New global surgery residency track to expand horizons

Jabaris Swain, MD, cares for a cardiac surgery patient in Rwanda.

As a teenager spending summers in Haiti, Alexi Matousek, MD, used to hike to the local hospital from the mountain village where his family ran a nonprofit literacy program. Matousek spent hours watching surgeons in a barebones suite extract tumors, close up wounds and treat other conditions common in poor countries. “I wanted to be a surgeon because of that experience,” he recalled.

Matousek soon realized he also wanted to help improve surgical care in the impoverished Caribbean country.

Now a clinical resident in surgery at BWH, Matousek is pursuing that dream. In July, he and colleague JaBaris Swain, MD, will inaugurate a new residency track in academic global surgery. The two-year Global Health Equity Residency in General Surgery is designed to train academic surgeons in the science and practice of surgical care delivery in austere settings, as well as produce research and policy leaders in the nascent field. It augments the standard five-year surgical training requirements.

Matousek and Swain will pursue master’s degrees at the Harvard School of Public Health, followed by a year of fieldwork (with Matousek in Haiti, and Swain in Rwanda), before completing their surgical training in Boston.

The track, housed in the BWH Center for Surgery and Public Health, is one of the few global surgery residencies in the U.S., said Associate Surgeon Robert Riviello, MD, MPH, who developed the program. “We’re seeking to build a cadre of people to engage as thought leaders in this field,” he said. “Our goal is to create a program that, over time, moves the needle of surgical care and delivery for destitute sick and injured populations.”

The residency, which is not yet fully funded, builds on the international experiences of BWH surgical residents Gita Mody, MD, MPH, and Kendra Bowman, MD, PhD. It also expands on efforts at BWH and the wider Harvard community to promote health equity and relieve suffering near and far, including the parallel Doris and Howard Hiatt Global Health Equity residency track in Internal Medicine. For example, BWH faculty, students, and colleagues have developed several low-cost surgical tools, among them a wound pump, a pulse oximeter, and a safety checklist championed by Atul Gawande, MD.

"This is truly a ground-breaking effort, and one that promises to shape academic global surgery as a career track.  Our hope is to tap the Center for Surgery and Public Health's expertise in rigorous health services research to address the significant challenges of surgical care delivery in resource poor settings," said Samuel Finlayson, MD, MPH, Kessler Director of the Center for Surgery and Public Health. "In getting this work off the ground, there is lots of thanks to go around, most notably to Dr. Zinner and Dr. Nabel.  Their support in these efforts has been invaluable."

"Establishing the BWH Global Surgery Residency Program has been a key milestone for the Center for Surgery for Public Health. This program is testament to our commitment to establishing and supporting necessary infrastructure, providing important resources, and fostering local relationships to ensure those in under-resourced settings have access to quality healthcare," said Michael Zinner, MD, Moseley Chair and BWH Surgeon-in-Chief. "The BWH Global Surgery Residency will transform the way our surgical trainees think about care and further enrich their development in ways that will benefit patients globally and locally."

Dire need

People in resource-poor countries bear a disproportionate burden of surgical disease, whether from advanced cancer, complicated childbirths, traffic accidents, infected wounds or burns from, say, thatched roofs that catch fire and collapse. However, more than two billion people worldwide lack adequate access to surgical care, according to a 2010 study by HSPH investigators.

“I’ve seen pregnant women die from dental abscesses that needed to be drained,” noted Riviello, who specializes in trauma, burns and acute care surgery and spends three months a year in Rwanda; his wife, Beth Riviello, MD, is a fellow in pulmonary critical care at BWH and MGH. “Impoverished people with cancer almost invariably have more advanced disease [than their wealthier counterparts]. Instead of breast lumps, they have tumors that erode through the chest wall.”

In the field

During his year in Africa, Swain plans to examine the costs and benefits of cardiac surgery interventions in the developing world. He’ll be amplifying his work with Team Heart, a volunteer group of BWH and MGH employees helping to build a cardiac surgery program in Rwanda, especially for patients with rheumatic heart disease—a sometimes fatal but preventable condition caused by uncontrolled infections.

Swain envisions a career as an academic cardiac surgeon in the U.S. who also spends time abroad practicing and teaching, “so that countries like Rwanda can begin developing sophisticated, cost-effective skills to participate in the care of their own patients.”

Matousek, while in Haiti, plans to establish an electronic medical record for a teaching hospital in Mirebalais that Partners In Health is constructing. The goal is to smooth daily workflow for surgical providers and track outcomes for quality improvement purposes.

Alex Matousek, MD, treats a patient in Haiti.

“The record keeping [in Haitian hospitals] is poor,” Matousek said. “If we can put together vital signs, lab results and notes in one place, that will revolutionize the way Haitian clinicians in that hospital can take care of their patients. If we add discharge summaries and other information, we’ll be able to track outcomes. We can’t just say we want to help poor people; we have to figure out and demonstrate what works.”

Swain and Matousek applaud BWH’s surgical leadership for supporting contributions to global health. “I feel very fortunate to be a part of this new era of health care delivery,” said Swain.

“I’m excited about working on these challenges for the rest of my career,” Matousek said. “That’s why I came to the Brigham.”

Global Health Equity Residency in General Surgery

What: A new residency combining rigorous general surgery training with a foundation in global health delivery science for selected surgical residents who aspire to improve access to high-quality surgical care for poor populations. It includes training in epidemiology, health care policy, social determinants of disease, ethics and administration.

When: 24 months focused on surgical global health delivery, including one of coursework leading to a master’s degree from HSPH and one of fieldwork in a non-U.S. setting (Haiti and Rwanda to start). This augments the 60 months of training required for ABS certification and takes place between the third and fourth years of clinical residency.

Who: Two positions will be offered in each class of BWH general surgery residents. Interested candidates will apply during their first year.