Canadian Association of General Surgeons
CAGS Committee for International Surgery
Annual Report
August 2007
Meetings:
There have been no formal meetings of the committee since the last report
(January 2007) but members have made significant progress in a number of
areas. As I will be stepping down as chair of the committee this year at the end
of my term, I have tried to compile a fairly detailed summary of the committee’s
activities over the last year. In doing so it is hard not to remark on the
tremendous amount of work committee members have put into their various
projects. It is also worth noting how much this committee has accomplished
since it’s beginning in 1998 towards increasing knowledge of international
surgery among Canadian surgeons and the steadily increasing number of them
who have become engaged in international work through CAGS.
This is a longish report and important documents are found in the appendices.
Appendix
I
II
III
IV
V
VI
VII
Document
Draft MoU with CNIS
Position Statement on Canadian Surgical Workforce SelfSufficiency and Overseas Recruitment
Statement Regarding CAGS In-Training Exam (Guyana)
Project report - Brian Ostrow
Project Report – T.E. Abraham
Project report - Robin Fairfull-Smith
Project Report – Yvonne Ying
Motions to be carried through the the CAGS Board meeting on September 5
2007:
1) Adoption of MoU with CNIS
2) Adoption of Statement on workforce self-sufficiency and recruiting
3) Link to SIA Website
Membership:
Current Committee Members are:
Massey Beveridge (Chair)
Gwen Hollaar
Geoff Ibbotson
St. Anthony
Calgary
Nepal/Alberta
(2004-7)
(2004-7)
(2004-7)
massey.beveridge@sympatico.ca
ghollaar@gmail.com
geoff_ibbotson@yahoo.ca
Bill Harris
Thunder Bay
(2004-7)
drwharris@hotmail.com
Brian Cameron
Brian Ostrow
Hamilton
Guelph
(2005-8)
(2005-8)
cameronb@mcmaster.ca
brian@bookshelf.ca
Jean Couture
Quebec
2005-8)
jean.couture@rrsss16.gouv.qc.ca
Jon Just
Kamloops
(2006-9)
jonjust@shaw.ca
Morab Hameed
Vancouver
(2006-9)
morad.hameed@vch.ca
Georges Azzies
Toronto
(2006-9)
georges.azzies@sickkids.ca
Alex Mihailovic (Resident Rep)
Toronto
(2006-8)
alex.mihailovic@utoronto.ca
2007 CSF International Surgery Symposium “Skill Sets for International
Surgery”:
Saturday Sept 8 2007 (14:30 - 16:20)
We are very pleased to have two eminent visiting speakers funded by the CAGS
Program Committee, Drs Deen Sharma from Guyana and Dr. Vincent Echave
from Sherbrooke who has vast experience working with Medecines sans
Frontieres. The Canadian Forces are keen to recruit civilian general surgeons
for the Afghanistan mission and two leading military surgeons, Homer tien and
Robert Young will present on their experience there. Unfortunately Max
Downham and the International College of Surgeons will not be able to send a
speaker.
Target audience: Surgeons and residents interested in international surgery
Learning Objectives

Participants will learn what is expected of surgical guests and visitors

Participants will understand opportunities for Canadian surgeons within
both Canadian and International organizations

Participants will learn about setting up their own international partnerships

Participants will learn about military surgery in Afghanistan and the
contrast with civilian practice
Program







14:30 Introduction – Massey Beveridge
14:40 Deen Sharma: What Skill set makes a good surgical visitor?
15:00 Brian Ostrow: Setting up a diabetic foot program in Guyana
15:20 Jon Just: Organizing Short Term Surgical Missions: Practicalities,
Pitfalls and Rewards
15:40 Homer Tien and Roland Young; The Afghanistan Experience:
Dispatches from a CF Trauma Surgeon
16:00 Vincent Echave: Opportunities for working overseas with MSF
16:20 Finish
MoU with CNIS (Appendix I)
CNIS has recently attained Program Status from CIDA and has promised to
deliver a series of ESS courses in Gulu, Uganda over the next two years. CNIS
hosted an ESS Instructors course for some 20 CAGS members just prior to the
2007 Bethune Round Table in Toronto. The course was very well received there
is a growing group of Canadian surgeons eager to practice what they have
learned.
CNIS, in order for the funds to flow from CIDA, needs to show matching
contributions from Civil Society. Further to CAGS letter of support for the CNIS
application for Program Status of July 20, 2006, Dr. Brian Ostrow has negotiated
a Memorandum of Agreement with CNIS that should benefit both CAGS
Volunteers and the CNIS.
This MoU goes a significant way towards recognizing the value of volunteer
surgeons time and provides tax receipts for travel and living expenses, a very
modest honourarium and a $1000 dollars a day during the 5 day ESS course.
Strategically it is good to strengthen relations between CAGS and CNIS and we
see this as a tangible and beneficial way to do this while providing a substantial
tax benefit to volunteers, all without any direct costs to CAGS. This will be
brought forward to the CAGS Board on September 5th.
Statement on Self-Sufficiency in Surgical Training.
Following a request at the CAGS Board meeting in September the CIS has
drafted a response to the Royal College’s Letter on International Recruitment
(Appendix II)
Uganda project
This program focuses on providing sub-specialty knowledge translation in
subjects identified by the host institution as important. Patrtnership with CNIS to
provide ESS teaching there will be a significant benefit to CAGS existing
program. Recent visitors have included Dr. Dan Poenaru (September, 2006) to
teach about reconstruction of imperforate anus and Barb LeBlanc in October/
Nov 2006 to focus again on hand surgery.
Dr. Neelesh Jain was scheduled to go in March/April 2007 but cancelled when
there was a deterioration in the security situation.
Dr. Barb Leblanc is scheduled to go for the fourth time in Sept/Oct 2007.
Two more volunteers (Ghee Whang and Steven Umtracht) are lined up for 2008
and Dr. Leblanc is already committed for the first ESS Instructors course in July
2008.
Guyana Project
The CAGS-Guyana project is completing its second year and the Guyana
training program has expanded to include 9 surgical residents. Joining the five
original residents, four new junior residents started the training program in May
2007.
