Clinical Orthopaedics and Related Research
© The Association of Bone and Joint Surgeons 2008
10.1007/s11999-008-0381-6

Symposium: ABJS/C.T. Brighton Workshop on Trauma in the Developing World

Providing Outreach Continuing Education in Countries with Limited Resources

Kaye E. Wilkins1 Contact Information

(1)  Department of Orthopaedics, University of Texas Health Science Center at San Antonio, Mail Code 7774, 7703 Floyd Curl Drive, San Antonio, TX 78229-3900, USA

Contact Information Kaye E. Wilkins
Email: drkwilkins@aol.com

Received: 8 January 2008  Accepted: 24 June 2008  Published online: 29 July 2008

Abstract  Obtaining continuing education can be difficult in countries with limited resources. Members of the Pediatric Orthopaedic Society of North America (POSNA) have developed a program for providing outreach continuing education courses in pediatric orthopaedics. POSNA members provide their own transportation to the host country, while the orthopaedic physicians along with the educational institutions in the host country in turn provide the support needed to carry out the courses. They also provide lodging, meals, and local transportation. Since its inception in 1998, 30 courses have been conducted in 19 countries with limited resources. The program has expanded to develop a partnership with the European Pediatric Orthopaedic Society. The protocol for organizing the courses is discussed.
The author certifies that he has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.
Introduction

Many orthopaedic surgeons in North America and Europe are developing goals to provide assistance and opportunity to their colleagues in countries with limited resources (hereafter referred to as CLR) to increase the knowledge and surgical skills in orthopaedics in these areas of the world. There are three major methods to achieve these goals. The first is sending teams to perform surgery in the various CLR. A second method is to bring selected orthopaedic surgeons from these countries to the orthopaedic centers in North America and Europe to participate in formal fellowships or observerships. The third method is to conduct continuing education courses in the various CLR. While the first two programs can be beneficial in many ways, the Pediatric Orthopaedic Society of North America (POSNA) has placed their emphasis on providing outreach continuing education in the various CLR.

Direct Surgical Help

The first manner in which many orthopaedic surgeons feel they can help is to visit other countries either as an individual or with a full-fledged surgical team, and perform multiple surgeries. Often the local surgical personnel will observe as the visitor or visitors perform the surgical procedures with their modern instruments and skilled teammates consisting of supportive anesthetic and nursing personnel. As a result, many of the patients receive excellent surgical treatment for their often complicated problems. In most instances the surgeons and their team leave after their short stay and followup care is provided by local medical and surgical personnel. Hugh Watts, MD, (Glendale, CA, USA) has termed this strategy “parachute surgery.” The team or individual surgeons parachute in, perform the surgery, and then evacuate almost as quickly as they have arrived.

Fellowships or Observerships

Bringing selected CLR colleagues to one of the major orthopaedic training centers in North America or Europe is an excellent method of training them to become skilled pediatric orthopaedists. However, only a few individuals from CLR can afford the luxury of being away from their home country for the extended period of time required by a fellowship. In addition, these fellowships are usually directed at the younger orthopaedists. The educational programs need to update those orthopaedists who have been practicing for extended periods of time.

Educational Experiences

In my experience, most surgeons in CLR desire the chance to improve their knowledge base. In North America and Europe, the local orthopaedic surgeons can update their knowledge and skills via the annual meetings of their major national orthopaedic societies and/or the numerous local and regional continuing education courses offered throughout the year. Thus, orthopaedic surgeons in North America and Europe have ample opportunities to upgrade both their knowledge and surgical skills. Unfortunately in CLR, the opportunities for continuing education are few or nonexistent. Few of the orthopaedic surgeons in these areas have financial resources to travel to the major orthopaedic education events in North America and Europe. By the same token, the local and national orthopaedic organizations in these countries rarely have sufficient financial resources to bring speakers with special expertise or experience to participate in their local meetings. As a result of these challenges to the local orthopaedic organizations in CLR, the Pediatric Orthopaedic Society of North America (POSNA), through its Committee on Orthopaedics in Underdeveloped Regions (COUR), has embarked on a program to provide continuing education courses in these countries.

