The Medical Mission and Modern Core Competency Training: A 10-Year Follow-Up of Resident Experiences in Global Plastic Surgery

Scoping Review of Ethical Discourse in Global Cleft Surgery Literature

BACKGROUND

The ethical discourse regarding the delivery of global surgical care has increased in the 21st century. The aims of this manuscript are to explore the differences in ethical domains in the global cleft surgical literature discussed by authors from high-income countries versus lower-middle-income countries and to elucidate changes in ethical discussions over the last decade.

METHODS

A thematic coding analysis was completed using NVivo 12 qualitative data analysis software. Articles were analyzed and coded for discussion of 24 distinct subdomains in the global cleft surgical literature from 1992 to 2022.

FINDINGS

The domains with the most significant discourse in the global cleft surgery literature found were (1) clinical care and delivery and (2) engagement in collaborations and partnerships. Furthermore, when manuscripts are first authored by low- and middle-income country (LMIC) authors, the subdomains of (1) level of visiting trainee supervision, (2) relevance of educational activities, and (3) patient/procedure/location selection increase in relative discourse. The impact of visiting trainees on local educational programs is the ethical subdomain that has the largest increase in the last decade. There are barriers to publication as evidenced by the exclusion of abstracts which included LMIC authors but did not result in publications in peer-reviewed journals.

CONCLUSIONS

A critical finding of this study is that the distribution of discussed ethical domains differs when LMIC authors are included as authors, in particular when primary authorship is from an LMIC author. To the authors' knowledge, there is no other study to date which has attempted this form of analysis.

Ethics in Global Plastic Surgery Missions

Background

Delivering ethical care in global plastic surgery is challenging due to the unique complexities of resource-limited settings. Additionally, the rise of medical tourism has highlighted the importance of informed consent and awareness of the potential risks that are associated with seeking medical care in foreign countries. This article aims to consider core medical ethics principles and apply them in the context of delivering global plastic surgery.

Methods

This article examines the application of the four core medical ethics principles in a framework set forth by Beauchamp and Childress, namely autonomy, beneficence, nonmaleficence, and justice, in the context of delivering plastic surgery in international settings. A literature review was performed, where all potential global plastic surgery articles were reviewed to better understand the application of the four core medical ethics framework in this context.

Results

Increased communication between visiting surgeons and local healthcare providers; heightened education of surgeons traveling to low-to-middle-income countries regarding local medical practices, resource availability, and cultural norms before providing surgical education; and a greater emphasis on collecting and publishing data analyzing short- and long-term outcomes in low-to-middle-income countries are all likely to improve the success of international medical missions, ensuring that all patients receive medical treatment in a manner that upholds Beauchamp and Childress' four core medical ethics principles.

Conclusion

Providing plastic and reconstructive surgery abroad can be done ethically if the four main principles of medical ethics (respect for autonomy, beneficence, nonmaleficence, and justice) are used.

Incorporating equity, diversity and inclusion (EDI) into the education and assessment of professionalism for healthcare professionals and trainees: a scoping review

BACKGROUND

Current definitions of professionalism for healthcare trainees often lack equity, diversity and inclusion (EDI) in the expectations and assessment of professionalism. While professionalism teaching is incorporated in healthcare training, equity-deserving groups still experience discrimination. This scoping review investigates the literature to understand how EDI and associated domains of cultural humility, and advocacy can be incorporated in healthcare trainees' education and assessment of professionalism.

METHODS

The Arksey and O'Malley framework was applied to this scoping review. MEDLINE, Embase & PsychINFO were searched up to March 2023, with terms surrounding health professionals, professionalism, EDI, cultural humility, and advocacy. Titles and abstracts (n = 3870) and full-texts (n = 140) were independently screened by two reviewers. Articles were included if they focused on EDI, cultural humility, or advocacy among healthcare students/trainees, and had outcomes related to professionalism. Articles lacking discussion of professionalism as an outcome were excluded. Themes were generated by mutual discussion. Risk of bias was assessed using the Cote et al. and Medical Education Research Study Quality Instrument (MERSQI) tools.

