Ethics of Surgical Training in Developing Countries

Abstract

I read the article by Ramsey and Weijer [1] with interest because I sit on the other side of the ‘‘travelling resident’’ spectrum, that of supervisor at a host institution in the ‘‘Third World.’’ Our institution follows exactly the kind of recommendations for acceptance of such residents that the authors recommend in their concluding points. This letter, therefore, is to show wholehearted support for their sentiments. This is especially true with respect to adequate supervision and guidance, which we provide, yet allowing the elective residents the opportunity to undertake the procedures themselves under such guidance as would be expected of our own trainees. Indeed, over and above any ethical issues, it is a stressful time of adjustment for many foreign doctors in a developing-world environment, where less reliance is placed upon specialized investigations and more emphasis is on clinical patient care. In addition, there may be many language and cultural barriers to contend with in a new country. However, I would like to add one caveat to the reasons why elective training may be essential for residents from the First World who go to particular areas of the Third World, namely, exposure to and preceptored training in aspects of surgery that are becoming less common in the First World, such as management of penetrating trauma. In the developed world, expertise in and volume of trauma surgeries is declining so that many practicing general surgeons do not have the experience of operating on an abdomen with a gunshot wound during their entire residency training, particularly if the resident comes from a European country. Therefore, I would like to place on record my recommendation that elective residents should have a minimum of three or four years of residency training under their belt before engaging in elective residencies in the Third World. This should also include some experience in ICU management of patients, since ‘‘intensivists’’ in developing nations are in short supply so overall patient care resides squarely in the treating clinician’s hands. Finally, before arriving at the elective destination, some preparatory study of the language and culture of the patients in that country is advised.