Surgery and Healing in the Developing World - Dartmouth-Hitchcock

Training Surgeons in the Developing World
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Qualifications for Surgery Residents
Experience in the developing world has shown that nurses with little more than
a sixth-grade education can be trained to do complicated surgery safely and competently.
If surgical training simply involved training people to perform operations
competently, training surgeons would be easy. But to master the seven areas listed at
the beginning of this discussion a surgeon must also know anatomy, physiology,
surgical pathology, pathophysiology, pharmacology, and not a little internal medicine.
He should be able to decide when to operate, when not to operate, and what
operation to perform. He must know how to avoid major complications, and after
the operation he must know how to keep his patient alive until he recovers, recognize
complications when they occur, and know how to treat them. Finally, he must
be able to do all of this in a variety of medical settings, some of them primitive.
Not all doctors are teachable, however. Those who learned some surgery by doing
it or who have had a small amount of on-the-job training may consider themselves
to be surgeons already. They may only want to find a hospital or an organization
willing to give them a diploma for what they already know.
Before a student surgeon begins his training, he and his teacher must have the
clear understanding that if the student is going to become a qualified surgeon he
will have to start his training all over again from the beginning. This understanding
should be written into a contract renewable yearly that both parties sign. It should
also be restated in more detail in a “Resident’s Manual” in a way that clearly establishes
what is expected of both the resident and the Program Director. More will be
said about this later.
Curriculum
The curriculum should include nine major elements:
• spiritual and ethical training,
• a systematic textbook-based study program,
• yearly in-service examinations,
• monthly, written case reports or research projects and operative logbooks
• a surgical library with a study area,
• weekly teaching conferences,
• direct supervision of preoperative and postoperative care,
• learning in the operating room under expert supervision, and
• “rotations” essential for surgical practice in the developing world.
Spiritual and Ethical Development
The medical ethics that underlie the practice of medicine as it is generally practiced
(with some exceptions) in the Western world are not universally appreciated or
practiced in the developing world. Medical students studying in the developing
world may learn about the Hippocratic oath but may never see it practiced in their
learning environment or incorporate it into their system of core beliefs. But without
a system of medical ethics that protects patients’ rights and insures that physicians
will act responsibly and truthfully for the patient’s benefit, the whole practice of
modern surgery begins to fall apart.
In some developing countries where there are few physicians, patients may be so
desperate that they will give up virtually all of their rights in order to receive a
doctor’s services. This inevitably leads physicians into carelessness and arrogance
and harms both patients and the quality of care. In any training program for sur-
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