Approximately 45% of the population of the developing world is under fifteen years of age1, yet many developing countries have little or no available health care for the treatment of bone, joint, and muscle problems in children. While the World Health Organization and other organizations focus on the eradication of human immunodeficiency virus (HIV), malaria, and other diseases2 through the development of vaccines and medications, little or no effort has been directed to diseases requiring surgical treatment, which according to one estimate account for 11% of the total global disease burden and a loss of 128 million disability-adjusted life years (DALYs)3. Weiser et al. estimated that approximately 234 million major surgical procedures are performed worldwide each year, yet the poorest one-third of the world's population undergoes only 3.5% of those procedures4. Gosselin and Heitto estimated that the cost of the surgical procedures performed at a district trauma hospital in Cambodia was $77.40 per DALY averted5. They noted that this was extremely cost-effective when compared with antiretroviral therapy ($350 to $500 per DALY averted).
Efforts to improve care for children with orthopaedic problems in the developing world have ranged from lectures and symposia to small private medical missions to the building of individual hospitals by nongovernmental organizations (NGOs). Many efforts that are focused on “teaching” are single-intervention courses in which experts donate a few days of time giving lectures and then leave. In contrast, medical missions primarily involve “doing” as opposed to teaching. Such a program that brings a group of physicians and surgeons to work for a short period may be more effective than a course, and it may also be able to provide a limited amount of teaching as well as the opportunity to work with local physicians to provide some follow-up if complications result. Still other efforts have gone to the extent of building Western-style hospitals and staffing these hospitals to provide on-site care. Hospital-building efforts can be very effective for the local community, but they are capital-intensive and focus permanently on only one area.
How, then, are we to promote sustainable care in pediatric orthopaedics in the developing world? Ultimately, the issue is how (and where) to teach pediatric orthopaedics. We know that requiring a Fellow from a developing country to travel to the developed world for a formal twelve to twenty-four-month fellowship poses problems with regard to visas and licensing. Furthermore, Fellows who are successful in overcoming the difficulties in obtaining a license may never return to their home country because of the dramatic discrepancy in pay and working conditions, resulting in a surgical “brain drain.” Lower-income countries provide 40% to 75% of the international medical graduates in the United States, the United Kingdom, Canada, and Australia6. This worsens the situation in the developing country by removing yet another physician who could have provided some patient care. According to Dormans, “The creation and support of training programs in the developing world will be the most effective way of addressing and improving the prospects…for those in the developing world who have musculoskeletal conditions.”7
To our knowledge, there has been no organized program focusing on children's orthopaedic issues that concentrates on hands-on teaching with a set curriculum and that operates on a continuous basis in developing countries to deliver a sustainable pediatric orthopaedic program. With this in mind, a program entitled Mobile Pediatric Orthopaedic Education (MoPOEd) was established to provide on-site “hands-on” teaching of a specific curriculum (developed with the assistance of the local physicians) by well-trained pediatric orthopaedic specialists over a period of time, with the goal of establishing sustainable pediatric orthopaedic education by the time the MoPOEd program ends.
In 2008, the MoPOEd program embarked on efforts to provide sustainable pediatric orthopaedic training at its first site, the Children's Surgical Centre (CSC) in Phnom Penh, Cambodia. At the time, there were no trained pediatric orthopaedic surgeons in the country of 14 million people. The CSC is a private NGO that provides free care to patients with problems requiring surgical treatment, including basic orthopaedics, plastic surgery (primarily for acid burn victims), and treatment of ophthalmologic diseases. The hospital is run by a retired U.S.-trained adult orthopaedic surgeon (Dr. James Gollogly). The CSC employs three full-time Khmer surgeons and three part-time Khmer surgeons. Occasional visits by surgeons from the U.S., Canada, and the U.K. provide some additional assistance in orthopaedics, plastic surgery, and ophthalmologic care. The six Khmer surgeons have basic general surgical training that includes obstetrics, plastic surgery, and abdominal surgery. (There is no programmatic surgical subspecialization in Cambodia.)