RESULTS

48 articles underwent thematic analysis. Studies investigated the disciplines of medicine, nursing, social work, physiotherapy, and dentistry. Most studies were qualitative in methodology (n = 23). Three themes emerged: (1) EDI-related interventions are associated with improved professionalism of healthcare trainees/workers (n = 21). Interventions employed were either an EDI-associated educational course (n = 8) or an exchange program to promote EDI competencies among trainees (n = 13). (2) Trainee definitions and perceptions of professionalism include themes related to EDI and cultural humility (n = 12). (3) Current standards of professionalism are perceived as non-inclusive towards historically-marginalized populations (n = 15). Literature investigating advocacy as it relates to professionalism is limited.

CONCLUSION

This review identified that core EDI principles and its associated domains of cultural humility and advocacy are often viewed as integral to professionalism. These findings create a strong impetus to incorporate EDI principles within professionalism frameworks in healthcare education. Future research should employ standardized tools for professionalism assessment to provide more conclusive evidence. Incorporating patient perspectives of professionalism can inform actionable recommendations for fostering inclusive healthcare environments.

Publishing Trends in International Humanitarian Cleft Lip and Palate Care: A Systematic Review

Background: Humanitarian outreach delivers essential cleft lip and palate (CLP) care in low- and middle-income countries. Objective: To review the literature regarding humanitarian CLP care and determine if a shift toward more sustainable care delivery is observed. Methods: A systematic review was performed on articles describing CLP repair in humanitarian settings from 1985 to 2020. Publications were categorized into trip reports, outcomes, teaching, and public health. Articles were stratified into three 12-year intervals (T1-T3) for analysis. Results: A total of 246 publications were included. Average annual publications increased 15.4-fold from T1 to T3 (p < 0.001). Among publications focused on delivering CLP-related care, descriptive trip report articles trended downward (58% in T1 vs. 42% in T3), whereas outcome-focused publications trended upward (42% in T1 vs. 58% T3). Public health research represented the greatest percentage of publications in T3 (50%). There were 22 teaching-related publications in T3 and only one in prior years. Conclusion: Research trends demonstrate a shift away from focusing solely on the number of surgical cases completed and toward more sustainable models of care delivery that address barriers to receiving longitudinal care.

The Implementation of International Electives for Plastic Surgery Residents: Current State and Future Directions

INTRODUCTION

Interest in international surgical missions has been rising exponentially, with the plastic surgery community being a leader in this endeavor. The role of residents in such missions remains a topic of debate. This systematic review aims to consolidate the literature relevant to the inclusion of plastic surgery residents on international surgical missions to devise an algorithm to facilitate resident participation.

MATERIALS AND METHODS

A comprehensive search of PubMed, Medline, and EMBASE was performed to identify studies relevant to plastic surgery resident involvement in the context of surgical missions. Relevant conclusions were retrieved from each study and compiled according to category.

RESULTS

Of 418 initial studies, 26 were retained for the qualitative synthesis. These were grouped into 3 categories: surveys (n=12), reflections (n=7), and reviews (n=7). The survey studies addressed the perceived value, educational impact, and long-term effect on participating residents. Three reflection studies were from the perspective of residents and 4 from staff, while all recounted the many benefits gained for participating residents. Review studies addressed the issue of accreditation and the ethics surrounding resident involvement.

CONCLUSION

This systematic review highlights the overwhelming support from residents and staff, the highly regarded educational value, and the positive global health effects associated with plastic surgery resident participation in international surgical missions. The authors hope this will encourage and facilitate the implementation of formal opportunities for residents within residency training programs.

Safety and Sustainability: Optimizing Outcomes and Changing Paradigms in Global Health Endeavors

Background

The need to address inequities in global surgical care has garnered increased attention since 2015, after the Lancet Commission on Global Surgery underscored the importance of ensuring safe, accessible, affordable, and timely surgical and anesthetic care. The vast unmet global plastic surgery needs make plastic surgery care essential in reducing the global burden of disease. In the past, many nonprofit organizations undertook humanitarian activities within low- and middle-income countries that were primarily service-provision oriented. The Lancet Commission on Global Surgery report prompted a shift in focus from direct patient care models to sustainable global surgical models. The realization that 33% of deaths worldwide were due to unmet surgical needs led to a global shift of strategy toward the development of local systems, surgical capacity, and a focus on patient safety and quality of care within international global surgery partnerships.

Methods

In this report, the authors explore some of the primary components of sustainable international global surgical partnerships discussed in a recent panel at the American Society of Plastic Surgeons Plastic Surgery The Meeting 2022, titled "Safety and Sustainability Overseas: Optimizing Outcomes and Changing Paradigms in Global Health Endeavors." A literature review elaborating the topics discussed was performed.

