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The concept of international humanitarian service continues to evolve, with the goal of improving health and equitable access to care for people around the globe. Addressing the health care needs of low- and middle-income counties (LMICs) has long been the focus of intergovernmental institutions such as the World Health Organization, nongovernmental organizations (NGOs), and faith-based groups that provide and facilitate the delivery of humanitarian aid worldwide. These services鈥攐nce thought to be the exclusive domain of larger organizations and governments because of logistics and costs鈥攏ow are being provided by private practice surgeons.

According to The Lancet Commission on Global Surgery 2030 report, 5 billion people worldwide lack access to safe, affordable surgical and anesthesia care, with nine out of 10 unable to access basic surgical care in LMICs.^1,2 The report calls for 143 million additional surgical procedures in LMICs annually to save lives and prevent disabilities. The occurrence of global epidemics, including the 2009 influenza pandemic and the coronavirus 2019 (COVID-19) pandemic, has only increased awareness of health care disparities around the world.^1,2

The factors motivating private practice surgeons to provide care to LMIC patients include enhancement of surgical and patient care skills, clinical autonomy, burnout relief, and, perhaps most notably, the personal satisfaction that comes with caring for patients demonstrating the greatest need. This article describes the challenges and benefits associated with private practice surgeons providing care in LMICs and offers insight into implementing this model.

West Michigan Surgical Specialists

West Michigan Surgical Specialists (WMSS), Wyoming, MI, is a 12-surgeon practice that provides trauma and acute care surgery for patients at Mercy Health Saint Mary鈥檚 and Metro Health Hospital. As a group, WMSS performs a spectrum of general surgery procedures, including endocrine, vascular access, kidney transplants, endoscopy, foregut, colorectal, hepatobiliary, and hernia repair.³

Three WMSS surgeons are involved with international humanitarian care: Joel A. Green, MD, FACS; Eric J. Mitchell, MD, FACS; and Michael DeJong, MD, FACS. Since 2013, members of WMSS have participated in 13 volunteer missions to Kibogora, a small village in the southwestern corner of Rwanda, and to Burundi in East Africa and Togo in West Africa, with each visit lasting two to six months. Only one WMSS surgeon participates in a mission visit at a time to ensure continuity and quality of care, call coverage, and overall stability of the practice.

鈥淢ost of us have a desire to serve and use the gifts and abilities we鈥檝e been given for a bigger purpose,鈥� said Dr. Mitchell, who joined WMSS in 2015. 鈥淎nd it鈥檚 not that we all go to the same place or participate in the same program, but just simply that we allow each other the freedom to go and serve.鈥�

鈥淚t鈥檚 important to have partners who support the idea of helping the poor and those who are medically underserved,鈥� added Dr. Green, who joined WMSS in 2011 right out of residency. 鈥淚f your partners are most concerned about the practice鈥檚 financial productivity, this might be a hard sell. But if you appeal to their sense of humanitarian goodwill, you may be surprised by the buy-in and support you receive from your partners.鈥�

One of the keys to including an international volunteer component in a private practice setting is the development of a fair financial compensation model. Financial compensation at WMSS has three components, including a base salary, call coverage, and a periodic bonus based on productivity. 鈥淚n this way, every surgeon is paid for being a part of the group and for how hard they work,鈥� Dr. Green said.

For example, when a WMSS surgeon goes on a humanitarian mission to Rwanda for six months, that surgeon鈥檚 base salary is reduced to a half-time salary. The surgeon isn鈥檛 paid for any call coverage while out of the country, and the productivity bonus is reduced naturally.

鈥淚 think if I was compensated the same as all of my partners who remained here in the U.S., there would be some strife in the group,鈥� said Dr. Green. 鈥淐reating a model that is fair financially helps your partners not feel like they鈥檙e being taken advantage of. Although it is a personal financial sacrifice, the trade-off is great, and I cannot say that my family or I have ever suffered financially due to the reduction in pay.鈥�

Dr. Green estimates WMSS surgeons have managed approximately 2,000 cases during their volunteer missions. At Kibogora Hospital, which is accredited by the College of Surgeons of East, Central and Southern Africa (COSECSA) and serves a population of at least 250,000, surgeons typically work five days a week and share weekend call duties.^4,5

