Global Surgery Education and Training Programmes—a Scoping Review and Taxonomy

Global surgery is an emerging field of study and practice, aiming to respond to the worldwide unmet need for surgical care. As a relatively new concept, it is not clear that there is a common understanding of what constitutes “global surgery education and training”. This study examines the forms that global surgery education and training programmes and interventions take in practice, and proposes a classification scheme for such activities. A scoping review of published journal articles and internet websites was performed according to the PRISMA Extension for Scoping Review guidelines. PubMed MEDLINE, EMBASE and Google were searched for sources that described global surgery education and training programme. Only sources that explicitly referenced a named education programme, were surgical in nature, were international in nature, were self-described as “global surgery” and presented new information were included. Three hundred twenty-seven records were identified and 67 were ultimately included in the review. “Global surgery education and training” interventions described in the literature most commonly involved both a High-Income Country (HIC) institution and a Low- and Middle-Income Country (LMIC) institution. The literature suggests that significant current effort is directed towards academic global surgery programmes in HIC institutions and HIC surgical trainee placements in LMICs. Four categories and ten subcategories of global surgery education and training were identified. This paper provides a framework from which to study global surgery education and training. A clearer understanding of the forms that such interventions take may allow for more strategic decision making by actors in this field

Undergraduate Surgical Education: a Global Perspective

Undergraduate surgical education is failing to prepare medical students to care for patients with surgical conditions, and has been significantly compromised by the COVID-19 pandemic. We performed a literature review and undertook semi-structured reflections on the current state of undergraduate surgical education across five countries: Egypt, Morocco, Somaliland, Kenya, and the UK. The main barriers to surgical education at medical school identified were (1) the lack of standardised surgical curricula with mandatory learning objectives and (2) the inadequacy of human resources for surgical education. COVID-19 has exacerbated these challenges by depleting the pool of surgical educators and reducing access to learning opportunities in clinical environments. To address the global need for a larger surgical workforce, specific attention must be paid to improving undergraduate surgical education. Solutions proposed include the development of a standard surgical curriculum with learning outcomes appropriate for local needs, the incentivisation of surgical educators, the incorporation of targeted online and simulation teaching, and the use of technology.

Analysing a Global Health Education Framework for Public Health Education Programs in India

Academic global health is of increasing interest to educators and students in public health but competency domains as well as education pathways that deliver this training, are still being identified and refined. This thesis was undertaken using an education program development paradigm and aimed to analyse the factors shaping global health education in India by examining multistakeholder perspectives. The research framework consisted of four components: curriculum and content, students, faculty and key experts, and employers. Studies captured the perspectives of students through a survey and focus group discussions, faculty and other key experts through semi-structured interviews, and employers through job advertisement analysis. We identified eleven global health competency domains focussed on three aspects: foundational competencies, core public health skills and soft skills. Global health and public health were seen as interconnected, with global health having transnational context and public health having a more national focus. Global health was seen as a nascent concept in India and although integration of global health education into the public health curriculum was supported, there were concerns given that public health is still too new a discipline in India. Global health competencies were seen as a ‘step up’ from the public health competencies. Based on the results, a two-level approach to global health education is proposed for Indian public health institutions. The first approach, targeted at recent graduates, focuses on a ‘foundational global health education’ within public health programs such as an MPH. The second approach is an ‘Executive Global Health Certificate Program’, aimed at experienced public health professionals planning to enter the global health workforce. This thesis has outlined a framework for Indian and other LMIC institutions looking to expand the scope of public health education and intend to develop global health education programs.

Foundation for International Education in Neurosurgery: The Next Half-Century of Service Through Education

The Foundation for International Education in Neurological Surgery (FIENS) was founded in 1969, decades before globalization became a worldwide phenomenon (1–3). Initially, efforts were focused on service delivery in under-resourced areas via short mission trips by individual neurosurgeons. The wisdom of furthering the impact by creating sustainable training programs in partnership with host organizations developed over time (3). FIENS is a neurosurgeons foundation working in partnership with various organizations to increase global access to neurosurgery missions through the principle of “service through education (3).” FIENS shifted its focus from a service delivery-centered approach to an approach centered on global health systems strengthening by emphasizing local neurosurgery resident education and residency program development (3). It has become clear that the integration of neurosurgical efforts within the local health system amplifies the overall impact of FIENS initiatives by promoting sustainable change through collaborative action in the service of local health system goals. From this point forward, initiatives coordinated by FIENS incorporated local stakeholders and workforce in addition to mechanisms for service delivery, health infrastructure, information management, governance, and funding.