Six Canadian surgeons, Dr. Bill Harris Dr. John Barnhill, Dr. Brian Ostrow, Dr.
Abe Abraham, Dr. Robin Fairfull-Smith, and Dr. Yvonne Ying (plastics) have
each spent two weeks at Georgetown Public Hospital doing tutorial and clinical
teaching. Dr Brian Cameron spent 2 weeks in Guyana visiting district hospitals
and discussing the ongoing logistics of the program. Upcoming plans include
developing collaborative projects in Diabetic Foot Care, Thyroid surgery, and the
Burn Unit. The daily tutorial module format seems to be working well, with
consistent participation by all surgical trainees and successful trainee evaluations
at the completion of each module. The surgeons have also taken on significant
clinical and on-call responsibilities supervising the residents in the operating
room, casualty department, and wards. The Guyanese surgical faculty have
been teaching the alternate modules in between visits by the Canadian
surgeons.
The CAGS Council approved the use of the CAGS In-Training exam by the
Guyanese surgical trainees and faculty, and Dr. Cameron invigilated the exam
during his February visit. All 5 senior residents and 3 Guyanese faculty wrote the
CAGS in-training exam. Most did not complete it in the available 3 hours, but
otherwise the level of questions was appropriate. It has been made clear to the
residents that this is a learning exercise that will be conducted under exam
conditions, and that they will receive no accreditation (Appendix III). The results
are confidential.
In October, Dr. Ron Lett of the Canadian Network for International
Surgery, conducted a Trauma Team Training (TTT) Instructor’s course for 16
Guyanese residents and faculty, and then with them a 3-day TTT Provider’s
course for an additional 25 participants. Training materials and equipment were
donated and funded through the CAGS-Guyana project as well as some local
Guyanese funding. The Guyanese Instructors are planning to run their own
course to train more providers in anticipation of the upcoming World Cup of
Cricket matches in Guyana in March.
Several dozen surgical textbooks were collected and donated by surgical
residents and faculty in Edmonton, co-ordinated by Dr. Anise Barton. The
recently dated surgical texts (Sabiston and Schwartz) were especially
appreciated by the Guyanese residents and the rest of the books are in process
of being shipped to the surgical library in Georgetown. There is still a need for
copies of the major surgical texts if less than 10 years old. Other texts have also
been purchased through the CAGS-Guyana project funds and delivered to
Guyana.
Since July 2006 there have been ongoing audio-conferences between Dr.
Cameron and the Guyanese surgical trainees. After initially using the telephone,
for the last two sessions Skype has provided a reliable and good-quality audio
connection, and we have spent an hour each time presenting and discussing a
powerpoint presentation. The presentations are prepared and emailed ahead of
time, taking turns between Canadian and Guyanese presenters.
Further clinical spin-offs of these visits have developed capacity in needle and
sentinel node biopsy techniques, and identified the need to establish a
functioning gastrointestinal endoscopy service at the hospital. Also a general
improvement in hospital morale has paralleled the developments in postgraduate
training and there are plans to begin other programs.
Applications have been submitted to the Canadian Cooperation Fund in Guyana
for funding the diabetic foot program and teaching the SOGC obstetrical
emergency course (ALARM).
Program funding will end in mid-2008 so a plan needs to be developed to
continue the ongoing CAGS-Guyana collaboration beyond that time, and to the
district hospitals where the graduates will be practicing.
Detailed visitor reports are attached (Appendices VI-VII).
Surgery-in-Africa Reviews
The Surgery-in-Africa reviews, a monthly web-based review of common topics in
African Surgery continues to thrive under the editorship of Brian Ostrow. Six
hours of Royal College MOCOMP points are now awarded for each review
completed and discussions are ongoing about making participation mandatory for
candidates for the COSECSA exams. Twenty thousand dollars funding has been
attracted from Jonhson & Johnson. The SIA reviews started at the University of
Toronto OIS, but CAGS may have a more important role in the future. There
should be a link from the CAGS web site.
Website
The CIS website is being moved from the servers at the U of T where it was
initially set up on OIS webspace to the new CAGS servers. Revision and
updating is required.
The list of regional resident advisors needs to be updated.
Universities.
Bob Taylor, the founding chair of this committee, is now heading-up the Branch
for International Surgery at UBC and they, in collaboration with the CNIS will host
the next Bethune Round Table in May 2008. rhtaylor@interchange.ubc.ca
Gwen Hollaar continues to operate a virtual office of international surgery in
Calgary. ghollaar@gmail.com
Tarek Razek at McGill is working with the Quebec Red Cross to train and recruit
Canadian doctors and nurses for Red Cross Emergency Response Units
(ERUs). tarek.razek@sympatico.ca
Andrew Howard, a pediatric orthopaedic surgeon, is the new director of the U of
T Office of International Surgery. howard.andrew@gmail.com Brian Ostrow is
largely responsible for Ptolemy and the Surgery-in-Africa Review series.
Appendix I
Memorandum of Understanding
between
The Canadian Network for International Surgery
and
The Canadian Association of General Surgeons
________________________________________________________________________
Articles of the MOU:
1. Purpose
The Canadian Network for International Surgery (hereafter referred to as CNIS) is a
Canadian international development organization that has a mandate and a
commitment to decreasing injury and improving access to surgical care in Africa.
This mandate is achieved in collaboration with Canadian and African partner
organizations.
This MOU sets out the terms and conditions of the partnering arrangement between
CNIS and the Canadian Association of General Surgeons (hereafter referred to as
CAGS).
The partnership is based on mutual interests and is focused on the achievement of
results as listed in this MOU and its appendices.
2. Contributions of the Parties
2.1 Subject to the payment and reporting terms and conditions in this MOU, CNIS
agrees to contribute funds for activities as specified in this MOU.
2.2 Participating CAGS surgeons will contribute the cost of airfare and expense
allowances for activities as specified in this MOU.
