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

A Call to Promote Global Surgery and Anesthesia as Essential Curriculum for Uniformed Medical Students

Global surgery and anesthesia is an emerging field in global health and academic medicine. Promoting the education of global surgery and anesthesia among uniformed medical students is imperative and will prepare the next generation of uniformed physicians for global surgical missions through both the DoD and civilian opportunities.

Interests and Barriers to Medical Students Participation in a Dedicated Global Surgery Curriculum

INTRODUCTION

Despite many institutions establishing global surgery (GS) programs to support clinical care and education in resource-limited settings, few have established a specific curriculum in GS. This study's objective was to assess medical student interest in such a curriculum and prospects for future careers in GS/global health (GH), and to define the barriers to pursuing an international rotation.

METHODS

We conducted an anonymous online survey of all 495 medical students at a major academic medical center in the mid-South that collected demographic data, country of origin, interest in a GS/GH elective, and barriers to pursuing a GS/GH rotation abroad. The data were analyzed using SPSS software.

RESULTS

Prior international experience increased the likelihood of a student's involvement in GS/GH and more preclinical (years 1 & 2) students (90%) than clinical students. (years 3 & 4) (70%) felt strongly about the value of a GS/GH experience. Of the 163 students who completed the survey, 80% expressed interest in a GS/GH elective, with preclinical students expressing more interest (90%) than clinical students (71%). This interest strongly correlated with an interest in pursuing a career in GH (94%) and/or GS (100%). Identified barriers to engagement in a GS/GH experience abroad included financing (74%), scheduling (58%), family obligations (23%), and personal safety (19%).

CONCLUSIONS

The students we surveyed were very interested in a GS/GH curriculum that included a rotation abroad, especially if they were to receive financial support. Preclinical students expressed more willingness to self-fund such experiences. The findings of this survey further strengthen the need to incorporate GS/GH in medical school curricula.

Academic global surgical competencies: A modified Delphi consensus study

Academic global surgery is a rapidly growing field that aims to improve access to safe surgical care worldwide. However, no universally accepted competencies exist to inform this developing field. A consensus-based approach, with input from a diverse group of experts, is needed to identify essential competencies that will lead to standardization in this field. A task force was set up using snowball sampling to recruit a broad group of content and context experts in global surgical and perioperative care. A draft set of competencies was revised through the modified Delphi process with two rounds of anonymous input. A threshold of 80% consensus was used to determine whether a competency or sub-competency learning objective was relevant to the skillset needed within academic global surgery and perioperative care. A diverse task force recruited experts from 22 countries to participate in both rounds of the Delphi process. Of the n = 59 respondents completing both rounds of iterative polling, 63% were from low- or middle-income countries. After two rounds of anonymous feedback, participants reached consensus on nine core competencies and 31 sub-competency objectives. The greatest consensus pertained to competency in ethics and professionalism in global surgery (100%) with emphasis on justice, equity, and decolonization across multiple competencies. This Delphi process, with input from experts worldwide, identified nine competencies which can be used to develop standardized academic global surgery and perioperative care curricula worldwide. Further work needs to be done to validate these competencies and establish assessments to ensure that they are taught effectively.

Partnering to build surgical capacity in low-resource settings: a qualitative study of Canadian global surgeons

OBJECTIVES

This qualitative study aimed to explore the perspectives of Canadian global surgeons with experience developing surgical education partnerships with low- and middle-income countries (LMICs) for the purpose of identifying factors for success.

DESIGN

A purposive sample of leaders from global surgery programmes at Canadian Faculties of Medicine participated in virtual semi-structured interviews. A six-phase thematic analysis was performed using a constructivist lens on verbatim transcripts by three independent researchers. Key factors for success were thematically collated with constant comparison and inter-investigator triangulation in NVivo software until theoretical saturation was reached.

PARTICIPANTS

Fifteen surgeons, representing 11 subspecialties at 6 Canadian academic institutions and a combined experience across 6 continents, were interviewed between January and June 2022.

RESULTS

Four facilitators for success of global surgery training programmes were identified, with a strong undertone of relationship-building permeating all subthemes: (1) facilitative skill sets and infrastructure, (2) longitudinal engagement, (3) local ownership and (4) interpersonal humility. Participants defined facilitative skill sets to include demonstrated surgical competence and facilitative infrastructure to include pre-existing local networks, language congruency, sustainable funding and support from external organisations. They perceived longitudinal engagement as spanning multiple trips, enabled by strong personal motivation and arrangements at their home institutions. Ownership of projects by local champions, including in research output, was noted as key to preventing brain drain and catalysing a ripple effect of surgical trainees. Finally, interviewees emphasised interpersonal humility as being crucial to decolonising the institution of global surgery with cultural competence, reflexivity and sustainability.

