Hand Surgery in Cambodia

Abstract

As a lower middle-income nation, Cambodia has made significant improvements in basic health but hand surgery development continues to lag behind due to scarcity of trained and quality surgical manpower. Most of the hand surgery development locally has been due to surgical volunteers from Asia, Europe, and the United States. The introduction of a structured and systematic community-oriented hand surgery training over a 5-year period was successful in producing local surgeons to meet the basic needs of hand surgery patients. Brachial plexus surgery has benefited significantly, with local surgeons able to independently manage cases with minimal support. With the expansion of local surgical manpower and guidance, motivation, and assistance of regional hand surgeons, the future of hand surgery in Cambodia looks promising.

Introduction

Cambodia was a protectorate of France for 100 years and became independent in 1953. It is a Southeast Asian nation whose landscape spans the Mekong Delta and the Gulf of Thailand coastline and lies between Thailand and Vietnam. The population of Cambodia in 2020 is 16,789,749 and 50% of the population is under 22 years old. They are mainly Khmer (97.6%), and its official language is Khmer and over 95% practice Buddhism. Phnom Penh, its capital, is the largest city with a population of 1.5 million, and 2.2 million in the metropolitan area. Cambodia is famous for its Angkor Wat, a massive stone temple built during the Khmer regime. 1

5.7% of the GDP is directed toward health, with 0.14 physician density per 1,000 residents and 0.8 hospital bed availability per 1,000 individuals within Cambodia. The infant mortality rate in 2019 was approximately 22.8 deaths per 1,000 live births. Only 75% of the country has improved access to drinking water and only 42% of the population has access to improved sanitation facilities. 2

In December 2017, approximately 31% of Cambodian citizens were covered either by the health insurance scheme or the Health Equity Fund. 3 The total health expenditure in Cambodia is said to be mainly out-of-pocket, as there is a lack of confidence and trust in the health system and staff. Most Cambodians tend to rely on traditional health practitioners and Khmer Traditional Medicine (KTM), which are more affordable.

Origin and Evolution of Hand Surgery in Cambodia

Since the French authorities took over the medical school again in Phnom Penh from the Vietnamese in the early 1990s, after 30 years of war and the genocide by the Khmer Rouge, hand surgery has been regarded as a minor discipline and is still a neglected specialty in Cambodia today. Only in the last 4 years has a plastic surgery program been initiated. The division of orthopedic practice into subspecialties is only just beginning, as young trainees return from France, primarily to use their training in specialties that were previously unavailable. Hence, there are increasing calls to set up arthroplasty, spine, and sports surgery rather than hand surgery, although there does not seem to be any central planning in organizing what subspecialties might most benefit the country.

In Phnom Penh, there are nine central government hospitals and four district hospitals dealing with approximately 80 to 90% of patients who attend hospitals (many do not because of the costs unless they hold the “poor card” issued by the local authorities). Outside of Phnom Penh, there are 29 provincial hospitals and 157 district hospitals.

Major Phnom Penh hospitals are self-financed and receive little financial support from the Ministry of Health (MOH). Hence, they charge for service, and they do not have fixed and published fees. The MOH has recognized “poor cards,” which some people have been given by local authorities on account of their recognized dire financial situation. These people receive free-of-charge treatment, but the fee waiver does not cover everything, particularly surgery, which is usually not offered if they cannot afford to pay.

Most trauma hand cases are dealt with by the orthopaedic or general surgeons on call in the government hospitals. There are three surgeons in the five central trauma hospitals who are known to do some hand surgery–two are in the Cambodia-China Friendship Preah Kossomak Hospital. One of them received some training in India and France and has attended short courses in Australia and Singapore as well, while the other has received 1 year of plastic surgery training in Korea. The third is a plastic surgeon who does some hand surgery at the Khmer Soviet Friendship Hospital (the biggest in Phnom Penh). There is a modicum of expatriate support for these three surgeons, as an Australian team and French team each visit once a year.

Hand surgery as a specialty was first introduced in Cambodia by an Australian hand surgeon who ran one of the NGO hospitals in Phnom Penh. It languished soon after he left and did not take off again until 2013 when a team of hand surgeons from Singapore and the United Kingdom (UK) undertook a project at the Children’s Surgical Center (CSC) to develop the service. The visiting hand surgeons have designed and developed a targeted hand surgery training program for the needs of the local patients and surgeons. They have been coming twice a year since then and have helped develop a very functional hand/microsurgical service where tendon and nerve repairs are now routine, as are free flaps and reconstruction of brachial plexus injuries (BPI).