3. Notice or Communication
3.1 Any notice or communication from CAGS to CNIS shall be addressed to:
Canadian Network for International Surgery
1985 West Broadway, Suite 105
Vancouver, BC, Canada V6J 4Y3
Telephone number:
Facsimile number:
E-mail address:
(604) 739-4708
(604) 739-4788
office@cnis.ca
3.2 Any notice or communication from CNIS to CAGS shall be addressed to:
CAGS
774 promenade Echo Drive
Ottawa, Ontario
Canada K1S 5N8
or
Brian Ostrow
44 Suffolk Street West
Guelph, Ontario
Canada N1H 2H8
Telephone / Facsimile number:
E-mail address:
(519) 821-4625 / (519) 824-3852
brian@bookshelf.ca
4. Applicable Laws
This MOU shall be governed by the laws in force in the Provinces of British
Columbia and Ontario.
5. Description of the MOU
5.1 The MOU between CNIS and CAGS is made up of:
5.1.1
5.1.2
5.1.3
5.1.4
5.1.5
these Articles of the MOU;
Part A - Project Description;
Part B - Reporting Requirements
Part C - Workshop Report
Part D - RBM Framework
6. Effective Date
The MOU shall become effective the later of July 1, 2007 and the date of the last
signature.
7. Duration
Unless sooner terminated as provided for in the MOU, the MOU shall remain in
effect until December 31, 2009.
The MOU has been signed for CNIS and CAGS by their respective representatives, duly
authorized.
____________________________
for Canadian Association of General Surgeons Date (Month, day, year)
_________________________
____________________________
Signature
Witness Signature
_________________________
Dr. Massey Beveridge
____________________________
Dr. Brian Ostrow
_________________________
____________________________
Chair, Committee for International Surgery Director, CAGS/Lacor Collaboration
for
Canadian Network for International
Surgery
____________________________
Date (Month, day, year)
_________________________
____________________________
Signature
Witness Signature
_________________________
Dr. Ronald Lett
____________________________
Doug Wallis
_________________________
President, CNIS
____________________________
Chairman of Board, CNIS
Part A
Project Description
1. Project Description
1.1
Maternal Health, Surgical Access & Safety Promotion for Africa
The program combines surgical training, including obstetric care, public
education and improved medical care to support injury prevention, and
resources for research and higher technical education including curriculum
development.
Rationale for the Program
Years of neglect and under-investment in basic health infrastructure in many
African countries has created a situation where a number of preventable
problems have attained the level and reach of pandemics. Injury from accidents,
medical procedures, and civil conflict is arguably responsible for more deaths
than the high-profile pandemics like malaria, tuberculosis and HIV/AIDS.
CNIS’s program addresses these basic issues, as well as the problems created by
inadequate surgical care and expertise, particularly in the field of obstetrics.
Program Goal
To reduce death and disability from surgical and obstetrical disorders in selected
African countries, by improving patient care, incidence and severity of injury,
and capacity of health institutions.
Program Components
Surgical and Obstetrical Skills
Injury Prevention and Safety Promotion
Injury, Safety, Surgical and Obstetrical Information
Public Engagement in Canada
Beneficiaries of the Program
There are direct and indirect beneficiaries of this program. Women across the
program countries will be the chief beneficiaries, both as patients (of obstetric
care) and as practitioners whose skills are improved with the training
disseminated by this program. Direct beneficiaries include learners and
instructors in ESS, at least 40% of whom will be women. Also among the direct
beneficiaries in injury control include staff of the ICC centres in Uganda and
Tanzania, and the leadership and members of the regional network. All those
who benefit from improved skills and service delivery will be indirect
beneficiaries. These include the marginalized, especially women and children.
1.2
Project Specifics with CAGS
Within the context of CNIS’ overall program, participating CAGS surgeons,
under the auspices of CAGS, will continue to provide clinical and surgical
support at the Lacor Hospital in Gulu, Uganda. CAGS has, since 2001,
independently collaborated with the surgical staff at Lacor Hospital in Gulu to
provide clinical and surgical support at the hospital. Under this program,
Canadian surgeons undertake 2 to 3 month voluntary visits imparting their
surgical expertise and undertaking clinical responsibilities. More recently, this
program has undertaken teaching of medical students from the new Medical
College in Gulu. The project described herein will in no way interfere with this
ongoing independent program but will in fact benefit from the involvement of
CAGS surgeons.
Surgical and Obstetrical Skills: CAGS collaboration with the CNIS and its
African partners will be in Gulu, northern Uganda.
One ESS instructors’ workshop will be held in July 2008. ESS providers’
workshops will be held in August 2008, February 2009, and August 2009.
1.3
This MOU is based on the Project as described in the Project Proposal dated
September 19, 2006 submitted by CNIS to CIDA.
1.4
CAGS agrees that the Program Planning Table attached to the proposal will be
used to measure the success of the Project.
2. General Responsibilities of CNIS
2.1
Purchase and provide equipment as needed for ESS workshops, and donate
equipment to Gulu University;
2.2
Provide allowances and honorariums for Gulu University Staff according to
ACC-ESS policy;
2.3
Pay participating Canadian CAGS surgeon economy class airfares Canada/Gulu
return;
2.4
Pay participating Canadian CAGS surgeon Cdn$25/day in transit plus cost of
visas, vaccinations, and hotel accommodation and meals on route, all based on
receipts;
2.5
Pay ESS certified instructor honorariums of Cdn$ 40/day, expense allowance of
Cdn$ 125/day for duration of workshops, and Cdn$1,000/day for duration of
workshops;
2.6
Pay daily allowances for CAGS surgeons during non-workshop clinical days at
Lacor Hospital of US$ 43.93/day (Canadian Treasury Board rate). After 30
days, the rate is US$32.95/day;
2.7
Administer the project activities, including disbursement of daily expense
allowances;
2.8
Report to CIDA on project activities; and
2.9
Supply tax deductible charitable receipts for the amounts donated in 3.3, 3.4, 3.5
and 3.6.
