UK Urologists Working Abroad

Assessment of need

Initial assessment of needs should be carried out with the members of staff from both institutions. Objectives in terms of research, service provision, management of resources, supply of learning materials and proposed visits need to be discussed and prioritised between leaders of the institution overseas and link members from the UK. This ensures that the expectations of both groups are similar. Any link should initially be small with limited goals that are achievable. This will give both partners confidence and provide the foundation upon which additional components can be established. Each link will develop at its own pace and each group must have an equal input, in the knowledge that imposition of Western priorities is inappropriate and likely to alienate the partners in the developing countries.

Communication to maintain the link

For any twinning venture to be durable, the key is communication. This should be by formal visits both to and from the developing country concerned and by communication between visits. The latter can be difficult because postal, telephone and computer links can be unreliable but regular contact is essential, particularly in the period after a visit. Ideally, e-mails or WhatApp messages should be exchanged regularly to assess the progress of both partners and to provide each with the relevant information and other support to ensure the visit has been a success for everyone. Good communications help to maintain momentum and strengthen longterm relationships.

Visiting

Twinning is not designed to make an overseas institution dependent upon visits although such visits are a means to enable the institution to recognise its weaknesses and to identify methods to overcome them. Visits between hospitals or departments are a very effective tool, but, alone and without proper planning, can achieve little. When both groups have agreed who should visit and in which direction to proceed, clear objectives need to be set out for the visit:

• What is the purpose of the visit?
• How will the objectives be met?
• Who will be involved from each side?
• How long is the visit? (Shorter than one week is not acceptable as climatic, medical and cultural adjustments take time; an ideal visit would last for more than two weeks).
• These issues should be agreed in advance so that there is adequate preparation and so that each group has similar expectations.

The visit should then be followed up by a report that highlights:

• what was achieved in relation to the goals set for the visit.
• what was not achieved and why.
• unforeseen benefits/problems.
• plans and recommendations for the future.
• The report should be circulated to the relevant parties so that lessons can be learned and clear plans devised for the future.

You are advised to visit the Urolink Publications & Social Media page for further useful information about setting up a link and sustaining it.

Visits to overseas centres need careful planning to ensure that the centre benefits from you, and your team, being there. Working in an environment without many of the facilities, techniques and instruments you rely on back home can be extremely challenging; this needs to be taken into account when planning the trip.

A printable 'Personal Survival Guide' is downloadable here Personal Survival Guide. This gives information about what you may need to plan for before you depart and after you arrive in your host centre.

Beforehand:

• You need to identify the local surgical lead and have a robust means of communicating with them, usually mobile, WhatsApp and email
• Ask when is convenient for you to be there, taking the seasons, religious festivals and other locally-relevant factors into account
• Determine what the local team want you to achieve during your visit, and then work out the logistics of building a team, finding the funding and organising the travel to provide the help required
• Create a team WhatsApp group
• Find out where you will be staying, who is paying for the accommodation and what the facilities there are.
• Arrange tickets, visas and work permits, if required
• Ensure relevant inoculations, and documentation, are in order and buy/prescribe malaria prophylaxis, if necessary
• Sort out any relevant equipment and operative materials, and know how you will get them to their destination. Check you have the relevant personal kit, or money, (link) with you
• Ensure you have sorted out transportation from the nearest airport to your accommodation, especially if you are arriving in the middle of the night!

When you are there:

• Meet the local team and do a ward round to see the patients they want you to operate on
• Have a robust mechanism for archiving patient details as local notes are often scant, or incomplete
• Work out a review schedule and agree operating lists
• Don’t overfill lists, start slowly and increase capacity if you can, which usually you can’t!
• Take plenty of bottled water with you to operating sessions
• Keep a record of what you do so you can provide Urolink with a report
• Have a really good time!

Urolink is keen to encourage longitudinal relationships with visit centres, because they facilitate ongoing educational activity. Ideally, Urolink would hope to see visit reports which contain statements of achievement similar to those below:

“ ... the Urolink team met with local surgeons & agreed to help with development of the curriculum & support examinations (COSECSA) ..."

" ... Consultants in the department are now performing regular TURP & collecting audit data to assess complications, length of stay etc ... trainees are performing flexible cystoscopy lists in the outpatient clinic (Zambia) ... "

" ... initial assessment of the service identified the need for TURP training performed under the supervision of the Urolink faculty (Zambia) ..."

