Cancer burden can be alleviated by training foreign medical graduates in surgical oncology

Many low- and middle-income countries do not have a defined medical specialty in surgical oncology and lack an educational infrastructure to respond to the local burden of cancer, but a Memorial Sloan Kettering Cancer Center (MSKCC) fellowship is succeeding in addressing this problem by training foreign medical graduates (FMG) in surgical oncology. Results of the MSKCC oncology fellowship program are reported on in an "article in press" on the Journal of the American College of Surgeons website in advance of print publication later this year.

Cancer care is a major public health priority worldwide. For patients with solid tumors, surgeons are at the center of care in countries that have few if any medical or radiation oncologists. This concern is the driving force behind the International General Surgical Oncology Fellowship at MSKCC. By educating and training FMGs, there is the possibility of a significant intervention in cancer care through the establishment of a qualified surgical oncology workforce "that understands local needs and can foster change towards care improvement, creating a sustainable model of intellectual and technological infrastructure for cancer management," study authors noted.

Historically, there has been a high rate of FMGs who stay in the U.S. permanently after training here. MSKCC is working to change this scenario and have FMGs return to their country of origin to help improve cancer care. The program accomplishes this goal by actively enrolling surgeons who have a long-term plan of practice and development back home. These steps have enabled the MSKCC program to see 80 percent of its trainees return to their home countries after their fellowships conclude. Not only can these surgeons use the skills they acquired to treat patients, they can also pass along those skills to others so that the training continues beyond their experience.

"This fellowship training program is more than just teaching trainees technical aspects of operations," said lead study author Sir Murray F. Brennan, MD, FACS, vice president for international programs; Benno C. Schmidt Chair in Clinical Oncology; and director, The Bobst International Center, at MSKCC, New York, N.Y. "There is a heavy emphasis on these surgeons becoming good educators, learning about databases, and how to evaluate surgical outcomes."

Study authors tracked FMGs who completed the MSKCC fellowship from 1994 to 2014. During that time, 39 trainees from 24 countries came through the program—17 from Europe, eight from Australia/New Zealand, six from the Middle East, five from Latin America, and three from Asia. The study authors said 69 percent of fellowship graduates were involved in academic positions with a high level of job satisfaction.

MSKCC has an overarching goal of seeing its trainees practice in their home country, and adjusts the experience of each fellow in the program so that he or she can get the most out of it. By individualizing the education and training they receive, trainees can learn skills for continuous self-improvement along with the technical knowledge they acquire during the program.

The MSKCC fellowship program provides FMGs direct surgical experience in the operating room and perioperative care experience to develop ownership of their patients. The inclusive nature of the program requires trainees to develop communication skills, which can be a challenge for those whose first language is not English.

Study authors said that the MSKCC fellowship gives broad exposure to different areas in surgery and fulfills the recommendations from the Society of Surgical Oncology (SSO) regarding training competences. Additionally, fellows surpass 120 cases per year—the SSO requirement—without interfering with the training of U.S. fellows. Study authors acknowledged that the limitations of the study are "the reporting bias that results from obtaining data from a survey and the inclusion of recently graduated fellows who are just starting their practice. Most of the fellows have come from [high income countries], which limit the generalization of the outcomes to less favored settings."

MSKCC has a long history of training foreign medical graduates—their efforts in this area date back to the early 20th century. The International General Surgical Oncology Fellowship specifically seeks to advance these efforts in surgical oncology. Dr. Brennan said that although MSKCC has seen success in training FMGs, there is still a need for other programs to help assist developing nations. One such program is the American College of Surgeons International Scholarship Program. "During 40 years, 212 surgeons from 62 countries have participated in the program with a positive effect on their practice and opening the possibility of international leadership and remarkable social interactions among surgeons," study authors noted.

"Our hope is to provoke a dialogue to develop other opportunities for international medical graduates at the senior or chief resident level, or even as community assistants," said Dr. Brennan. "We should do more of this training. It's the kind of outreach we have to provide."