3 General Responsibilities of CAGS
CAGS shall be responsible and accountable for its portion of the successful
management and implementation of the Project work as described in 1.2 above. To
this end, in addition to responsibilities already described in the present MOU, CAGS
or CAGS surgeons shall:
3.1
report to CNIS on the CAGS activities funded through this MOU;
3.2
provide ESS certified surgeons (subject to availability) to participate in ESS
workshops;
3.3
donate cost of Canada/Gulu return airfare to CNIS for CAGS clinical activities
and/or ESS work;
3.4
donate cost of participating Canadian CAGS surgeons at $1,000/day times
number of workshop days;
3.5
donate cost of expenses for non-workshop days (Canadian Treasury Board rate
of US$ 43.93/day, (reduced by 25% after 31 days)
3.6
ensure that they carry sufficient medical insurance. This and travel medication
is at the volunteer’s expense.
3.7
reference aspects of the project related to gender equality and the involvement
of women;
3.8
maintain annual organizational membership in CNIS;
3.9
encourage CAGS surgeons who visit Lacor Hospital to obtain ESS instructor
status and participate in this project; and
3.10 participation in this project by visiting CAGS surgeons is completely voluntary
and will not preclude their visit to Lacor Hospital.
Part B
Reporting Requirements
1. Reporting
1.1
Reporting from CAGS, or CAGS surgeons, to CNIS shall be submitted by
electronic mail.
1.2
Financial and narrative reporting to CNIS shall be done in September 2008,
March 2009, and September 2009.
1.3
CAGS surgeons will report to CNIS on their CNIS-funded activities (focusing
on results and lessons learned), including specific references to gender issues.
CAGS surgeons will append their narrative report to the standard CNIS Partner
Workshop Report (Part C).
Part C
CAGS Surgeon Report
Name of Surgeon: _______________________________________________________________
Date leaving Canada: ____________________________________________________________
Date returning to Canada: ________________________________________________________
Dates of ESS workshops attended: _________________________________________________
Calculation of payment from CNIS to CAGS surgeon:
- Canada/Gulu airfare: Cdn $ ____________________________________
- visas, vaccinations, in transit costs (itemize): _______________________
- honorarium: Cdn $40/day times ___ days = _______________________
- expense allowance: Cdn $125/day times ___ days = _________________
- professional fee: Cdn $1,000/day times ___ days = __________________
plus (if desired)
- non-workshop allowance: US $43.93/day times ___ days = ___________
TOTAL: Cdn $ _____ plus US $ _____
Calculation of contribution from CAGS surgeon to CNIS:
- Canada/Gulu airfare: Cdn $ ____________________________________
- professional fee: Cdn $1,000/day times ___ days = __________________
plus (if desired)
- non-workshop allowance: US $43.93/day times ___ days = ___________
TOTAL: Cdn $ _____ plus US $ _____
Please also fill out as much of the following report as you are able. Thank you.
CNIS Partner Workshop Report
(The following format must be used in reporting on the CNIS supported activity)
Date:________________________
Partner:________________________________________
Address:________________________________________
Officer:_______________________
****Narrative Report:
VERY IMPORTANT!! ****
Name of Workshop (e.g. ESS Instructors’, ESS Providers’):
_________________________
Dates of Workshop:________________________________________
Number of Learners Registered(Total/Male/Female):_____________________
Number of Learners Completed(Total/Male/Female):_____________________
List of names with contact address and peer contact name attached: Yes __________
No __________
Number of Certified Instructors:___________
Number of Non Certified Instructors:_______
Number of Male Instructors:_______________
Number of Female Instructors:_____________
Full Time Facilitator: Yes __________ No __________ Name: __________________
Patron Participation (please specify):
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Provide details of workshop components presented:
(indicate as applicable)
Units completed:
Number of days of course:
Topics:
Activities:
Lectures:
Case Studies Reviewed:
Technical Skills (Simulated):
Technical Skills (Clinical):
Team Exercises:
Pre-tests results:
Post-test results:
Quizzes completed:
Number of Reference books distributed:
Number of Student handbooks distributed:
Equipment Deficiencies:__________________________
Evaluation Performed: Yes__________ No__________
Evaluation
Results:_________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
General Comments: Variance from submitted plan and budget:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Actual
Budgeted Actual (copies Receipt Variance Comments
Expenditure
(refer to
of receipts
Ref.
(Explanation of
request)
should be
variance)
attached)
Office Support
Consumables
(Surgical, other)
Certified
Instructors
Non Certified
Instructors
Other (specify)
(please support this report with sales receipts and payment sheets)
Signatures:
Director:__________________________________________
Patron:__________________________________________
CNIS Approval:________________________________________
PART D
RBM framework components related to the CNIS – CAGS partnership:
Activities
A. Surgical & Obstetrical Skills
A1. Structured Curriculum
Development & Implementation:
A1a. New curriculum developed &
current curriculum upgraded
A1b. Instructors’, practitioners’ &
TOTOT courses implemented.
