The landscape of academic global surgery: a rapid review

Introduction

After the 2015 publication of the Lancet Commission on Global Surgery, universal access to surgical care emerged as a global priority. In low- and middle-income countries (LMICs), 9 out of 10 individuals lack access to safe and affordable surgical care (1). The Lancet Commission on Global Surgery’s follow-up report calls for a larger academic priority for global surgery while emphasizing the need for training programs for future surgeons, obstetricians, and anesthesiologists in LMIC (2).

A large portion of global surgery work involves clinical and educational activities by volunteer medical missions, non-governmental organizations (NGOs), and short-term medical trips. The role of academic institutions, however, has not been documented as much (3). Although academic institutions’ role in global surgery has been restricted: consisting of short-term volunteerism during surgeons’ spare time, it is noted that academic surgical culture, innovation, teaching, and service can significantly contribute to unmet needs in global surgery (4). Moreover, academic institutions can bring global partnerships together and offer surgical training to ensure reliable and consistent delivery of care.

Notably, the demand for surgical residency education in HICs has increased. For instance, approximately 87% (n=61) of residents in a surgery department at Yale’s New Haven Hospital responded that they were interested in pursuing international surgery activities (5). In addition, 76% of residents plan to incorporate global surgery into their future careers, according to a survey of 74 residents in the United States (6). However, studies on academic global surgery programs (AGSPs) have been limited. Thus, this rapid review aimed to provide a current landscape of the available evidence of AGSPs by categorizing and summarizing the evidence. This study will also shed light on future directions and opportunities for AGSPs.

Methods

A rapid review is a form of systematic review that is streamlined and accelerated, to fast-track knowledge synthesis (1). We conducted this rapid review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis checklist (2) (Supplementary).

Eligibility criteria

Academic global surgery (AGS) has been defined as “the exchange of clinical, teaching, or research resources between two academic institutions” (7). Based on this definition, we focused on collaboration and bilateral education between HICs and LMIC institutions in which official training programs served the surgical needs of the international community.

We conducted database searches on PubMed (Medline) using the search terms “global surgery” and “academic programs”, without a specific period to include all the searchable articles. This database was selected following discussion with experts in the field, and a preliminary search. We included articles that were: (I) published in English, (II) published in a peer-reviewed journal, and (III) published in an original article form. Of the articles meeting the inclusion criteria, we excluded studies that were not related to AGSPs and/or targeted the wrong population.

Study selection

A total of 390 articles were obtained from the PubMed search. Electronic search results were downloaded and uploaded to the Rayyan system (http://rayyan.qcri.org/), a free web-enabled application for health care professionals to conduct systematic reviews (3). First, we excluded seven articles as duplicates. Then, two reviewers (JY and ML) independently screened all identified articles (n=383) based on the inclusion and exclusion criteria. Of those articles, 324 were excluded based on the eligibility criteria. The remaining 59 texts were then examined in detail, and 29 were excluded because they were not original research articles. Of the 30 remaining articles, eight were excluded because they did not include AGSPs. A report on an invitational education program that focused on training HIC students was excluded. Finally, another article was excluded because it was published in a language other than English, leaving 20 articles for the final analysis (Figure 1). Any disagreement between the two reviewers during the screening process was discussed until a consensus was reached. Other reviewers (SC, JH) also joined the discussion to resolve any disagreements.

Figure 1 Flow chart of the literature search and screening process.

Data extraction and data synthesis

The following characteristics were extracted from the 20 studies (also presented in Table 1): author(s), year of publication, study location, study sample, study objectives, and outcome measures. Considering our study aim and the heterogeneity of study designs, measures, and settings, we synthesized the studies descriptively, as opposed to performing a formal meta-analysis.

