Twenty surgeons in one

As a doctor in one of the hospitals we have just described, you are unlikely to be a fully qualified specialist surgeon with 5 to 8 years of postgraduate training. Instead, you will probably be a ''general duty medical officer' with one or two years of surgical experience or less. But somehow you have to care for the sick in all of the 20 specialist fields shown in the frontispiece, into which surgery has fragmented in recent years. The chance of your being able to refer patients to specialists is remote. There may be no maxillofacial surgeon, or hand surgeon, in the country, and if it is a small one, it may not even have a specialist anaesthetist. Even your own teaching hospital may lack the complete range of specialists. Nor, despite present training programs, is the situation in many countries likely to improve much in the near future. Even your nearest regional hospital may only have one or two general surgeons. But surgery will be only part of your work[md]you will also have to be a physician, and a paediatrician, and manage the district.

So you will have to do your best in all these fields simultaneously. To help you we have collected from among the armamentarium of diverse experts: (1) Their easier methods which you could use. Fortunately, many of them, despite the fact that they are normally only part of an expert's expertise, are not too difficult. For example, the position of safety in a hand injury (75-8), or Lord's anal stretch (22-10), are within the competence of any doctor. (2) Those methods, either easy or difficult, which you will have to use to save a patient's life. (3) Those difficult, disability-preventing but non-urgent methods, for which you should refer a patient, but may not be able to, such as sequestrectomy for osteomyelitis (7.6).

Many countries do not even have enough general duty doctors to do all the surgery that needs doing, let alone specialists. Malawi, for example, has recognized that surgery may have to be done by specially trained medical assistants, and Tanzania has trained its AMOs (Assistant Medical Officers) to do emergency surgery. Here is the report of a surgeon (Dr Gunnar Isaksson) on visiting one such AMO trained by the programme at the KCMC (Kilimanjaro Christian Medical Centre) in Tanzania. We quote it to emphasize that, not only may surgery have to be done by non- specialists, but that it is, on occasions, excellently done by non-doctors.

REPORT ON AN AMO ''How nice it was to see how well he was managing his tasks[...]he seemed to be well in control, and happily did various operations. He had done several Caesarean sections, two laparotomies for intussusceptions, some hydrocelectomies, and fracture reductions, etc. He was treating three cases of fractured femur with skeletal traction in a very satisfactory way. His management of burns did not give cause for criticism. He had not done a sufficient number of hernia operations to feel confident about them; so he had gathered some and we operated on five of them together, after which he now wants to go on doing them himself. To go to Kiomboi was an inspiration for the work with our AMO training program. Perhaps there is no AMO teaching program in your country, and yet you are hopelessly overworked. Could you train an auxiliary to do the simpler hernias, Caesarean sections and circumcisions?

Hankins GW, ''Surgery in a Mission Hospital', Annals of the Royal College of Surgeons of England 1980;62:439[nd]44.[-3] Cook J, Loefler IPJ, Gilchrist DS, Bewes PC, ''Surgery in a District Hospital', Journal of the Royal College of Surgeons of Edinburgh 1978;23:151[nd]64.