Guest bloggers Gita Mody, JaBaris Swain and Maurice Musoni discuss sustainable surgical care delivery and their experience in Rwanda with Team Heart.
Sustainable models for delivery of both Emergency and Essential surgical care and specialty surgical care are needed to eliminate global disparities in health. The most cost-effective, feasible, and replicable methods to implement the complex systems needed to provide surgery are still debated. However, to quote ophthalmologist and founder of the Himalayan Cataract Project Dr Geoffrey Tabin at the recent Extreme Affordability Conference held by the Center for Global Surgery at the University of Utah, “high quality [surgical] care is the key to sustainability.” Some would argue that traditional short-term missions, which are often caricatured as a visiting team parachuting into a foreign environment, providing clinical care for a few short days or weeks, and exiting never to be seen again, are a poor return on the investment. But, can short-term missions be structured in such a way to become components of a high-quality, sustainable plan?
In our experience, they can. Team Heart represents such an effort, with the aim of establishing a self-sustaining cardiac surgical program in Kigali, Rwanda. Since 2007, Team Heart has worked with King Faisal Hospital, a 140-bed referral hospital in Kigali, to provide sophisticated cardiac surgical intervention for critically ill patients suffering from the consequences of advanced rheumatic heart disease. Team Heart encompasses collaborative partnerships with the Rwanda Heart Foundation, the Rwanda Ministry of Health, and a group of committed volunteers from several Harvard-affiliated academic medical centers, many of whom return year after year.
Throughout the Team Heart mission, opportunities for knowledge transfer and skill expansion are abundant. Both Rwandan and American trainees are actively involved in pre- and postoperative patient care, operative management, and team logistics. The trainees work closely with Rwandan faculty members to review complicated cases and collaborate on comprehensive, multi-disciplinary plans for the patients. Daily bedside teaching rounds emphasizing physical exam and diagnosis, opportunities to first-assist in the operating theatre, and hands-on fundamentals of echocardiography are just a few examples of learning opportunities. One Rwandan trainee, inspired during his involvement in the mission over the several years, is now being sponsored by Team Heart to complete a fellowship in South Africa such that he can return to lead a cardiothoracic program in Rwanda.
Members of Team Heart also remain committed to providing high quality patient care and utilizing proven systems improvement tools, which are nimbly adapted to the available Rwandan resources and infrastructure. In the debrief session after the last mission, care delivery innovations imported from Boston teaching hospitals such as the Intensive Care Unit record keeping forms and the surgical safety checklist were selected to be incorporated into the daily operations of the host hospital. The mission, by demonstrating the feasibility of specialty surgical service delivery at the host hospital, has both inspired and prepared the local health care administration to undertake building its own cardiac surgery program. For example, ancillary services including the blood bank and laboratory noted that by participating in the mission, they have acquired insight on how to restructure their departments going forward. So, indeed, herein lies one example of a surgical mission that is leading to a lasting and safe care delivery system.
Another model of sustainable surgical care delivery is the incorporation of short- term visits of surgeons into longitudinal community-based health care activities. Operation Smile, an international volunteer organization that performs reconstructive surgery missions around the world, is piloting deployment of its volunteers in overlapping rotations to provide continuous plastic surgery services at Butaro Hospital, a 150-bed rural district hospital in northern Rwanda supported by Partners In Health. The overall objective of the rotations is to go beyond direct clinical care delivery and provide mentorship and training such that the roles of visitors including operating theatre and ward nurses, surgeons, and anesthesiologists can be effectively transitioned to local staff. The process of integrating short-term visitors into the hospital’s daily schedule requires patience and flexibility by all parties, but the impact of these missions is anticipated to far exceed the number of surgeries completed.
How to measure the impact of short-term surgical missions was the subject of discussion at a recent Academic Global Surgery journal club session held at the Brigham and Women’s Hospital Center for Surgery and Public Health. While short-term missions that involve surgical residents have demonstrated positive impact on the core educational and professional competencies of North American trainees, future studies are needed to demonstrate their long-term impact on global surgical care delivery by local and visiting residents. Furthermore, cost-benefit analyses including the clinical effectiveness, skill transfer, and quality improvements resulting from these missions must be conducted. In the meantime, the Team Heart and Operation Smile missions represent invaluable exposure for surgical residents, both Rwandan and American, to mentors committed to training the next generation of global health leaders.
Gita Mody and JaBaris Swain are general surgery residents at the Brigham and Women’s Hospital and Arthur Tracy Cabot Research fellows at the Center for Surgery and Public Health. They were both recipients of the Team Heart Stanley Rawn Travel Award for the 2012 mission, and Dr Mody serves as a surgical consultant for Partners In Health. Maurice Musoni is a surgical postgraduate at King Faisal Hospital in Kigali, Rwanda and will begin training at the University of Witwatersrand, South Africa, in General and Cardiothoracic Surgery this year.