Outputs
Outcomes
Impact
A. Surgical & Obstetrical Skills
A1. Structured Curriculum
Development & Implementation:
A1a. ESS curriculum content & target
audience expanded, new curriculum
developed
A1b.Competent ESS instructors train
interns in essential surgical skills, hernia
& operative obstetrical procedures, &
other surgical areas, e.g. wound
management, amputation, burns
A. Surgical & Obstetrical Skills
Primary care providers deliver quality essential
surgical skills in northern Uganda through:
- new and expanded curriculum
- increased number of women trained in surgical
skills
- improved infrastructure and management
- evaluation and research re surgical skills and
surgical care changes curriculum & promotes
policy change
A. Surgical Skills
Quality of, and
access to, surgical
care by the rural
populations and the
urban poor is
improved in northern
Uganda, and
maternal mortality is
reduced
Appendix II
Canadian Association of General Surgeons
Position Statement on Canadian Surgical Workforce Self-Sufficiency and
Overseas Recruitment
Whereas the Canadian Association of General Surgeons (CAGS) is in receipt of
the Royal College of Physicians and Surgeons of Canada statement on medical
workforce self-sufficiency (June 2006), and
Whereas CAGS is deeply concerned by the failure of Canadian Governments to
support and fund adequate medical school and residency positions to provide for
the present and future needs of the Canadian population for surgical care, and
Whereas CAGS strongly supports the RCPSC call for increased Canadian
medical and especially surgical training positions, and
Whereas CAGS understands that the surgeons of the future will need more time
to keep abreast of rapid developments in the field, to teach and conduct
research, and
Whereas CAGS holds that no physician should be required to be on-call more
frequently than one-in-five for a sustained period, and
Whereas CAGS appreciates that the onerous working hours of contemporary
surgical practice actively discourage many able candidates from pursuing
surgical careers, and
Whereas CAGS supports the human rights of surgeons everywhere and deplores
the conditions under which many are forced to practice, and
Whereas CAGS recognizes and supports the right of individual surgeons to
migrate in order to seek the life and employment of their choice, and
Whereas CAGS supports the practical and educational merits of international
exchanges and partnerships, and
Whereas CAGS deplores discrimination against qualified surgeons from
overseas in the form of licensing agreements restricting their practice to under
serviced areas, and
Whereas CAGS regards the lack of surgeons in developing countriesi as a global
emergency, that lives are being lost in these countries for lack of adequately
trained surgeons and that ongoing brain drain of surgeons will cause the death
toll to rise even further, and
Whereas CAGS understands that most doctors from developing countries have
been trained there at public expense and deplores that the people of some of the
world’s poorest countries are in effect paying for the healthcare of people in
Canada, and
Whereas CAGS believes that Canada, as one of the world’s wealthiest countries,
ought not only to plan for self-sufficiency in its surgical workforce but also should
make a robust contribution to training surgeons who will work in developing
countries, and
Whereas Canadian surgeons have a substantial contribution to make to the
training of medical students, residents and practicing surgeons in developing
countries,
Now therefore, CAGS endorses the generalities of the RSCPC resolution on
Workforce Self-Sufficiency (#2005-090) and proposes the following principles to
guide Canadian Policy makers engaged in ethical planning for self-sufficiency in
the Canadian surgical work-force:
Principle 1
The number of places in Canadian surgical training programs should be
increased immediately and the rate of increase should be sustained until such
time as we are training sufficient surgeons to provide for both present and future
domestic needs including consideration of the aging population, the predictable
increase in the sophistication and complexity of surgical care, and
accommodation for a generation of surgeons who will demand more balance in
their lives.
Principle 2
That international medical graduates qualified to practice surgery in any Province
should receive equal treatment in regards to licensing and mobility of practice as
Canadian graduates.
Principle 3
That recruitment of surgeons from developing countries, particularly those
identified in the 2006 World Health Report as those with a critical shortage of
healthcare workersii is unethical and unacceptable, with the possible exception of
those individuals whose human rights are threatened or those who are forced to
practice under impossible conditions.
Principle 4
That each Province that relies on recruiting international medical graduates to fill
its surgical workforce requirements should, for each surgeon it recruits from a
developing country, contribute an amount equal to the cost of training a surgeon
in Canada to programs supporting surgical training in developing countries
through partnerships, exchanges, scholarships and other educational programs
designed to retain surgeons in those countries.
i
Developing countries are those ranked with Low & Medium Human Development by the United
Nations Development Program’s Human Development Index:
http://hdr.undp.org/reports/global/2005/
ii
WHO (2006) World Health Report 2006: Working Together for Health, p 12, Fig 1.5
http://www.who.int/whr/2006/06_chap1_en.pdf
Appendix III
TO: RESIDENTS AND FACULTY OF THE UNIVERSITY OF GUYANA
POSTGRADUATE DIPLOMA IN SURGERY PROGRAMME.
RE: THE CAGS IN-TRAINING EXAMINATION
The Canadian Association of General Surgeons (CAGS) has agreed to
allow the use of this exam in Guyana as a learning experience. In Canada
this is NOT an evaluating examination, and no letters or certificates are
issued to those who take this exam. It is a self-assessment exam to help
residents prepare to write their later qualifying exams of the Royal College
of Physicians and Surgeons of Canada at completion of their training. The
CAGS In-Training exam is written each year by all surgical residents in
Canada, and residents can compare their own overall scores with those of
their peers and faculty who choose to write the exam. “Passing” the
examination means nothing in terms of their certification.
For the purposes of the University of Guyana Postgraduate Diploma in
Surgery Programme, this exam is NOT an evaluating examination. It is
meant as a learning and practice exercise to give feedback to the trainees
and faculty. The exam will be marked and results discussed by a CAGSGuyana project Canadian faculty member. Individual results or certificates
will NOT be issued to candidates. Canadian residents who take this exam
pay a fee; for Guyanese trainees and faculty the fee will be covered
through the CCF project funds.
In summary, CAGS wishes to make it very clear to Guyanese trainees and
faculty writing the CAGS in-training examination that:
1) Using this examination of CAGS DOES NOT certify or support any
educational/academic status for any successful candidates.
2) No requests for individual results, letters, or certification will be
accepted.
2) The security and confidentiality of this examination MUST BE
guaranteed.
3) All examination books and marking sheets must be returned to the
CAGS Test Committee.
Please sign below indicating your understanding and agreement with the
information above, as a pre-requisite to writing the examination.
Appendix IV
`Report on CAGS sponsored trip to Georgetown Public
Hospital – January 5-19, 2007
Submitted by Brian Ostrow
January 23, 2007
A. Diploma Course in Surgery
What I did: (based on notes contained in “issues” files in Appendix)
1. Supervised 5 sessions with residents on Vascular module B.
2. Supervised 3 sessions on Research Methods.
3. Set exam - required 178 answers in 90 minutes – a little too difficult perhaps –
however everyone passed >80%
4. Went on ward rounds, M&M rounds on Fridays, supervised debridements on
ward and several surgeries, primarily amputations, in OR.
5. Performed 5 gastroscopies and taught technique – I recommend that all CAGS
visitors are endoscopy competent. There is no local capacity. These tests are
important in supplementing the inadequate GI radiologic capacity. I don’t think
any residents are currently capable of independent endoscopy, but achieving this I
think should be a goal. We will have to provide more equipment. (see endoscopy
appendix)
6. Wrote protocol for care and cleaning of gastroscope (see endoscopy appendix)
7. Gave 1 hour lecture on peripheral vascular disease with 4th year medical students
8. Provided residents with digital/paper information: ankle block, amputation
techniques, Schwartz’s chapters on Arterial, Venous and Spleen.
