Visiting surgeons believe program will improve patient care

“The rate of orthopaedic illiteracy is very high, even among doctors,” explains Henry Holdbrook-Smith, MD. “Most of them, apart from the basics, have very little knowledge as to what to do with most orthopaedic cases, so they tend to refer them all to the big hospitals.”

That’s why he believes the Academy’s Africa Cooperative Education (ACE) initiative is so important. With an estimated one orthopaedic surgeon for every 1.2 million people in his home country of Ghana, Dr. Holdbrook-Smith’s concern is understandable.

Dr. Holdbrook-Smith was one of three orthopaedists from Korle Bu Teaching Hospital in Accra, Ghana, who visited the United States during the 2008 AAOS Annual Meeting. He is also a contact for the ACE program—an AAOS initiative that will send American orthopaedic educators to the West Africa region throughout the next 4 years in a “train-the-trainers” approach that will not only educate local surgeons but also create a self-sustaining program to improve patient care throughout the region. After the 4-year cycle is completed, the program will rotate to another region in Africa.

Herbalists and bonesetters
With a centralized, government-funded medical system, Ghana has three large teaching hospitals that handle the most difficult cases. Regional hospitals form the next ring outward, followed by district hospitals, and eventually health posts staffed primarily by nurses. A few small private hospitals cater to general medicine and family practice needs and refer anything they can’t handle to the larger facilities. Finally, an informal yet embedded culture of traditional herbalists and bonesetters serves as “primary” caretakers—the first stop for patients who need medical attention.

Although many traditional healers are well-meaning, their methods don’t often lend themselves to quality orthopaedic outcomes. Complicating the situation is the fact that the traditional healers see hospitals as a threat to their livelihood, so many have rebuffed attempts by the medical establishment to introduce them to the basics of modern health care.

“I guess every developing country—if you look at it historically—has had battles between orthodox practice of medicine and the local practice of medicine,” says Dr. Holdbrook-Smith’s colleague, Abednego Ofori Addo, MD. “Unfortunately, we’re still in the problem phase. As far as the population is concerned, some things are better handled with a traditional healer.”

“Orthopaedics is more complicated than other specialties that must deal with traditional healers,” explains Agbeko Ocloo, MD, the third visiting surgeon. “Women in the villages traditionally deliver babies. The obstetricians have been able to open a dialog with them—providing them with basic knowledge of hygiene and how to recognize problems.

We’ve not had the opportunity to do that in orthopaedics.”

Correcting issues created by bonesetters makes medicine more complicated for orthopaedic surgeons working in West Africa, and better equipping these physicians to deal with such issues is one of the primary goals of ACE.

“In every region there is a surgeon who does everything,” explains Dr. Holdbrook-Smith. “If those surgeons understood basic orthopaedics, they could do a few things and know which cases to refer to us.”

Expanding education
The ACE program, which will be inaugurated in November 2009, is designed to share knowledge in a way that will make the entire West African region more self-reliant in orthopaedic training. In the early years of the program, American specialists will make up about two-thirds of the faculty. As the knowledge and capabilities of the local medical personnel increases, the proportion of West African faculty will increase as well. After 4 years—if all goes as planned—the West African faculty will take over and the ACE program will begin the process anew in another region.

The ACE initiative has two components for two different audiences: basic orthopaedic training for any practicing physician in West Africa who provides musculoskeletal health care and an advanced course designed for senior orthopaedic residents and certified orthopaedic surgeons. When these physicians return to their local hospitals, they can pass on what they’ve learned to their colleagues.

Although ACE is not designed specifically to increase the overall number of orthopaedic surgeons in the region, the program, by better educating all levels of medical personnel in basic orthopaedic care, will have a ripple effect. In the long run, organizers hope that even traditional healers will begin to understand that modern medicine has benefits for their customers.

“If this program goes well, it will create a platform for us to interact with [the herbalists and bonesetters],” says Dr. Addo, “and maybe show them that we are not their enemies. We are friends. Some cases are best dealt with by orthopaedic surgeons; when you see such cases, send the patient to us.”

According to the Ghanaian surgeons, the biggest ongoing issue is trauma, although they all agree that, on any given day, they could see almost any orthopaedic condition imaginable. “Everything you see in the United States, we see in Ghana, and more,” says Dr. Ocloo.

“We are overwhelmed with trauma—probably 90 percent of our energy is directed to trauma. But we see almost everything.”

Practical goals
“Sometimes the type of treatment depends on what the patient can afford,” says Dr. Holdbrook-Smith. “We want to interact [with the American surgeons] to see what would be the best, most cost-effective treatment for these patients. As we learn from them, perhaps they can learn from us.”

“As this program opens lines of communication, it also enables individual connections. If I see something that I’m not comfortable dealing with, I can send an e-mail asking advice,” says Dr. Ocloo.

Beyond all of the globe-spanning plans for the ACE program, the real value of the program was summarized by Dr. Addo.

“I would like, at the end of this program,” he says, “that if a member of my family back in my village goes to a district hospital with a condition such as septic arthritis of the hip or clubfoot, the medical staff would at least be able to diagnose it, start proper treatment, and refer to a center where it can be dealt with properly.”

Peter Pollack is a staff writer for AAOS Now. He can be reached at ppollack@aaos.org