Looking forward – November 2019

For the last few years, leaders of the American College of Surgeons (ACS) have been visiting countries outside the U.S. to learn about their health care systems—both the challenges and the achievements. ACS Past-President Carlos A. Pellegrini, MD, FACS, FRCSI(Hon), FRCS(Hon), FRCSEd(Hon), coauthor of this month’s column, has led this effort with Dawn Davis of World Learning, a not-for-profit organization that arranges professional exchanges to encourage cross-cultural dialogs and networking.

To date, as part of this program, ACS delegations have visited Cuba, Israel, and Kosovo. We will be traveling to Morocco in March 2020 to learn about the kingdom’s expanding health care system. This column focuses on what we have learned through these trips—the purpose of which is to establish relationships with our counterparts in other countries. Participants in these visits pay their own way and work full days, meeting with government leaders, surgeon colleagues, and other health care professionals.

Cuba

A delegation of 51 ACS leaders visited Cuba in spring 2017 in an effort to strengthen ties with surgeons of the island nation.* The Cuban people have developed an efficient national health care system, which trains health care professionals, including physicians, from all over the world and provides relief services to countries in need.

We learned about Cuba’s three-tiered health care system, which includes community clinics where primary care and basic health care is provided (tier 1); in-district hospitals that provide general surgery services, acute care, and some specialized surgical care (tier 2); and tertiary and quaternary hospitals in Havana that provide specialized services (tier 3). We found that although surgeons can provide some technologically advanced procedures, they are lacking the supplies and resources to meet the needs of pediatric patients and patients with certain types of cancer. It is worth noting that tertiary outcomes are weak; for example, the mortality rate for Whipple operations is 11 percent.*

We also learned about Cuba’s surgical training system, which is provided at no cost to residents. This system has had some unintentionally negative consequences, including overproduction of physicians, nurses, and other providers, who must then be rented out to low-income countries.*

The Cuban surgeons with whom we met expressed interest in pursuing the following opportunities:*

• Collaborating with U.S. medical schools and with the ACS in training and research
• Gaining fair access to technology, pharmaceuticals, and equipment
• Reducing restrictive regulations that they believe disproportionately disadvantage Cuba and the nation’s health care system

Israel

A group of 17 Fellows visited Israel in April 2018. The purpose of the trip was to learn about the development of surgery and the state of surgical services, the challenges and advances in the delivery of surgical and health care services, approaches to civilian and military trauma, and the financing of health care in Israel.^†

The Israeli National Health System provides free care to the nation’s population. Despite a large national defense, Israel has no designated military hospitals.^†

We learned about graduate medical education in Israel, including the 30 resident training programs, most of which are affiliated with hospitals rather than universities, distributed throughout the country. Training is for six years, including six months of mandatory research, with examinations at the midpoint and upon completion. Many graduates seek fellowship training in the U.S. but find these difficult to obtain. Some in-country fellowships for trauma and colorectal specialization are well established, whereas fellowships in breast, metabolic (bariatric), and endocrine surgery are in development.^†

Because of ongoing conflicts with neighboring countries and territories, Israel hospitals are well prepared for mass casualty events. The hospitals we visited also were equipped to provide advanced surgical care.^†

All in all, our visits to several medical centers served to demonstrate that although the people of Israel must constantly be prepared for warfare, they do not let this situation weaken their creative spirit or their technological progress.^†

Kosovo

In June 2019, 16 ACS delegates visited Kosovo, which became an independent country in 2008 after its separation from Serbia. Since then, the republic has focused largely on building economic and government stability rather than the mixed public-private health care system, which is underfinanced, with the lowest per capita expenditure in Europe. Kosovars were very welcoming and displayed a real hunger for learning about the College’s resources.

Kosovo has primary care centers in each of its 38 municipalities, seven secondary hospitals, and one tertiary care hospital in the capital city of Pristina. Future plans include the following:

• Updating old hospital infrastructures
• Introducing electronic health records
• Establishing a health insurance fund
• Improving cancer care, which most Kosovars obtain outside the country or in private facilities

Patients may receive care at public institutions for a nominal fee, but the wait times are long; for example, it can take up to two years for a cardiac stent. Workforce needs are engineered centrally, with hospitals submitting requests for specialists and allocations made by the Ministry of Health. The only medical school is in Pristina and graduates 150 physicians per class. Postgraduate training occurs outside of Kosovo, mostly in Germany, Turkey, and Switzerland. Many surgeons choose to remain in those countries after they complete their training, creating a “brain drain.”

The Ministry of Health has expressed interest in collaborating with the U.S. on education, training, and quality improvement. The ACS delegates offered to share several resources with our colleagues, including Advanced Trauma Life Support^® training and the Red Book, Optimal Resources for Surgical Quality and Safety.

Morocco

Invitations for the visit to the Kingdom of Morocco, March 15−22, 2020, are being sent to ACS leaders, including the Board of Regents. The focus of this trip will be on the North African country’s efforts to expand its health care system.

The World Health Organization (WHO) in 2008 cited access to care through the public health care system as one of the greatest challenges facing Moroccans. Although the country has a universal health care system, it suffers from a lack of public facilities. In response, a number of privately funded health care centers have sprung up across the nation, providing services to patients who can afford to pay out of pocket or to purchase supplemental coverage.

We will meet with government representatives, hospital administrators, and health care professionals to discuss the following issues:

• Public health priorities
• The role of the WHO and other nongovernmental organizations in ensuring access to care
• Development of surgery and state of surgical services
• Approach to trauma and crisis response
• Quality and value in the delivery of health care
• Cancer care, centers of excellence, and population

Ongoing mission

We have learned a lot through these visits. As we become more experienced, we anticipate that the role the ACS can play in global health care will become more clearly defined. This program is still evolving, and both the surgeon authors of this column have found these experiences enriching professionally and personally. Ms. Davis and her colleagues at World Learning would be willing to consider arranging other opportunities for interested Fellows of the College. We would encourage you to join us on this journey and to offer suggestions regarding other countries that we should consider visiting.

If you have comments or suggestions about this or other issues, please send them to Dr. Hoyt at lookingforward@facs.org.

*Sinanan MN, Pellegrini CA, Riojas D. ACS leaders visit Cuba, discover opportunities for collaboration. Bull Am Coll Surg. 2017;102(12)18-26. Available at: http://bulletin.facs.org/2017/12/acs-leaders-visit-cuba-discover-opportunities-for-collaboration/. Accessed October 3, 2019.

^†Salcedo-Wasicek C, Langdale LA, Kao LS, Oyetunji S, Weymuller EA, Jimenez C, Pellegrini CA. ACS delegation visits Israel. Bull Am Coll Surg. 2018;103(11):12-18. Available at: http://bulletin.facs.org/2018/11/acs-delegation-visits-israel/. Accessed October 3, 2019.