After an initial visit in 2008, a program to provide on-site teaching of pediatric orthopaedic surgery was proposed to Dr. Gollogly, the Chief Executive Officer of the CSC. Three Khmer surgeons were anticipated to attend the first thirteen-month session of the program. Dr. Gollogly was also consulted on the development of a curriculum that would address locally endemic orthopaedic conditions. Funding was then sought to cover travel expenses, room, and board for the visiting surgeons. The hospital at which the lead author (R.M.B.) was practicing at the time and a 501(c)3 nonprofit institution agreed to permit donations to the program to be channeled through their organizations to avoid the legal hurdles of developing a separate nonprofit organization. In addition to donations from individuals, a grant was received from the Ronald McDonald House Charities for the first year of training.
The main hospital of the CSC has a single large surgical suite containing three operating tables and anesthesia machines. In addition, the CSC has a smaller off-site clinic containing a single, more modern, operating room. In 2008, the orthopaedic surgical equipment included one power saw/drill, hand drills, Steinmann pins, some basic plates and screws, rongeurs, Rush rods, and osteotomes. No fluoroscopy was available, and most radiographs were obtained only off-site. The temperature in the operating suite generally ranged from 80° to 95°F (25° to 30°C). In 2009, access to power equipment had been improved, more standard implants were available, and radiographic facilities were present on-site, although no intraoperative fluoroscopy was available.
Members of the Pediatric Orthopaedic Society of North America (POSNA) were solicited personally and by e-mail to participate in the program. A syllabus was developed to coincide with the curriculum, and permission was granted by Lippincott Williams & Wilkins to copy figures from existing textbooks. Plans were made to translate the syllabus into Khmer. In addition to this syllabus, each Fellow was provided with thirty-two orthopaedic textbooks on a compact disc through the auspices of Global Help8.
Over the next year, a MoPOEd surgeon would travel to the CSC each month for a two-week teaching period. Each MoPOEd surgeon received materials regarding the goals of the program, the CSC clinic and surgery, visas, housing, and required vaccinations. Each MoPOEd surgeon was expected to present a number of Microsoft PowerPoint lectures, with the requirement that copies of these lectures be given to each of the Khmer Fellows for their personal use. Efforts were made to encourage the use of locally available orthopaedic implants.
MoPOEd surgeons provided teaching in the clinic, established the weekly surgical schedule, assigned Fellows to each case, and provided hands-on assistance in the operating room. Except for very difficult cases, the Khmer surgeon was always expected to be the primary surgeon. Each surgical case was categorized into one of six diagnostic categories: trauma, infection, neurological, neoplasia, developmental, and congenital. The patient's age, sex, cultural background, diagnosis, surgical procedure, and date of surgery as well as the names of the surgeons involved in the case were recorded in the MoPOEd database by the surgeons and hospital staff. In addition, a list of the number of PowerPoint presentations given by each MoPOEd surgeon was requested.
The success of the program was evaluated with use of written examinations, direct observation of the Fellows during the year in the clinic and surgery, and the retention rate of the Fellows in the program. At the beginning of the program, a MoPOEd surgeon administered an examination consisting of thirty-five multiple choice questions to each Fellow. At the conclusion of the thirteen months of training, a more difficult 100-question multiple choice examination was administered to each Fellow. Both examinations were given in English. The first and second MoPOEd surgeons to visit the CSC returned as the last two visiting surgeons to evaluate the Fellows in the clinic and operating rooms.
Thirteen MoPOEd surgeons visited the CSC during the thirteen-month period from February 2009 through February 2010, and each provided two weeks of instruction. Six Khmer surgeons requested to participate in the MoPOEd course and all were enrolled. All six of the Khmer Fellows remained in the program for the entire year (100% retention).
Two hundred and three patients were treated surgically (with 242 procedures) during the thirteen-month program. The patients ranged in age from two to seventy-five years (mode, sixteen years; mean, twenty-six years). The patient diagnostic categories are listed in Table I, and the procedure types are listed in Table II. The largest number of patients were treated for neglected trauma, followed by congenital abnormalities. Examples of procedures included stabilization of fractures, repair of nonunions and malunions, clubfoot releases, triple arthrodesis, tumor resections, osteotomies, and spinal fusions. Complications included postoperative infections, loss of fixation, and a compartment syndrome following supracondylar humeral osteotomy. Some of these complications occurred when a MoPOEd surgeon was not on-site and thus were not documented fully in the MoPOEd records. The complications were managed by Dr. Gollogly, by a currently visiting MoPOEd surgeon and the CSC Fellows, or by the next visiting MoPOEd surgeon.