9. Held two Ptolemy training sessions. There is limited knowledge of this and not
too many people showed up. 6 in first and 8 with residents in second. However, I
received 4 new applications and taught some people how to use Reference
Manager.
10. Distributed 50 cds on Ptolemy training/Surgery in Africa/Reference Manager
What I observed:
1. The general atmosphere on the wards is not optimum for a number of reasons.
Lack of human resources (see below) is perhaps the biggest constraint. The
nursing shortage is acute and the nurses are poorly motivated and perhaps
educated and there are doctor/nurse tensions. Orders are frequently not
implemented. Access to testing is often chaotic and the charting could be
2.
3.
4.
5.
6.
improved. (Curiously the access to and results from CT scanning, a private
facility is good). None of this is all that unusual in a developing world context,
but it makes the rigorous application of standards and quality of care, important in
a teaching program, difficult.
Probably the most serious defect I observed in the surgery program was the
surgical manpower. There are ostensibly 3 surgeons.
a. Dr. Amir, who, I think, acquits himself adequately in terms of supervising the
residents, seeing his patients, etc. This is not to say that his work is without
complications – there were several concerns during my stay. However I think he
is the only one who does significant teaching.
b. Dr. Zhang is a Chinese surgeon having completed I think 6 months of a 2 year
stay. He has significant problems with English, so must rely on the residents to
explain the history, etc. More importantly he has no training or interest in
extremity problems. Note that the diabetic foot comprises 30-50% of the inpatient
load. There were also some standards issues relating to his care.
c. Dr Rambaran is not only chief of surgery but has other major administrative
responsibilities, which significantly preclude his clinical activity. This has a major
impact on his ability to supervise the residents and his patients. There are two
residents on General surgery, one with Dr. Amir and one with Dr, Zhang. Dr.
Rambaran has none but he relies even more than the others for supervision of his
patients. As a result the residents must switch their supervision of his patients
weekly. The result both from a teaching perspective and from a clinical point of
view is not really optimal. I think that provision of a third active surgeon would
be an important improvement or lessening Dr. Rambaran’s administrative
responsibilities.
The consequences of the above are that there is an inordinate amount of work for
the general surgical residents. Just doing rounds takes up a lot of their time, the
debridements, which are a daily necessity, are often delayed or postponed as well
booking of emergencies is difficult. This is nowhere more evident than in the care
of the diabetic foot patients. The residents have many other responsibilities,
including clinics, booking cases, minor surgery, call + extra call because of
shortages. They operate independently on a number of cases in a graded
responsibility manner. Their handover may be sloppy at times. In general I don’t
think they are supervised enough.
I think the overall motivation and interest of the residents is good, although a long
general surgery rotation can be debilitating. I noticed that there is good teaching
between residents. Note: Tinnie assisting Legall on amputation. I have no idea the
degree to which the surgeons teach the residents in the OR.
The capability level of the 5 residents is easy to rank– Martin, Rajkumar,
Rambaran at the top, not necessarily in that order, then Tinnie and Legall in that
order. Legall, I would rate an early R1, although he is obliged to make decisions
on a higher level; Tinnie late R1 early R2, the others R2. These are smart guys
and will respond positively to improved teaching.
Since most teaching is done on a case by case basis, I think my decision to not
operate or take call was a disappointment (considering everyone is overworked).
That plus my involvement in the diabetic program and not having a background in
teaching residents limited my impact. I would advise all subsequent CAGS
visitors be university teachers and active operators. It may actually be of value to
increase the number of visits to 6/year or more, particularly in view of the surgical
manpower issues. I think in general these visits bring a much needed atmosphere
of clinical rigor not to mention assist in the workload.
7. I am not impressed with the STEP training materials. However I have nothing to
replace it with.
8. I think some assistance in preparation for the POS exams would be needed –
access to SESAP?
9. There were several deaths which I think were questionable. They have M&M
rounds but these were not presented yet.
10. There was no clear method of teaching modules. It appeared that they went
through the questions one by one – reading them. I thought that boring and I
didn’t have enough time – I got the residents to give little sessions which was OK.
More preparation of visitors might have been helpful on this front.
11. Some of the surgical clinical behaviour is odd – for example cases of sigmoid
volvulus are never sigmoidoscoped – always taken to the OR directly –
Hartmann’s seems to be standard procedure. Of course in Canada as well there is
a large variability in surgical approach too.
12. Janice is extremely competent and a treat to work with.
13. One might well regard the hierarchical relations between consultants, residents,
students, nurses, etc. to be a feature similar to an earlier time in Canada.
B. Diabetic Foot Program
What I did:
1. I spent considerable time on this which took away from my ability to supervise
the residents. However the consequence of the possible improvements will make a
big impact on the activity of the residents.
2. Investigated in and outpatient Diabetic foot program and recommended changes.
(see Draft Guidelines Diabetic foot in appendix)
3. Gave CME lecture on Diabetic foot
4. Presented Draft guidelines at M & M rounds
5. Initial investigation of mechanism for CCF proposal.
C. Georgetown in general
1. Georgetown is a small but agreeable city. The architecture, food and general
hospitality make it an agreeable short term stay. Everyone mentions security but,
if precautions are taken vis a vis areas of town, I felt completely safe during both
day and night.
2. Georgetown club is a dated institution. The prime reason for continuing to stay
there is its relatively low cost, nearness to the hospital – 5 minutes walk and
excellent free 24/7 internet connectivity
3. The swimming pool next door is accessible on request – ask the adminstrator to
give you a temporary membership.
4. The key to accessing the Scotiabank ATM is to have a Mastercard or Debit card
that works with CIRRUS or MAESTRO systems.
5. Need to sort out when the restaurants are open: German only for lunch 10-3 each
day. Coal Pot not Sunday’s also lunch only. Best so far – Dutch Bottle. Stepper’s
near hospital – has very good, cheap, clean vegetarian food.
D. Expenses
1. Note Return date – January 21 not 19 – total stay 18 days.
2. I have enclosed my own calculations (adding two days unreceipted if I had stayed
in Georgetown Club) see Appendix
3. Note addition of VAT 16% and VISA charge 5%
4. It is difficult (although I could have made a greater effort) to have complete
receipts.
