I would say that it's essentialbefore, during and after, really.
And that's the key to these global surgerycollaborations is building
a relationshipthat's going to stand not only the stress,
the test of distance,but like the test of time,
something that I learned actuallydoing a lot of this research
(12:22):
during the pandemic was that maintaining
those relationships are absolutelyessential is the core to any project.
We spent two years on one of my projectsmeeting
virtually over Zoom during COVIDbecause 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.
(12:45):
I mean, obviouslywe had worked with them for several years,
but it felt like we knew each otherjust by meeting virtually.
But I think establishing that trust
is incredibly important
because it allows both partiesto be honest when something isn't working.
And there were there was a time actuallyin one of my last projects
where something to do with our needsassessment really just wasn't working.
And I think that if we didn'thave that trust
(13:06):
in that established relationshipof working really well together,
I think that the project probablywould 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 hada really good relationship going
and allowed themto bring their concerns to us
and we pivoted and we worked on a solutionthat was going to work for everybody.
(13:27):
And then in terms of communication,moving forward, I think that these
these global surgerycollaborations really depend
on these long lasting partnerships.
There's a reason why people sign
memoranda of understanding and contractsand all of this kind of stuff
because everyone wants it towork and to last a long time.
And I think recognizing
that building those relationshipstakes respect on both sides.
(13:49):
It takes time.
It takes continued investmentover and over
really explainsa lot of the longitudinal side
of global surgery in terms of traineestaking over projects from each other
and setting up the next personthat's going to go after you for success
and continuing communication both withthe people that are going to follow you.
(14:10):
So traineesthat are going to take over my projects,
but also making sure that they havethe contacts that they need in the host
site as well to continue that relationshipmoving forward.
That gives me a viewinto 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
(14:30):
a team, to build communicationand that open communication,
you know, and I think
even just going inwith the intent of sustainability
made a lot of sense to me, but alsoI think is something that I don't hear
people thinking about when they're firstgetting into global surgery or when they
(14:51):
you know, when I hearespecially from students who are hoping
to make that part of their trainingor part of their career, that they just
haven't thought about the factthat this is most of these relationships
end up being long term, and particularlyif there's going to be
a reciprocal benefit
from the investment of timeon the side of both parties
(15:13):
that, you know, doing a short projectin 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 principlesor the focus on global surgery
(15:35):
to really make a long term impacton the lack of access to care?
How can we invest
in global surgery or in
addressingthis lack of access to surgical care?
I think that your point on sustainabilityreally is the crux here.
And when I was first getting startedin global surgery, one of my mentors
(15:58):
explained it very beautifully to methat I still think about quite often.
And the goal when you're you're startingand developing these long term
relationship is to always keepin the back of your mind that the goal is
that hopefully someday you're no longerneeded, right?
These short-termmission trips are wonderful
and they can offloada lot of surgical volume for places.
(16:22):
But I think that honing inon sustainability
and keeping in mindthat the goal is to serve the whole local
system, serve the servethe infrastructure, build the workforce
for the long termby teaching skills, setting up registries
that trainees and different academicsin other places can help manage,
providing education,improving access to resources.
(16:43):
These are all important thingsso that hopefully the goal is that,
you know, eventually the local surgeons
and local traineescan 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 thatmaybe they want additional training.
(17:04):
With laparoscopy, you have over a periodof a couple of years
building their systemfor training, for laparoscopy.
You send a couple of surgeons down,
help the attending surgeonslearn laparoscopic skills.
You help them maybe provide
a couple of laparoscopic box trainersso that the trainees can start learning.
You train the trainer,you train the attending surgeon,
then how to train their trainees,
(17:25):
and then hopefully over the periodof a couple of years
you have enough attending surgeonsthat are skilled in laparoscopy.
They have the resources that they need.
Hopefully by that timewith some additional assistance
and they're training their own traineeson laparoscopy.
