Training and accrediting international surgeons

Beyond the Ivory Tower: Perception of academic global surgery by surgeons in low- and middle-income countries

Interest in global surgery has surged amongst academics and practitioners in high-income countries (HICs), but it is unclear how frontline surgical practitioners in low-resource environments perceive the new field or its benefit. Our objective was to assess perceptions of academic global surgery amongst surgeons in low- and middle-income countries (LMICs). We conducted a cross-sectional e-survey among surgical trainees and consultants in 62 LMICs, as defined by the World Bank in 2020. This paper is a sub-analysis highlighting the perception of academic surgery and the association between practice setting and responses using Pearson's Chi-square test. Analyses were completed using Stata15. The survey received 416 responses, including 173 consultants (41.6%), 221 residents (53.1%), 8 medical graduates (1.9%), and 14 fellows (3.4%). Of these, 72 responses (17.3%) were from low-income countries, 137 (32.9%) from lower-middle-income countries, and 207 (49.8%) from upper-middle-income countries. 286 respondents (68.8%) practiced in urban areas, 34 (8.2%) in rural areas, and 84 (20.2%) in both rural and urban areas. Only 185 (44.58%) were familiar with the term "global surgery." However, 326 (79.3%) agreed that collaborating with HIC surgeons for research is beneficial to being a global surgeon, 323 (78.8%) agreed that having an HIC co-author improves likelihood of publication in a reputable journal, 337 (81.6%) agreed that securing research funding is difficult in their country, 195 (47.3%) agreed that their institutions consider research for promotion, 252 (61.0%) agreed that they can combine research and clinical practice, and 336 (82%) are willing to train HIC medical students and residents. A majority of these LMIC surgeons noted limited academic incentives to perform research in the field. The academic global surgery community should take note and foster equitable collaborations to ensure that this critical segment of stakeholders is engaged and has fewer barriers to participation.

Design, delivery and effectiveness of health practitioner regulation systems: an integrative review

BACKGROUND

Health practitioner regulation (HPR) systems are increasingly recognized as playing an important role in supporting health workforce availability, accessibility, quality, and sustainability, while promoting patient safety. This review aimed to identify evidence on the design, delivery and effectiveness of HPR to inform policy decisions.

METHODS

We conducted an integrative analysis of literature published between 2010 and 2021. Fourteen databases were systematically searched, with data extracted and synthesized based on a modified Donabedian framework.

FINDINGS

This large-scale review synthesized evidence from a range of academic (n = 410) and grey literature (n = 426) relevant to HPR. We identified key themes and findings for a series of HPR topics organized according to our structures-processes-outcomes conceptual framework. Governance reforms in HPR are shifting towards multi-profession regulators, enhanced accountability, and risk-based approaches; however, comparisons between HPR models were complicated by a lack of a standardized HPR typology. HPR can support government workforce strategies, despite persisting challenges in cross-border recognition of qualifications and portability of registration. Scope of practice reform adapted to modern health systems can improve access and quality. Alternatives to statutory registration for lower-risk health occupations can improve services and protect the public, while standardized evaluation frameworks can aid regulatory strengthening. Knowledge gaps remain around the outcomes and effectiveness of HPR processes, including continuing professional development models, national licensing examinations, accreditation of health practitioner education programs, mandatory reporting obligations, remediation programs, and statutory registration of traditional and complementary medicine practitioners.

CONCLUSION

We identified key themes, issues, and evidence gaps valuable for governments, regulators, and health system leaders. We also identified evidence base limitations that warrant caution when interpreting and generalizing the results across jurisdictions and professions. Themes and findings reflect interests and concerns in high-income Anglophone countries where most literature originated. Most studies were descriptive, resulting in a low certainty of evidence. To inform regulatory design and reform, research funders and governments should prioritize evidence on regulatory outcomes, including innovative approaches we identified in our review. Additionally, a systematic approach is needed to track and evaluate the impact of regulatory interventions and innovations on achieving health workforce and health systems goals.

Remote Robotic Surgery and Virtual Education Platforms: How Advanced Surgical Technologies Can Increase Access to Surgical Care in Resource-Limited Settings

Advanced surgical technologies consist of remote and virtual platforms that facilitate surgical care and education. It also includes the infrastructure necessary to utilize these platforms (e.g., internet access, robotic systems, and simulators). Given that 5 billion people lack access to safe and timely surgical care, the appeal of these technologies to the field of global surgery lies primarily in its ability to eliminate geographical barriers and address surgeon shortages. This article discusses the use of virtual and remote technologies in resource-limited settings, the potential applications of these technologies, the possible barriers to their integration, and the impact these technologies may have on access to surgical care and education. Specifically, it will explore how robotic surgery, telesurgery, virtual education platforms, and simulations have the potential to be instrumental in enhancing worldwide access to safe surgical care.

