A March, 1999 article in the Journal of the American Medical Association revealed that physicians who are involved in managed care, or practice in areas with a high level of managed care penetration, provide less charity care. R. Richard Coughlin, MD, Associate Clinical Professor in the Department of Orthopaedic Surgery, the University of California, San Francisco (UCSF), and attending orthopaedic surgeon at the San Francisco General Hospital, has implemented a program to expose orthopaedic residents to an overseas volunteer experience early in their training with the hope of continuing involvement in such experiences throughout their careers.
In physician training and practice in the Western world, the focus is often on highly specialized surgery requiring sophisticated implants and equipment. However, the latest revision hip prosthesis has little use in a country where sterile operating rooms are a rarity. Residency training in the Western world takes place within a set of controlled environments, in which the foundations of orthopaedic knowledge and technique are built. Having the opportunity to function in a different environment, and to experience unusual pathology, allows for rapid expansion and growth from this base. In overseas missions, residents broaden their horizons and open their eyes to the larger world of orthopaedic care outside of United States tertiary medical centers.
UCSF began incorporating overseas missions into its orthopaedic resident training in 1992. From 1992 through 1998, fifteen of thirty-six graduating orthopaedic residents went on overseas volunteer missions. Of those fifteen residents, six (40%) have gone on additional volunteer missions after graduation; and three of these graduates have since led other volunteer missions that included UCSF residents.
In 1998, the Orthopaedic Research and Education Foundation earmarked funds to sponsor a pilot program for a resident rotation at an Orthopaedics Overseas site. Dr. Holly Brown (UCSF Class of 1999) was the first American resident to be selected. She spent two and a half weeks at the Bedford Orthopaedic Center in Umtata, South Africa, a former homeland under apartheid. The caseload consisted of a variety of general orthopaedic problems with an emphasis on fracture management. At the Bedford Orthopaedic Center, a considerable amount of the trauma is sub acute in nature due to the delay in initial presentation to the hospital. The patient load is quite heavy. In addition to trauma, there are many tuberculosis infections and pediatric cases, with only one orthopaedic center to care for over three million people.
From 1996 to the present, a formal overseas elective rotation was developed as an opportunity for all fourth year UCSF residents. Residents may do this elective while rotating at the San Francisco General Hospital. This is the first and only such elective officially offered through an orthopaedic surgery program in the country. Residents are given a specific set of goals and objectives for the rotation. They keep a journal of all of their operative cases, listing the diagnosis, treatment and level of supervision provided by the Program Director. In addition, residents record the patients they see in consultation in outpatient, inpatient and emergency department settings. Residents teach the local staff of health care providers, and document the audience, setting and topic of all lectures and formal education they provide. The residents learn valuable lessons, both clinical and philosophical, during their rotation. Historically, three-quarters of all residents who have done the elective, engage in future volunteerism missions, well above the national average. Funding for this elective comes directly from faculty support and philanthropic donations from individuals and industry.
In recognition for promoting and implementing this activity, Dr. Richard Coughlin, Associate Clinical Professor at San Francisco General Hospital, was awarded the Volunteer of the Year Award at the luncheon for Orthopedics Overseas at the recent AAOS Meeting. This award was presented to Dr. Coughlin by Dr. Terry Canale, Chairman of Orthopedics Overseas and former President of the AAOS, in grateful recognition of his dedication to improving the quality of orthopaedic care and training in South Africa. In addition to this recognition, Dr. Coughlin is a co-author of the paper entitled “Overseas Volunteerism in Orthopedic Education” that appeared in the inaugural article for the Orthopedic Forum and in the March 2000 Journal of Bone and Joint Surgery.
Dr. Brown stated, In the environment of managed care and social negativism towards medicine that permeates the current American mindset, it is extremely refreshing, and inspiring to work in an environment where patients are so grateful for, and appreciative of, the care that they receive. Places do exist where physicians can do what they do best, be good doctors and take good care of patients, without having to answer to insurance companies, managed care organization, or lawyers. Experiences like these remind us (physicians) of why we entered the field of medicine.
Through the overseas rotation, residents gain a unique learning opportunity that complements and consolidates their orthopaedic residency training. UCSF’s commitment is to foster the lifelong spirit of volunteerism in our orthopaedic residents, and to promote like behavior in other orthopaedic training programs across the United States. By decreasing barriers to volunteerism and encouraging early participation in volunteer activities, UCSF hopes to nurture a culture of physician involvement within the United States orthopaedic community.
The UCSF/SFGH Orthopaedic Trauma Center is fully committed to advancing the field of orthopaedic trauma worldwide through leadership in patient care, conducting high quality research, and local/regional, national and international outreach. Like other public institutions, its efforts are critically dependent upon philanthropic donations from individuals, foundations, and industry. The Center is indebted to the generous donors for supporting our work.