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.

Identifying knowledge needed to improve surgical care in Southern Africa using a theory of change approach

Surgical healthcare has been prioritised in the Southern African Development Community (SADC), a regional intergovernmental entity promoting equitable and sustainable economic growth and socioeconomic development. However, challenges remain in translating political prioritisation into effective and equitable surgical healthcare. The AfroSurg Collaborative (AfroSurg) includes clinicians, public health professionals and social scientists from six SADC countries; it was created to identify context-specific, critical areas where research is needed to inform evidence-grounded policy and implementation. In January 2020, 38 AfroSurg members participated in a theory of change (ToC) workshop to agree on a vision: ‘An African-led, regional network to enable evidence-based, context-specific, safe surgical care, which is accessible, timely, and affordable for all, capturing the spirit of Ubuntu[1]’ and to identify necessary policy and service-delivery knowledge needs to achieve this vision. A unified ToC map was created, and a Delphi survey was conducted to rank the top five priority knowledge needs. In total, 45 knowledge needs were identified; the top five priority areas included (1) mapping of available surgical services, resources and providers; (2) quantifying the burden of surgical disease; (3) identifying the appropriate number of trainees; (4) identifying the type of information that should be collected to inform service planning; and (5) identifying effective strategies that encourage geographical retention of practitioners. Of the top five knowledge needs, four were policy-related, suggesting a dearth of much-needed information to develop regional, evidenced-based surgical policies. The findings from this workshop provide a roadmap to drive locally led research and create a collaborative network for implementing research and interventions. This process could inform discussions in other low-resource settings and enable more evidenced-based surgical policy and service delivery across the SADC countries and beyond.

Minority Underrepresentation in Academia: Factors Impacting Careers of Surgery Residents

BACKGROUND

Underrepresentation of minorities within academic surgery is an ever present problem with a profound impact on healthcare. The factors influencing surgery residents to pursue an academic career have yet to be formally investigated. We sought to elucidate these factors, with a focus on minority status.

METHODS

A web-based questionnaire was sent to all administered to all ACGME-accredited general surgery programs in the United States. The main outcome was the decision to pursue a fully academic versus non-academic career. Multivariable logistic regression was used to identify characteristics impacting career choice.

RESULTS

Of the 3,726 residents who received the survey, a total of 1,217 residents completed it - a response rate of 33%. Forty-seven percent planned to pursue non-academic careers, 35% academic careers, and 18% were undecided. There was no association between underrepresented minority status and academic career choice (Odds Ratio = 1.0, 95% Confidence Interval 0.6 - 1.6). Among all residents, research during training (OR=4.0, 95% CI 2.7-5.9), mentorship (OR=2.1, 95% CI 1.6-2.9), and attending a residency program requiring research (OR=2.3, 95% CI 1.5-3.4) were factors associated with choosing an academic career. When the analysis was performed among only senior residents (i.e., 4^th and 5^th year residents), a debt burden >$150,000 was associated with choosing a non-academic career (OR=0.4, 95% CI 0.1-0.9).

CONCLUSIONS

Underrepresented minority status is not associated with career choice. Intentional recruitment of minorities into research-oriented training programs, increased mentorship and research support among current minority residents, and improved financial options for minorities may increase the number choosing an academic surgical career.

Early experience in establishing and evaluating an ACGME-approved international general surgery rotation

BACKGROUND

In 2011, the Accreditation Council for Graduate Medical Education Surgery Residency Review Committee first provided guidelines for elective international general surgery rotations. The Vanderbilt general surgery residency program received Surgery Residency Review Committee approval for a fourth-year elective in Kenya beginning in the 2011-2012 academic year. Because this rotation would break ground culturally and geographically, and as an educational partnership, a briefing and debriefing process was developed for this ground-breaking year.

OBJECTIVES

Our objectives were to prepare residents to maximize the experience without competing for cases with local trainees or overburdening the host institution and to perform continuous quality assessment and improvement as each resident returned back.

METHODS

Briefing included health protection strategies, a procedures manual containing step-by-step preparation activities, and cultural-sensitivity training. Institutional Review Board exemption approval was obtained to administer a questionnaire created for returning residents concerning educational value, relations with local trainees, physical environment, and personal perceptions that would provide the scaffold for the debriefing conference.

RESULTS

The questionnaire coupled with the debriefing discussion for the first 9 participants revealed overall satisfaction with the rotation and the briefing process, good health, and no duty hours or days-off issues. Other findings include the following: (1) emotional effect of observing African families weigh cost in medical decision making; (2) satisfactory access to educational resources; (3) significant exposure to specialties such as urology and radiology; and (4) toleration of 4 weeks as a single and expressed need for leisure activity materials such as books, DVDs, or games. The responses triggered adjustments in the briefing sessions and travel preparation. The host institution invited the residents to return for the 2012-2013 year as well as 2013-2014.

CONCLUSION

Detailed preparation and the follow-up evaluation for assessment and improvement of this nascent international surgery experience are associated with resident satisfaction and the host institution has agreed to continue the rotation.

Cost comparison of microscopy vs. empiric treatment for malaria in Southwestern Nigeria: a prospective study

Background

Presumptive treatment for malaria is common in resource-limited settings, yet controversial given the imprecision of clinical diagnosis. The researchers compared costs of diagnosis and drugs for two strategies: (1) empirical treatment of malaria via clinical diagnosis; and (2) empirical diagnosis followed by treatment only with Giemsa smear confirmation.

