WashU Medicine’s general surgery residency program promotes opportunities for residents to expand the scope of their surgical expertise while providing essential surgical care in underserved communities around the world. With substantial efforts from motivated faculty with interests in global surgery, opportunities are becoming more available to trainees around the world.
The residency program allows trainees to pursue global rotations with accredited programs outside the country. To gain global experience, trainees may join weeklong volunteer surgery missions with Surgical Outreach for the Americas (SOfA) or an eight-week rotation in Malawi, in conjunction with University of Cincinnati College of Medicine. Whether as volunteers or as core components of a team to earn credits, WashU general surgery residents are providing essential services globally.
Malawi
In 2012, Paul Wise, MD, was recruited to return to WashU Medicine and join the faculty after having completed his colorectal fellowship training at WashU in 2004. He left his position at Vanderbilt University Medical Center with the hope of becoming the colorectal fellowship program director.
“I came back with the intention of leading the fellowship program as Vanderbilt did not have one at the time, and no intention to start one in the near future,” says Wise. “Becoming residency program director was definitely not on my radar screen.” He adds that he foresaw serving as program director for two to three years, then reevaluating. “Ten years and a pandemic later, I finally stepped down from that role in July,” says Wise. “This opportunity has been so humbling, and it inspired me to do all that I could to offer residents the highest quality training experiences that we could provide.”
As program director, Wise was responsible for a period of expansion in the Department of Surgery, in which many facets of the general surgery residency were fleshed out. One major aspect of the growth Wise oversaw was the development of the Malawi rotation opportunity alongside colleagues from University of Cincinnati.
A major difficulty that surgical training programs run into is achieving “credit” or accreditation for global rotations, partly due to a frequent lack of American Board of Surgery-certified surgical faculty embedded in an international program.
In 2011, the Residency Review Committee (RRC) for surgery approved international surgery rotations to count toward graduation requirements, which paved the way for elective opportunities such as the Malawi rotation to become available for trainees who wish to gain experience and provide care overseas or in lower resource environs.
Since 2016, the general surgery residency program has offered an eight-week elective rotation for senior residents at Mzuzu Central Hospital in Malawi. Located in southeastern Africa, Malawi, one of the poorest nations in the world, faces significant challenges improving health care and medical infrastructure for its population of nearly twenty-one million. Residents on this rotation provide necessary surgical care to a community with limited resources, serving alongside local house officers and attending surgeons in a collaborative team.
“After starting in my position as program director, I recognized that there was a great desire from a lot of our trainees with interests in having global surgery be part of their future,” says Wise.
Since WashU did not have faculty present in any global programs, Wise had to rely on good relations with surgeons at University of Cincinnati, along with support from Timothy Eberlein, MD, who was the chair of the Department of Surgery at the time. Eberlein ensured that residents would have resources and support from WashU on their eight-week rotations.
“Early on in my tenure, I dreamed of creating a global surgery training track that could train surgeons to perform everything from urological, OBGYN procedures and orthopedic procedures, in addition to general surgery, for trainees who want to spend time in developing countries,” says Wise. “But I recognized that there are strict requirements for accreditation in overseas programs, so finding a site where trainees could have appropriate supervision was the preliminary task to get this idea off the ground.”
While no global surgery track exists at WashU as of now, Wise helped lay the groundwork to establishing that dream program, starting with Malawi.
In 2016, Wise joined resident Stephanie Chang, MD, in Malawi as part of his assessment of the facilities, environs and faculty. “I spent a lot of time treating patients with needs outside of my specialty, like a patient presenting with facial and other injuries after a motor vehicle crash or a patient with a parotid tumor,” says Wise. “As a colorectal surgeon, that’s not something I’m typically doing, so there was a lot of thinking on your toes and being creative.” Wise notes that the limited resources require surgeons to actively problem solve and be true clinicians and physicians. “They didn’t have a CT scanner or an MRI,” says Wise. “They had ultrasound, plain x-rays, and limited labs, and that was it, so we had to get creative for diagnosing injuries and trust our clinical skills. We had to rely on limited resources, but the engaged staff and appreciative patients made it worthwhile and exciting.”
Since Wise’s initial assessment of the facilities in Mzuzu Central Hospital, WashU has sent as many as three trainees on the eight-week rotation each year.
SOfA
SOfA was established in 2008 with a $20,000 grant from the BJC Foundation. Peggy Frisella, past administrator of Washington University Institute for Surgical Education (WISE) and Brent Matthews, MD, past chief of Minimally Invasive Surgery, discussed the lack of surgical care in underserved countries in Central and South America.
“We had the idea of establishing a continuous after-care program,” says Frisella, “which is where the notion came from.” In January 2009, SOfA completed their site visit to the Dominican Republic.
SOfA mission teams consist of surgeons, surgery residents, anesthesia providers, perioperative nursing, pediatric critical care, sterile processing technicians, interpreters, and a team coordinator. The team must also partner with local public health centers, including the CMO, internal medicine, general surgery, nursing, rural health coordinators and surgical training programs.
As of 2024, the organization has performed over two thousand surgical procedures, alleviating disease burden in underserved regions in the western hemisphere.
Hands-on Experience
Transplant surgeon and current general surgery residency program director, Jennifer Yu, MD, MPHS, participated in both SOfA and the Malawi rotation during residency. Yu applauds bridge-building efforts by Wise to evaluate access for trainees and establish relations with on-site faculty and hospital staff.
Yu went to Malawi as a rising chief, seeking to gain leadership expertise. “I wanted to go because I knew it would challenge me to perform in a resource-limited situation,” says Yu. “I knew it was a time where I was growing into the role of a senior leader of the team, and I was seeking those leadership skills to bring back home.”
Yu encourages trainees to pursue global rotation programs to gain experience providing care in situations that challenge surgeons to be creative.
“There’s a lot of value in gaining the skills and understanding for how to work in a resource-limited environment,” says Yu. “I wanted the challenge of thinking through how to perform in tight situations, so that I could be better equipped to teach these skills myself.”
Yu assures that trainees in global programs will receive the support necessary to excel, while also being challenged sufficiently to gain surgical skills they seek.
Global Surgery in Extramural Programs
General surgery residents are also encouraged to consider participating in extramural non-clinical global surgery initiatives. During their research years, some surgical residents are pursuing opportunities overseas. Catherine Zivanov, MD, MPHS, and Helen Li, MD, are performing a needs assessment, studying how educational programs can build a permanent support structure for residents seeking to provide global care. Both have been highly active in global initiatives—Li having spent a year of research time in Kenya with colleagues from Indiana University , as a Fogarty LAUNCH Fellow, and Zivanov, who is currently conducting surgical oncology research in Nigeria as a Memorial Sloan Kettering Global Cancer Disparities Initiatives research fellow.
Li is interested in creating a means to be able to facilitate capacity-building by helping train surgeons overseas to develop didactic teaching skills at WashU Medicine.
The WashU Medicine general surgery residency program seeks to facilitate educational opportunities that meet the needs of all trainees. “For those especially passionate about surgical equity, we hope to support our residents through clinical, research and educational pursuits,” says Yu. “We’ll continue to improve our offerings to support the professional growth of our trainees.”
Currently, Hailey Shepherd, MD, is on rotation in Malawi and will return to St. Louis in late December. Other residents who have been on the rotation recently are Maria Martinez, MD, Meghan Kelly, MD, and Ebunoluwa Otegbeye, MD.
“I wish I could make all my residents go on a global surgery rotation,” says Wise. “It’s humbling, and you really appreciate so much that we take for granted here in the U.S. and at our institution.”