The aforementioned Australian hand surgeon has recommenced visiting Cambodia annually, encouraging other hand surgeons to join him and working in all the hospitals they can reasonably reach. His team has also been helping at CSC, as has another team from the University of Hong Kong (HK) which tries to come twice a year. The Australian and HK teams have concentrated mainly on helping with the difficult and interesting cases rather than running a structured program, and they try annually to offer an orthopedic workshop on some relevant topics.

Private hand surgery in Cambodia is limited due to the overall poverty, so generally, the surgery performed is either acute or traumatic or at the whim or interest of the surgeons. There is no proper structure or organization of hand surgery services: no systematic training of staff or coordination of services, and general apathy toward the need for hand surgery reigns in the country.

The four larger NGOs have some autonomy to run their surgical hospitals in Cambodia. The CSC specializes in working with disabled people–congenital, acquired, and post-infective disabilities, which include manual dexterity. Hence CSC, with expatriate surgical help, has developed the most extensive hand surgery service in Cambodia, ranging from correction of congenital hand deformities, neurological problems such as cerebral palsy, trauma-related hand injuries, and most recently, BPI.

At CSC, around 5,000 surgical procedures are performed per year. Patients were not charged for their operations or treatment until July 1, 2020, when the COVID-19 pandemic forced a change through a severe drought of donations. Hand surgery comes under orthopedic/plastic surgery. Many of the patients are self-referred through word-of-mouth recommendations.

Surgical Volunteerism and Hand Surgery

The Lancet Commission on Global Surgery 4 estimates that five billion people worldwide, especially those in low and middle-income settings, lack access to safe, affordable, and timely surgery. The World Health Organization (WHO) and other organizations worldwide are working toward strengthening emergency and essential surgical care and supporting volunteerism initiatives to meet the needs of the disadvantaged and provide training to healthcare workers. 5 Hand surgery presents with its own unique challenges. As compared with life-and-death situations, hand disabilities are often seen as insignificant in comparison with conditions treated by de facto specialties like general or even orthopaedic surgery. The practice of hand surgery requires specialist skillsets that are not universally available, even in developed countries. 6 The impact of hand disabilities have only been recognized in recent years with the use of utilities such as quality-adjusted life years (QALY) rather than life expectancy, highlighting the socioeconomic impact of hand injuries on a person’s livelihood. 7 Despite this evidence, the development of hand surgery remains lacking in developing countries.

Every year, many surgeons from the developed countries, either individually or in groups, travel to the developing world to volunteer to operate, teach, and train the local surgeons for the benefit of the local communities. It is an altruistic response to disparities and inequitable access to global healthcare resources. 4 These surgeons are proud to respond to societal needs and concerns, echoing the altruistic roots of their surgical profession. 8 Most definitions of volunteerism have four main components: free-willed behavior, no material reward, helping strangers/beneficiaries, and performing on a long-term basis or in a formal setting. 9 10 There are similarities between the definitions of volunteerism and altruism. Altruistic behavior is perceived as a mark of true professionalism in medicine: a sense of duty, the motivator of volunteering. 11 12

Visiting surgeons can volunteer in a range of services from surgical care to education and training. Surgery is a treatment modality, and the need for surgery varies according to disease patterns. In pursuing a sustainable and long-term relationship with the host, and for the volunteerism program to be successful, it is crucial for the visiting surgeons to be sensitive to the local culture, have mutual respect, and manage the expectations of their hosts and the patients. 13

A vital part of surgical volunteerism involves needs assessment to ensure that the visiting surgeons are responsive and are addressing the needs of the community. It is essential to appropriately match the expertise of the visiting surgeons to the local needs, in order to attain maximal gain of the skills they have to offer. Their role is not to take over but to support the local surgeons by assisting them with difficult cases and integrating their volunteer work with a training program. Hence, the importance of optimal utilization of local resources that are already in place. The visiting surgeons will have to collaborate with the local surgeons to arrange for an appropriate facility where they can operate safely and for the patients to receive perioperative and follow-up care. 14

Grimes and Lane 14 advocated that the visiting surgeons should focus on training the local surgeons and other medical staff involved in patient care. Cheok et al 15 documented a model in surgical volunteerism in Cambodia to train the local surgeons in hand surgery using a targeted curriculum, which is informed by the local resources and the health needs of the community, focusing on context-appropriate skills and various teaching programs. The local surgeons continue to be supported by the visiting surgeons in their absence via digital/mobile technology. The project succeeded in helping the local surgeons’ practice competently and independently within 5 years and for the sustainability of the hand surgery service in Cambodia.