鈥淭he breadth of surgery we do there is, by necessity, much larger than what we do in the U.S.,鈥� said Dr. Green. 鈥淚 benefited from training with an orthopaedic surgeon on one of my first mission trips, so I鈥檝e continued to perform trauma orthopaedic surgery in Rwanda. We also do quite a bit of urology, otolaryngology, and plastic surgery cases, in addition to general surgery.鈥�

鈥淲hen we are overseas, we do a little bit of everything鈥攊ncluding bread-and-butter general surgery, some orthopaedics, a lot of urology, a handful of traumatic head injuries, and, when needed, some gynecology, but it depends on the doctors who are there,鈥� Dr. Mitchell added. 鈥淥ftentimes, there鈥檚 a doctor of a different surgical specialty there, but if not, that specialty falls on us as the general surgeons.鈥�

Finding a private practice that supports international volunteerism

It is not uncommon for young surgeons to seek out a practice in close proximity to family or near where they trained, and these individuals may need to sacrifice location or type of partnership if they intend to pursue a partnership that supports time away to participate in surgical missions. Drs. Green and Mitchell urge physicians to begin networking as residents to find practices that have international service as a priority. Attending mission conferences or connecting with organizations such as Global Missions Health Conference (www.medicalmissions.com), the Global Surgery Foundation (www.globalsurgeryfoundation.org/), and 糖心网页版 (ACS) Operation Giving Back (OGB) (www.facs.org/ogb) also can provide opportunities to network with other surgeons interested in international missions.

ACS OGB, founded in 2004, seeks to leverage the 鈥減assion, skills, and humanitarian ethos鈥� of the surgical community to meet the needs of the medically underserved around the world. The OGB website features a virtual hub of resources, including a volunteer board (www.operationgivingback.facs.org/opportunities) where surgeons can locate volunteer opportunities that match their skills and interests. (If you are an ACS member, you will need your ACS credentials to log in.) For job opportunities in private practice, filter 鈥済lobal surgery鈥� in the Surgeon Sector of the ACS Surgeon Jobs portal (surgeonjobs.facs.org/).

鈥淭his might seem bold, but when interviewing at a practice, simply ask them, or state from the outset, that you are interested in international humanitarian work. Decide on the amount of time that you want to spend volunteering and make them aware of this. I think how they respond to this kind of request is a good litmus test of that practice,鈥� according to Dr. Green, who informed WMSS when interviewing at the practice that he anticipated being out of the country three to six months annually doing international service work.

鈥淚 fully expected they would say, 鈥榃ell, we鈥檙e not really interested. We want a full-time partner,鈥欌�� said Dr. Green. 鈥淚 hadn鈥檛 realized that they already had a surgeon who was involved in the U.S. Army Reserves who periodically would have to go and spend three months in Germany or a couple of months here or there. So, their practice already had some flexibility in that way, and they were very supportive of my request.鈥�

Practice settings that provide the flexibility for partners to engage in humanitarian work abroad still are relatively rare, according to Drs. Green and Mitchell, but interest in this type of practice model continues to grow.

鈥淚t seems if you鈥檙e talking about the employed surgeon model versus the private practice surgeon model, the private practice surgeon may have more flexibility to do this. Autonomy with scheduling, and productivity requirements can differ between private practice and employed models,鈥� Dr. Green said.

鈥淚鈥檝e definitely seen over the last decade an interest and a lot of chatter at meetings, including meetings [hosted by] the ACS, regarding the desire to go overseas and do something bigger, do something to give back,鈥� added Dr. Mitchell. 鈥淓verybody finds out that you do overseas trips and the universal response is, 鈥極h, I would love to do that someday.鈥� There seems to be some inertia that needs to be overcome in order to begin volunteering, and I think it鈥檚 just a matter of people learning how to overcome the barriers associated with overseas missions.鈥�

Barriers and benefits

Private practice surgeons considering global volunteerism may be apprehensive about engaging in this work because of call and continuity of care concerns, time away from family, and the financial burden associated with overseas missions, and younger surgeons may have concerns about building a practice while out of the country.

鈥淪ome people say they just can鈥檛 get away from their daily work,鈥� Dr. Mitchell said. 鈥淭hey wonder who is going to take care of their patients and who is going to take their call. One solution is to educate your partners back home that they are actually participating in your service by helping you out while you are gone. With our group, the nine partners who don鈥檛 go overseas feel like they are giving back by taking on extra call and covering our long-term patients.鈥�

As for time away from family, Dr. Mitchell encourages physicians to include spouses and children on overseas trips whenever possible. 鈥淚t just takes a little bit of extra courage and faith to bring the family with you. I have five kids ranging from six to 15 years old, and they love Africa. It鈥檚 a children鈥檚 playground. They鈥檙e outside getting dirty, climbing trees, making new friends, learning new cultures, and it is an invaluable experience for them,鈥� he said.

