Working overseas gives residents such as William Scott Green, MD, of UCSF, the opportuniy to transition to independence through surgeries such as this repair of a neglected femur fracture.
Courtesy of Edwin D. Harrington, MD

AAOS Now

Published 6/1/2008
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David Rovinsky, MD, FACS; R. Richard Coughlin, MD

Orthopaedic residents need experience abroad

Volunteering overseas has beneficial impact at home

For more than 15 years, the University of California, San Francisco (UCSF), Orthopaedic Surgery Program has built international volunteer rotations into the resident experience. It’s a practice that we consider basic to our goal of producing professional, compassionate, and competent orthopaedic surgeons—and one we believe that every orthopaedic surgery residency program should emulate. (See “If there’s a will, there’s a way”)

UCSF began sending residents on short (1- to 2-week) volunteer missions in 1992. After noting the very positive impact this had on resident education, UCSF initiated a formal 1-month elective abroad in orthopaedic surgery in 1998, in conjunction with Orthopaedics Overseas.

Since 2000, 75 percent of residents (35 of 47) have chosen to participate in this overseas elective. They’ve served in Mthatha, South Africa (31 residents); Managua, Nicaragua (2 residents); Blantyre, Malawi; and Wenzhou, China (1 resident each). Several residents have continued to volunteer with Orthopaedics Overseas after graduating, and two UCSF residents currently serve on the Board of Directors of Orthopaedics Overseas.

The international orthopaedic elective experience meets the following core competencies of the Accreditation Council for Graduate Medical Education (ACGME): professionalism, patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, and systems-based practice.

Improving professionalism
Volunteering overseas has a beneficial impact on professionalism. With fewer orthopaedic surgeons willing to take emergency call, increasing numbers of surgery centers, and declining reimbursements, orthopaedic surgeons in the United States are facing a crisis of professionalism. Add to this the 80-hour work week limitations and resident physicians may come to see orthopaedic surgery more as a job or business than as a true calling.

Spending a month or more practicing medicine in a developing country, caring for truly needy patients, serves to restore our perspective. Upon returning from South Africa, Holly K. Brown, MD, said it best: “Places do exist where physicians can do what they do best, be good doctors and take good care of patients, without having to answer to insurance companies, managed care organizations, or lawyers. Experiences like these remind us of why we entered the field of medicine.”

Mastering basic orthopaedic principles
Overseas resident volunteers learn that treatment of pathology in a developing country with limited infrastructure requires adherence to basic orthopaedic principles. They must determine diagnoses based primarily on the history and physical examination, with the occasional plain radiograph. They have direct experience with treatment principles and techniques that are not currently emphasized in residency, such as definitive management of fractures in casts or with traction. Working in these environments also reinforces the basic principle of prima non nocere—first do no harm. The emphasis is always on performing simple, reproducible, safe procedures using local resources.

The UCSF overseas program also mandates that the residents give instructional lectures during their overseas rotation. Nothing fosters mastery of a topic better than having to teach it to others who may or may not speak English and who have widely varying backgrounds in medicine.

Cultural competence and sensitivity
ACGME guidelines include a training requirement for cultural competency and sensitivity. What better way to teach cultural sensitivity than by immersing the student in a foreign culture, where he or she doesn’t speak the language and is in the minority? Working in a foreign country, alongside local physicians, is a powerful experience and an invaluable learning opportunity for many residents.

Global perspective
Spending a month or more overseas practicing orthopaedic surgery also gives residents a global perspective on health care. Many return with a greater appreciation for the vast resources available in the United States. In addition, problem-solving and performing surgery with limited resources encourage residents to be more versatile, adaptable, and creative in the operating room when they return home.

Research opportunities
UCSF encourages residents to undertake research while at the overseas site. Residents quickly learn that modern orthopaedic literature—with its focus on high technology, novel implants, and arthroscopy—has little bearing on the practice of orthopaedics in the developing world. Residents have been able to participate in refining a systematic approach to treatment of disease in foreign healthcare systems through outcomes studies performed during their rotations.

Transitioning to independence
The greater oversight required by insurance regulations in the United States means that orthopaedic residents are losing the opportunity for independence once afforded them during residency—the “county clinic.” An overseas rotation enables residents to experience greater independence while still being closely supervised and helps them make the difficult transition from resident to attending physician.

Volunteering is addictive
Orthopaedic residents who have an opportunity to do a rotation overseas are much more likely to volunteer overseas again. Comments from residents also indicate that these experiences change the way they view volunteering at home in their communities.

Once residents have a “taste” of volunteering overseas, they can find it addictive. Because the pathology seen in other countries is often bread-and-butter orthopaedics such as trauma and infections, residents are willing and interested in volunteering.

At the UCSF, we have seen first-hand the tremendous positive impact the overseas rotation has had on our residents. The investment in creating an overseas program has paid off more than we could have ever imagined. Try it—you may be surprised at the difference it makes.

David Rovinsky, MD, FACS, is clinical assistant professor of orthopaedic surgery at the John A. Burns School of Medicine.

R. Richard Coughlin, MD, is professor of orthopaedic surgery at UCSF.

For more on their experiences with an orthopaedic residency overseas volunteer program, see Rovinsky D, Brown HP, Coughlin RR, Paiement GD, Bradford DS: Overseas volunteerism in orthopaedic education. J Bone Joint Surg Am 2000; 82:433-436.