5. I estimate (total costs with Doppler) – (resort at the end) = C$4100
6. The receipts are being sent by mail.
Overall assessment
CAGS involvement is absolutely crucial to the development and training of these
residents. It should if possible be increased in all spheres.
Appendix V
T.E. Abraham, M.B.B.S, F.R.C.S(C), F.A.C.S
55 Kingsford Place
Oakville, Ontario
L6J 5X8
Report On Visit to Guyana – CAGS – April 22 to May 2, 2007
I wish to take this opportunity to thank CAGS and the organizers of the Guyana project
for allowing me to take part in this on going program of Surgical teaching in Guyana. I
was in Guyana from the 22nd of April, 2007 to the 2nd of May 2007 and I believe I had a
very successful and satisfying visit and was able to accomplish all of my objectives and
complete my assignments. Although my visit was initially planned to last till the 4th of
May, I had to cut the length short by 2 days because of the absence of some of the
residents who had to present papers at the Caribbean Surgical conference during that
time. However, this did not adversely affect the teaching assignments as I was able to
hold some sessions on the weekends ( Saturdays ) as well.
My hosts, Dr. Madan Rambaran, the Medical Director of the the Georgetown public
hospital corporation and his assistant the recently married Janice Gonzales were most
gracious and offered all the help I needed while in Guyana.
My arrival in Guyana went without any glitches on a Sunday morning and the driver
arranged by the Georgetown hospital was promptly at the airport to pick me up. As you
know I had carried with me a Gastroscope belonging to the hospital in Guyana which was
repaired in Canada through Dr. Harris. I had anticipated some problems in getting this
machinery through the customs, but I was pleasantly surprised by how easy it was to get
through.
My accommodations were at the Georgetown Club, an old British institution still
operating quite successfully. The only slight snag was that on account of being a Sunday
the place was virtually deserted with just the security guard at the gate through most of
the day. The kitchen of course did not operate on Sundays. This was not really a problem
as Church’s Chicken across the street appeared to be open all the time. Future visitors,
especially female faculty, should be aware that there is no dining facility available at the
Club on Sundays and on holidays. The Pegasus hotel is a short cab ride away and is a safe
and secure place to hang out at, if necessary.
I went to the Hospital on Monday morning and met with Dr. Rambaran. Janice was still
on her honeymoon and returned I think about two days later. I had been to Guyana before
and knew how to find and meet with the residents on the floor, which I did almost every
day in the mornings, going on rounds with the residents. I also did take the calls for
Dr.Rambaran, while I was there giving him a short break from the call duties. The
residents on the General Surgery rotation this time were Dr. Allan Tinnie and Dr. Shawn
Legall. I was very happy and gratified to see the wound management protocol initiated by
Dr. Brian Ostrow being used frequently. The diabetic foot management is a major issue
in Guyana and it was very obvious that Brian has made a significant impact. The Doppler
was being used to check the vascular supply and monofilament was being used to check
sensations.
I had hoped to get the Endoscopy project started up again, but ran into difficulties. The
repaired Gastroscope was probably working, but since it was a Videoscope it needed to
be working together with the image processor and light source. I am not a technical wiz
and the residents and I could not get an image to appear on the monitor. We had the
Guyanese bio medical team to look at the machines, but had no luck in getting it to work.
I understood that Dr. Harris will be returning to Guyana some time in the future. I would
like him to be aware of these problems and perhaps find solutions to them prior to his
departure. Even though the resident Shawn Legall is keen to take on the project, I think
he has become frustrated and will need a little extra help in getting the machines working
and the project underway.
I met with all the residents on Monday afternoon at the tutorial session and planned how
we will tackle the assignments. The entire topic of Endocrine surgery was split into
Thyroid, Parathyroid and Adrenals and then further split into smaller topics that was
assigned to each resident. The residents were well prepared at each session with very
slick Power Point presentations and we had very lively discussions in which all of the
residents participated well. I found that the residents do not lack in theoretical knowledge
or information. They however do have some difficulty with some very practical clinical
fundamentals. Some of this is due to some hospital policies where certain tests are simply
not available. For example, we can get an extensive battery of thyroid tests including T4,
T3, and TBG ? but cannot get TSH! I did have discussions with Dr. Rambaran and he is
looking into this.
Because of my shortened visit I gave the final examination on Monday the 30th of April. I
had prepared questions and answers and did the evaluation of the results immediately
after the test. The test consisted of 52 questions, some of which were multiple choice and
some short answers. They completed the test in about 90 mins and we then reviewed all
the answers immediately after. The scores ranged from 93% to 97% and no one failed.
In addition to my assigned Endocrine surgery I also revisited Perioperative management
as requested. We were able to cover Fluid balance and Electrolytes fairly completely, but
this topic was not included in the test.
During any visit to the Department of Surgery at the GPHC it is hard not to be impressed
by the number of Thyroid operations being done and the number of the population with
large Goiters. Guyana is a coastal country where most residents consume sea food, and
therefore Iodine deficiency is an unlikely cause of this problem. There has never been any
systematic study done on this topic and I thought that this could be a good project for one
of the residents to tackle. With Dr. Rambaran’s involvement and encouragement I have
put together a project for one of the residents to take on the near future. The details are
attached along with this.
The CME lecture by the visiting faculty is normally given towards the end of the week,
but due to my shortened visit, I gave my lecture on the Monday April 30th. My topic was
“Management of Thyroid Masses” and I was very pleasantly surprised by the good turn
out I had, nearly 40 people. We had numerous questions and participation from the
audience. After the CME lecture I was treated to a great dinner at one of the local
restaurants by the residents who insisted on paying for my meal.
This was my first CAGS sponsored visit to Guyana, but I have been to Guyana at other
times in the past. Overall, in my view, Guyana looked much improved this time
compared to my previous visits. This could have been due to recent improvements in the
infrastructure such as roads brought about by the recent cricket matches. The travel to and
from the airport was actually quite pleasant with wide roads and no pot holes! I enjoyed
my visit very much and look forward to doing it again some time in the future.