CONCLUSIONS

The interviewed surgeons perceived strong cross-cultural relationships as fundamental to all other dimensions of success when working in low-resource capacity-building. While this study presents a comprehensive Canadian perspective informed by high-profile leadership in global surgery, a parallel study highlighting LMIC-partners' perspectives will be critical to a more complete understanding of programme success.

Academic Global Surgery: Creating Opportunities, Equity, and Diversity

A workforce trained in the development and delivery of equitable surgical care is critical in reducing the global burden of surgical disease. Academic global surgery aims to address the present inequities through collaborative partnerships that foster research, education, advocacy and training to support and increase the surgical capacity in settings with limited resources. Barriers include a deficiency of resources, personnel, equipment, and funding, a lack of communication, and geographical challenges. Multi-level partnerships remain fundamental; these types of partnerships include a wide range of trainees, professionals, institutions, and nations, yet care must be taken to avoid falling into the trap of surgical "voluntourism" and undermining the expertise and practice of long-standing frontline providers. Academic global surgery has the benefit of developing a community of surgeons who possess the tools needed to collaborate on individual, institutional, and international levels to address inequities in surgery that are spread variously across the globe. However, challenges for surgeons pursuing a career in global surgery include balancing clinical responsibilities while integrating global surgery as a career during training. This is due in part to the lack of mentorship, research time, grant funding, support to attend conferences, and a limitation of resources, all of which are significantly more pronounced for surgeons from low-resource countries.

With equity in mind: Evaluating an interactive hybrid global surgery course for cross-site interdisciplinary learners

There is limited understanding of the role of transcultural, cross-site educational partnerships for global surgery training between high- and low- or middle-income country (LMIC) institutions. We describe the development, delivery, and appraisal of a hybrid, synchronous, semester-long Global Surgical Care course by global health collaborators from widely different contexts, and evaluate the equity of the collaboration. The course was collaboratively modified by surgical educators and public health professionals with emphasis on collaboration ethics. Faculty from high-income and LMICs were paired to deliver lectures. To collaborate internationally, students and faculty participated either onsite or online. Perceptions and knowledge gained were quantitatively evaluated through participant and faculty cross-sectional surveys, using Likert scales, prioritization rankings, and free text responses analysed qualitatively. Equity was assessed using the Fair Trade Learning rubric and additional probes. Thirty-five learners from six institutions participated. Teams produced mock National, Surgical, Obstetric, and Anaesthesia Plans (NSOAPs) for selected LMICs, and reported a 9% to 65% increase in self-reported global health competencies following the course. Online learners had favourable perceptions of learning, but experienced connectivity challenges. Barriers to effective group work included time differences and logistics of communication for dispersed team members. Individuals taking the course for academic credit scored significantly higher than other learners in peer assessments of participation (8.56±1.53 versus 5.03±3.14; p<0.001). Using the Fair Trade Rubric, 60% of equity indicators were ideal, and no respondents perceived neo-colonialism in the partnership. Blended, synchronous, interdisciplinary global surgery courses based on "North-South" partnerships with a focus on equity in design and delivery are feasible but require careful and deliberate planning to minimize epistemic injustice. Such programs should address surgical systems strengthening, and not create dependency. Equity in such engagements should be evaluated and monitored in an ongoing fashion to stimulate discussion and continuous improvement.

Cultural Sensitivity and Ethical Considerations

Global surgery is a burgeoning area of global health. Surgeons can engage in one-or many-of the facets of global healthcare delivery: clinical care, capacity building, education, research, etc. Working in an increasingly global community, surgeons must be aware of the richness of cultural diversity at home and around the world such that they can provide culturally sensitive care. This chapter focuses on the most common way in which surgeons engage in global surgery: surgical short-term experiences in global health (STEGHs). Surgical STEGHs pose an intricate set of ethical dilemmas. As team leaders, surgeons must understand the community they intend to serve on these trips. Further, they should confirm that everyone who joins them is prepared to deliver care in a culturally sensitive and competent manner. Finally, surgeons must consider potential ethical dilemmas that may arise before, during, and after surgical STEGHs and have strategies to navigate them.

Global pediatric surgery and anesthesia inequities: how do we have a global effort?