Regarding the costs of funding these trips, both Dr. Green and Dr. Mitchell acknowledge that there is some financial sacrifice involved, especially because WMSS does not engage in fundraising to support these humanitarian efforts. 鈥淢ake these trips a line item in your personal budget, plan for it, and live a little below your means so that you can afford to take that financial hit each year without it being something that becomes cumbersome,鈥� Dr. Mitchell said.

Dr. Green noted that private practice surgeons at various stages in their careers will likely face different obstacles when it comes to mission work. 鈥淔or younger surgeons just starting practice, concerns about financial stability and growing a practice are at the forefront. Personally, I really benefited from joining a mature practice where the partners鈥� goals, as far as humanitarian service and faith, are pretty well aligned. We share the load of patient care all the time, covering each other鈥檚 patients on call over nights and weekends. My partners鈥� willingness to extend this sharing to times when I鈥檓 overseas has brought practice stability that wouldn鈥檛 have been possible otherwise,鈥� Dr. Green said.

The benefits for private practice surgeons engaging in international humanitarian service often outweigh the challenges. 鈥淚 would say it鈥檚 the hardest work I鈥檝e ever done, but it鈥檚 the most rewarding as well,鈥� Dr. Green said. 鈥淭he unending need can be overwhelming. You feel like you could work all day and all night and not even make a dent when you鈥檙e the only surgeon at a mission hospital. But if you ask a surgeon to think back to what they imagined practice would be like when they were in training鈥攚ithout the stress of dealing with electronic medical records, insurance companies, medicolegal issues, and administrative negotiations鈥攊nternational humanitarian service comes close to that ideal. It is refreshing to simply treat a patient in the way you think they need to be treated,鈥� Dr. Green said.

The mutual exchange of knowledge and surgical technique between U.S. surgeons and surgeons overseas is another benefit of humanitarian service. 鈥淚f you go in with the attitude of 鈥榣et鈥檚 learn from each other,鈥� it ends up being a great relationship,鈥� Dr. Mitchell said. 鈥淎 great example of this is when I first went on a mission as a brand-new attending in 2013. One of my first nights on call was with a third-year surgery resident who was Kenyan. We had a guy with a traumatic subdural hematoma, which is typically taken care of by neurosurgeons here in the U.S. I was not trained in neurosurgery, and so the third-year resident and I did the case together. We evacuated the subdural, and since he was the one who had done 10 more than I had, he pretty much led me through the case.鈥�

Dr. Green said he has learned a great deal about performing complex operations in a resource-poor setting from Ronald Tubasiime, MD, a Rwandan surgeon at Kibogora Hospital. 鈥淚n the U.S., we rely heavily on equipment and technology, much of which is not available in low-to-middle income countries,鈥� he said. 鈥淚t requires a certain amount of creativity and flexibility to treat some of the diseases that we would not think twice about treating in the U.S. How do you manage an intra-abdominal abscess without an interventional radiology service? What鈥檚 the best way to close the common bile duct after exploration if you don鈥檛 have a T-tube? You realize what you can gain from a physical examination and learn to get by with the few laboratory tests and imaging studies that are available.鈥�

Southwestern Medical Clinic

Southwestern Medical Clinic (SWMC), St. Joseph, MI, was established by five physicians in 1968, with a focus on general surgery, primary care (internal and family medicine), obstetrics-gynecology, and pediatrics.⁶ Since its inception, the practice has been focused on supporting international humanitarian service and has consistently attracted like-minded physicians. SWMC eventually grew into a large medical group with more than 80 health care professionals at 11 locations in Berrien County, MI.

In 2010, SWMC and Lakeland Health (now Spectrum Health Lakeland) merged into a single entity providing health care services to the community throughout southwestern Michigan. 鈥淥ur group was a model for many other private practice groups with a focus on medical missionary work,鈥� said Roy E. Winslow, MD, FACS, who joined SWMC in 1997. 鈥淲e had to be very careful when we met with Lakeland Health System because we wanted to be able to preserve our commitment to medical mission work, which is how we have attracted and retained most of our physicians. When we negotiated with the health system, we were able to maintain our affiliation, our own identity, and our own board that supervises physicians and mission work,鈥� Dr. Winslow said.