Results

This report focuses on cultural competence and humility, international collaboration, and the use of technology and innovation, all of which are needed to promote sustainability and patient safety, within global surgery efforts.

Conclusions

The adoption of these components into international surgical collaborations will lead to greatly enhancing the development and sustainability of mutually beneficial relationships.

How Consistent are International Rotations Between Plastic Surgery Training Programs?

Institutional partnerships between plastic surgery residency programs in the United States and providers in low- and middle-income countries can serve as bilateral and longitudinal capacity-building relationships. In the United States, obtaining approval for international rotations by a home institution and national review committee is highly encouraged but not required before resident international engagement. Acquiring approval at the institutional level is the first step to allow trainees to participate in international rotations on elective time rather than on vacation time. National approval through the American Council of Graduate Medical Education and American Board of Plastic Surgery allows cases to count toward the resident's yearly case log.

Methods

All 101 integrated and independent plastic surgery program directors/coordinators were asked to participate. The survey identified the requirements and details of existing international rotations.

Results

In total, 57 programs responded (56% response rate) to the survey. An estimated 54% of all programs offered international rotations to their residents, and 94% of these programs obtained institutional approval. Additionally, 69% of these programs have received national approval.

Conclusions

Institutional requirements for programs to provide international rotations vary significantly across institutions, which results in disparate experiences for residents and poses potential risks to international partners. This study will help promote transparency regarding international rotation requirements and better equip faculty to enhance international rotations that cater to the needs of the institution, residents, and most importantly, the host countries.

Global Cleft Lip and Palate Outreach: A Google Trends Analysis

Understanding patient awareness of cleft lip and/or palate (CL/P) and evaluating demand for necessary procedures may serve to better target future efforts in global outreach.

We utilized internet search query data from Google Trends for the terms: "cleft lip," "cleft palate," "cleft lip and palate," "cleft surgery," and "cleft repair" from January 2004 to January 2021. Relative search volumes (RSV) recorded for the top 5 highest displaying countries and top 3 available regions within those countries were compared against global outreach by Operation Smile and Smile Train, as measured by the number of patients treated. World Health Organization (WHO) indicators were used to validate the RSV values for each country and better understand the current infrastructure and need for cleft care in those countries.

Globally, there was an increase in RSV for the terms "cleft lip," "cleft palate," "cleft repair," and "cleft surgery" between 2004 and 2021. For "cleft lip," the countries with the highest displaying RSVs included: Ghana (100%), Zimbabwe (97%), Nepal (78%), the Philippines (64%), and Kenya (52%). Countries with high RSVs and moderate to high WHO indicators included Ghana, Kenya, India, Nigeria, and Zimbabwe. Countries with high RSVs and poor WHO indicators included Nepal and Pakistan. Some countries had specific regions with high search demand that are not currently targeted for global outreach.

Using Google Trends' data may help find more feasible locations and targeted care for efforts in global outreach with better patient awareness and turnout where demand for CL/P is increasing.

Considerations for Embedding Inclusive Research Principles in the Design and Execution of Clinical Trials

There is a growing recognition that the clinical research enterprise has a diversity problem, given that many clinical trials recruit historically marginalized individuals or patients reflective of real-world data at a rate that is far below the incidence and prevalence of the disease for which the investigational therapy or device is targeting. This lack of diversity in clinical research participation can obscure the safety and efficacy of drug therapies and limits our collective ability to develop effective treatments for all patients, leading to even wider health disparities. This review article provides an in-depth analysis of the impact of this bias on public health, along with a description of some of the barriers that prevent historically marginalized populations from participating in clinical research. Some practical solutions that can be employed to increase diversity in clinical trial participation are also discussed, including the crucial role clinical trial sponsors, research organizations, patients, and caregivers need to play in supporting the industry to achieve this ambitious but necessary goal.

The personal impact of involvement in international global health outreach: A national survey of former Operation Smile student volunteers

BACKGROUND

Humanitarian surgical organizations such as Operation Smile provide global health opportunities for students and medical trainees. Prior studies have shown a positive benefit for medical trainees. This study aimed to determine if the international global health experiences of young student volunteers impact their career choices as adults.

METHODS

A survey was sent to adults who were involved with Operation Smile as students. The survey elicited information about their mission trip experience, education, career, and current volunteer and leadership activities. Data were summarized with descriptive statistics and qualitative analysis.