Additionally, FIENS-supported trainees expressed the need for ongoing support in the early stages of their careers. In response, the Foundation expanded its scope to include postgraduate education, evolved, as global health organizations must, understand that lasting impact occurs through teaching, leading to self-sustaining health systems in regions of need.

Feasibility of the application of multimedia animations as preoperative guides for urgent abdominal surgeries in public hospitals in Brazi

Introduction: Preoperative education helps patients feel less anxious and improve self-care while decreasing hospitalization time and demand for postoperative analgesia. Health literacy, culture and language play vital roles in patients’ understanding of health issues and may influence treatment outcomes. Obstacles are more evident in low and middle income countries (LMICs), where inadequate patient education levels are higher and hospital resources lower. Methodology: This is a prospective pilot study assessing the feasibility of online preoperative multimedia animations as guides for surgical patients in an LMIC. Patients admitted to a public hospital in Brazil for acute cholecystitis or appendicitis were included. Feasibility was represented by acceptability rate and ease of integration with department protocols. Results: Thirty-four patients were included in the study. Twenty-six patients concluded the intervention (feasibility rate of 76.5%). Demographic factors seemed to affect results, indicated by higher acceptability from those with lower education levels, from younger patients and from women. No issues were reported regarding integration to local protocols. Discussion: Few studies have evaluated use of multimedia resources for preoperative patients. No studies assessed the use of animations and none analyzed digital patient education resources in an LMIC. This study demonstrated that the use of animations for patient education in LMICs is feasible. A step-based protocol approach is proposed by this study to aid the implementation of patient education digital interventions. Conclusion: The implementation of this tool is feasible and presents patients with easier access to appropriate and engaging information, allowing better surgical preparation and recovery. It can be offered online, allowing it to be sustainable while creating the foundations for a modern patient education culture in LMICs

Global Neurosurgery and the Congress of Neurological Surgeons: Collaboration, Innovation, and Opportunity to Improve Care, Education, and Access.

Global neurosurgery encompasses the neurosurgical care and public health efforts to ensure timely and safe neurosurgical care access for all who need it (1). Over the past several decades, global neurosurgery has been championed by many individuals, which has led to a broader interest in developing larger collaborative, sustainable neurosurgical care efforts. On a national level, neurosurgical educational opportunities have grown through courses, online education, and fellowships. Given the growing global burden of neurosurgical disease, there is a significant opportunity and need for worldwide neurosurgery and neurosurgical education worldwide, especially in low- and middle-income countries (LMICs).
To advance global neurosurgery from an educational standpoint, the Congress of Neurological Surgeons (CNS), American Association of Neurological Surgeons (AANS), World Federation of Neurological Surgeons (WFNS), and other international neurosurgical societies have successfully developed programming. The CNS has led with a robust educational platform and offerings for neurosurgeons through in-person courses, fellowships, webinars, online case databases (2), publications, guidelines, and virtual grand rounds. SANS online education and questions modules offer neurosurgeons the ability to learn and self-test to advance their fund of knowledge, education, and continuing education

Peer-led surgery education: A model for a surgery interest group

Abstract
We present a systematic, sustainable, student-led model for a Surgery Interest Group in a low and middle-income country setting to encourage other medical students to establish similar groups in their institutions. Our model was developed at the Aga Khan University Medical College, Karachi, and is comprised of medical students, teaching associates, residents, faculty and alumni. The group focuses on connecting medical students with an interest in surgery with opportunities to help them match in surgery training programs. The opportunities include, but are not limited to, skill development, personal development, mentorship and research. Our model has shown growth and expansion over the last four years, and can be successfully replicated in medical colleges across similar settings.

Surgical residents’ opinions on international surgical residency in Flanders, Belgium

Background
International electives benefit training of medical residents due to exposure to an increased scope of pathologies, improved physical examination skills, communication across cultural boundaries and more efficient resource utilization. Currently there is no mechanism for Belgian surgical residents to participate in international training opportunities and little research has addressed the international mobility of Belgian residents. The goal of this study was to examine the attitudes of Belgian residents towards international training among surgical residents.

Methods
An anonymous, structured electronic questionnaire was sent to a cohort of Belgian residents, including surgical residents, by e-mail and social media.