The expenses for the MoPOEd program for the thirteen-month period totaled $83,196 and included MoPOEd surgeon travel, room and board; procurement of a computer, printer, and local cell phone; printing; on-site data collection; and administrative expenses. The latter totaled $8000 and was given to Cedars-Sinai Medical Center as a stipend for the time spent on coordination of travel, receipts, and other administrative issues by the author's medical assistants.
The MoPOEd program represents an initial effort at developing a traveling fellowship to teach the principles and techniques of pediatric orthopaedics in developing countries. By stressing the concept of training the health care givers at home and with locally available implants, we hope to promote the three principles of “train, retain, and sustain.” The most important of these three principles is sustainability; attaining this goal will require patience and follow-up.
The program was well accepted by both the CSC and the Fellows, who were pleased to host the MoPOEd surgeons and to participate. In fact, twice the expected number of Fellows signed up for the program. One reason for this response rate may have been a desire for additional training that could give such surgeons a self-marketing advantage over others in their country. In the Cambodian medical market, care is delivered by a number of sources, including “public hospitals,” private hospitals and clinics, NGOs, private physicians, and local healers. Because of economic pressures, each practitioner is competing for any patient who may have the ability to pay. (For instance, the “public” hospitals are not free, and they will charge the family in advance for the ability to be admitted. As soon as the family runs out of money, the patient is discharged, regardless of his or her state of health.) Thus, no practitioner is generally willing to refer a patient to another practitioner.
One of the major goals of MoPOEd is the prevention of migration of surgeons from the developing country. There have been other efforts at limiting the “brain drain” of medical graduates in developing countries to the developed world. The University of Ottawa has utilized a “Sandwich” Fellowship for both ophthalmology and orthopaedics that involves a number of rotations involving the Fellow and the mentor with whom they have been matched; the mentor visits the home institution of the Fellow, then the Fellow travels to the University of Ottawa, and this cycle continues until the program is completed. Kassam et al. reported on the results of the pilot program in ophthalmology in 2009 and stated that the program was well accepted9. They did identify some problems, such as delays related to visas and licensure, political instability of the Fellow's country, and difficulty in identifying the appropriate amount of clinical responsibility to be given to the Fellow. The actual cost of the program was not stated.
Although such a program has potential benefits, there are additional concerns that can be raised. First, is the Fellow who applies the most capable, or only the most senior or the most socially acceptable? Second, once a Fellow is licensed in the developed world, it remains possible that he or she will refuse to return home. Third, the program results in the training of only one surgeon; whether he or she will be able to train others appropriately to provide care is questionable. Fourth, during the program the Fellow will not be able to provide care in his or her home environment, resulting in a temporary decline in available care in that area. Fifth, is it necessary to have a fully trained specialist, or is it better to have generalists who will be able to perform a majority of the necessary procedures? Sixth, are the implants and equipment appropriate? Should the Fellow be trained in an institution that has all of the technology available in the developed world, only to return to his or her home country where such materials are either unavailable or too expensive?
Other efforts to limit the medical “brain drain” have been conducted by the Foundation for Advancement of International Medical Education and Research (FAIMER), which works to develop sustainable medical education in developing countries. These efforts include the FAIMER Institute (which provides a two-year fellowship focused on training medical educators), the International Fellowships in Medical Education (IFME), and regional institutes. Measures used by the Institute to measure success include the number of international presentations and peer-reviewed publications and grants by its graduated Fellows10. Although this is perhaps a reasonable goal for general medical education, these benchmarks are not the same as the ones that MoPOEd focuses on—namely, on-site clinical care involving technical skills and further training of additional health care workers.
When we recruited surgeons for the MoPOEd program, special efforts were made to recruit POSNA members. E-mails were sent to many POSNA members by the lead author, and POSNA also sent an e-mail to each member. Although we did not survey the overall interest of POSNA members in participating in such a program, it was clear from the response rate that many members were interested in becoming involved in orthopaedic care in the developing world. By removing financial concerns involving the direct cost to the prospective MoPOEd surgeon, the only other factors facing potential volunteers were the loss of practice income, their interest level, and their schedule. We believe that by removing the travel costs, more surgeons would be willing to participate in such programs.
