Pediatric Hand Surgery Training in Nicaragua: A Sustainable Model of Surgical Education in a Resource-Poor Environment

Recent reports have demonstrated that nearly two-thirds of the world’s population do not have access to adequate surgical care, a burden that is borne disproportionately by residents of resource-poor countries. Although the reasons for limited access to surgical care are complex and multi-factorial, among the most substantial barriers is the lack of trained surgical providers. This is particularly true in surgical subspecialties that focus on life-improving, rather than life-saving, treatments, such as pediatric hand and upper extremity surgery, which manages such conditions as congenital malformations, trauma and post-traumatic deformities including burns, and neuromuscular conditions (brachial plexus birth palsy, spinal cord injury, and cerebral palsy). Many models of providing surgical care in resource-limited environments have been described and implemented, but few result in sustainable models of health-care delivery. We present our experience developing a pediatric hand and upper extremity surgery training program in Nicaragua, a resource-limited nation, that grew out of a collaboration of American and Nicaraguan orthopedic surgeons. We compare this experience to that of surgeons undergoing subspecialty training in pediatric upper limb surgery in the US, highlighting the similarities and differences of these training programs. Finally, we assess the results of this training program and identify areas for further growth and development.

Recent reports have demonstrated that nearly two-thirds of the world's population do not have access to adequate surgical care, a burden that is borne disproportionately by residents of resource-poor countries. Although the reasons for limited access to surgical care are complex and multi-factorial, among the most substantial barriers is the lack of trained surgical providers. This is particularly true in surgical subspecialties that focus on life-improving, rather than life-saving, treatments, such as pediatric hand and upper extremity surgery, which manages such conditions as congenital malformations, trauma and post-traumatic deformities including burns, and neuromuscular conditions (brachial plexus birth palsy, spinal cord injury, and cerebral palsy). Many models of providing surgical care in resource-limited environments have been described and implemented, but few result in sustainable models of health-care delivery. We present our experience developing a pediatric hand and upper extremity surgery training program in Nicaragua, a resource-limited nation, that grew out of a collaboration of American and Nicaraguan orthopedic surgeons. We compare this experience to that of surgeons undergoing subspecialty training in pediatric upper limb surgery in the US, highlighting the similarities and differences of these training programs. Finally, we assess the results of this training program and identify areas for further growth and development.
Keywords: pediatric hand surgery, orthopedic surgery training, nicaragua, resource-poor environment, surgical education introduCtion Although the origin of the adage "Give a man a fish, and you feed him for a day. Teach a man to fish, and you feed him for a lifetime, " is debated, the principle it conveys, that the acquisition of skills promotes self-sufficiency, can be found in numerous diverse philosophies. The ubiquity of this concept suggests that it is applicable to the acquisition of any scarce resource, including medical and surgical care.

BaCKground and rationale
In 2015, the Lancet Commission on Global Surgery estimates that nearly 5 billion people, approximately two-thirds of the world population, do not have access to adequate surgical care (1). Not surprisingly, this burden is borne disproportionately by people in resource-poor nations (1), with the poorest third of the world population receiving only 3.5% of all surgical procedures (2). Given Pediatric Hand Surgery Training in Nicaragua Frontiers in Public Health | www.frontiersin.org April 2017 | Volume 5 | Article 75 that an estimated 30% of global diseases are treatable with surgical intervention, the lack of access to safe, timely, and appropriate surgical care results in substantial morbidity, mortality, and disability. Additionally, although the relationship between health and socioeconomic status is complex, several studies have established an association between poor health (especially in childhood) and poor socioeconomic status in both developed and developing nations (3,4). Consequently, in addition to a moral imperative to address disparities in access to adequate surgical care, the dedication of resources to improve surgical care in resource-poor environments will likely have economic benefits at both the individual and societal level, the ramifications of which are likely to be far reaching.
The reasons for inadequate surgical care in resource-poor environments are multi-factorial, including inadequate infrastructure (facilities, electricity, water), limited physical resources (surgical and anesthesia supplies and equipment), lack of adequately trained anesthesia and surgical providers, and under-utilization of surgical services for financial, cultural, and religious reasons (5,6). Moreover, strategies to improve global health often focus on infectious and communicable diseases, rather that surgically treated diseases, which are often characterized as expensive and technologically demanding to treat, despite emerging evidence that suggest that surgical care is cost effective (7). Although there are many reasons for lack of surgical care, the shortage of trained surgical providers is among the most significant barriers to essential surgical care worldwide (8).
If we accept the wisdom of the "teach a man to fish" philosophy, part of the solution to limited access to surgical care may be to increase the number of qualified surgeons by providing training experiences in surgical disciplines in which there are currently inadequate numbers of trained local providers. The goal of such a training program would be to develop surgeons who are not only capable to delivering surgical care but who are also able to mentor and train additional surgeons (residents, colleagues) to create a sustainable supply of knowledgeable, competent surgical providers. We describe our experience developing collaboration between American and Nicaraguan surgeons to provide pediatric hand and upper extremity surgery in Nicaragua.

