Skills upgrading for newly qualified surgeon: Is the district hospital in Kenya suitable?

Abstract

Background: Surgical training in many settings involves acquisition of both knowledge and skill in an environment of adequate caseloads and dedicated supervision. With adequate surgical activity in these settings, the trainee's confidence is boosted to the point of independence. This skill acquisition is a continuous process, especially so for those who qualify from an exit training program like the one at the University of Nairobi (UON). The continuity is maintained for two years after the masters in surgery program under an experienced surgeon leading to registration by the medical board. This seems to have changed with the posting of newly qualified surgeons to the district hospitals, which has meant a transition from trainee to service provider in the absence of supervision. Objective: This study sought to document the caseload and type of surgical pathologies in the district hospital, the morbidities/mortality for cases operated on at the district, the proportion of the cases referred to higher level surgical centres and the reasons for referrals. Setting: The Kapenguria District Hospital (KDH) in the Rift Valley province of Kenya. Methodology: Records of all surgical patients attended to at the KDH between April 2007 and September 2007 were reviewed. Information collected included the nature of surgical pathology, investigations ordered and where these were done, surgical treatment offered, referrals, post-operative complications and lengths of stay. All operations were performed or supervised by the author. Data were entered onto an SPSS 12.0 software program and analyzed for summary data. Results: Two hundred and ninety patients were evaluated. The main surgical pathologies were general trauma, goitres and herniae. There were 29 (10%) referrals to higher level facilities mainly due to lack of surgical instruments. Most investigations requested could not be done at KDH. The morbidity and mortality rate for the group of surgical patients was 12.4% and 4.1% respectively. Hospital stay averaged 3.46 days. Conclusion: The district hospital presents a potential setting for acquisition of surgical skills with its variety of surgical pathology and reasonable outcome data. However, the low volumes, lack of investigative capacity and surgical instruments compounded by absence of supervision, dictates that improvements in the system must be effected before the district hospital can be an ideal environment for the immediate post-residency training.