And so within a couple of yearsyou have hopefully completed that circle
of nowthey can continue training their own.
And then maybe by that point you have sucha well-established relationship
(17:49):
that you've established another need.
Maybe the, you know,maybe there's something else going on
and they would like better supportin managing a trauma registry.
And so hopefully with thesewell-established collaborations,
the the goal post is always moving,I think.
And so I think that that'sone of the important things
to think about sustainabilityis that this isn't 10 years
(18:11):
of just coming down to operatefor a week at a time and then leaving.
This is years and years of investmentin a relationship
and a collaboration where, as I said,the goalpost is always moving.
You have different goals every time andhopefully you're checking the boxes and
and helping get people set up for successfor the long term.
I love the look at the long termand again, look at, you know,
(18:34):
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 timeto host people coming or to collaborate.
And I think a
lot about surgical disease
when we talk about access to careand the global burden of surgical disease,
(18:54):
you know, it's not always a one-timevisit or,
you know, the the 60 days of recoveryafter your surgery.
Patients who have abdominalsurgeries can have obstructive
symptoms in the future and needadditional surgeries or need follow up.
And I think that sometimes
those outside of the surgical communityforget that surgical diseases
(19:16):
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 endon, Dr.
Scott, is what is your adviceto surgeons who are interested
(19:37):
or students who are interestedin getting involved in global surgery?
I understand you pursued a master'sin public health as part of your training.
How can people startif they want to get involved in this area?
I think that there are certainlya lot more resources
now than when I started getting involvedin global surgery, which is right around
(19:59):
the time of the Lancet paper,really around 2015, as many of the current
trainees and currentattendings can probably attest to.
I think the biggest thing for methat I can suggest to others
would be to find a mentor.
And that mentor can be an attendingsurgeon or it can be another resident.
Finding a mentor to helpkind of guide you in that process.
Someone who shares the same passionsthat you have, someone
(20:22):
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 thingsthat did come out of
the pandemic is our ability to networkvirtually.
Your mentor
no longer has to be someone at your ownmedical school, in your own program.
I have mentors all over the country that Ithat I consider as part of my network,
(20:44):
and that's based off of,you know, getting involved on
different kind of social mediaand things like that.
I think the other thing that you can dois that there are quite a few groups
that are very well establishednow that are involved in global surgery.
The one that I led the task force forfor this paper
is the Resident and Associate Societyof the American College of Surgeons.
(21:05):
We have a global surgeon
workgroup that's actually now on its wayto becoming its own committee,
but it is accessible to trainees
all over the country and actuallyinternational trainees as well.
You become a member of the RAS ACSand you can just ask to be involved
in the mailing list and you can joinanyone can join the meetings.
And I think that that really openeda huge world for me in terms of
(21:28):
being involved in global surgery.
I joined one of the meetingsand people were working on projects
all over the country,all over the world, different trainees,
as I said, here in the United Statesand internationally,
and just joining the meetingsand reaching out to people
and people asking for volunteersto help with things really helped
expand my network and certainly expandmy experience in global surgery.
(21:49):
And so I think a lot of
that is much more accessible now than evenit was probably a decade ago.
And the fact that your networkcan open up a huge world
for you virtually, to be quite honest.
And so I think in
finding a mentor and getting involvedin some of those organizations
and some of those smallercommittees really can help
(22:10):
and theycan help you find a mentor as well.
So wonderful.
Thank you, Dr.
Scott, for taking the time to tell usa little bit more about the research
and the ideas behind your consensusstatement and for the work that you do.
Thank you so much for having me.
Thanks for your time.
Thank you for listening
to the Journal of the American Collegeof Surgeons Operative Word podcast.
(22:34):
If you enjoyed today's episode,spread the word on social media
by using the hashtag #JACSOperativeWord.
Subscribe to the operative wordwherever podcasts are available
or listen on the American Collegeof Surgeons website at FACS.org/podcast.
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