In an editorial in the Journal of Plastic and Reconstructive Surgery in 2006, Dr. O. Gordon Robinson, Jr. writes about an unsettling experience he had with a colleague. This colleague asked if he could observe a cleft lip procedure. When asked why, he replied that he wanted to know how to do this procedure, as he would be departing on a mission to Honduras where there was significant need for cleft lip repair operations. Dr. Robinson makes the point that it is unfair for physicians to go to developing countries with the objective of performing procedures that they do not perform in their home practice. While this imperative makes sense, there may be some circumstances in which surgeons are obligated, or at least permitted, to deviate from their scope of practice when volunteering in developing countries.
In my own personal discussions with surgeons who volunteer overseas, each one seems to have their own perception of the limits of their scope of practice when working abroad. An acute care surgeon who volunteers in Africa told me that he is willing to perform some operations outside of his home scope of practice. For example, he will do cancer operations such as low anterior resections because he is comfortable with the anatomy of these procedures, and there are not surgical oncologists available to perform them. A thoracic surgeon who has been volunteering abroad for many years performs general surgical procedures during missions to South America while his home practice consists solely of thoracic surgery. He is a board certified and trained general surgeon, so he feels that these procedures are within his scope of practice even though he does not perform them on a regular basis at home.
Rather than relying on the moral compass of each individual surgical volunteer, perhaps the surgical community should come together to develop practice guidelines for the scope of practice that surgeons should adhere to while working in developing countries. This is important for a number of reasons, with the first being the increasing popularity of global surgery. Surgical mission trips provide an opportunity for surgeons to travel to exotic places and have the rewarding experience of providing care for patients in dire need. The popularity and availability of global health opportunities reflect the increase in the global burden of surgical disease. The World Health Organization estimates the burden of surgical disease to be 11%, with the majority of this in low- and middle-income countries. This is likely to increase more as other contributors to the global burden of disease, such as infectious diseases, are better controlled and treated.
The questions that I have for the AAS audience are these:
- What should the scope of practice be for volunteer surgeons in developing countries?
- Should they strictly adhere to their scope of practice from the developed world?
- Should they be allowed to broaden this scope based on community need and availability of other surgical providers? Are there exceptions to these rules, such as in emergency situations?
- Who should define the acceptable limits to scope of practice for surgical missions: individual surgeons, surgical mission organizations, home practice organizations, surgical societies, or another entity?
As surgeons take a larger role in global health, it is important that we as a community take on challenging questions such as the ones above. I invite the AAS community to provide insight into these questions through direct answers as well as personal narratives that describe staying within or going beyond scope of practice in global surgery.
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Anji Wall, MD, PhD
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