In the same study by Cheok et al, 15 the dedicated, international faculty of accredited hand surgeons were committed to sustained involvement with the center in Cambodia. They made biannual trips to ensure capacity building and sustainability of the project and a concerted effort to involve the local surgeons, medical staff, and patients to gain a comprehensive understanding of the impact of their mission.

There is currently an impressive amount of energy with surgical volunteerism among the surgical community, but it is crucial to unify the fragmented efforts to improve surgical care globally.

Design and Development of Hand Surgery Curriculum in Cambodia

The challenges of hand surgical practice and education in developing countries include the lack of trained surgical educators and a relevant curriculum that is community-based and outcome-oriented. There is a dependency on volunteerism by international surgeons to provide the much-needed service, but it is often fragmented and nonsustainable, with little transfer of skills to local surgeons.

One of the first official curriculums in hand surgery in Cambodia was offered by the team of accredited hand surgeons from Singapore and the UK who had competencies in medical education and instructional design and technology. The short-term goal was mainly to help the local surgeons deal with difficult reconstructive cases. Some cases needed more than just one visit by the expatriate surgeons before the local surgeons could fully understand the decision-making process and be able to perform the complex surgical skills independently. Therefore, a long-term goal was necessary, and it initiated the development of the hand surgery curriculum ( Fig. 1 ).

Fig.1.

Local surgeons and Singapore/United Kingdom team of volunteer surgeons.

The curriculum resulted from a three-part process of defining the community needs, designing the curriculum (around the community needs), and then delivering the curriculum using pedagogical methods appropriate to the local community. This formed the basis to develop a targeted surgical skill acquisition program in the management of common hand cases and the identification of local surgeons to be included in the educational program, which was built on a model of problem-based teaching, flipped classrooms, and workshops. Assessment of progress was performed through case-based discussion and direct observation of procedures following a period of direct supervision and practice.

An analysis of 600 cases in the community showed the following breakdown: burn and trauma deformities (75%), congenital hands (24%), and nerve injuries (0.8%). An evidence-based approach to curriculum design was used, based on an analysis of 260 cases managed by the volunteer team from Singapore/UK over an 18-month period (May 2013 to November 2014). The breakdown of cases was as follows: burn contractures (21%), congenital hands (18%), trauma deformities (27%), nerve injuries, including plexus injuries (29%), and tumor reconstructions (5%). The increase in treating nerve injuries (0.8% to 29%) was the direct result of the visiting experts, improving hand assessments by the local surgeons, and the conduction of a microneural workshop for the local surgeons.

Following the analysis of the local community needs, a curriculum focused on three main conditions was designed: (1) congenital hand differences, (2) deformity corrections (from burns, trauma, and venomous injuries), and (3) nerve reconstruction. As part of the pedagogical strategy, the following skill acquisition workshops were conducted for the local surgeons ( Fig. 2 ):

Fig. 2.

Microsurgical skills workshop.

• A fracture workshop with saw bone.

• Basic principle of skin flaps and design.

• High-fidelity, low-cost animal model (pig trotter) workshops for

• Tendon.

• Nerve repair.

• Basic nerve microsurgery.

The following cases were used to provide work-based training for local surgeons ( Table 1 ).

Table 1. Portfolio of cases used for the Hand Surgery Training Program in Cambodia 2013–2019.

Year types of surgery	2013	2014	2015	2016	2017	2018	2019
Abbreviation: BPI, brachial plexus injuries.
BPI	3	8	11	9	12	8	18
Nerve injuries	0	0	0	6	7	3	1
Traumatic limb deformities	10	6	4	4	17	6	6
Congenital limb deformities	5	2	7	5	11	8	12
Burn contractures/others	5	2	4	0	5	5	9
Tumors (musculoskeletal)	1	2	1	0	2	1	0
Spasticity	0	0	0	1	2	2	6
Others	0	2	2	0	0	0	0
Total	24	22	29	25	56	33	52

Two years following the initial visit by the Singapore/UK team, a BPI reconstruction service was set up at CSC. In addition, routine operations in hand surgery have been expanded to include tendon transfers, peripheral nerve reconstructions involving grafts, and more recently, highly selective neurectomies in cerebral palsy and adult stroke/head injury patients. This methodology of discerning, designing, and delivering a surgical skill acquisition program in hand surgery for an underdeveloped community has shown to be effective. Any program implemented must be locally relevant, effective in skill transfer, and result in a sustainable hand surgery service, and this model can potentially be reproducible in other similar countries.