Table 1 Data extracted from studies included in this review (n=20)
Full table

First, we categorized the eight studies that examined the needs of the AGSPs. This was achieved by studying participants or stakeholders’ perceptions of AGSPs, according to the study population and the assessment results. The study population was divided according to professional titles (residents, faculty, and program directors). We focused on measures of interest, perceived benefits, and the needs of AGSPs. All the identified study results were descriptively summarized. Next, we extracted the following elements from the nine studies on AGSPs implementation: program type, program length, specialty (other than general surgery), funding, program delivery, program provider, program location, number of accumulated program participants, participant criteria, and program years. If programs were published more than once (12,18), they were grouped together in the table. However, if programs adopted different program delivery methods or different countries, studies were separated. Program type was categorized according to different types of training sessions, which were indicated as official training sessions in the curriculum. Program delivery was also categorized according to different education delivery methods.

Notably, six of the nine studies not only described their own program delivery experiences, they also furnished evaluations of their programs. The following key characteristics of AGSPs evaluations were extracted: program name, sample size, evaluation method, and evaluation results.

Results

Characteristics of the selected studies

Table 1 illustrates the characteristics of the 20 studies included in the review. The selected studies were published in the last ten years, between 2008 and 2018. Among them, 15 studies (15/20, 75%) were completed in HICs, including the United States and Canada (5,6,8-12,14-17,22-25), while five were conducted in other LMICs, including Ethiopia, Tanzania, Uganda, and Ghana (13,18-21). Of the 20 selected studies, eight explored the need for AGSPs by investigating faculty and student perceptions of AGSPs (5,6,9,14,19,20,22,24). Nine studies examined the delivery of AGSPs (8,11,12,15,16,21,25), and three surveyed residencies with global health training programs (10,17,23). Studies also reached diverse groups, including HIC trainees (8/20, 40%) (5,6,8,9,11,12,15,16), LMIC trainees (5/20, 25%) (13,18-21), HIC faculty (3/20, 15%) (5,12,15), LMIC faculty (1/20, 5%) (18) and program directors (2/20, 10%) (14,24). Most were cross-sectional studies (19/20, 95%) (5,6,8-19,21-25); they included a variety of data sources, like surveys (15/19, 100%) (5,6,8-12,14-16,18,19,21,23,24), qualitative data (2/19, 10.5%) (9,12), and case studies (3/19, 5.2%) (17,22,25). Two mixed-method study designs are also featured in the selected literature (2/20, 10%) (11,12). Other study methods are longitudinal studies, including a pre- and post-survey (1/20, 5%) (13) and one initial and follow-up survey (1/20, 5%) (18).

Perceptions of AGSPs

Assessing interests in AGSPs

Of eight articles focusing on perceptions toward AGSPs, three articles revealed a strong interest in AGSPs among HIC residents who had previously engaged in global health activities (Table 2). Studies generally asked the residents on interests in international electives and post-residency plans for global surgery, and a majority responded positively. Furthermore, Johnston et al. noted that 93% (n=27) of residents expressed interest in commitment to global surgery after residency, and of those residents, 65% preferred international electives during their training (6). Two articles assessed residents without prior global health activities, and the level of interest was high. However, Cheung et al. indicated that many residents were uncertain about how to integrate global surgery into their careers (5). One study measured the HIC faculty’s interest in involvement with AGSPs. Cheung and the research team assessed the interest of HIC faculty from all surgical departments and discovered that a majority (86%, n=29) expressed interest in AGSPs (5). Three studies identified the surgical program directors’ interest in AGSPs. The program directors showed a strong interest in the academic international programs, went on further by showing interest in how the authorization groups would recognize the rotation. They were interested in developing an international health track, which would be two years of the global health course. The majority of program directors showed interest in participating in designing databases to facilitate the standardization of international electives and educational exchange (24).

Table 2 Perceptions of residents, faculty, and program directors toward global surgery program (n=8)
Full table

Perceived benefits of the AGSPs

Four studies reviewed the perceived benefits of global surgery activities in academic medical institutions. All studies mentioned that implementing an international elective as part of the curriculum is essential because these activities improve the clinical skills of the local surgical team. Moreover, Grigorian et al. and Cadotte et al. pointed out that local hospitals took advantage of mentorship, balanced ratio with respect to residents and faculty, and developed data collection, monitoring, and evaluation skills (20,22). Discussing the benefits of the AGSPs, Rickard et al. asserted that, by working across cultures, participants might be more adaptable, cost sensitive, and have a greater impact on their home institutions (9).