The overall cost of the program during the thirteen months was $83,196, which amounts to $13,866 per Fellow trained. We do not expect that a Fellow would subsequently be accepted by any agency or professional society as a fully trained pediatric orthopaedic surgeon. Such full training would be expected to require an additional eleven months. However, we believe that Fellows will provide substantially improved care for pediatric orthopaedic patients as a result of their training, making them the local experts. In addition, we hope that they will pass this information on to other Khmer surgeons, ultimately resulting in sustainability. By the end of the first twelve months, we began requiring each Fellow to give PowerPoint lectures to the other Fellows and MoPOEd surgeons. This allowed us to gauge their understanding of the material, determine their ability to convey information to their peers, and assist them in their use of PowerPoint. Most lectures were at the level that we would expect of junior orthopaedic residents in the U.S. However, given that they had not been preparing any lectures prior to the arrival of MoPOEd, this is a substantial improvement. A number of the surgeons were delivering lectures at the local medical school.
The most important missing ability appears to be that of critical thinking. The Khmer Fellows were trained in medical school to memorize and to follow orders, but they appear not to have been trained to question. This may be related to certain aspects of the Asian culture. Furthermore, after more than fifty years of conflict within the country, in which the Khmer Rouge executed virtually all professionals and educated people, the motivation for taking a risk by questioning authority would have to be quite substantial. This lack of critical thinking is unlikely to change quickly, and it will clearly be the limiting step in improving pediatric orthopaedic care by Khmer physicians. How to instill this capacity is a difficult question.
Although we had only planned to teach pediatric orthopaedics, many of the patients who came to the CSC were adults with pediatric orthopaedic conditions (such as neglected clubfeet, scoliosis, and neglected injuries from childhood). Because of this, we chose to extend the definition of “pediatric” to twenty-five years of age. In addition, there was no way to predict who would show up for treatment at the clinic. Since the CSC provides virtually the only free care for surgical problems in Phnom Penh, many of the patients who arrived were older than twenty-five years of age. However, we felt that the Fellows could still learn important orthopaedic principles by participating in their care.
It has been suggested that many of the lessons about pediatric orthopaedics that were taught to these Fellows will instead be utilized on adult patients because of the economics of private practice: adults are more likely to have the funds and the ability to seek care than children are, and the Fellows may therefore provide little or no care to children. Although this criticism is likely to have merit, we believe that any lesson regarding good decision-making and good technique may improve care for any patient regardless of age. Thus, even if the Fellows never care for another pediatric orthopaedic patient after leaving the program, the nonpediatric patients that they do care for will still experience the benefit of the training. In addition, we expect that the Fellows will be called on to care for a child on at least some occasions during their career, and they will have had the benefit of the MoPOEd program when that occurs.
The temporary nature of the program, which has a set time by which it ends, is a critical aspect of the MoPOEd approach. We believe that unless the program is limited in time, it will be assumed by the hosts to be a permanent fixture, and they will avoid taking ownership of the teaching. Thus, establishing a time frame at the beginning prevents the host from assuming such permanence, forces them to take ownership, and avoids a feeling of abandonment when the program ends.
This report raises a number of questions. Is it possible to teach international Fellows techniques and principles of pediatric orthopaedics at their home institutions? Can Western pediatric orthopaedic surgeons adapt to teaching in less than optimal conditions without the benefits of fluoroscopy? Will the program be sustainable locally so that further native surgeons can be trained in pediatric orthopaedics by graduates of the program? Although it is possible to teach surgical techniques, is it possible to teach critical thinking and decision-making in such a setting? Is it cost-effective to teach on-site? The major question that we hope to answer once we have a sufficient duration of follow-up is whether the MoPOEd program will result in any sustainable pediatric orthopaedic training program in Phnom Penh. The existence of such sustainability will require many years to demonstrate. However, if such a program is not attempted, the probability that a sustainable pediatric orthopaedic program will develop in this region will be even lower.