RESULTS

114 prior volunteers responded. The majority participated in leadership conferences (n = 110), mission trips (n = 109), and student clubs (n = 101) while in high school. Many graduated from college (n = 113, 99%) and completed post-graduate degrees (n = 47, 41%). The most highly represented occupational industry was healthcare (n = 30, 26%), including physicians and medical trainees (n = 9), dentists (n = 5), and other healthcare providers (n = 5). Three-fourths reported that their volunteer experience impacted their career choice, and half reported that their experience allowed them to connect with career mentors. Their experience was associated with the development of leadership skills, including public speaking, self-confidence, and empathy, and increased awareness of cleft conditions, health disparities, and other cultures. Ninety-six percent continued to volunteer. Narrative responses revealed that the volunteer experiences impacted their inter- and intrapersonal development into adulthood.

CONCLUSIONS

Participation in a global health organization as a student may encourage a long-term commitment to leadership and volunteerism and foster interest in a healthcare career. These opportunities also encourage development of cultural competency and interpersonal skills.

LEVEL OF EVIDENCE

III, Cross-Sectional Study.

Mechanisms Driving Postgraduate Health and Social Science Students' Cultural Competence: An Integrated Systematic Review

PURPOSE

The COVID-19 pandemic revealed a global urgency to address health care provision disparities, which have largely been influenced by systematic racism in federal and state policies. The World Health Organization recommends educational institutions train clinicians in cultural competence (CC); however, the mechanisms and interacting social structures that influence individuals to achieve CC have received little attention. This review investigates how postgraduate health and social science education approaches CC and how it accomplishes (or not) its goals.

METHOD

The authors used critical realism and Whittemore and Knafl's methods to conduct a systematic integrated review. Seven databases (MEDLINE, CINAHL, PsycINFO, Scopus, PubMed, Web of Science, and ERIC) were searched from 2000 to 2020 for original research studies. Inclusion criteria were: the use of the term "cultural competence" and/or any one of Campinha-Bacote's 5 CC factors, being about postgraduate health and/or social science students, and being about a postgraduate curriculum or a component of it. Thematic analysis was used to reveal the mechanisms and interacting social structures underlying CC.

RESULTS

Thirty-two studies were included and 2 approaches to CC (themes) were identified. The first theme was professionalized pedagogy, which had 2 subthemes: othering and labeling. The second theme was becoming culturally competent, which had 2 subthemes: a safe CC teaching environment and social interactions that cultivate reflexivity.

CONCLUSIONS

CC conceptualizations in postgraduate health and social science education tend to view cultural differences as a problem and CC skills as a way to mitigate differences to enhance patient care. However, this generates a focus on the other, rather than a focus on the self. Future research should explore the extent to which insight, cognitive flexibility, and reflexivity, taught in safe teaching environments, are associated with increasing students' cultural safety, cultural humility, and CC.

Cleft Lip and Palate Repair Training to Bridge the Gap in Low-Income Countries

There is a significant unmet need for cleft repair in low-income countries. The procedure is challenging due to limited access, small fragile flaps, and the depth at which sutures need to be placed. The aim of this analysis is to review available literature pertaining to cleft lip and palate repair training, with a focus on those applicable to low-income countries.

Does International Surgical Mission Involvement During Residency Predict Involvement in Practice?

ABSTRACT

Despite efforts to incorporate global health rotations during residency, it is unclear whether this experience affects the likelihood that plastic surgeons will continue such missions during practice. The authors conducted a survey of the American Society of Plastic Surgeons and the American Council of Academic Plastic Surgeons members regarding the impact of international experiences before practice upon future involvement. 138 surveys were analyzed. Ten percent participated in missions before medical school, 13% during medical school, 53% in residency, and 61% in practice. Sixty-seven percent of surgeons in an academic practice continued to engage in international missions, versus 55% in nonacademic practices (P = 0.152). No significant difference in the number of surgeons participating in missions was found between those who had attended their first mission before starting practice instead of those starting in practice (P = 0.163). Surgeons who graduated recently were more likely to have attended a mission during residency (P = 0.015). Fifty-four percent of surgeons reported that a mentor initiated their interest in missions, and 44% reported that their involvement in missions had decreased over the last 5 years, with most citing a financial disincentive. Given that over 2/3 of plastic surgeons from all practice types participate in international missions, it would behoove residency programs to offer formal training in global health to facilitate this interest. Our study is the largest thus far attempting to quantify the downstream effects of surgical mission participation in residency and highlights the need for further inquiry into this matter.