ComPetenCies and standards
In the US, hand surgery fellowship training is available to graduates of ACGME-accredited residencies in orthopedic surgery, plastic surgery, and general surgery, and pediatric orthopedic training is available to orthopedic surgery residency graduates. Following hand surgery or pediatric orthopedic fellowship training, approximately five US surgeons each year elect to obtain an additional 6 months of training in pediatric hand surgery, to prepare them to care for children with congenital hand malformations, neuromuscular conditions such as brachial plexus birth palsy, spinal cord injury, cerebral palsy, and post-traumatic deformities. These highly specialized surgeons acquire the diagnostic skill set of pediatric orthopedists by gaining an understanding of the impact of growth on musculoskeletal deformities, the treatment of syndromes, and the technical skill set of hand surgeons (training in complex reconstructive procedures that treat pediatric hand conditions).
While no formal accreditation of pediatric hand surgery exists, this discipline, a hybrid subset of pediatric orthopedic surgery and hand surgery, has become well established in the US. Most children's hospitals now include a pediatric hand surgeon on their staff and the Pediatric Hand Study Group (PHSG), established in 1995, meets twice-yearly, performs multicenter research projects, and presents an international award each year for the best pediatric hand article (9)(10)(11)(12)(13)(14). The senior author (Michelle A. James) is a founding member of the PHSG and has directed a pediatric hand fellowship training program at Shriners Hospital for Children Northern California since 2009, training eight pediatric hand fellows (http://shrinerschildrens.org/pediatric-handupper-extremity-surgery-fellowship). In this training program, pediatric hand fellows typically perform approximately 100 cases in a 6-month period ( Table 1).

learning enVironment nicaragua and the nicaraguan Health system
Nicaragua is the largest country in Central America by land mass area, approximately the size of the stat of New York in the US, and has a population of 6.1 million people. The majority of the population lives in the Pacific region of the country, along the western coast, with 25% of the total population in the capital city Managua (15). Nicaragua also is the poorest country in Central American and the second poorest country in the Western Hemisphere (16) with nearly 50% of the population living under the poverty line and a per capita gross national income of US $2,720 (17).
The Nicaraguan health-care system has three tiers with both private and public components. The private health-care sector serves Nicaraguans with the financial resources to pay for care, approximately 10% of the population. The public sector includes the Nicaraguan Social Security Institute (Instituto Nicaraguense de Seguridad Social or INSS), which covers salaried government workers (10-20% of the population) and the Ministry of Health (Ministerio de Salud or MINSA), which provides health-care services for the remainder (approximately 70-80% of the population). In addition to being the predominant health-care provider in Nicaragua, MINSA is also the health-care regulatory agency and is responsible for all matters related to the provision of healthcare, from establishing healthcare policy and government priorities to the salary schedule for providers (16).

medical education and orthopedic surgery residency in nicaragua
There are both public and private medical schools in Nicaragua. Admission to public medical school is based on the results of a standardized admissions test, and tuition is covered by the government. Medical education in public medical schools lasts 8 years after high school (5 years of medical studies, 1 intern year, 2 years of social service). By contrast, private medical schools (American University, Catholic University, Military School)  (19), there are no subspecialty orthopedic fellowships available in Nicaragua, although some residents complete an additional year of residency focusing on a particular subspecialty, and a small number seek subspecialty training in other countries, but due to financial and regulatory barriers, few surgeons pursue fellowship training.
According to the Asociación Nicaragűense Orthopaedia y Traumatología (ANOT), there were 210 actively practicing orthopedic surgeons in Nicaragua, about half of whom practice in Managua [3.5 orthopedic surgeons for every 100,000 people, compared with 8.5 per 100,000 in the US (19)]. However, not all Nicaraguan orthopedic surgeons belong to ANOT, so this estimate may not be accurate. Few Nicaraguan orthopedic surgeons have subspecialty training in pediatric orthopedic surgery or hand surgery, and no surgeons are trained specifically in pediatric hand surgery, a unique discipline that includes some of the most intricate and complex surgery in orthopedics. Other than service trips of surgeons from developed countries, pediatric hand surgeons are not available to treat congenital hand malformations, neuromuscular disorders (spinal cord injury, cerebral palsy, brachial plexus palsy), and post-traumatic deformities. At the time of the first Brigada de las Manos trip in 2009, it was apparent that there existed in Nicaragua a large population of children with hand conditions, with little treatment available. The orthopedic surgeon sub-director of the children's hospital (Gabriel Ramos Zelaya) requested that the Brigada provide hand surgery training to one of the junior orthopedic surgeons (Jairo J. Rios Roque), so that he could provide ongoing care between Brigada trips, and eventually gain expertise to care for complex pediatric hand problems independently. Jairo J. Rios Roque's practice has been based at a public children's hospital since 2009 and he has extensive experience, although no formal training, in pediatric orthopedic surgery, and a strong interest in hand surgery. The senior author (Michelle A. James) investigated various options for international hand fellowships in the US, and discovered that licensing and credentialing requirements virtually precluded hands-on training in the US for Jairo J. Rios Roque. Together, the sub-director and senior author developed a model of training that includes:

