Download Sterling Braun - University of Kansas Medical Center

Plastic Surgery: Practice, access, and training in Ghana
1. To understand the role of Plastic Surgery in the healthcare system in Ghana including
access and barriers to care.
The profound burden of unmet surgical need in low and middle income countries recently
emerged as a leading concern in global health. The World Bank estimates that inability to access
surgical treatment costs more lives annually than HIV/AIDS, tuberculosis, and malaria combined.1
The Lancet Commission on Global Surgery found that surgically treatable conditions account for 2832% of the global disease burden.2 Among the most affected regions is Western sub-Saharan Africa
with nearly 19 million cases of unmet surgical need annually.2
Historically, barriers to the expansion of surgical care included the misconception that surgery
was too costly for lower and middle income countries.3 In contrast to this perception, the Lancet
Commision on Global Surgery indicated that unmet surgical need threatens the economic growth of
developing countries costing about 2% of annual GDP by 2030.4 Collectively, these realizations led
the international health community to focus efforts on improving global access to safe and affordable
surgery.
Plastic surgery stands to play an important role in the improvement of surgical access globally.
The scope of the plastic surgery care includes many of the 44 “Procedures Essential for Population
Health” listed by the World Bank. Included in this list were procedures for traumatic injuries, burns,
and congenital malformations.5 Plastic surgeons provide wide-ranging care including acute and
chronic care for burn patients, hand trauma, facial trauma, congenital deformities, oncologic
reconstruction, and acute and chronic wound management. Considering the breadth of plastic surgery
care in the clinical milieu, its expansion has valuable potential in strengthening global access to
surgical treatment.
Currently, eight full-time plastic surgeons practice in Ghana, a country of 25.9 million people in
Western sub-Saharan Africa.10,11 The eight plastic surgeons are split between two tertiary care
hospitals, which makes access to plastic surgery an arduous task for patients. The Ghana Health
Service operates at three levels: the first level is the 110 district level hospitals, the second level
consists of 10 regional referral hospitals, and finally four teaching hospitals serving as tertiary care
centers. The plastic surgeons have faculty appointments at two of the teaching hospitals: Korle Bu
Teaching Hospital in the capital city of Accra and Komfo Anokye Teaching Hospital in the second
most populous city of Kumasi.11 These tertiary care teaching hospitals receive referrals from the 10
regional hospitals and the 110 district-level hospitals in Ghana.
The district hospitals serve as first referral centers for most of the population and serve 100,000200,00 people and typically have 50-200 beds6,11. Unfortunately, these hospitals are often ill equipped
to provide surgical treatment. The district hospitals are staffed by one medical officer (MD) who is
often not formally trained in surgery but may be perform simple, high-demand procedures such as
cesarean sections, suturing, and abscess drainage. One study found that 6 of 17 district hospitals
surveyed employed a fully trained general surgeon.7
Due to the lack of an experienced staff surgeon, many district hospitals refer patients for
management within the scope of Plastic Surgery including acute burn management (35% of
facilities), skin grafting (71%), pediatric surgery (57%), and hand surgery.8 Consequently, specialist
referral hospitals are often overwhelmed and patients unable to travel cannot access care. The
strengthening of surgical care provided by district hospitals, including procedures for burn care and
hand trauma, is the first recommendation of the Bellagio Essential Surgery Group in its report aiming
to increase access to surgery in sub-Saharan Africa.9
2. To understand recruitment, selection and training of Plastic Surgeons in Ghana
The current plastic surgery workforce in Ghana amounts to a density of 0.03 plastic surgeons per
100,000 population compared with 2.42 per 100,000 in the U.S.10,11,12. The World Health
Organization estimated general surgeons were also quite scarce in Ghana at 0.49 per 100,000
population.13 The shortage of formally trained surgeons in Ghana is also reflected by a shortage of
physicians overall. The physician shortage resulted, at least in part, because over two-thirds of
medical graduates trained in Ghana left the country between 1993 and 2000.14 In order to provide
adequate access to surgical care in Ghana, the workforce of plastic surgeons and general surgeons
likely must increase. Expansion of the surgical workforce may require either an increase the size or a
restructuring of the training programs.