Methods

Patients with a diagnosis of clinical malaria were recruited from a mission/university teaching hospital in southwestern Nigeria. The patients underwent free Giemsa thick (diagnosis) and thin (differentiation) smears, but paid for all anti-malarial drugs. Clinical diagnosis was made on clinicians' judgments based on symptoms, including fever, diarrhoea, headache, and body aches. The paediatric regimen was artesunate (6-9 tablets of 3 mg/kg on day one and 1.5 mg/kg for the next four days) plus amodiaquine (10 mg/kg day 1-2 and 5 mg/kg on day three in suspension). Adults were given two treatment options: option one (four and one-half 50 mg artesunate tablets on day one and nine tablets for the next four days, plus three 500 mg sulphadoxine/25 mg pyrimethamine tablets) and option two (same artesunate regimen plus nine 200 mg tablets of amodiaquine at 10 mg/kg day 1-2 and 5 mg/kg on day three). The researchers calculated the costs of smears/drugs from standard hospital charges.

Results

Doctors diagnosed 304 patients (170 adults ages >16 years and 134 pediatric) with clinical malaria, prescribing antimalarial drugs to all. Giemsa thick smears were positive in 115/304 (38%). The typical patient cost for a Giemsa smear was 550 Naira (US$3.74 in 2009). For children, the cost of testing all, but treating only Giemsa positives was N888 ($6.04)/child; the cost of empiric treatment of all who were clinically diagnosed was lower, N660 ($4.49)/child. For adults, the cost of testing all, but treating only Giemsa positives was N711 ($4.84)/adult for treatment option one (artesunate and sulphadoxine/pyrimethamine) and N730 ($4.97)/adult for option two (artesunate and amodiaquine). This contrasts to lower costs of empiric treatment for both options one (N610 = $4.14/adult) and two (N680=$4.63/adult).

Conclusions

Empiric treatment of all suspected cases of malaria was cheaper (at the end of the dry to the beginning of the rainy season) than only treating those who had microscopy-confirmed diagnoses of malaria, even though the majority of patients suspected to have malaria were negative via microscopy. One can acknowledge that giving many malaria-uninfected Nigerians anti-malarial drugs is undesirable for both their personal health and fears of drug resistance with overuse. Therefore, funding of rapid diagnostic tests whose performance exceeds the Giemsa smear is needed to achieve an ideal of diagnostic confirmation before treatment.

Medical students' experiences of moral distress: development of a web-based survey

PURPOSE

To develop an instrument for measuring moral distress in medical students, measuring the prevalence of moral distress in a cohort of students, and identifying the situations most likely to cause it. Moral distress, defined as the negative feelings that arise when one knows the morally correct thing to do but cannot act because of constraints or hierarchies, has been documented in nurses but has not been measured in medical students.

METHOD

The authors constructed a survey consisting of 55 items describing potentially distressing situations. Responders rated the frequency of these situations and the intensity of distress that they caused. The survey was administered to 106 fourth-year medical students during a three-week period in 2007; the response rate was 60%.

RESULTS

Each of the situations was experienced by at least some of the 64 respondents, and each created some degree of moral distress. On average, students witnessed almost one-half of the situations at least once, and more than one-third of the situations caused mild-to-moderate distress. The survey measured individual distress (Cronbach alpha = 0.95), which varied among the students. Whereas women witnessed potentially distressing situations significantly more frequently than did men (P = .04), men tended to become more distressed by each event witnessed (P = .057).

CONCLUSIONS

Medical students frequently experience moral distress. Our survey can be used to measure aspects of the learning environment as well as individual responses to the environment. The variation found among student responses warrants further investigation to determine whether students at either extreme of moral distress are at risk of burnout or erosion of professionalism.

The role of the Veterans Affairs Medical Centers in patient care, surgical education, research and faculty development

Veterans Administration (VA) medical centers have had a long history of providing medical care to those who have served their country. Over time, the VA has evolved into a facility that has had a major role in graduate medical education. In surgery, this had provided experience in the medical and surgical management of complex surgical disease involving the head and neck, chest, and gastrointestinal tract, and in the fields of surgical oncology, peripheral vascular disease, and the subspecialties of urology, orthopedics, and neurosurgery. The VA provides a venue for the attending physician and resident to work in concert to allow the resident to shoulder increasing accountability in decision-making and delivery of care in the outpatient arena, the operating room, and the intensive care unit. Medical students assigned to a VA hospital are afforded a great opportunity to be exposed to preoperative planning, discussions leading to informed consent for surgery, the actual operation, and postoperative care. Numerous opportunities at the VA are available for novice and experienced medical faculty members to develop and/or enhance skills and abilities in patient care, medical education, and research. In addition, the VA offers unique opportunities for academic physicians and other healthcare professionals to administer its many programs, thereby developing leadership skills and experience in the process. The VA is uniquely situated to design and conduct multicenter clinical trials. The most important aspect of this is the infrastructure provided by the VA Cooperative Studies Program. Of the four missions of the Department of Veterans Affairs, research and education is essential to provide quality, state of the art clinical care to the veteran. The National Surgical Quality Improvement Program (NSQIP) is an example of how outcomes based research can favorably impact on patient outcome. Looking across the horizon of information solutions available to surgeons, the options are limited. This is not the case for the Department of Veterans Affairs. With the congressionally mandated charge for the VA to compare its quality to private clinicians, the advent of the "Surgery Package" became possible. The VA will continue its leadership position in the healthcare arena if it can successfully address the challenges facing it.