PURPOSE OF REVIEW

The SARS-CoV-2 (COVID-19) pandemic has highlighted the inequities in access to healthcare while also revealing our global connectivity. These inequities are emblematic of decades of underinvestment in healthcare systems, education, and research in low-middle income countries (LMICs), especially in surgery and anesthesiology. Five billion people remain without access to safe surgery, and we must take appropriate action now.

RECENT FINDINGS

The pediatric perioperative mortality in low-resourced settings may be as high as 100 times greater than in high-resourced settings, and a pediatric surgery workforce density benchmark of 4/1 million population could increase survivability to over 80%. Delay in treatment for congenital surgically correctable issues dramatically increases disability-adjusted life years. Appropriate academic partnerships which promote education are desired but the lack of authorship position priority for LMIC-based researchers must be addressed. Five perioperative benchmark indicators have been published including: geospatial access to care within 2 h of location; workforce/100,000 population; volume of surgery/100,000 population; perioperative mortality within 30 days of surgery or until discharged; and risks for catastrophic expenditure from surgical care.

SUMMARY

Research that determines ethical and acceptable partnership development between high- and low-resourced settings focusing on education and capacity building needs to be standardized and followed.

An Online, Modular Curriculum Enhances Surgical Education and Improves Learning Outcomes in East, Central, and Southern Africa: A Mixed-Methods Study

Objective

We aimed to determine the impact of a standardized curriculum on learning outcomes for surgical trainees in East, Central, and Southern Africa (ECSA).

Background

As surgical education expands throughout ECSA, there is a recognized need for a standardized curriculum. We previously described the design of a novel, large-scale, flipped-classroom, surgical curriculum for trainees in ECSA.

Methods

In January 2020, the first year of curricular content for trainees of the College of Surgeons of ECSA was released, containing 11 monthly thematic topics, each with 2 to 5 weekly modular subtopics. We aimed to evaluate 3 outcomes utilizing data sources incorporated into the curriculum structure. Learner engagement was assessed by the number of trainees completing curriculum topics. User experience was evaluated using quantitative and qualitative feedback responses to embedded surveys for each content week. Curriculum impact on trainee examination performance was assessed by comparing certification examination scores stratified by the number of curricular topics each trainee completed.

Results

Two hundred seventy-one trainees (96%) in 17 countries accessed at least 1 weekly module. Trainees completed a median of 9 topics (interquartile range: 6-10). The feedback survey response rate was 92% (5742/6233). Quantitative and qualitative responses were positive in overall module value (93.7% + 2.6%), amount of learning experienced (97.9% + 1.4%), confidence in achieving learning objectives (97.1% + 2.4%), and ease of use of the module (77.6% + 5.98%). Topic-related certification examination performance improved significantly with increased completion of thematic topics.

Conclusions

A standardized surgical curriculum in ECSA demonstrated excellent trainee usage, positive feedback, and improved examination scores.

Design of a Novel Online, Modular, Flipped-classroom Surgical Curriculum for East, Central, and Southern Africa

Objective

We describe a structured approach to developing a standardized curriculum for surgical trainees in East, Central, and Southern Africa (ECSA).

Summary Background Data

Surgical education is essential to closing the surgical access gap in ECSA. Given its importance for surgical education, the development of a standardized curriculum was deemed necessary.

Methods

We utilized Kern's 6-step approach to curriculum development to design an online, modular, flipped-classroom surgical curriculum. Steps included global and targeted needs assessments, determination of goals and objectives, the establishment of educational strategies, implementation, and evaluation.

Results

Global needs assessment identified the development of a standardized curriculum as an essential next step in the growth of surgical education programs in ECSA. Targeted needs assessment of stakeholders found medical knowledge challenges, regulatory requirements, language variance, content gaps, expense and availability of resources, faculty numbers, and content delivery method to be factors to inform curriculum design. Goals emerged to increase uniformity and consistency in training, create contextually relevant material, incorporate best educational practices, reduce faculty burden, and ease content delivery and updates. Educational strategies centered on developing an online, flipped-classroom, modular curriculum emphasizing textual simplicity, multimedia components, and incorporation of active learning strategies. The implementation process involved establishing thematic topics and subtopics, the content of which was authored by regional surgeon educators and edited by content experts. Evaluation was performed by recording participation, soliciting user feedback, and evaluating scores on a certification examination.

Conclusions

We present the systematic design of a large-scale, context-relevant, data-driven surgical curriculum for the ECSA region.

WITHDRAWN: Invited Commentary: Global Surgery Education: Whose Needs Should We Serve?

The Publisher regrets that this article is an accidental duplication of an article that has already been published DOI- 10.1016/j.jss.2021.07.016. The duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.