SWMC has a separate financial structure within the Spectrum Health Lakeland system that supports international humanitarian service. Each SWMC physician contributes 3 percent of his or her salary to a fund that supports work overseas.

鈥淲e have quite a few doctors, especially in primary care, who don鈥檛 take the opportunities to travel overseas or find it鈥檚 difficult to do so with their families,鈥� Dr. Winslow said. 鈥淏ut they still identify with the group and its focus on missionary work as something they support.鈥� The SWMC board provides oversight for mission trips and approves physicians to draw a small weekly stipend, covered by the fund, for the weeks surgeons are working overseas and not receiving their standard salary.

The SWMC board also oversees physician productivity, work schedules, and call schedules. The Spectrum Health Lakeland system is the employer of all SWMC staff, pays their salaries, and manages billing and other practice-related logistics.

To meet the challenges associated with moving from the autonomy of being a physician-owned practice to a hospital-owned group, SWMC developed a faith statement and a code of conduct. 鈥淭hese documents clearly spell out our practice type so that the larger health system is aware that legally we are involved with missionary work and that we recruit and retain physicians for this purpose. The larger hospital board was willing to accept this and assured us that we could continue this work,鈥� Dr. Winslow said.

Full-time and part-time service

Historically, SWMC has employed a handful of physicians who work full-time overseas and return to the U.S. on furlough to provide care at the practice. At present, SWMC employs one surgeon, Daniel Stephens, MD, FACS, who provides care full-time in Sudan, with one-month furloughs in the U.S. (Dr. Stephens鈥� father, Roland R. Stephens, MD, FACS, a founding member of SWMC, received the ACS Surgical Humanitarian Award in 2018 for his 50 combined years of surgical care to underserved populations around the world, primarily at the Karanda Mission Hospital in Zimbabwe.)

鈥淲e鈥檝e had doctors who are working full time in various locations around the world in international hospitals. When they take a furlough after three years, they don鈥檛 have to go find a place to work. They come right back to our group, and we welcome them with open arms,鈥� Dr. Winslow said. SWMC organizes office schedules a year in advance and call schedules are developed on a monthly basis.

In addition to the surgeons who work full time abroad, a base group of three SWMC surgeons, including Dr. Winslow, volunteers overseas on rotation annually for shorter durations. These missions, which last three to eight weeks, have included trips to Rwanda, Kenya, Togo, Cameroon, Haiti, Bangladesh, and Zimbabwe. Dr. Winslow and his colleagues perform a range of general surgery services as part of this work, including urology, orthopaedics, and OB-GYN. 鈥淚n these remote locations, often you are the only qualified surgeon there of any specialty, so you truly get to do general surgery of the old style,鈥� Dr. Winslow said.

Medical missions are especially beneficial to younger surgeons, who sometimes leave training with less multispecialty exposure in areas such as orthopaedics or gynecology. Senior surgeons also find that working in LMICs enhances their knowledge base.

鈥淚 always learn because there鈥檚 so much variety and so many intense experiences of very advanced diseases,鈥� Dr. Winslow said. 鈥淚鈥檓 often looking stuff up in old, dusty textbooks or on the Internet if I have access, or I鈥檓 e-mailing colleagues in the U.S. for advice. Ultimately, if you鈥檙e working at a remote, mission-type hospital, you鈥檙e not going to have access to [computerized axial tomography] scans or advanced lab testing, so you have to learn to trust your basic medical training鈥攜our hands, your stethoscope, your experience as a skilled physician.鈥�

Surgeon wellness

Despite the limitations and challenges associated with international humanitarian work, the surgeons at SWMC find overseas missions to be restorative and invigorating. 鈥淭his work helps to sustain my overall wellness. When my colleagues and family see me after returning from a mission, they see me coming back refreshed and more joyful and at ease with myself,鈥� Dr. Winslow said.

