The College of Surgeons of East, Central, and Southern Africa: Successes and Challenges in Standardizing Neurosurgical Training

The Status of Specialist Neurosurgical Training in Nigeria: A Survey of Practitioners, Trainers, and Trainees

OBJECTIVE

Despite the well-known neurosurgical workforce deficit in Sub-Saharan Africa, there remains a low number of neurosurgical training programs in Nigeria. This study sought to reassess the current status of specialist neurosurgical training in the country.

METHODS

An electronic survey was distributed to all consultant neurosurgeons and neurosurgery residents in Nigeria. Demographic information and questions relating to the content, process, strengths, and challenges of neurosurgical training were explored as part of a broader survey assessing neurosurgical capacity. Descriptive statistics were used for analysis.

RESULTS

Respondents identified 15 neurosurgical training centers in Nigeria. All 15 are accredited by the West African College of Surgeons, and 6 by the National Postgraduate Medical College of Nigeria. The average duration of core neurosurgical training was 5 years. Some identified strengths of Nigerian neurosurgical training included learning opportunities provided to residents, recent growth in the neurosurgical training capacity, and satisfaction with training. Challenges included a continued low number of training programs compared to the population density, lack of subspecialty training programs, and inadequate training infrastructure.

CONCLUSIONS

Despite the high number of neurosurgery training centers in Nigeria, compared to other West African countries, the programs are still limited in number and capacity. Although this study shows apparent trainee satisfaction with the training process and contents, multiple challenges exist. Efforts at improving training capacity should focus on continuing the development and expansion of current programs, commencing subspecialty training, driving health insurance to improve funding, and increasing available infrastructure for training.

Global Neurosurgery: A Retrospective Cohort Study to Compare the Effectiveness of Two Training Methods in Resource-Poor Settings

BACKGROUND AND OBJECTIVES

Many low- and middle-income countries are experiencing profound health care workforce shortages. Surgical subspecialists generally practice in large urban centers but are in high demand in rural areas. These subspecialists must be trained through sustainable programs to address this disparity. We quantitatively compared the relative effectiveness of 2 unique training models to advance neurosurgical skills in resource-poor settings where formally trained neurosurgeons are unavailable.

METHODS

Neurosurgical procedure data were collected from 2 hospitals in Tanzania (Haydom Lutheran Hospital [HLH] and Bugando Medical Centre [BMC]), where 2 distinct training models ("Train Forward" and "Back-to-Back," respectively) were incorporated between 2005 and 2012.

RESULTS

The most common procedures performed were ventriculoperitoneal shunt (BMC: 559, HLH: 72), spina bifida repair (BMC: 187, HLH: 54), craniotomy (BMC: 61, HLH: 19), bone elevation (BMC: 42, HLH: 32), and craniotomy and evacuation (BMC: 18, HLH: 34). The number of annual procedures at BMC increased from 148 in 2008 to 357 in 2012; at HLH, they increased from 18 in 2005 to 80 in 2010. Postoperative complications over time decreased or did not significantly change at both sites as the diversity of procedures increased.

CONCLUSION

The Train Forward and Back-to-Back training models were associated with increased surgical volume and complexity without increased complications. However, only the Train Forward model resulted in local, autonomous training of surgical subspecialists after completion of the initial training period. Incorporating the Train Forward method into existing training programs in low- and middle-income countries may provide unique benefits over historic training practices.

Becoming a neurosurgeon in France: A qualitative study from the trainees' perspective

Introduction

The training of neurosurgeons is evolving in a world of socio-professional changes, including the technological revolution, administrative pressure on stakeholders, reduced working hours, geographical heterogeneity, generational changes, to name but a few.

Research question

This qualitative study aimed to explore experiences and feedback of French neurosurgical trainees concerning their training.

Material and methods

The grounded theory approach was used with 23 neurosurgical trainees' interviews. Inclusion was continued until data saturation. Six researchers (an anthropologist, a psychiatrist, and four neurosurgeons) thematically and independently analyzed data collected through anonymized interviews.

Results

Data analysis identified three superordinate themes: (1) The Trainee-Senior Dyad, where the respondents describe a similar bipolarity between trainees and faculty (trainees oscillating between those who fit into the system and those who are more reluctant to accept hierarchy, faculty using an ideal pedagogy while others refuse to help or invest in training); (2) The difficulty to learn (describing pressure exercised on trainees that can alter their motivation and degrade their training, including the impact of administrative tasks); (3) A pedagogy of empowerment (trainee' feelings about the pertinent pedagogy in the OR, ideal sequence to progress, progressive empowerment especially during the shifts, and stress of envisioning themselves as a senior neurosurgeon).

