Cambodia is a country of 15 million people, still recovering from a chequered past. In the 1970s, under the Khmer Rouge, most of the medical profession, together with the rest of the educated population, was executed – the fortunate few fled the country. Very few returned, leaving a country with a lack of senior doctors to train the new cohort of juniors that are enthusiastic to improve the country’s medical services. Unfortunately corruption is rife and those without money struggle to find adequate medical care.
The World Health Organization (WHO) has identified that >360 million of the world’s population suffers from disabling hearing loss, the majority of this burden lying in developing countries with a large proportion (especially in children) being of correctable causes (chronic otitis media (COM), wax impaction, etc).
Ear surgery provision in Cambodia is scarce at best. There would appear to be no local surgeons performing effective middle ear surgery. Various surgical teams, from the UK, France and Singapore for example, provide outreach surgical camps for a couple of weeks a year. Whilst this may be valuable, it largely fails to provide the country with its own sustainable service for the future. The current fellowship described here is a new approach to humanitarian ENT surgical provision, yet one that has already proved effective in orthopaedics.
The fellowship is open for post-certificate of completion of training (post-CCT) surgeons, usually those who have just finished training and are looking to further their skills prior to a consultant appointment. The duration of the fellowship is expected to be six months and will work very well tagged with a second six-month fellowship in a developed country (Charlie Huins will continue on to Sydney for the Graham Fraser Fellowship, for example). The fellowship is endorsed and supported by Professors Birchall & Saeed at the Royal National Throat Nose and Ear Hospital.
Children’s Surgical Centre.
The aim is for the fellow to run an otology service for the duration of his/her stay. There is a huge amount of pathology that requires surgical management and we expect a very healthy logbook to be developed during the placement. The majority of the work will relate to chronic otitis media, but in reality there is likely to be some general ENT service provision as well. The base is the Children’s Surgical Centre (CSC – www.csc.org) in Phnom Penh, Cambodia’s capital city. It is a charitable Non-Governmental Organisation (NGO) hospital that provides care for those that cannot afford to pay – the government hospitals, themselves offering limited ENT services, none of it otological, charge for treatment. CSC is a very well established unit that has already proved its success in its provision of both orthopaedic and ophthalmology services. Despite its name, adults as well as children are treated since children are considered those less than 25 years of age. Theatre space is assured and equipment has been obtained through charitable donations – we are very grateful to Medtronic and AneticAid for their generous support. The fellow will work together with Dr Davy, a local Khmer doctor who has spent her three postgraduate years in ENT; she is keen to learn and will benefit from the fellow’s teaching and guidance. There is a superb audiological service available via All Ears Cambodia (www.allearscambodia.org), an NGO long-established in Phnom Penh. This organisation has already trained local medics around the country to manage simple ear conditions, perform aural toilet and take otoscopic images. They are eager to work together with the otology fellow in a mutually beneficial partnership in order to develop a referral pathway for those requiring surgery, together with a network of ear care for postoperative management such as pack removal and ongoing mastoid cavity care. With outreach clinics already established in the north, west and east of the country, this will be available nearer to a patient’s home, thus avoiding the concerns that once operated upon, patients may never return (often due to financial constraints). Pre and postoperative audiological data will be readily available for meaningful analysis of the fellow’s outcomes.
French-trained anaesthetists perform an excellent service.
Four-table communal operating theatre.
In order to provide guidance and support for the fellow there will be weekly contact with a mentor back in the UK – Matt Clark has agreed to take on this role for the foreseeable future. Each week the fellow and mentor will communicate via Skype to discuss cases, formulate management plans, and provide support. Further support is offered by Professors Birchall and Saeed who, together with the authors, are keen to establish this as a long-lasting and well-respected fellowship.
We have designed a standardised electronic case history sheet with inserted otoscopic pictures, such that cases to be discussed can be circulated easily. Combined with occasional visits and links with those other teams providing their outreach projects, the fellow should feel well supported. Jim Gollogy, an orthopaedic Yorkshireman and director of CSC, will help with practical day-to-day issues that arise.
The authors visited Phnom Penh earlier this year to recce the set-up, resulting in establishing all of the above. From a practical perspective, the post is paid sufficiently well to provide a great standard of living out there (at $2000 per month) and the cost of a return flight is included. The city and country are fascinating and the people very welcoming and friendly. There is a large ex-pat community, and many are involved in humanitarian care of some type.
(L-R) Matthew Clark with Dr Davy, the local Khmer SHO-grade ENT doctor and Charlie Huins.
We are in no doubt that within a few years’ time this fellowship will become highly sought after as its reputation grows. It is an opportunity to provide the finishing trainee with some fascinating and unique aspects for his/her curriculum vitae (CV) in preparation for consultant job applications. Not only will the logbook look very healthy, the fellow will be able to demonstrate his/her ability to manage a service, teach junior doctors and work in challenging situations – so many of the skills required as a new consultant. There will be undoubted opportunities for research projects and publications. And not least, this will be a life-influencing experience that is likely to have a lasting effect upon the fellow.
Our current challenge is to ensure that we have successors for the immediate post, before we are able to report on the real success that Charlie will undoubtedly experience over this next six months. We would encourage anyone interested to contact any of us involved via the contact details listed. Take a step outside of your comfort zone, challenge yourself with something unique and exciting - the rewards will certainly follow!
Declaration of competing interests: None declared.