la Brigada de las manos
(1) Twice-yearly week-long Brigada visits. The Brigada includes two experienced pediatric hand surgeons (Michelle A. James and another member of the PHSG), a pediatric orthopedic occupational therapist, and additional volunteers. During these visits, the Brigada surgeons work with Jairo J. Rios Roque and the La Mascota staff to see approximately 100 children in clinic and to schedule and perform 20-25 operations (see Table 2). Jairo J. Rios Roque functions as a pediatric hand fellow, performing at least half of the cases together with a Brigada surgeon (Figure 1) Although Jairo J. Rios Roque's experience is not a consolidated period of six contiguous months, but is rather occurring over years in a series of 1 week intervals, it is similar in number of cases and types of cases to a typical pediatric hand surgery training fellowship in the US (see Tables 1 and 2). There is substantial overlap in the most frequent diagnoses and procedures, with surgeries for polydactyly, syndactyly, sequelae of upper extremity trauma, and neuromuscular conditions (arthrogryposis, cerebral palsy) being among the most common procedures performed (Figures 2-6). Moreover, the volume of operative cases performed by Jairo J. Rios Roque is comparable to those of the typical US pediatric hand surgery fellow during his or her 6-month fellowship. SHCNC pediatric hand surgery fellows typically perform 100 surgical cases during their 6-month training experience and, after 7 years, Jairo J. Rios Roque has performed approximately half of the 220 cases with the Brigada during that time, and observed many of the other cases. Finally, the Nicaraguan training experience employs the concepts of graduated responsibility, such that Jairo J. Rios Roque's responsibility and ability to independently care for patients in clinic and the operating room increases,
(Continued)  Figure 1 | Jairo J. rios roque, md and michelle a. James, md following a syndactyly release procedure performed at Hospital "la mascota" in managua, nicaragua. commensurate with his experience, skills and core competencies, benchmarks for determining Jairo J. Rios Roque's progress, and ability to practice pediatric hand surgery independently. Nevertheless, there are differences between the Nicaragua training experience and the SHCNC experience. The biggest difference is the lack of availability of hand fellowship training for Jairo J. Rios Roque as a prerequisite to pediatric hand surgeon training. Although hand fellowships focus on the care of adult hand problems, they provide training in the basic hand surgical skills needed to perform most pediatric hand surgical procedures. For this reason, Jairo J. Rios Roque's training is prolonged, and will likely not ultimately include the most complex procedures, especially those that require microsurgical skills. Table 2 does not include brachial plexus exploration and reconstruction surgeries, due in part to the fact that the hospital lacks a surgical microscope,

disCussion sustainability
In addition to the mentor model of surgical education we have described here, several other methods to improve the availability and capacity of surgical providers in resource-poor environments are have been utilized, including: direct provision of surgical services (mission trips of visiting surgeons to resource-poor countries); fellowships (medical providers from resource-poor countries travel to the US to obtain experience and training not available in their home country); and attendance at international conferences and courses (which provide learning opportunities in the form of lectures and surgical simulations) (21). Each of these strategies, while beneficial, has certain limitations. Direct provision of surgical services (i.e., "parachute trips") does not expand the skills or ability of local providers. Most US fellowships for foreign medical providers are limited to observerships, which do not allow hands-on training, and the provision of surgical services is not conducted in the context of their local resources, often relying on expensive technology that is not available in their home institution. Finally, international conferences and courses, like observerships, require substantial commitment of both time and resources, which is not feasible for many providers.
In contrast to the above surgical experiences, the training model we have implemented in Nicaragua results in sustainable delivery of health-care services to children with hand conditions. As Jairo J. Rios Roque's responsibility and ability to independently care for patients in clinic and the operating room increase, patients with congenital and acquired hand conditions will be able to receive appropriate care from Jairo J. Rios Roque directly, throughout the year, without the services of the Brigada. Moreover, he will be able to educate and train the Nicaraguan residents and orthopedic surgeons in the care of patients with these conditions. Finally, the next step in sustainable surgical education is to establish research initiatives that investigate the outcomes of the treatment provided, to publish the results of these investigations, and allow the study findings to inform surgical decision making. Currently, we are planning to include Hospital La Mascota in the development of registry of congenital hand differences, which would ultimately be used to determine the outcomes and effective of surgical treatments for these conditions. Because Hospital La Mascota is the sole provider of surgical services for these complex conditions, a registry of the patients treated here will provide unique and comprehensive perspective into the incidence of these conditions, the need for surgical treatment, and outcomes of operative interventions; this could then be compared to similar registries in the US, enhancing our understanding of how to best improve the hands and lives of patients with these conditions.

ConClusion
The disparity between the need for surgical care and its availability in resource-poor countries is substantial, which has far reaching consequences for individual, social, political, and economic