Discussion and conclusion

Respondents emphasize the heterogeneity of their training both intra- and inter-university-hospital. Their critical analysis, as well as the formalization of their stress to become autonomous seniors, can be an important link with the reforms and optimizations currently being carried out to improve and standardize the training of young French neurosurgeons.

State of African Neurosurgical Education: An Analysis of Publicly Available Curricula

BACKGROUND

Africa bears more than 15% of the global burden of neurosurgical disease; however, it has the lowest neurosurgical workforce density worldwide. The past decade has seen an increase in neurosurgery residency programs on the continent. It is unclear how these residency programs are similar or viable. This study highlights the current status and interdepartmental and regional differences, with the main objective of offering a template for improving the provision of neurosurgical education on the continent.

METHODS

PubMed and Google Scholar were searched using keywords related to "neurosurgery," "training," and "Africa" from database inception to October 13, 2021. The residency curricula were analyzed using a standardized and validated medical education curriculum viability tool.

RESULTS

Curricula from 14 African countries were identified. The curricula differed in resident recruitment, evaluation mode and frequency, curriculum content, and length of training. The length of training varied from 4 to 8 years, with a mean of 6 years. The Eastern African region had the highest number of examinations, with a mean of 8.5. Few curricula had correlates of viability: ensuring that the instructors are competent (64.3%), prioritization of faculty development (64.3%), faculty participation in decision making (64.3%), prioritization of resident support services (50%), creating a conducive environment for quality education (42.9%), and addressing student complaints (28.6%).

CONCLUSIONS

There are significant differences in the African postgraduate neurosurgical education curriculum warranting standardization. This study identifies areas of improvement for neurosurgical education in Africa.

Clinical application and outcomes of reconstructive microsurgery in Africa: A systematic review and meta-analysis

BACKGROUND

Reconstructive microsurgical free flap techniques are often the treatment of choice for a variety of complex tissue defects across multiple surgical specialties. However, the practice is underdeveloped in low- and middle-income countries. The aim of this systematic review was to evaluate the clinical application and outcomes of reconstructive microsurgery performed in Africa.

METHODS

Seven databases (PubMed, Web of Science, MEDLINE, CINAHL, Academic Search Complete, Embase, and Google Scholar) were searched for studies reporting microsurgical procedures performed in Africa. The risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal Tools and quality of evidence using the GRADE approach. Meta-analysis was performed using a random effects model to estimate the pooled proportion of events with 95% confidence intervals. The primary outcome was free flap success rate, and the secondary outcomes were the complication and flap salvage rates.

RESULTS

Ninety-two studies were included in the narrative synthesis and nine in the pooled meta-analysis. In total, 1376 free flaps in 1327 patients from 1976 to 2020 were analyzed. Head and neck oncologic reconstruction made up 30% of cases, while breast reconstruction comprised 2%. The pooled flap survival rate was 89% (95% CI: 0.84, 0.93), complication rate 51% (95% CI: 0.36, 0.65), and free flap salvage rate was 45% (95% CI: 0.08, 0.84).

CONCLUSION

This meta-analysis showed that the free flap success rates in Africa are high and comparable to those reported in high-income countries. However, the comparatively higher complication rate and lower salvage rate suggest a need for improved perioperative care.

REVIEW REGISTRATION

Registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 25th September 2020, ID: CRD42020192344.

Access to training in neurosurgery (Part 1): Global perspectives and contributing factors of barriers to access

Introduction

Neurological disorders are one of the leading causes of death and disability adjusted life years (DALYs). Efforts have been made to increase the neurosurgical workforce in an attempt to address the global disease burden. Despite these efforts, there continues to be a shortage of neurosurgeons in both high-income countries (HICs) and low-and middle-income countries (LMICs).

Research question

The aim of the study was to identify the barriers to neurosurgical training in LMICs and HICs.

Materials and methods

We administered an electronic survey targeting medical students, neurosurgery residents, and recent neurosurgery graduates from 69 countries in both HICs and LMICs. Questions were framed to assess barriers to training.

