Global Neurosurgery at the University of Toronto: Past and Present Efforts, and a Charter for the Future

Kenneth McKenzie arrived in Toronto in 1923, bringing the legacy of being the first neurosurgeon in Canada. Since then, Toronto has established itself as the hub of Canadian neurosurgery, in both volumes of cases, the strength of trainees, and research output (1). As one of the most extensive training programs in North America (2), Toronto has had ongoing international connections, chiefly through the fellowship programs within our division. The earliest instance in which Toronto demonstrated a concerted work efford in global neurosurgery was through the persistent and continued struggle of Ab Guha (1957-2009), who amongst many philanthropic activities, establish the National Neuroscience Institute in Calcutta (India), his city of birth, as his goal. Since then, interest in global neurosurgery has remained strong within our division, with multiple continued and consistent collaboration areas. These include Mark Bernstein’s travels within Africa and SouthEast Asia, expanding the reach of awake craniotomies; James Rutka’s efforts to strengthen local surgeons throughout Ukraine; George Ibrahim’s collaborations in Haiti to expand the surgical treatment of pediatric neurosurgical conditions; and Mojgan Hodaie’s work on structured curricula for neurosurgery residents. Simultaneously, Toronto neurosurgery has focused on encouraging fellows from low- and middle-income countries (LMIC’s) to join our center, in many cases funded by the first Chair in International Neurosurgery (3).

As a result of these activities, several clinical fellows who trained in Toronto and returned to bring their expertise to their local sites must be highlighted, including Grace Mutango (pediatric neurosurgery, Uganda), Nilesh Mohan (neuro-oncology, Kenya), Claire Karakezi (neuro-oncology, Rwanda), Selfy Oswari (Indonesia), and a substantial number of short-term visitors from a breadth of international sites.

The Out-of-Pocket Cost Burden of Cancer Care—A Systematic Literature Review

Background: Out-of-pocket costs pose a substantial economic burden to cancer patients and their families. The purpose of this study was to evaluate the literature on out-of-pocket costs of cancer care. Methods: A systematic literature review was conducted to identify studies that estimated the out-of-pocket cost burden faced by cancer patients and their caregivers. The average monthly out-of-pocket costs per patient were reported/estimated and converted to 2018 USD. Costs were reported as medical and non-medical costs and were reported across countries or country income levels by cancer site, where possible, and category. The out-of-pocket burden was estimated as the average proportion of income spent as non-reimbursable costs. Results: Among all cancers, adult patients and caregivers in the U.S. spent between USD 180 and USD 2600 per month, compared to USD 15–400 in Canada, USD 4–609 in Western Europe, and USD 58–438 in Australia. Patients with breast or colorectal cancer spent around USD 200 per month, while pediatric cancer patients spent USD 800. Patients spent USD 288 per month on cancer medications in the U.S. and USD 40 in other high-income countries (HICs). The average costs for medical consultations and in-hospital care were estimated between USD 40–71 in HICs. Cancer patients and caregivers spent 42% and 16% of their annual income on out-of-pocket expenses in low- and middle-income countries and HICs, respectively. Conclusions: We found evidence that cancer is associated with high out-of-pocket costs. Healthcare systems have an opportunity to improve the coverage of medical and non-medical costs for cancer patients to help alleviate this burden and ensure equitable access to car

Silver linings: a qualitative study of desirable changes to cancer care during the COVID-19 pandemic

Introduction: Public health emergencies and crises such as the current COVID-19 pandemic can accelerate innovation and place renewed focus on the value of health interventions. Capturing important lessons learnt, both positive and negative, is vital. We aimed to document the perceived positive changes (silver linings) in cancer care that emerged during the COVID-19 pandemic and identify challenges that may limit their long-term adoption.

Methods: This study employed a qualitative design. Semi-structured interviews (n = 20) were conducted with key opinion leaders from 14 countries. The participants were predominantly members of the International COVID-19 and Cancer Taskforce, who convened in March 2020 to address delivery of cancer care in the context of the pandemic. The Framework Method was employed to analyse the positive changes of the pandemic with corresponding challenges to their maintenance post-pandemic.

Results: Ten themes of positive changes were identified which included: value in cancer care, digital communication, convenience, inclusivity and cooperation, decentralisation of cancer care, acceleration of policy change, human interactions, hygiene practices, health awareness and promotion and systems improvement. Impediments to the scale-up of these positive changes included resource disparities and variation in legal frameworks across regions. Barriers were largely attributed to behaviours and attitudes of stakeholders.

Conclusion: The COVID-19 pandemic has led to important value-based innovations and changes for better cancer care across different health systems. The challenges to maintaining/implementing these changes vary by setting. Efforts are needed to implement improved elements of care that evolved during the pandemic.

Fellowship exit examination in orthopaedic surgery in the commonwealth countries of Australia, UK, South Africa and Canada. Are they comparable and equivalent? A perspective on the requirements for medical migration

nternational migration of healthcare professionals has increased substantially in recent decades. In order to practice medicine in the recipient country, International Medical Graduates (IMG) are required to fulfil the requirements of their new countries medical registration authorities. The purpose of this project was to compare the final fellowship exit examination in Orthopaedic Surgery for the UK, Australia, Canada and South Africa. The curriculum of the Australian Orthopaedic Association (SET) was selected as a baseline reference. The competencies and technical modules specified in the training syllabus, as well as the specifics of the final fellowship examination as outlined in SET, were then compared between countries. Of the nine competencies outlined in SET, the curricula of the UK, South Africa and Canada were all compatible with the Australian syllabus, and covered 97.7%, 86% and 93%, respectively, of all competencies and sub-items. The final fellowship examinations of Australia, South Africa and the UK were all highly similar in format and content. The examination in Canada was substantially different, and had two written sessions but combined the oral and clinical component into a structured OSCE using standardized patients and the component included unmanned stations. There were no significant differences for completion certificate of training and/or board certification observed between these countries. The results of this study strongly suggest that core and technical competencies outlined in the training and education curriculum and the final fellowship examination in Orthopaedic Surgery in Australia, South Africa and the UK are compatible. Between country reciprocal recognition of these fellowship examinations should not only be considered by the relevant Colleges, but should also be regulated by the individual countries health practitioner registration boards and governing bodies.