Perceived barriers

A number of studies have reported the perceived need for assistance with AGSPs. There is some evidence that HIC surgical residents felt a lack of funding sources and information for formal international electives. It is also noteworthy that HIC faculty expressed the need for protected time, promotion credit, and different compensation plans for those engaging in AGS. Medoff et al. and Mitchell et al. discovered that credentialing and credit for training experience is important as well as an organized structure through which to share the training experience (14,24).

Implementation of AGSPs

Program characteristics: types, length, specialties, and funding

First, three different program types were identified: clinical training, research training, and cultural training (Table 3). All eight reviewed programs included clinical training (100%), while four also included research training (50%), and only one explicitly included cultural training for cultural preparation (12.5%). Only one program studied by LeCompte et al. included all three training sessions (8).

Table 3 Characteristics of Academic Global Surgery Program (AGSP) delivery (n=9)
Full table

Meanwhile, reported program lengths ranged from two weeks to one year. Five out of eight (62.5%), except the one without information, provided a 4-week program. A program studied by Ozgediz et al. was the only program that delivered a program for more than a month (12.5%) (25). Information regarding the specialty other than general surgery has rarely been reported. Only two programs marked specialty surgical education, in anesthesia (13) and obstetrics and gynecology (OBGY) (21), respectively. Regarding funding, most programs were financially supported by HIC provider institutions.

Program delivery

Programs were delivered in two different ways. Seven programs (87.5%) were delivered by sending HIC residents or faculty members to LMIC settings (HIC-LMIC). In contrast, only one program (12.5%) adopted a bilateral method, which means that there was an exchange of residents between HIC and LMIC (21). It was found that sending HIC residents to LMIC settings (HIC-LMIC) usually takes a form of elective residency rotation in the university, and most of the participants require eligibility criteria such as a PGY of 3 or higher. Meanwhile, one program sent both residents and faculty members (7,24), while 5 programs sent residents only (8,11,15,16,25) and one program sent the faculty only (13).

Program locations

Notably, all of the programs were initiated by academic institutions in the US or an alliance of those institutions. At the same time, there was heterogeneity in the locations of each program including not the only US but Kenya (8), Dominican Republic (11), Ecuador (11), Ethiopia (11), Nicaragua (11), Tanzania (12,18), Uganda (15,25), Malawi (16), and Ghana (21). Among these different locations, six were African countries, and the other three were Caribbean, South American, and Central American countries. Unlike others, a program provided by Gundersen Health System, University of Wisconsin College of Medicine (11), took a one-to-many approach. It was conducted in four different countries, accounting for two-thirds of all identified program locations. Meanwhile, only one program that accepted LMIC residents as a part of bilateral exchange had been partly conducted in the US (21).

AGSPs evaluations

Six studies evaluated AGSPs, and we identified the strength and limitations of AGSPs by analyzing the evaluation results. Details of the assessment for each study are provided in Table 4.

Table 4 Evaluations of delivered Academic Global Surgery Program (AGSP) (n=6)
Full table

Strengths of AGSPs

The findings were almost all positive, reporting qualitative changes in knowledge and patterns of thought. The AGSPs with the host institution made both HIC and LMIC residents more confident in their learning (11-13,18), brought evidence-based medicine, and maturing clinical rotations due to the complexity of the cases. Residents valued experiencing global surgery by participating in the rotation, and the majority of participants described that their participation in the program positively changed their attitude and perception towards a future career in global surgery (12,21). Some HIC participants felt that the program improved their teaching skills and helped them establish a close relationship with their colleagues at the host institution (8).