Academic Global Surgery Curricula: Current Status and a Call for a More Equitable Approach

INTRODUCTION

We aimed to search the literature for global surgical curricula, assess if published resources align with existing competency frameworks in global health and surgical education, and determine if there is consensus around a fundamental set of competencies for the developing field of academic global surgery.

METHODS

We reviewed SciVerse SCOPUS, PubMed, African Medicus Index, African Journals Online (AJOL), SciELO, Latin American and Caribbean Health Sciences Literature (LILACS) and Bioline for manuscripts on global surgery curricula and evaluated the results using existing competency frameworks in global health and surgical education from Consortium of the Universities for Global Health (CUGH) and Accreditation Council for Graduate Medical Education (ACGME) professional competencies.

RESULTS

Our search generated 250 publications, of which 18 were eligible: (1) a total of 10 reported existing competency-based curricula that were concurrent with international experiences, (2) two reported existing pre-departure competency-based curricula, (3) six proposed theoretical competency-based curricula for future global surgery education. All, but one, were based in high-income countries (HICs) and focused on the needs of HIC trainees. None met all 17 competencies, none cited the CUGH competency on "Health Equity and Social Justice" and only one mentioned "Social and Environmental Determinants of Health." Only 22% (n = 4) were available as open-access.

CONCLUSION

Currently, there is no universally accepted set of competencies on the fundamentals of academic global surgery. Existing literature are predominantly by and for HIC institutions and trainees. Current frameworks are inadequate for this emerging academic field. The field needs competencies with explicit input from LMIC experts to ensure creation of educational resources that are accessible and relevant to trainees from around the world.

Humanitarian Maxillofacial Mission's Success Requires Experienced Surgeons, Careful Planning, and Meeting With the Local's Care Needs

PURPOSE

Meeting with local needs of low- and middle-income countries during maxillofacial humanitarian mission is not easy. This article aimed to report on 5 years of experience in humanitarian maxillofacial surgery missions. In addition, several key points for best practices and meeting the medical needs of local populations are discussed.

METHODS

In this retrospective case series, all medical charts of patients managed during humanitarian maxillofacial surgery missions organized within the department of maxillofacial surgery of Le Dantec Hospital (Senegal) were analyzed. Disease characteristics, treatments modality, and outcomes were reviewed. Moreover, missions planning and costs were studied.

RESULTS

Between 2015 and 2018, 5 humanitarian missions were organized totalizing 177 patients, one-third of which were treated surgically. Tumors (35%) and sequelae from previous surgeries, cancrum oris or trauma (24%) were the most frequently treated disorders. Most patients were treated with free flap reconstructions (35%). Postoperative complications were observed for only 3 patients (5%). With a median follow-up of 13 months, no sequelae requiring specific treatment were observed. The estimated total cost for each mission was $39,000.

CONCLUSION

In order to benefit both the locals and the volunteers, humanitarian maxillofacial missions should be carefully planned and volunteers appropriately prepared. Other keys to the success of such missions are setting up training and support programs, reflecting upon ethical considerations, understanding local cultural customs and ensuring mutual respect with the locals. Frequent self-evaluation and long-term mission sustainability are critical. Finally, mission costs should be evaluated.

A Pilot Study of Surgical Trainee Participation in Humanitarian Surgeries

BACKGROUND

The impact of general surgery resident participation on operative case time and postoperative complications has been broadly studied in the United States. Although surgical trainee involvement in international humanitarian surgical care is escalating, there is limited information as to how this participation affects care rendered. This study examines the impact of trainee involvement on case length and immediate postoperative complications with regard to operations in low- and middle-income settings.

METHODS

A retrospective chart review was conducted of humanitarian surgeries completed during annual short-term surgical missions performed by the International Surgical Health Initiative to Ghana and Peru. Between 2017 and 2019, procedures included inguinal hernia repairs and total abdominal hysterectomies (TAHs). Operative records were reviewed for case type, duration, and immediate postoperative complications. Cases were categorized as involving two attending co-surgeons (AA) or one attending and resident assistant (RA).

RESULTS

There were 135 operative cases between 2017 and 2019; the majority (82%) involved a resident assistant. There were no statistically significant differences in case times between the attending assistant (AA) and resident assistant (RA) cohorts in both case types. All 23 postoperative complications were classified as Clavien-Dindo Grade I. In addition, resident assistance did not lead to a statistically significant increase in complication rate; 26% in the AA cohort versus 74% in the RA cohort (P = 0.3).