Results

Of the 198 responses received (31.3% response rate), 72% identified as male, 27% female, and 0.5% as non-binary gender. 33 respondents were from HICs and 165 were from LMICs. 70.1% of respondents reported no availability of dissection labs in their home institutions. There was a significant difference in availability of subspecialty training between LMICs and HMICs (p ​= ​0.001) but no significance was seen for competitiveness of programs (p ​= ​0.473).

Discussion and conclusion

There are limitations to our study: it is not comprehensive of training programs globally, there is sampling bias, especially among LMICs, and the accuracy of responses is unclear. Nonetheless, our results highlight the need for a deliberate focus on designing and implementing both short and long term goals in tackling barriers to access to neurosurgical training, with a conscientious effort to involve interested stakeholders and governments to invest in the training and education of their neurosurgical workforce.

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In comparing LMICs to HICs, there was no significant difference found in ranked competitiveness for entering neurosurgical training.

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A significant difference was found in weekly work hours (p ​= ​0.016) and subspecialty training availability (p ​= ​0.001) between LMICs and HMICs.

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54.4% of countries represented in our study did not have neurosurgical subspecialty training available.

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A significant number of our respondents (70.1%) reported no availability of dissection and surgical skills labs in their home institutions.

The impact of COSECSA in developing the surgical workforce in East Central and Southern Africa

BACKGROUND

The Association of Surgeons of East Africa (ASEA) was formed in 1952. In 1996 a Steering Committee was formed to transform ASEA into a surgical college. The College of Surgeons of East Central and Southern Africa was officially launched in December 1999 in Nairobi, Kenya. Today the College consists of 14 constituent member countries but trains in 20 countries in Sub-Saharan Africa.

PROGRAMMES

COSECSA runs a 5 year training programme in all the surgical specialties. In the first 2 years trainees do the Membership (MCS) programme. This is followed by 3 years of the Fellowship (FCS) programme. More recently the College has started a 2 year sub-specialty Fellowship in paediatric orthopaedics.

GRADUATES

The main aim of the College was to expand and improve surgical training in the COSECSA region. This goal was partially realised in December 2020 when the total number of surgeons produced by the College from inception reached 557.

RETENTION

Another key success story of COSECSA is that the majority of graduates have remained in the region leading to a high retention rate of 88.3%.

WOMEN IN SURGERY AFRICA (WISA)

Since the formation of WISA in 2015 the College has witnessed an increase in the number of female trainees. Currently only 9% of surgeons in the region are women.

CONCLUSION

In its current Strategic Plan (2021-2025) COSECSA aims not only to increase the surgical workforce in the region but also to modernise its training programmes and strengthen its governance structures.

Plastic Surgery Across Continents: A Comparison of Residency Training in Subsaharan Africa and the United States

ABSTRACT

There is a demonstrated need for access to plastic surgical care in low- and middle-income countries worldwide. Recently, there is increasing interest in promoting transcontinental partnerships between academic institutions to improve training opportunities for local surgeons while increasing access to care for patients. Before such programs can be established, it is crucial for US-based surgeons and educators to understand the existing training models in different countries. The aim of this study is to identify the current plastic surgery training model in the College of Surgeons of East, Central, and Southern Africa (COSECSA) group of African nations and compare this to training in the United States. The curricula of 2 accrediting bodies of plastic surgery, COSECSA and the Accreditation Council for Graduate Medical Education of the United States, were compared. Similarities included the length of dedicated plastic surgery training, curriculum content, and final evaluation structure. Differences include training pathways, assessment methodology, and regulation regarding specific competencies, program requirements, and resident benefits. These findings establish a baseline understanding of how plastic surgical training is organized, delivered, and evaluated in Africa, highlight opportunities for educational initiatives, and serve as a foundation for future efforts to develop collaborative partnerships in these communities. Future research will include a survey sent to program directors and plastic surgery attendings in the COSECSA regions to gather additional information.

State of Neurosurgical Education in Africa: A Narrative Review

BACKGROUND

There is no comprehensive report of neurosurgery postgraduate education in Africa. This narrative review aimed to map out the landscape of neurosurgery training in Africa and highlight similarities and differences in training.

METHODS

The keywords "neurosurgery," "education," and "Africa" were searched on PubMed and Google Scholar from inception to January 17, 2021. Next, a complementary hand search was conducted on Google using the keywords "neurosurgery," "residency," and the individual African countries in English and official languages. The relevant data were extracted and compiled into a narrative review.