In Ghana, medical education begins after the completion of primary education around age 18.
After completing primary school, students enter university medical school, which is a seven-year
program. After medical school, the newly minted doctors complete a two-year house officership with
four six-month rotations in general medicine, pediatrics, Obstetrics and Gynecology, and surgery.
After completing house-officership, the doctors graduate to medical officers with a total of nine-years
of training under their belts and at the spry age of 27, assuming the most direct route.
Medical officers then must complete at least one-year attending to a district hospital. The district
assignment is determined by the Ghana Health Service, and the medical officers may request sites but
possess no direct control over placement. After completing the district assignment, medical officers
may then pursue a residency if they choose. After applying to residency, they will interview and be
examined before acceptance. The residency path to become a plastic surgeon first involves a five-year
general surgery training followed by three-years of specialty training in plastic surgery. In all, the
medical training for plastic surgery totals eighteen-years and a consultant plastic surgeon who
matriculated directly would be 36 years of age. Comparatively, a direct path in the US would take
fourteen-years to become a plastic surgeon around 32 years of age.
Financing of medical education also differs from the US model. Medical students and house
officers receive a salary paid by the teaching hospital. Upon completion of house officership, the
assigned district hospital pays the salary. To begin a residency, the district must approve the release
and agree to sponsor the salary of the medical officer. Without sponsorship from the district, residents
would have no salary and also be charged fees for residency training. Ostensibly, this system creates a
strong disincentive for the pursuit of residency and specialization.
Establishing a more direct and accessible training program for plastic surgery could potentially
improve the shortage. Such a model was implemented in 1989 when the Ghana Health Service
established a training program in obstetrics and gynecology to address a critical shortage of trained
OB-GYN physicians. As of November 2006, 37 of 38 specialists who completed that program
remained in Ghana to establish a practice. The physicians who remained cited the most important
factor in staying was simply the presence of a viable option to obtain expedient specialty qualification
from a training program in Ghana. In my interview with Dr. Farhat, he noted that a proposal to
establish a similar model for plastic surgery has been presented to the West African College of
Surgeons.11 However, it remains to be seen if such a training pathway will be implemented.
3. To understand how plastic surgeons from high resource countries can help strengthen the
plastic surgery workforce in Ghana.
The swift, visual realization of results and the relatively low cost and resource requirement of
plastic surgery procedures make it a portable specialty and one that has historically been involved in
global outreach. Thus, several models for providing plastic surgery care in low and middle income
countries have been developed. One model of involvement is brief surgical missions, in which
surgeons and other team members travel to a low-resource setting to perform surgeries for a short
period. Other models involve longitudinal partnerships between academic plastic surgery programs
in high resource countries and training programs in low resource settings. In this case, plastic surgery
care exists in the host country, but the workforce cannot not adequately to meet the need.
Additionally, several non-profit organizations provide partnership models including SmileTrain,
Operation smile, and Interplast among others.
Short-term medical missions are brief visits by surgeons from high-resource countries, and they
can help to provide one-time care to patients in need of treatment. The visits may focus on treatment
for congenital malformations such as cleft-lip and cleft-palate or congenital hand deformities such as
syndactyly, polydactyly, and camptodactyly. Critics note that such missions fail to establish
sustainable surgical care, because the relationship with local teams is brief and the trip displaces the
work of local surgeons, particularly in poorly planned approaches.15 These criticisms compelled
plastic surgeons to shift to a model that engages in longitudinal efforts to strengthen the plastic
surgery workforce in developing healthcare systems. The current model attempts to accomplish this
with multiple visits to the same site coordinating with the same surgeons in the host country.16
Longitudinal partnerships between plastic surgeons in high resource countries and their
counterparts in low and middle income countries seek to impart the local plastic surgeons with
knowledge and skills to become self-sufficient in providing surgical care to the population in need.
