American surgeons poorly prepared for humanitarian operations

(Reuters Health) - A Haitian physician taught American-trained vascular surgeon Dr. David Kuwayama how to perform C-sections in a Caribbean clinic, and a Congolese surgeon taught him other basic surgical procedures in an African war zone.

“It is the norm - not the exception - that when we go abroad, the non-American surgeons are teaching the American surgeons how to do numerous things,” said Kuwayama, who regularly serves on humanitarian missions for the medical aid group Medecins Sans Frontieres (MSF), known in the U.S. as Doctors Without Borders.

Kuwayama and other American surgeons who volunteer overseas have faced a consistent and growing mismatch between their training and the basic surgical needs of people they treat outside the U.S.

A new study confirms their suspicions: ever-more specialized American surgical training programs fail to teach young surgeons how to deliver babies by C-section, how to repair broken bones or many of the other skills frequently needed in areas stricken by wars, earthquakes and other disasters.

Two-thirds of major surgeries performed in MSF projects were procedures that most general surgical residents never learn in the U.S., according to the report in the World Journal of Surgery, online August 4.

Cesarean sections, for example, were the most common surgery in MSF projects, the study found. But the average general surgery resident reported graduating without ever having delivered a baby by C-section.

“C-sections, the single most life-saving operation performed in most humanitarian missions, is never performed - not even once - by American graduates,” said Kuwayama, the study’s senior author and a professor at the University of Colorado Denver in Aurora. “That number is shocking.”

Kuwayama and his team compared logs of cases performed by U.S. surgical residents with cases performed at MSF facilities. Fewer than half of the procedures U.S. surgical trainees performed were relevant to surgical practice in MSF projects.

American general surgery residents are critically deficient in exposure to obstetrical, gynecological and orthopedic care - essential skills in humanitarian operations, the study found.

Dr. Sherry Wren, professor of surgery at Stanford University School of Medicine in California, has witnessed the mismatch while working as a surgeon in sub-Saharan Africa.

“This mismatch has been accelerated over the last 20-plus years,” Wren, who was not involved with the study, said by email. Sub-specialization has exacerbated the problem, she said, along with American surgeons’ use of high-tech devices absent from MSF clinics.

A power tool used to perform a skin graft in the U.S. won’t be available in South Sudan, Kuwayama said.

“You’re not going to have power tools to do an array of things like a skin graft,” he said in a phone interview. “The tools may be lower tech. It doesn’t mean they’re easier to use. They may be more difficult to use.”

Pediatric surgeon Dr. John Lawrence, president of the board of directors of MSF-USA, has been working with a group exploring ways to better prepare newly trained surgeons to work in austere settings.

His group is considering establishing MSF training programs, lasting from three weeks to three months, to expose surgeons to procedures identified as absent from their training, Lawrence, a co-author of the study, said by email.

Short, one- to three-day, courses, like one Wren runs at Stanford to prepare surgeons for humanitarian missions, can help address the problem, Wren and Kuwayama said.

But the demand for short courses far outstrips their availability, and short courses can only pack in so much.

“There is no easy fix as surgeons become more specialized,” Wren said.

“The definition of general surgery has continued to narrow over the years,” Kuwayama said. “Pretty much every organ system has been co-opted by specialists.”

While that benefits American patients who need a specialist like Kuwayama to perform complicated endovascular thoracic surgery, when U.S. surgeons work overseas, they come up short, he said.

Despite their lack of training, most U.S. medical students and surgical residents say they want to work abroad, he said.

“But the problem is we are not training people to be fully functioning participants in the kinds of projects they’ve expressed a desire to participate in,” he said.


World J Surg 2017.