T.E. Abraham
Appendix VI
CAGS- Guyana General Surgery Training project
Visit – 18th to 29th June 2007
R. J. Fairfull Smith
Dear Brian
Here is a summary of my visit.
Travel was uneventful, and the Georgetown Club is a very convenient place to stay.
Agree that US$250 -300 should cover most needs. The club wireless internet connection
worked well both in my room and the main lounge/bar, although the provider connection
dropped out a few times, probably during power outages. The club has a generator so you
do not notice the cut in power. The taxi driver, Munir Khan, that brought me into town
was subsequently very helpful.
The residents were a great bunch of guys. I found them very enthusiastic and always open
to discussion. I did the tutorials as required, see below. I did not do any clinical work
except the occasional ward round. The first couple of days I spent getting orientated and
catching up with my sleep. (Arrived a bit sleep deprived, had been very busy at home)
This seemed to lead to a loss of momentum regarding clinical work. I would get more
involved from the beginning next time.
The faculty seemed very enthusiastic, and the sense I had was that the program and the
residents have had a very positive impact on the hospital. I guess there are some issues to
sort out about where the graduating residents will go, but I think you know more about
that than I do.
We did the following tutorials. They might seem a bit ambitious and beyond the STEP
manual, but that is what the residents wanted. The residents took it in turn to present, I
did have some talks prepared but they did not want that. I just commented and
occasionally expanded on the subject.
18th June – Anatomy of liver, pancreas & bile ducts – Chris Prashad
19th June – Cholelithiasis & Gallbladder disease – Shilindra Rajkumar
20th June – Gallbladder & Bile duct surgery – Carlos Martin
21st June – Hepatocellular & Cholangio Ca – Cheet. Mahadeo
26th June – Benign tumours & Cysts of the liver – Shawn Legall
27th June – Trauma to the liver – Rajendra Sukraj
On Friday 22nd June we did oral exams of all the 2nd year residents with Sheik Amir &
Madan Rambarran. It was not an exam that we marked but more of practice run for the
residents and Sheik and Madan. We had a discussion afterwards, I think it would be good
for them to have another 1 or 2 practice runs. When it comes to the real exam I think we
need to develop a set of questions or scenarios with points for the examiners to check off.
It is too easy for the examiners to fall back on asking for lists and theory. The exam
should test clinical judgment so should be scenario based.
On 28th June I set a written exam. I gave them a couple of the STEP manual scenarios
and questions, which they all passed fairly easily. I also gave them a 20 question MCQ
and “name the structure on anatomy pictures” exam, which they did not have to pass, but
they all did well to very well.
The STEP manual only has four questions related to HPB, and I have to say they are not
very good. I found them carelessly written, occasionally wrong and confusing. Having
said that, I am not sure what we could use instead.
I did two CME lectures, “Review of Acute Pancreatitis” and second one that was a bit
esoteric which I OK’d with Madan first, “Is there a Role for Surgery in Metastatic
Colorectal Cancer?” During the second week I took the 3rd year students for a couple of
tutorials and the final year students for a very long session! a pre-exam review of all of
abdominal general surgery. I noted that 70% of the class is female, the surgery program
will, I presume, eventually reflect that. For those that are interested in teaching, the
students were very receptive and a pleasure to teach. Could this be worked into the
Canadian surgeons’ visit?
For information, for the weekend I went to Karanambu ranch in the Rupunini district,
near Lethem. I found it fascinating. Masses of bird life and interesting savannah and trips
through the forest and swaps. You have to be reasonably tolerant of bugs and heat and
humidity, especially in the wet season. I will certainly make time next time I go to
Guyana for more exploration in the area.
Madan wants to me to look into helping them to develop laparoscopic surgery, which I
am happy to do. I have some ideas and possible leads to industry money to help make this
happen. Will keep you informed.
Robin Fairfull Smith
Appendix VII
Summary Report July 2007
CAGS-CIS Surgery Residency Training Program
Plastic Surgery Unit
Yvonne Ying
There was no specific Plastic Surgery segment in the STEP curriculum. The curriculum
for the 2 weeks was therefore drawn from a number of books, as well as material outside
the STEP modules. These included wound healing from Core Modules 2 (Perioperative
Management), hand fractures and burns, as well as flaps and grafts from Core Modules 3
( Trauma), and hand infections from System Module A (Locomotor).
I had arrived prior to the 2 designated weeks, and met with the residents to define topics
of interest, and to assign topics for presentations. The first 6 classes had presentations by
the residents on the various topics, with discussions and highlighting of the important
points following. I was responsible for providing the material/presentations for 2
sessions. The first day was spent on practicing local flaps using models of leatherette or
stretch fabric on wooden frames. The second day was on flaps for hand reconstruction.
We then went through a series of cases to practice applications of these various flaps.
The exam was on the 9th day, and a review of the exam as well as review of questions on
the final day.
The resident feedback was that the hands-on sessions were very useful and enjoyable, and
more interactive sessions like that would be beneficial. I had provided a few short
summery chapters from one of my review books on a couple of the topics, which they
also found useful. They had suggested if a key article could be provided (or reference
provided that they could download), it would be helpful for giving updated information in
a more concise format.
CME rounds were presented on the first Friday evening. I had given a list of topics to Dr.
Rambaran to choose, and the chosen topic was Pressure Ulcers.
From a clinical work perspective, I spent some time on the burn unit assessing the burn
management and needs. As it turns out, there was no plastic surgeon available, as the
plastic surgeon provided by China was on his annual leave for 6 weeks surrounding my
visit. While away, the burns are managed by the general surgeons, but for the most part
patients are left on cruise control with his pending return. I did some burn teaching with
the nurses, and teaching regarding splinting and nutrition. I did 3 burn cases during this
time, a syndactyly release, and a cleft lip revision. There was a resident who helped to
co-ordinate my OR bookings, but for the most part, the intern was assigned to assist me.
There is no resident/GMO who rotates on plastic surgery. I believe that a rotation on
burns/plastics would be helpful, although the current plastic surgeon does not generally
operate early, so if considered, this may be delayed until the burn unit management
changes.