RESULTS

A total of 76 African training programs that recruit more than 168 trainees each year were identified. Less than half (40.7%, n = 22) of African countries have at least 1 neurosurgery training program. Egypt (n = 15), Algeria (n = 14), and Nigeria (n = 10) have the highest number of training programs, whereas Algeria (0.33), Egypt (0.15), and Libya (0.15) have the highest number of training programs per 1 million inhabitants. The College of Surgeons of East, Central, and Southern Africa has 16 programs in 8 countries, whereas the West African College of Surgeons has 17 accredited programs in 3 countries. The duration of training varies between 4 and 8 years. There is limited information available in the public domain and academic literature about subspecialty fellowships in Africa.

CONCLUSIONS

This review provides prospective applicants and African and global neurosurgery stakeholders with information to advocate for increased investment in African neurosurgery training programs.

Neurosurgery in Ethiopia: A New Chapter and Future Prospects

BACKGROUND

Inequitable access to surgical care is most conspicuous in low-income countries (LICs), such as Ethiopia, where infectious diseases, malnutrition, and other maladies consume the lion's share of the available health resources. The aim of this article was to provide an update on the current state of neurosurgery in Ethiopia and identify targets for future development of surgical capacity as a universal health coverage component in this East African nation.

METHODS

Publicly available data included in this report were gathered from resources published by international organizations. A PubMed search was used for a preliminary bibliometric analysis of scholarly output of neurosurgeons in Ethiopia and other low-income countries. Statistical analysis was used to determine the correlation between the number of neurosurgeons and academic productivity.

RESULTS

Neurosurgeon density has increased >20-fold from 0.0022 to 0.045 neurosurgeons per 100,000 population between 2006 and 2020. The increase in neurosurgeons was strongly correlated with an increase in total publications (P < 0.001) and the number of new publications per year (P = 0.003). Despite recent progress, the availability of neuroimaging equipment remains inadequate, with 38 computed tomography scanners and 11 magnetic resonance imaging machines for a population of 112.07 million. The geographic distribution of neurosurgical facilities is limited to 12 urban centers.

CONCLUSIONS

Ethiopian neurosurgery exemplifies the profound effect of international partnerships for training local surgeons on progress in low-income countries toward improved neurosurgical capacity. Collaborations that focus on increasing the neurosurgical workforce should synchronize with efforts to enhance the availability of diagnostic and surgical equipment necessary for basic neurosurgical care.

An online tumor board with international neurosurgical collaboration guides surgical decision-making in Western Kenya

Telecollaboration via web-based platforms has emerged as a tool to relieve constraints on the establishment of tumor boards for neurosurgical oncology. Challenging tumor cases arising in low- and middle-income countries may benefit from the use of such models. The case of a 5-year-old boy presenting in Western Kenya with a challenging tumor and symptomatic hydrocephalus was presented on a novel web platform to a multi-national audience of neurosurgeons. The treating neurosurgeon invited a physician network to review the case vignette and radiographic images. Respondents independently offered input during a prescribed response period. Three respondents provided surgical opinions during a 24-h response period. The treating neurosurgeon utilized the pooled input to determine a course of action for the patient. When a web-based platform is available, lone neurosurgeons in low-resource settings may nevertheless apply multi-national, multi-institutional perspectives to challenging oncology cases.

Leveraging the lessons learned from studies on the cultural context of epilepsy care in Uganda: Opportunities and future directions

In this summary paper, we review the body of research contained in this special issue, The Intersection of Culture, Resources, and Disease: Epilepsy Care in Uganda, and corollary recommendations for a way forward. We review key findings and conclusions for the studies, which tell a story of culture and care-seeking through discussions and data gleaned from a rich research landscape traversing community village dwellings, shared communal areas, churches, and urban hospitals. The voices and perspectives of over 16,000 study participants inclusive of people living with epilepsy, their neighbors and healthcare workers, traditional healers, and faith leaders are reported. From this, we synthesize findings and prioritize a set of recommendations to advance epilepsy care in Uganda. Progress will require infrastructure strengthening, multilevel educational investments, and an ambitious, extensive program of community sensitization. These proposed priorities and actions outline a way forward through formidable but surmountable challenges but require harmonized efforts by government and other relevant stakeholders, scholars, clinicians, and community leaders. This article is part of the Special Issue "The Intersection of Culture, Resources, and Disease: Epilepsy Care in Uganda".