POSNA-sponsored Education
These courses are termed “outreach continuing education courses” (OCEC). The first of these courses was produced in Port Au Prince, Haiti, in 1998 as a cooperative venture between Société Haitienne de Traumatologie et d’Orthopedie (Haitian Orthopaedic Society) and the Department of Orthopaedics at the University of Texas Health Science Center in San Antonio, Texas (Fig. 1). This was the first continuing education course in orthopaedics ever conducted in Haiti. The theme of the course was “The Management of Fractures in the Pediatric Patient.” It was performed entirely by using the local resources available in Port-au-Prince, Haiti. The orthopaedic surgeons from the neighboring Dominican Republic were invited to participate in this course. As a result, all the English lectures had to be translated into both Spanish and French. The various physicians participating in this course had enough language skills to do a reasonable job of providing some semblance of simultaneous translation. The local Haitian orthopaedic society provided the venue in one of the best hotels in Port-au-Prince. They also provided the food and lodging for the faculty. The faculty members paid their own transportation costs to Haiti. All of the registration fees were retained by the Haitian Orthopaedic Society.
MediaObjects/11999_2008_381_Fig1_HTML.gif
Fig. 1 The first continuing education course was produced in Port Au Prince, Haiti, in 1998 as a cooperative venture between Société Haitienne de Traumatologie et d’Orthopedie (Haitian Orthopaedic Society) and the Department of Orthopaedics at the University of Texas Health Science Center in San Antonio, Texas.

The faculty was truly international, with four participants coming from the United States, two from Canada, and one each from Puerto Rico, Cuba, and France. In addition, physicians from Haiti were included in the faculty. The structure of the courses consisted of 2 hours of didactic lectures followed by 1 hour of interactivity in which each of the faculty members presented cases to small groups of the attendees. These cases were designed to re-emphasize points presented in the preceding lectures. This course was so well received that it was repeated 18 months later and was expanded to cover both adult and pediatric orthopaedic topics. In the second course there was a larger faculty, and professional translators provided the simultaneous translation. Again, interactive sessions between the faculty and participants were included in the course structure.

The ability to successfully conduct a fairly sophisticated continuing education course in orthopaedics in a CLR such as Haiti stimulated POSNA to embark on organizing similar courses pertaining to pediatric orthopaedics in other countries. Initially, these courses were organized on a fairly informal basis. As more courses were organized, a formal protocol was produced so that the process of conducting these courses would be uniform. Until 2006 this protocol applied only to POSNA. In that year POSNA developed an agreement to conduct these OCECs as cooperative ventures with the European Pediatric Orthopaedic Society (EPOS). This partnership has created a synergistic effect since POSNA has many contacts in the Spanish-speaking world while EPOS has similar contacts in the French-speaking world. The first POSNA/EPOS cooperative course was conducted in Bratislava, Slovakia, in January 2007. The present protocol now includes guidelines for developing future OCECs to include faculty from both organizations (Appendix 1).

As of February 2008, 30 OCECs on pediatric orthopaedic subjects had been organized and completed in 20 separate countries (Table 1). The only area yet to be covered is Africa. However, plans are being made to organize and conduct OCECs in Africa in the near future. As can be seen, some of these courses have been repeated in the same countries. This is due to the long-term relationship established with the Pediatric Orthopaedic Society in India (POSI) to conduct OCECs each year as a part of their annual meeting in India. A similar partnership has been developed with the pediatric section of the Association of South East Asia Nations (ASEAN) to conduct OCECs in Southeast Asia. In the majority of these courses the faculty is limited to no more than six members of POSNA and/or EPOS. In each of the courses, local individuals from the host region are also included in the faculty. The philosophy has always been that these courses are a two-way learning process. Often, the local orthopaedists have experience that can be beneficial to the faculty members from North America and Europe. In addition, there has been an emphasis on using interactive techniques in these courses to engage the participants in the exchange of information.
Table 1 Outreach Continuing Education Courses (OCEC) conducted since 1998 by region