Predictors of Complication Following Cleft Lip and Palate Surgery in a Low-Resource Setting: A Prospective Outcomes Study in Nicaragua

BACKGROUND

Higher rates of postoperative complication following cleft lip or palate repair have been documented in low resource settings, but their causes remain unclear. This study sought to delineate patient, surgeon, and care environment factors in cleft complications in a low-income country.

DESIGN

Prospective outcomes study.

SETTING

Comprehensive Cleft Care Center.

PATIENTS

Candidate patients presenting for cleft lip or palate repair or revision.

INTERVENTIONS

Patient anthropometric, nutritional, environmental and peri- and post-operative care factors were collected. Post-operative evaluation occurred at standard 1-week and 2-month postoperative intervals.

MAIN OUTCOME MEASURES

Complication was defined as fistula, dehiscence and/or infection.

RESULTS

Among 408 patients enrolled, 380 (93%) underwent surgery, of which 208 (55%) underwent lip repair (124) or revision (84), and 178 (47%) underwent palate repair (96) or revision (82). 322 (85%) were evaluated 1 week and 166 (44%) 2 months postoperatively. 50(16%) complications were identified, including: 25(8%) fistulas, 24(7%) dehiscences, 17(5%) infections. Mid-upper arm circumference (MUAC) ≤12.5 cm was associated with dehiscence after primary lip repair (OR = 28, p = 0.02). Leukocytosis ≥11,500 on pre-operative evaluation was associated with dehiscence (OR = 2.51, p = 0.04) or palate revision fistula (OR = 64, p < 0.001). Surgeons who performed fewer previous-year palate repairs had higher likelihood of palate complications, (OR = 3.03, p = 0.01) although there was no difference in complication rate with years of surgeon experience or duration of surgery.

CONCLUSIONS

Multiple patient, surgeon, and perioperative factors are associated with higher rates of complication in a low-resource setting, and are potentially modifiable to reduce complications following cleft surgery.

Rethinking Global Health Education in Plastic Surgery Residency

Surgical disease is now among the most common, preventable, and growing contributors to the global burden of disease. The attitudes of trainees toward global surgery and the viability of a global surgery as an academic track have blossomed. More optimized experiences within residency education are necessary, however, to prepare the next generation of global surgeons. The field of plastic surgery is thus at an important crossroads in the effort to incorporate global surgery into training programs in a uniform fashion across the country. The recent American Council of Academic Plastic Surgeons meeting in February 2020 was dedicated to identifying strategies that will enhance the adoption of global surgery practices within plastic surgery. In this article, we discuss the principles, themes, and ideas that emerged from this session, and further develop concrete initiatives believed to be potentially fruitful. Some have been discussed in other surgical disciplines or presented in isolation to the plastic surgery community, but never as a cohesive set of recommendations that take into account the background and shortfalls of the current model for global health education in the 21st century. We then introduce five recommendations to optimize learner education: (1) clarification of learner expectations and roles; (2) domestic teaching for optimization of field experiences; (3) expansion of longitudinal, formal rotations; (4) strengthening of the role of research; and (5) integration of program financing.

Leadership and surgical training part 1: preparing to lead the way?

Every day surgeons lead teams on the wards, in clinics and operating theatres, but most trainees and some surgeons do not consider themselves as leaders. Leadership skills are increasingly important for surgeons, who need knowledge of organizational structure and policy, management strategy and team dynamics to deliver and improve health care in resource-constrained environments. The Royal Australasian College of Surgeons recognizes leadership as one of 10 core surgical competencies but leadership curricula within surgical training programmes are not well defined. There is limited opportunity for formal leadership training and development prior to becoming a consultant.

Experiences and impact of international medical volunteering: a multi-country mixed methods study

OBJECTIVE

To assess the experience and impact of medical volunteers who facilitated training workshops for healthcare providers in maternal and newborn emergency care in 13 countries.

SETTINGS

Bangladesh, Ghana, India, Kenya, Malawi, Namibia, Nigeria, Pakistan, Sierra Leone, South Africa, Tanzania, UK and Zimbabwe.