In fact, researchers suggest that 鈥渆ngagement is the positive antithesis of burnout鈥� and that there is a 鈥渟trong business case for organizations to invest in efforts to reduce physician burnout and promote engagement.鈥�^7,8 A survey of 465 physicians at a large academic medical center aimed at evaluating career satisfaction found that physicians who spent at least 20 percent of their time engaged in work that is most meaningful to them had a burnout rate that was approximately half of those who spent less time performing activities they considered professionally fulfilling.⁹

Dr. Winslow鈥檚 greatest satisfaction comes from his interactions with the patients in LMICs. 鈥淚t still amazes me how they鈥檙e so appreciative of anything we can do for them, even if things don鈥檛 go perfectly. This still surprises me coming out of a North American mindset where we all feel anxious if things don鈥檛 go well. I鈥檓 often astonished by the resilience and strength of these patients. They have so little and are so joyful.鈥�

Finding the right fit

Health care systems may not have policies in place that offer employees time off for volunteering abroad, although some hospitals may have protocols that allow for shorter trips in the form of paid vacation or personal time off with the proper documentation. Finding a practice or institution that understands that accessible surgical care is essential to improving global health outcomes is key for surgeons motivated to give back in this way.

鈥淚 think you have to be a little aggressive and say, 鈥楬ere鈥檚 what I want to do, and here鈥檚 why I鈥檓 going to do it,鈥欌�� Dr. Winslow said. 鈥淎t Spectrum Health, they saw a group of physicians who are outstanding and who have trained all over the country but came here because they wanted to be in this group that has a primary focus on mission work.鈥�

Dr. Winslow advised surgeons considering international volunteer service to start by networking with surgeons who have experience in this area. 鈥淭hey need to call me, they need to call Joel Green, they need to talk to ACS OGB鈥攕omebody who鈥檚 actually doing it and say, 鈥楬ow鈥檇 you do that? How鈥檇 you get started?鈥欌��

Conclusion

While Drs. Green, Mitchell, and Winslow have not established specific partnerships with each other鈥檚 programs, and thus have not worked together abroad, there is a mutual respect that exists among this cohort of surgeons.

鈥淲hile we don鈥檛 have any formal professional connection, Dr. Winslow was a surgeon mentor to me,鈥� said Dr. Green. 鈥淚 knew him when I was in residency, and he shared with me his experience at Kibogora Hospital. I really looked up to him as I thought about what my practice might be like in the future.鈥�

Both WMSS and SWMC have worked with a few international relief partner organizations, including World Medical Mission (WMM), an NGO and affiliate of Samaritan鈥檚 Purse, which is a partner organization with ACS OGB.¹⁰ WMM deploys physicians to 66 remote hospitals and clinics in Africa, Asia, Oceania, Latin America, and the Middle East. WMM assists with logistics, including flights, visas, in-country travel, and lodging; WMM volunteers are fully self-funded.

鈥淚鈥檝e been to Rwanda a dozen times so I already know people on the ground, and I don鈥檛 actually need an agency to help me make those arrangements,鈥� said Dr. Winslow. 鈥淥n the other hand, when I went to Cameroon, WMM made all the arrangements for me.鈥�

鈥淚f you鈥檝e never volunteered abroad, take advantage of the experience and education offered by those who have already done it. Don鈥檛 try to do it on your own,鈥� added Dr. Green. 鈥淭he logistics can be daunting and it鈥檚 easy to fail. There鈥檚 an African proverb that says, 鈥業f you want to go fast, go alone. If you want to go far, go together.鈥� I think that鈥檚 applicable to so many situations, but probably none more than international medical service.鈥�

References

1. Meara JG, Leather AJM, Hagander L, et al. Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386(9993):569-624.
2. The Lancet Commission on Global Surgery. Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development: Executive Summary of The Lancet Commission on Global Surgery Report. Bull Am Coll Surg. 2015;100(6):12-15. Available at: . Accessed April 30, 2021.
3. West Michigan Surgical Specialists. About us. Available at: . Accessed April 30, 2021.
4. College of Surgeons of East, Central and Southern Africa. Accredited hospitals. Available at: . Accessed April 30, 2021.
5. Action Kibogora. Kibogora Hospital. Available at: . Accessed April 30, 2021.
6. Spectrum Health Lakeland. About us. Available at: . Accessed April 30, 2021.
7. Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: Nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc. 2017;92(1):129-146.
8. Kimball AB. Proven strategies to counter COVID-induced physician burnout. Physician鈥檚 Weekly. January 7, 2021. Available at: . Accessed April 30, 2021.
9. Shanafelt TD, West CP, Sloan JA, et al. Career fit and burnout among academic faculty. Arch Intern Med. 2009;169(10):990-995.
10. 糖心网页版. Operation Giving Back. Our partners. Available at: . Accessed April 30, 2021.