Region and country

Courses conducted

Courses per region

Central America

 

5

    Cuba

2

  

    Haiti

2

  

    Honduras

1

  

South America

 

5

    Chile

1

  

    Ecuador

1

  

    Bolivia

1

  

    Paraguay

2

  

India

  

6

    In 2006, 2007, and 2008, separate OCECs were conducted in six separate locations in India

    

Southeast Asia

  

6

    Vietnam

2

  

    Thailand

2

  

    Malaysia

1

  

    Singapore

1

  

Eastern Europe

  

6

    Estonia

1

  

    Croatia

1

  

    Romania EPOS/POSNA

1

  

    Slovakia EPOS/POSNA

1

  

    Bulgaria EPOS/POSNA

1

  

    Poland EPOS/POSNA

1

  

Middle East

  

2

    Basra, Iraq

1

  

    Cairo, Egypt EPOS/POSNA

1

  

Total, all countries and regions

30

  

In finding coordinators for these OCECs in the host countries the protocol has been to work with the public orthopaedic training centers only. Working with private individuals who might use these courses to further their own reputations or personal income has been discouraged.

Discussion
Benefits

It has been my observation that both the faculty and participants benefit from the OCECs. For the POSNA/EPOS faculty, they often have an opportunity to learn how many complex conditions rarely seen in their areas, such as chronic advanced osteomyelitis or severe untreated angular deformities of the lower extremities, can be managed with limited resources. Many of the POSNA faculty members have developed long-term relationships in such countries as India, Vietnam, and Iraq. Another major advantage of these OCECs is that the POSNA/EPOS faculty members are away from their busy practices only for 1 week at the most. Another byproduct is the enthusiasm of the faculty members for participating in these courses has encouraged other POSNA/EPOS members to want to participate in future courses.

Besides gaining knowledge from attending these OCECs, the participants have gained other benefits as well. Some of these benefits are difficult to document and quantify. Some POSNA faculty members, as a result of their participation in these courses, have developed long-term friendships with the orthopaedists in the host countries. These faculty members have been able to identify some bright young pediatric orthopaedic surgeons from these countries to become involved in the POSNA International Scholarship Program. In May 2007, pediatric orthopaedic surgeons from Haiti, India, Ecuador, Paraguay, and Chile were awarded scholarships to pay for their travel and lodging expenses to attend the POSNA annual meeting in Hollywood, Fla. Similarly, in May 2008, three individuals from Ecuador, Columbia and Kenya attended the POSNA annual meeting. Other orthopaedic surgeons have come to North America to participate in short-term observerships or even short-term fellowships.

Downsides

While the benefits are great, participation in the OCECs can have some downsides. In many countries visas are required and can be time-consuming to obtain, especially if the country carries a U.S. State Department Travel Advisory. There are language differences and also risk of exposure to unusual communicable diseases not present in North America. On rare occasions, the courses may have to be canceled or delayed because of political unrest in the host country.

Cost Factors

The only expenses incurred by POSNA and EPOS are those involved in providing administrative assistance in the announcement of the course activities to their members. Regarding the cost to the individual members, there are no figures. The personal expense that I have incurred in my participation in some of these courses has been in the range of US$1000 to $2000. This does not include loss of professional income during the time spent away in the involved country. It has not been an issue for the POSNA members to pay their own travel expenses.

Expansion of the Program

An enthusiasm has developed with both POSNA and EPOS members to participate in the OCECs. In the past it was difficult to recruit faculty for these courses. Now, many of the courses are oversubscribed. Members of POSNA’s Committee on Orthopaedics in Underdeveloped Regions are now providing assistance to the American Society for Surgery of the Hand and the Orthopaedic Trauma Association to organize OCECs. The subjects covered in the POSNA/EPOS courses are, for the most part, determined by the wishes of the orthopaedic surgeons in the host countries.