PARTICIPANTS

Medical volunteers from the UK (n=162) and from low-income and middle-income countries (LMIC) (n=138).

OUTCOME MEASURES

Expectations, experience, views, personal and professional impact of the experience of volunteering on medical volunteers based in the UK and in LMIC.

RESULTS

UK-based medical volunteers (n=38) were interviewed using focus group discussions (n=12) and key informant interviews (n=26). 262 volunteers (UK-based n=124 (47.3%), and LMIC-based n=138 (52.7%)) responded to the online survey (62% response rate), covering 506 volunteering episodes. UK-based medical volunteers were motivated by altruism, and perceived volunteering as a valuable opportunity to develop their skills in leadership, teaching and communication, skills reported to be transferable to their home workplace. Medical volunteers based in the UK and in LMIC (n=244) reported increased confidence (98%, n=239); improved teamwork (95%, n=232); strengthened leadership skills (90%, n=220); and reported that volunteering had a positive impact for the host country (96%, n=234) and healthcare providers trained (99%, n=241); formed sustainable partnerships (97%, n=237); promoted multidisciplinary team working (98%, n=239); and was a good use of resources (98%, n=239). Medical volunteers based in LMIC reported higher satisfaction scores than those from the UK with regards to impact on personal and professional development.

CONCLUSION

Healthcare providers from the UK and LMIC are highly motivated to volunteer to increase local healthcare providers' knowledge and skills in low-resource settings. Further research is necessary to understand the experiences of local partners and communities regarding how the impact of international medical volunteering can be mutually beneficial and sustainable with measurable outcomes.

Healthcare providers' and managers' knowledge, attitudes and perceptions regarding international medical volunteering in Uganda: a qualitative study

OBJECTIVES

The study sought to explore the knowledge, attitudes and perceptions of healthcare providers and health programme managers regarding the benefits, challenges and impact of international medical volunteers' clinical placements. Views on how to better improve the work of international medical volunteers and the volunteer organisation Voluntary Service Overseas (VSO) for the benefit of local communities were also explored.

SETTINGS

Public healthcare facilities, VSO offices in Gulu and VSO offices in Kampala, Uganda.

PARTICIPANTS

Ugandan healthcare providers (n=11) and health programme managers (n=6) who had worked with or managed international medical volunteers.

INTERVENTIONS

Data collection was conducted using key informant interviews. Transcribed interviews were coded by topic and grouped into categories. Thematic framework analysis using NVivo identified emerging themes.

RESULTS

Both healthcare providers and managers reported a beneficial impact of volunteers and working with the volunteer organisation (clinical service provision, multidisciplinary teamwork, patient-centred care, implementation of audits, improved quality of care, clinical teaching and mentoring for local healthcare providers); identified challenges of working with volunteers (language barriers and unrealistic expectations) and the organisation (lack of clear communication and feedback processes); and provided recommendations to improve volunteer placements and working partnership with the organisation (more local stakeholder input and longer placements). Most healthcare providers were positive and recommended that volunteers are enabled to continue to work in such settings if resources are available to do so.

CONCLUSIONS

Healthcare providers based in a low-resource setting report positive experiences and impacts of working with international medical volunteers. Currently, there is lack of local feedback processes, and the establishment of such processes that consider local stakeholder reflections requires further strengthening. These would help gain a better understanding of what is needed to ensure optimal effectiveness and sustainable impact of international medical volunteer placements.

Diversity and Cultural Competency in Oral and Maxillofacial Surgery

Health disparities in the United States have been well documented over the past several decades and continue to affect the American population. As the world becomes more diverse, it is imperative that the health care professional workforce is trained to care for the diversifying patient population, striving to improve health disparities in the United States and worldwide. Improving the diversity within the health care professional workforce likely will aid in emphasizing the importance of cultural competency of health care professionals, with the development of programs aimed at cultural competency training and assessment.

Teledermatology and its Current Perspective

Teledermatology is one of the most important and commonly employed subsets of telemedicine, a special alternative to face-to-face (FTF) doctor--patient consultation that refers to the use of electronic telecommunication tools to facilitate the provision of healthcare between the "seeker" and "provider." It is used for consultation, education, second opinion, and monitoring medical conditions. This article will review basic concepts, the integration of noninvasive imaging technique images, artificial intelligence, and the current ethical and legal issues.