CONCLUSIONS

This pilot study examining 135 operative cases over 2 y of humanitarian surgeries demonstrates that there were no differences in operative duration or complication rates between the AA and RA cohorts. We propose that surgical trainee involvement in low- and middle-income settings do not adversely impact operative case times or postoperative complications.

Global Surgery: A 30-Year Bibliometric Analysis (1987-2017)

INTRODUCTION

There has been a growing interest in addressing the surgical disease burden in low- and middle-income countries (LMICs). Assessing the current state of global surgery research activity is an important step in identifying gaps in knowledge and directing research efforts towards important unaddressed issues. The aim of this bibliometric analysis was to identify trends in the publication of global surgical research over the last 30 years.

METHODS

Scopus^® was searched for global surgical publications (1987-2017). Results were hand-screened, and data were collected for included articles. Bibliometric data were extracted from Scopus^® and Journal Citation Reports. Country-level economic and population data were obtained from the World Bank. Descriptive statistics were used to summarise data and identify significant trends.

RESULTS

A total of 1623 articles were identified. The volume of scientific production on global surgery increased from 14 publications in 1987 to 149 in 2017. Similarly, the number of articles published open access increased from four in 1987 to 68 in 2017. Observational studies accounted for 88.7% of the included studies. The three most common specialties were obstetrics and gynaecology 260 (16.0%), general surgery 256 (15.8%), and paediatric surgery 196 (12.1%). Over two times as many authors were affiliated to an LMIC institution than to a high-income country (HIC) institution (6628, 71.5% vs 2481, 28.5%, P < 0.001). A total of 965 studies (59.5%) were conducted entirely by LMIC authors, and 534 (32.9%) by collaborations between HICs and LMICs.

CONCLUSION

The quantity of research in global surgery has substantially increased over the past 30 years. Authors from LMICs seemed the most proactive in addressing the global surgical disease burden. Increasing the funding for interventional studies, and therefore the quality of evidence in surgery, has the potential for greater impact for patients in LMICs.

Ethical considerations in global surgery: a scoping review

Introduction

An unmet burden of surgical disease exists worldwide and is disproportionately shouldered by low-income and middle-income countries (LMICs). As the field of global surgery grows to meet this need, ethical considerations need to be addressed. Currently, there are no formal guidelines to help inform relevant stakeholders of the ethical challenges and considerations facing global surgical collaborations. The aim of this scoping review is to synthesise the existing literature on ethics in global surgery and identify gaps in the current knowledge.

Methods

A scoping review of relevant databases to identify the literature pertaining to ethics in global surgery was performed. Eligible articles addressed at least one ethical consideration in global surgery. A grounded theory approach to content analysis was used to identify themes in the included literature and guide the identification of gaps in existing literature.

Results

Four major ethical domains were identified in the literature: clinical care and delivery; education and exchange of trainees; research, monitoring and evaluation; and engagement in collaborations and partnerships. The majority of published literature related to issues of clinical care and delivery of the individual patient. Most of the published literature was published exclusively by authors in high-income countries (HICs) (80%), and the majority of articles were in the form of editorials or commentaries (69.1%). Only 12.7% of articles published were original research studies.

Conclusion

The literature on ethics in global surgery remains sparse, with most publications coming from HICs, and focusing on clinical care and short-term surgical missions. Given that LMICs are frequently the recipients of global surgical initiatives, the relative absence of literature from their perspective needs to be addressed. Furthermore, there is a need for more literature focusing on the ethics surrounding sustainable collaborations and partnerships.

Pediatric Cardiac Service Development Programs for Low- and Middle-Income Countries in Need of Improving or Initiating Local Services

Pediatric cardiac services are deficient in most of the world. Various estimates are that between 80 and 90% of the world's children do not receive adequate cardiac care for their congenital or acquired heart disease. We began a modest effort in 1992 to assist in the development of pediatric cardiac services in low- and middle-Income countries (LMIC). Since then, we have provided services in 32 countries based on 3 distinctive development strategies, in order to meet the local needs for pediatric cardiac services. Our goal has always been to provide education, training and sufficient experience so that eventually we leave a site with a fully functional, independently operating pediatric cardiac service that is sustainable over time. The margin between success and failure is dependent upon a number of factors and we hope that this chapter will provide others with the tools for success.

A realized vision of access to safe, affordable surgical and anaesthesia care

Where is the funding?