The American Academy of Orthopaedic Surgeons (AAOS) and the Scoliosis Research Society (SRS) both have established programs to provide continuing education courses in other countries. The major difference from the POSNA programs is that each of these organizations has an administrative individual who plays a major role in the organization and conducting of their courses. The travel expenses for the faculty members are provided by the AAOS or the SRS. Thus, there can be a substantial cost to these two organizations to conduct their outreach continuing education courses. POSNA and EPOS have eliminated much of the so-called overhead in producing these OCECs. Essentially all of the administrative tasks for the individual OCECs conducted by POSNA are taken care of by the POSNA member who is the course coordinator.

Where Do We Go From Here?

In an effort to improve the knowledge in countries with limited resources, POSNA and EPOS plan to continue organizing more OCECs. In an effort to expand the base of subjects covered in these future OCECs, other subspecialty orthopaedic organizations are being encouraged to develop similar programs of providing low-cost OCECs using the model presently being perfected by POSNA and EPOS.

In summary, this program has demonstrated that continuing education can easily be provided relatively inexpensively for countries with limited resources. However, some specific guidelines need to be considered when organizing these courses: (1) Ask the individuals in the host countries what subjects they want covered. Do not tell them what they need. (2) Always include local individuals as faculty. Everybody has something to contribute. (3) Build interaction with the audience into the programs. This is a good way to become more closely acquainted with the participants. In addition, it will assure that your audience remains awake. (4) Try to recruit faculty based upon the needs of the subjects. Don’t try to recruit the faculty totally based on one’s personal contacts. (5) Don’t simplify the lectures. Most of the participants want to learn about state-of-the-art treatment.

Appendix 1
EPOS/POSNA Partnership on Organizing and Conducting Outreach Continuing Education Courses (OCEC) Protocol

Mission Statement

For both Societies, the education and training that are aimed to advance the knowledge in pediatric orthopaedics of orthopedic residents/trainees and surgeons are an essential part of their mission.

History

Both POSNA and EPOS have acknowledged in the past the desire of pediatric orthopaedists to continue and improve their professional education. During the last few years, we have become increasingly aware that the need for specialization and continuing education is often hampered in many parts of the world by the lack of resources. The funds are often insufficient to ensure the physicians’ participation at the conferences and courses organized locally with leading specialists, or to allow them to travel to other countries to attend professional meetings and courses with lecturers who are experts in their specialty.

This state of affairs has yielded the idea to unite the efforts of our societies and create a common education task force, which will include a small group of four to six pediatric orthopaedists who are POSNA/EPOS members (or members of the alliance organizations). They will volunteer to travel and join the specialists from the host/inviting country as well as those from neighboring countries in conducting teaching activities.

POSNA and EPOS members have a professional responsibility to advance the knowledge in pediatric orthopaedics and to strengthen their collaboration based on mutual respect and equality with the worldwide community of pediatric orthopaedists.

Structure

EPOS and POSNA have decided to cooperate in setting up Outreach Continuing Education Courses (OCEC) in pediatric orthopaedics within the framework of a full partnership.

The board of each society shall nominate a delegate or chairman who will be responsible for the communication between the societies.

Both societies have agreed to exchange information about planned OCEC, preferably at least one year in advance before making final decisions with regard to event location, date, faculty or program. The Board of each society should consider the option whether to participate or not in a specific course.

The number of volunteers from EPOS and POSNA, as well as the number and titles of lectures of each faculty will be decided by the coordinator of the initiating organization in agreement with the local course director according to the needs of the specific instructional course.

The announcement of the projected courses, recruitment and nomination of volunteers will be coordinated by the chairmen who will use to this end the websites and communication resources of all the parties involved: POSNA, EPOS, the local host, as well as those of the allied societies. Our societies will use the available internet-based systems to support the events organization as well as the creation of a network of potential volunteers and a virtual meeting space for those interested in having organized such a course in their region.

Funding of the Course

Members in POSNA, EPOS, or allied organizations who volunteer to participate and lecture at an instructional course will fund their own travel expenses to and from the host country. The local host or hosting organization will provide the accommodation and meals to the visiting EPOS and POSNA faculty.