The local surgeons and residents have presented the results of the brachial plexus surgery conducted by the local surgeons following the training program at local and international meetings.

National and International Fellowship Training

Apart from the workshops and training courses delivered by the expatriate teams, there has been no Cambodian-led training in hand surgery ( Fig. 3 ). However, CSC has had the opportunity to send two junior doctors to Ganga Hospital in India for hand surgery courses for 6 weeks, and to Singapore for the skills workshops. The local surgeons have been invited to attend or present papers at a few international hand meetings, including the Federation of European Societies for Surgery of the Hand (FESSH). These have been greatly facilitated with the help of international bodies like the British Foundation for International Reconstructive Surgery and Training (BFIRST).

Fig. 3.

Local surgical team performing brachial plexus injuries (BPI) recon independently.

In 2017, South Korea offered a fellowship in microsurgery and reconstruction. This has brought practical knowledge and experience for the surgeon to perform free-vascularized flap operations at CSC. Further training opportunities at Ganga Hospital in India offered rich experiences in reconstructive hand surgery as well as education via multimedia platforms such as video recordings of actual cases performed at the Ganga Hospital.

Using Technology for Delivering Training and Remote Service

As Cambodia lacks very experienced surgeons, CSC has been a leader in using telemedicine for consultations in complicated cases and delivery of training. The I-path network, started by the University of Basle, Switzerland, has been the main vehicle for remote consultations, with over 600 consultations made since its initiation in 2012. A CSC doctor posts the details and photos of a case online, and the members of each group, consisting exclusively of expatriate surgeons who have worked at CSC and understand the limitations in Cambodia, will give their advice, which may take up to a week. However, for an urgent response, the use of the cross-platform messaging and voice over internet protocol service (VOIP), WhatsApp, has been extensively utilized. This has been helpful for ongoing support and scaffolding for the hand surgical education of the local surgeons. Thus, for consultations with an expert in Asia, the same day answer is usual; the European response may arrive by the end of the business day, but a North American response is only available the next day.

The electronic medical records were developed locally in CSC with the initial help of the IT students from the local technology institute and their visiting IT experts. The medical records though not fully structured have all the operation notes and include the image repository for clinical and X-ray images with simple search functions. Most visiting surgeons have commended that they are far more accessible and useful than what they experience in their own hospitals.

For the development of their knowledge and skills, the trainee doctors at CSC present the morning educational lectures (each lasting ~5 minutes) on appropriate topics to encourage communication and reporting in surgical care and outcomes.

To allow for on-demand, self-directed, and self-paced learning among the local surgeons, the use of a dedicated hand surgery open educational resources (OER) was employed and include the following:

• Hand surgery international channel on the video-sharing platform YouTube.

• An open online hand surgical learning program on the Moodle platform (a learning management system) @HandSurgeryEducation.

This approach facilitated distance and online learning. The support that it provided produced unique, high-quality surgical educational experiences that leverage the use of technology and global connectivity. It also allowed for enhancing access and efficiency, using digital multimedia, and provided authenticity and meaningful communication opportunities between the local surgeons, the mentors, and the surgical volunteers.

The usefulness and effectiveness of the program were assessed by the structured questionnaire and interviews with the participants and the stakeholders. Objectively and subjectively, there was an increase in the knowledge base and surgical competencies of the participants. The stakeholders perceived the program to be beneficial in allowing for effective transfer of knowledge and skills from visiting surgeons to the local surgeons.

Conclusion

Hand surgery in Cambodia has been an exemplar for the use of surgical volunteerism to produce a targeted and dedicated training program based on the needs of the community and the local surgeons. This crucial process involves identifying motivated and skilled surgical learners and engaging the local surgical faculty and stakeholders. It requires a committed team of trainer surgeons, with competencies not only in hand surgery but also in surgical education, instructional design, and technology to be able to deliver a cost-effective and efficient program.