Guidelines for Short-Term Hand Surgery Outreach Trips: Building Trust and Establishing Continuity

Global outreach in hand surgery can be exceptionally rewarding for volunteers and their organizations, patients and their communities, and the host medical community. Success can be defined by individual cases that restore function and provide opportunities for a patient and family to contribute to society; however, the broader missions of medical collaboration, education, cultural exchange, and personal growth are critical factors toward building trust and establishing continuity of care for long-term success. Each outreach site and brigade encounters challenges; however, careful planning facilitates optimal conditions and reasonable expectations for enhancing outcomes.

Pilot Evaluation of the Impact of a Mission-Based Surgical Training Rotation on the Plastic Surgery Skills and Competencies Development of General Surgery Residents in Rwanda

OBJECTIVE

Increasing subspecialty surgical capacity in Rwanda requires innovative approaches to augment the skills of pre-existing surgical providers. Short-term, high-intensity training programs can be effective for surgical education, however, few studies have investigated the quality of skills acquired through a condensed surgical experience. This study aims to determine the efficacy of a 3-week surgical training rotation (STR) to teach plastic surgery skills to general surgery residents in Rwanda.

DESIGN

A survey-based, prospective observational study of general surgery residents and volunteer plastic surgery educators participating in an Operation Smile STR. Resident self-assessment scores of surgical capabilities at the beginning and end of the rotation were compared to surgeon evaluation of resident performance. Progression of resident performance and change in inter-rater reliability between residents and educators were analyzed. Student's t test with significance at p < 0.05 was used to confirmed statistical significance.

SETTING

This study took place during the Operaiton Smile STR at the Rwinkwavu District Hospital, a primary level hospital in Rwinkwavu, Rwanda.

PARTICIPANTS

All residents (5) and surgeon evaluators (4) who participated in the STR were included in this study. All study participants completed all study surveys.

RESULTS

Residents reported a significant increase in confidence with the majority of procedures performed by the end of the rotation. Surgeons identified significant improvement in all resident skills by 2 weeks (p < 0.05). Resident ability to perform self-assessment improved, as determined by a significant decrease in inter-rater error margin from -0.61 to -0.10 over the course of the rotation (p < 0.01).

CONCLUSIONS

In this pilot study, a 3 week rotation improved surgical competencies and technical skills of general surgery residents learning plastic surgery. These findings support using the short-term STR as a method for task-sharing education. Further studies are needed to determine durability of skills transfer and long-term impact on surgical capacity.

The Creation of a Sustainable Otolaryngology Department in Malawi

There is a significant lack of surgeons in the developing world. Malawi Africa is one of the poorest and medically underserved countries in the World, with surgical care particularly lacking. Providing surgical services has numerous barriers, such as availability of well-trained surgeons, infrastructure, continuity of care, and access to care. There is currently one otolaryngologist in Malawi who provides complete access to this subspecialty. The development of the otolaryngology department was successful through institutional, local, national, and international collaboration, with a long-term goal of sustainability. An established department can train the next generation of surgeons for the preservation and growth of the surgical workforce. Once the department approaches independence, the role of outside collaboration transforms primarily from financial to a bi-directional partnership encompassing education, training, and leadership.

Limited availability of global health opportunities in US orthopaedic trauma fellowship programs

Purpose

Orthopaedic residents are increasingly seeking international health electives (IHEs) during training, and many such experiences involve providing orthopaedic trauma care. However, little is known about the availability of IHEs during orthopaedic trauma fellowship training. The purpose of our study is to assess the global health opportunities available to US orthopaedic trauma fellows.

Method

We conducted an online, Research Electronic Data Capture (REDCap)-based survey of orthopaedic trauma fellowship program directors (PDs) in the United States. The survey link was sent by the Orthopaedic Trauma Association (OTA) Fellowship Committee to all US OTA-approved orthopaedic trauma fellowship PDs. Follow-up reminder e-mails were delivered at set time intervals from baseline over a period of 4 weeks.

Results

The overall response rate was 80% (43/54). Only 3 of 43 responding programs (7%) offer a structured global health program, but over the last 10 years, 12.5% of the remaining programs (5/40) have had a fellow participate in an IHE during fellowship training. Around 100% of PDs reported fellow satisfaction with their IHEs, and all PDs agreed that the educational experience provided by their fellows' IHE participation was valuable. Among programs with no recent fellow IHE participation and without a structured global health program, 9% of PDs (3/35) expect to institute such a program. Lack of funding, lack of established international partner sites, and fellow time away were the most common perceived barriers to IHE participation. A total of 54% of PDs agree that participation in an IHE during training plays a major role in shaping fellows' future professional and volunteer activities.