Focusing efforts on training surgeons in the host country may be the most sustainable and costeffective method for providing adequate surgical care.17 Non-profit organizations have also adopted
the partnership model as a means for improving global provision of surgical care. Though Operation
Smile initially used international teams to provide care, as of 2012, two-thirds of patients received
care from local plastic surgery teams.18
At Komfo Anokye Teaching Hospital in Kumasi, Ghana, the plastic surgery department has
formed partnerships with several surgeons from the United States. Once yearly a plastic surgery
professor from the University of Utah visits with a resident to give lectures and operate with local
residents. Through this relationship the residents at KATH also use telecommunication to ask
questions regarding care and procedures that they may perform after the mission has ended.
Additionally, a Ghanaian plastic surgeon, originally from Kumasi and now practicing in the US,
returns for one week each year with his charity “Restore” to perform free surgery at KATH. More
recently, two hand surgeons from the U.S. have been involved with KATH in an effort to teach
methods of providing hand surgery under local anesthesia. This method of “wide awake” hand
surgery allows residents to provide affordable, fast, and more convenient access to the treatment of
hand injuries.
In my interview with Dr. Farhat, chief resident in plastic surgery at KATH, he expressed his
gratitude and noted that the visits had imparted him with a great deal of knowledge and skill. He went
on to say that these visits provide the opportunity to learn new techniques and gain experience with
new technology. The relationships also allow the residents and faculty at KATH to join educational
video conferences to continue learning and communicating after the surgeons return to the US.
Though the visits are typically brief, usually lasting one week, they afford the opportunity for
substantial educational benefit. He felt that having multiple visits throughout the year with different
surgeons was also helpful to continue reinforcing learned concepts and procedures.
Dr. Farhat felt that the visiting surgeons’ familiarity with KATH allowed them to learn about the
environment and the available supplies, so that they would know what to expect. Dr. Farhat pointed
out that initial visits can be a surprise to surgeons. “Sometimes coming from an environment where
you have everything available people expect [it] here and they are shocked something is not available.
If they come several times they learn, so they’ll know what to bring.” He welcomed this opportunity
to work with the resources surgeons bring along. “I think it’s helpful…sometimes we have not had
exposure to technology. [One American surgeon] brought a tourniquet I had not seen before and left
us samples. He also brought a wire suture that even [the Canadian surgeon] had not seen before
which he was surprised to find that he loved.”
Dr. Farhat noted that the faculty and nurses at KATH also welcomed the visiting surgeons and
looked forward to their return. “The theater nurses love them, because they learn a lot from
interacting and working with the surgeons.”
Dr. Farhat provided some helpful advice to first time travelling surgeons “[your] minds should be
open to a lot of things that may be different from the US. Accept everything and try not to
critisize…because you tend to step on people’s toes. Be patient and friendly when pushing for a
change. From all the years I’ve spent in Ghana…I’ve learned you can never change something in 24
hours…don’t measure your success in days or weeks but measure it in years.”
Dr. Farhat did point out aspects of plastic surgery he would like to learn about on future visits.
“One thing I haven’t had experience with yet is microsurgery. We have a microscope that is faulty,
but I haven’t seen any micro I think it would be helpful.” Dr. Farhat was offered an invitation to
travel to the Utah for an exchange visit. However, current barriers to such a trip include the
prohibitive cost of the flight to the US and difficulties in obtaining a Visa. Though he felt these issues
would not be insurmountable, and he hopes to set up a trip someday.
In closing Dr. Farhat expressed his hope that my visit would establish a relationship between the
KATH plastic surgery department and the plastic surgeons at the University of Kansas. “I am also
hoping that you will be a bridge to Kansas. If you happen to [match] there just mention to see if [the
surgeons] will travel here. I think if we have more people coming we would have a mission almost
every month.”
References
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