win-win training

Presentations from registrars who had worked in developing countries such as Malawi and Kenya were a feature of the joint congress of the British Orthopaedics Trainees Association (BOTA) and World Orthopaedic Concern (WOC), held in September 2009.

Highlights included Steve Mannion, who spoke on on working abroad, and Lucy Obolensky, who discussed setting up the first Kenya Orthopaedic Project (KOP) at Nanyuki District General Hospital in February 2009. The project was partly funded by Medical and Educational Aid to Kenya, but the rest of the funding was raised by sponsorship and donations. Kenya does not have the luxury of a national health service and patients must pay for clinic visits or surgery. The cost of orthopaedic surgery in this environment is prohibitive and many fractures go untreated, as do other common diseases such as severe osteoarthritis and osteomyelitis.

WOC was set up over 30 years ago in response to the ever-growing need for trauma and orthopaedic skills in developing countries. Furthermore, it helps developing countries set up their own orthopaedics education and services, as well as highlighting the growing need for orthopaedic surgery in such countries.

The statistics are sobering: there are just three orthopaedic surgeons for the whole of Malawi, with a population of over 12 million people. That equates to one surgeon per four million head of population, compared with 1:15,000 on average in Western Europe. In the UK, this figure is about 1:37,000, although the BOA has recommended that this figure be improved to 1:15,000, in line with other Western European countries.

Setting up the KOP involved gathering the support of senior colleagues and allied healthcare workers, such as ODPs and theatre staff. A team of 12, including two consultant surgeons, two consultant anaesthetists, three scrub nurses, recovery nurse and ODP, used one week of their annual leave to volunteer in Nanyuki. The aim was to deliver operational and educational services to Nanyuki General Hospital to help offset the huge number of patients who were waiting for surgical treatment. In that one week, 18 operations were performed despite constant challenges, from the lack of operative equipment to moral and ethical dilemmas regarding patient management. With restricted time and resources, only a limited number of patients could be treated, and deciding which patients would benefit the most from surgery, sadly, highlights the nature of developing-world medicine.

What I heard about WOC at the congress was truly inspiring and I felt that this sort of work deserved better publicity. The European Working Time Directive and shift away from training towards service provision within NHS trusts mean trainees are losing most of their training opportunities. Perhaps the opportunity to work and train in developing countries could represent a ‘third way’? Clearly, trainees who work abroad in developing countries should not be operating without the appropriate support of senior colleagues and always in the best interest of the patient. The standard of surgical care should not be compromised, irrespective of the country. This is not a chance to ‘have a go’ at patients in developing countries. It is, however, a great opportunity for trainees to support more senior surgeons as they provide operative and educational sessions, and to be a part of a team that could leave a long-lasting impression on patients with little access to healthcare.

The Crisp Report on ‘Global Health Partnerships’, published in 2007, sets out the role for UK health services in helping developing countries improve their healthcare provision. As part of Lord Crisp’s recommendations, one key factor was the need for NHS trusts to recognise the training opportunities available for both medical and other allied healthcare workers when volunteering their services abroad. Here is one of the key recommendations from the report:

‘In order to enable health workers to gain international experience and training:
•An NHS framework for international development should explicitly recognise the value of overseas experience and training for UK health workers and encourage educators, employers and regulators to make it easier to gain this experience and training
•Medical, nursing and healthcare schools should work with others to ensure work experience and training placements in developing countries are beneficial to the receiving country
•The Postgraduate Medical Education and Training Board (PMETB) should work with the Department of Health, Royal Colleges, medical schools and others to facilitate overseas training and work experience.’

Unfortunately, my impression from trainees is that their hospitals and deaneries don’t share these ideas. Heavy resistance and active discouragement is often met and trainees are told that such activities are not considered valuable. This is an enormous shame because, having seen some of the operational logbooks from trainees working in developing countries and the breadth of disease encountered, trainees can only benefit for their experiences abroad.

As part of KOP, data was taken from the eLogbook to analyse the average number of cases performed by an orthopaedic ST3 in one week and a survey was sent to all South-west trainees (n=25) for information on how many competencies and workplace-based assessments were completed in one week. The results showed that in one week during KOP, over 70 patients were seen in clinic and 18 operations performed. Of the 18 operations, the orthopaedic trainee assisted in 15 and performed three operations under supervision. An average week logbook entry for ST3 trainees, taken from eLogbook statistics, contains six elective and three trauma operations. The figures from one week in the KOP doubled these operative numbers. Six workplace-based assessments were completed in one week on the project – significantly more than an average of 0.16 per week in UK (p=0.0003). Furthermore, exposure to conditions such as clubfoot, neglected trauma and end-stage osteomyelitis and tumours is invaluable experience for trainees.

The opportunity to engage in practically applied research is also encouraged and, certainly, the presentations by the other trainees at the BOTA/WOC congress showed the high level of quality and research methodology performed. Such research also has a practical application. For example, one project involved the use of a modified Ponsetti treatment for managing clubfoot. This was a randomised prospective trial with a large number of patients and is comparable with the best research project carried out in the UK.

BOTA must continue its support for WOC and encourage more trainees to take part in such programmes. In conjunction with Heraeus, BOTA have been fortunate to secure funding for a travel scholarship to allow a trainee to join Lucy Obolensky in Kenya as part of the KOP. Furthermore, BOTA should work to convince programme directors, deaneries and hospital trusts that such work is beneficial for the trainee and, in the long-term, for patients in the UK.

For more information on Word Orthopaedic Concern, visit: www.wocuk.org

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