The major component of any Urolink visit or of any collaborative twinning programme, in terms of benefit to the recipient, is undoubtedly teaching. There is only limited value in undertaking visits which solely concentrate on management of a small number of clinical problems or cases prepared by the host Department. Any long-term gain can only be achieved by teaching staff to manage clinical problems once the visiting team have returned home.

Teaching essentially takes two forms; first, performing procedures and training individuals to undertake them on their own, and, second, formal teaching through lectures, seminars and presentations.

Planning the educational visit

• Before leaving home to embark on a visit to a developing country, it is essential that you are organised
• Agree teaching/training goals
• Agree areas specified by the developing department rather than to teach on subjects or cases judged as appropriate in the UK
• Establish who the target audience will be and what their perceived goals are for the teaching programme
• Establish what teaching facilities are available including audiovisual equipment
• Assist with organisation where appropriate to maximise the teaching opportunity.

What to take with you to teach

For formal teaching Powerpoint® presentations are probably he most appropriate but do depend on the facilities available locally. It is usually helpful to bring a number of "props" which will help to get messages across and to add an element of variability to lectures and presentations. Taking examples of catheters, ureteric stents and X-ray images is, therefore, well worth the extra luggage space required. A general supply of "handouts" is also taken, summarising the salient points of any teaching undertaken, including both formal presentations and surgical techniques is often useful.

How to teach abroad

• It is essential to pitch the level and the topic of any teaching session appropriately to the trainees and to ensure that the messages are simple and brief.
• Remember that English is the second or, sometimes, the third language of the medical staff from developing countries so you need to ensure that appropriate language is used with minimal abbreviations and a degree of repetition of the salient points.
• Small presentations broken up by periods of audience involvement and the opportunity for the audience to ask questions are preferred to long didactic lectures. MDT or case-based discussions are a good way of putting points across.
• It is important never to underestimate the knowledge of medical staff in developing countries, particularly relating to clinical conditions common to the locality.

Inevitably both formal and surgical teaching will result in mutual benefit with knowledge being shared by both parties. Always allow plenty of time for discussion.

UK urological trainees may wish to spend a longer period of time abroad than can be provided by a 'workshop'. This can be taken as an Out of Programme Experience or "OOPE". For further information, click here to go to the Urolink section, "FAQs About Urolink" and select the dropdown "Can I take study leave for a visit abroad?"

In most circumstances you must seek approval for an OOPE from both your Programme Director and Deanery; you should allow plenty of time for any deliberations which may be needed. Your OOPE is more likely to be successful if you set clear aims and objectives in advance of your departure. Further information about OOPEs (and returning from them) can be found in the following links:

• Joint Committee on Surgical Training ... "Return to Work Guidance"
• The Gold Guide 2020 ... Information for trainees
• Royal College of Surgeons ... "Guidance on OOPEs"
• Taking time out of training ... British Medical Journal article
• Alexandra Zachou's 2015 OOPE in Tanzania & Senegal ... read Alexandra's report

Urolink only supports urologically-related teams, surgeons, nurses, technicians volunteering to work, usually for short periods, in the developing world.

It recognises, however, that some individuals may wish to volunteer for other humanitarian reasons, including in disaster relief. Their needs can be helped by reference to the Website Links on Working Abroad for organisations such as the ICRC, MSF, Mercy Ships, RedR and VSO and by looking at these articles:

• The way I see it, voluntary service is a good idea - Mark Goldring; BMJ Careers 334:238; June 2007
• Voluntary service abroad - Samshudin Suleman; BMJ Careers 329: 27; July 2004
• Working in a disaster zone - Imran Anwar BMJ Careers 332 (7547): 161; April 2006
• Missionary work for beginners - Emily Haberman; BMJ Careers 332: 153; April 2006
• Fifteen minutes with an MSF volunteer - Sabina Dosani; BMJ Careers 333 (7582): 239; December 2006
• Fifteen minutes with the President of Medicins sans Frontieres - Karen Hebert; BMJ Careers 329; 68; August 2004
• Preparedness for humanitarian crises needs to be improved - Altaf Musani and Irshad Shaikh; BMJ Careers 333; 843-845; October 2006