Orthopaedic resident William Scott Green, MD, of UCSF, visits patients at the Itipinic Clinic in Mthatha, South Africa.
Courtesy of Edwin D. Harrington, MD


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

If there’s a will, there’s a way

Overcoming barriers to an overseas volunteer program for residents

Creating an overseas volunteer rotation for orthopaedic residents requires overcoming significant institutional barriers. The orthopaedic surgery residency program at the University of California, San Francisco (UCSF), has overcome these challenges, proving that implementing an overseas volunteer rotation for residents can be accomplished—with a small amount of political will.

Find a champion
Implementing an international orthopaedic elective requires a faculty “champion” with overseas volunteer experience. This person serves as the program director, helping to coordinate the elective rotation with the overseas sites. Ideally, this faculty member has visited at least one site, because there is no substitute for local knowledge. He or she also helps sustain the established program by communicating the benefits of volunteering to residents.

Ensure an educational experience
A well-designed elective in international orthopaedics can easily meet the core competencies established by the Accreditation Council for Graduate Medical Education.

At UCSF, all international orthopaedic electives take place at Orthopaedics Overseas sites, which are staffed by board-certified orthopaedic surgeons and are affiliated with medical schools recognized by the World Health Organization.

Residents must keep a log of all surgical cases, noting the diagnosis, procedure performed, indication, and level of supervision. The program director reviews these logs when residents return home to ensure that educational objectives have been achieved.

Residents are also required to log their work hours to ensure compliance with the 80-hour resident work week. This is rarely an issue in the international electives, due to the more relaxed pace of medical care.

To make the most of a short time abroad, residents can often participate in ongoing research projects that were initiated by other residents. Opportunities to investigate clinical outcomes after surgical or nonsurgical treatment are abundant.

Residents are encouraged to give lectures to the local medical staff during their stay. Local medical staff members often have a wide variety of educational backgrounds, from orthopaedic officers and nurses to board-certified orthopaedic surgeons. Preparing and delivering these lectures is an excellent educational opportunity for the residents on many levels.

Find the time
Because resident labor has become a very valuable commodity, many programs shudder at the thought of losing a resident for a month.

Originally at UCSF, the 4-week elective in international orthopedics ‘straddled’ two domestic clinical rotations, with no one hospital deprived of a resident. One week comes from each hospital rotation, 1 week from the resident’s personal vacation time, and 1 week educational leave by the home institution. Distributing the onus and responsibility among all involved parties ensures their commitment to the success of the rotation. Now, the rotation is “carved” from the 4th year rotation at San Francisco General Hospital, which supports the emphasis on trauma management, cultural competency, and care of the vulnerable.

Find the money
Funding is often cited as a major obstacle to developing an elective in international orthopaedics. In fact, the cost of food and lodging in the host country is usually quite low. Airfare and transportation costs vary, depending on the location of the rotation, but are generally less than $1,500. The major cost is the resident’s salary for the month, which may not come from federal Medicare dollars, because care is not being provided for patients in the United States.

At UCSF, funding comes from several sources, including department funds for “education,” private sector and industry donors, and an OREF grant to Orthopaedics Overseas that helps fund travel expenses. Probably the most sustainable method of providing funding is by establishing an endowment.

Call for help!
Commitment and creativity are required to create a successful elective in international orthopaedics for orthopaedic residents. UCSF has been able to create a successful, sustainable model for an overseas elective that may help provide solutions to obstacles at your institution. Please contact the authors for additional information and assistance in developing a rotation at your institution. You will find the rewards are well worth the effort!

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.

He can be reached at coughlin@orthosurg.ucsf.edu