Results
In total, 342 respondents filled out the questionnaire out of a total of 5906 Belgian residents. The results showed that 334 of the residents came from Flanders (10.8%) and 8 came from French-speaking Brussels and Wallonia (0.28%). Surgical specialties represented 46% of respondents and included surgical, obstetric and anaesthesiology residents. The majority (98%) were interested in an international rotation, both in low- and middle-income countries (LMICs) and in high-income countries. A total of 84% were willing to conduct an international rotation during holidays and 91% would participate even when their international stay would not be recognised as part of their residency training. A minority (38%) had undertaken an international rotation in the past and, of those, 5% went to an LMIC.

Conclusion
The majority of surgical residents consider an international rotation as educationally beneficial, even though they are rarely undertaken. Our survey shows that in order to facilitate foreign rotations, Flemish universities and governmental institutions will have to alleviate the regulatory, logistical and financial constraints.

An evaluation of obstetric ultrasound education program in Nepal using the RE-AIM framework

Background
Nepal has a high prevalence of congenital anomaly contributing to high infant mortality. Ultrasound, an important tool to detect congenital anomalies and manage maternity-related risk factors, is not properly used in Nepal because Nepali doctors have limited opportunities for learning ultrasound techniques. Hence, we developed and implemented an ultrasound education program from 2016 to 2018. The objective of this study is to evaluate the education program using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework.

Methods
We conducted a mixed-method study to evaluate each component of RE-AIM. The team collected quantitative data from administrative records, tests, surveys, and an online follow-up survey. Qualitative data were collected from individual in-depth interviews at least a year after the program. The proportions, means, and t-tests were used for quantitative data, and thematic coding for qualitative data.

Results
A total of 228 healthcare workers representing 27.3% of the districts of Nepal were reached from 2016 to 2018. The program improved participants’ knowledge (29.3, 8.7, and 23.8 increases out of 100, each year, p< 0.001, n=85) and self-confidence (0.6, 0.3, 1.3 increases out of 4.0, p< 0.01, n=111). The participants were highly satisfied with the program (4.2, 4.1, and 4.0 out of 5.0, n=162). Among the respondents of the online follow-up survey (n=28), 60.7% had used ultrasound in their daily practice after the education program, and a medical institution established an ultrasound training center. The absence of clear accreditation and practical guidelines in ultrasound use were presented as barriers for adoption and maintenance.

Conclusion
The program was successful in improving participant’s knowledge and self-confidence in ultrasound techniques and showed great potential for the adoption and maintenance of the techniques in their practice. Continuous implementation of the program and institutional policy changes to facilitate ultrasound use may increase the ultrasound use and improve ultrasound service quality in Nepal.

Feasibility and integration of an intensive emergency pediatric care curriculum in Armenia

Background: Emergency pediatric care curriculum (EPCC) was developed to address the need for pediatric rapid assessment and resuscitation skills among out-of-hospital emergency providers in Armenia. This study was designed to evaluate the effectiveness of EPCC in increasing physicians’ knowledge when instruction transitioned to local
instructors. We hypothesize that (1) EPCC will have a positive impact on post-test knowledge, (2) this effect will be maintained when local trainers teach the course, and (3) curriculum will satisfy participants.

Methods: This is a quasi-experimental, pre-test/post-test study over a 4-year period from October 2014‑November 2017. Train-the-trainer model was used. Primary outcomes are immediate knowledge acquisition each year and comparison of knowledge acquisition between two cohorts based on North American vs local instructors.
Descriptive statistics was used to summarize results. Pre-post change and differences across years were analyzed using repeated measures mixed models.

Results: Test scores improved from pretest mean of 51% (95% CI 49.6 to 53.0%) to post-test mean of 78% (95% CI 77.0 to 79.6%, p < 0.001). Average increase from pre- to post-test each year was 27% (95% CI 25.3 to 28.7%). Improvement was sustained when local instructors taught the course (p = 0.74). There was no difference in improvement when experience in critical care, EMS, and other specialties were compared (p = 0.23). Participants reported satisfaction and wanted the course repeated. In 2017, EPCC was integrated within the Emergency Medicine residency program in Armenia. Discussion: This program was effective at impacting immediate knowledge as well as participant satisfaction and intentions to change practice. This knowledge acquisition and reported satisfaction remained constant even when the instruction was transitioned to the local instructors after 2 years. Through a partnership between the USA and Armenia, we provided OH-EPs in Armenia with an intensive educational experience to attain knowledge and skills necessary to manage acutely ill or injured children in the out-of-hospital setting. Conclusions: EPCC resulted in significant improvement in knowledge and was well received by participants. This is a viable and sustainable model to train providers who have otherwise not had formal education in this field