Conclusion

There are limited global health opportunities among US orthopaedic trauma fellowship programs, with only 7% (3/43) offering a structured global health program. Perceived barriers include lack of funding, lack of established partner sites, and concerns related to clinical/call coverage. Greater efforts to establish sustainable funding and international partnerships may increase opportunities for IHEs during orthopaedic trauma fellowship training.

Teledermatology and teledermatopathology as educational tools for international dermatology: a virtual grand rounds pilot curriculum

BACKGROUND

Teledermatology may improve dermatologic care access in underserved areas and expand the clinical experience of dermatologists-in-training. The potential for teledermatology to supplement global health curricula in dermatology residency education has not been explored.

METHODS

An international virtual grand rounds (VGR) curriculum was created based on teledermatology cases from Kabul, Afghanistan. The learning objectives included understanding the diagnosis and management of skin diseases in unfamiliar resource-limited settings and highlighting socioeconomic, cross-cultural, and ethical issues. A 17-item, Likert scale questionnaire was used to assess the effectiveness of the curriculum, including specific Accreditation Council for Graduate Medical Education (ACGME) competencies, as well as interest in global health and teledermatology.

RESULTS

The survey was completed by 85 of 118 VGR attendees (72% response rate). Most respondents considered the curriculum valuable to their education (mean 4.5 on a 5-point Likert scale; standard deviation, 0.5), learned more about diagnosis and treatment of skin diseases in international settings (4.5; 0.6) and in the US (4.1; 0.8), and learned more about socioeconomic, cultural, and ethical issues in skin health (4.6; 0.5). The majority also reported being more interested in global dermatology (4.1; 0.8) and would recommend VGR to a colleague (4.5; 0.6).

CONCLUSION

This pilot curriculum provided an innovative platform to enhance undergraduate and graduate medical education in international dermatology. International teledermatology education may be used to address multiple ACGME core competencies and increase resident awareness of sociocultural determinants of skin health.

Plastic and Reconstructive Surgery in Global Health: Let's Reconstruct Global Surgery

Since the inception of the Lancet Commission in 2013 and consequent prioritization of Global Surgery at the World Health Assembly, international surgical outreach efforts have increased and become more synergistic. Plastic surgeons have been involved in international outreach for decades, and there is now a demand to collaborate and address local need in an innovative way. The aim of this article was to summarize new developments in plastic and reconstructive surgery in global health, to unify our approach to international outreach. Specifically, 5 topics are explored: current models in international outreach, benefits and concerns, the value of research, the value of international surgical outreach education, and the value of technology. A “Let’s Reconstruct Global Surgery” network has been formed using Facebook as a platform to unite plastic and reconstructive surgeons worldwide who are interested in international outreach. The article concludes with actionable recommendations from each topic.

Short-term volunteer health trips: aligning host community preferences and organizer practices

BACKGROUND

Short-term medical missions (STMMs) are quite common and largely understood to be a response to health needs in low-income countries. Yet most information about STMM practices is anecdotal. Even less is known about the preferences of in-country host communities regarding STMMs.

OBJECTIVE

We aimed to gather enough quantitative and qualitative information from both STMM organizers and host community staff to compare dominant practices of organizers as well as preferences of host community staff. We use these data to discover differences between practices and preferences and suggest ways in which STMMs can be more responsive to the communities they serve.

METHODS

Researchers gathered online survey responses from 334 STMM organizers and conducted interviews to determine existing practices. Similar methods were used to collect 49 online survey responses from, and conduct 75 interviews with, host community staff.

RESULTS

Organizer practices and host community staff preferences are different in several areas. Organizers admit to minimal screening and preparation of volunteers whereas host staff have clear ideas of topics that should be covered in preparation, including culture and basic language skills. Organizers prioritize provision of clinical care during trips whereas host staff prioritize capacity building. Practices and preferences also differ in relation to the length of STMMs, the nature of the partnership itself, and the type of assessment and evaluation that is needed.

CONCLUSIONS

The large amount of data gathered for this study allows us to confidently say that organizer practices are often not aligned with host community staff preferences. Several concrete changes can be made to STMMs to bring practices more in line with the desires of the communities they serve.