Limitations of AGSPs

One of the limitations of AGSPs is the communication barrier due to language differences. In addition, a study revealed that the HIC residents faced emotional challenges from dealing with preventable death and disability due to resource constraints, poor clinical practice, and concerns about taking cases away from the host institution colleagues (12). Another limitation was that LMIC residents had less chance to experience hands-on training than did residents in the US (21). Furthermore, a study indicated that the LMIC residents changed their attitudes toward their future careers; most LMIC residents felt more inclined to pursue careers outside their home country than before the rotation, which contradicted the aim of the exchange program (ibid).

Recommendations by current AGSPs

Table 4 also outlines recommendations from the AGSPs that are worth noting. These recommendations include securing funding, pursuing collaborative curriculum development, adding accreditation, including a pre-elective program, and offering academic incentives. The most commonly reported recommendations in all studies were securing funding. Five studies (83.3%) reported that financial support is necessary to create a sustainable AGSPs (8,11,12,18,21). Three studies (50%) insisted that home institutions ought to work collaboratively with the host institution on curriculum development, including clinical teaching, patient care, and research (12,13,18). While collaboratively supporting the work for surgical residency course advancement, one study stressed that accrediting the AGSPs by a responsible body would alleviate barriers for residents’ participation in global surgery activities (25). Two studies (25%) stated that offering a standardized pre-elective program as a part of an AGSPs was helpful for residents to prepare for cultural differences, clinical skills, and anticipated safety issues (8,12). One study indicated that academic incentives should be provided to surgeons who use their vacation or personal time to participate in global surgery (8).

Discussion

Academic collaboration between HICs and LMICs is a potential avenue to address the global surgical need by enhancing knowledge in global surgery. In this rapid review, we identified 20 studies to systematically organize the needs described by participants and stakeholders of AGSPs, key program characteristics of AGSPs, and their evaluation results.

Overall, studies have shown that institutional interests in AGSPs remain high among surgical residents, faculty, and program directors. It must also be noted that many programs have been implemented in the past ten years and were still very much focused in a few countries. Most studied the implementation of general surgery courses, but a few of them were limited to those of surgical subspecialties. Various elements of AGSPs implementation were identified in this rapid review, including: funding, collaborative curriculum, accreditation, pre-elective programs, and academic incentives. Furthermore, the reviewed studies have shown that the participants in AGSPs among HIC residents improved their clinical practice and knowledge, research skills, and career aspirations. However, the reviewed studies do not capture the effects on LMIC surgical residents’ motivation and learning.

Critical components of AGSPs and bilateral academic collaborations

Cultural training

One of the critical components of AGSPs is related to cultural training. Academic medical institutions should plan to integrate pre-departure sessions focused on cultural awareness into the curriculum to help students prepare for language and cultural differences. Social relationships are one of the key factors that affect the effectiveness of the surgical skill transfers from HIC residents and faculty to LMIC trainees (26). However, in our study, we discovered that a few programs included cultural training to properly orient trainees to the local language, culture, and medical environment before arriving at the host institutions. Structured preparation can provide HIC residents and faculty with cultural specificities and expectations for their international experience, political, environmental, or health crises, and overall measures required while working clinically abroad.

Building trust and relationships

Another core component for fostering bilateral partnerships is building trust and relationships that drive local empowerment and shape equitable partnerships (27). The evaluation study of a ten-year team-based collaborative capacity-building program for pediatric cardiac surgery in Uzbekistan examined that a team-based approach, in which everyone holds equal responsibility for processes and outcomes of surgery, results in a trustworthy relationship (28). Nevertheless, in our study, only one program measures the development of long-term relationships and trust as the program’s outcomes. Therefore, the academic medical institutions should consider complementing the AGSPs with the team-based approach to promote self-sustainability for surgical care.

Using a theory of change (TOC) frameworks for AGSPs

Developing a TOC is the first prerequisite for constructing and implementing program models and assessing program effects (29). TOC can explicate how a program works and achieve the intended outcomes based on describing pathways of set preconditions (steps) that lead to the outcomes (30). For example, in the case of AGSPs, the TOC mapping process can identify preconditions necessary to achieve the long-term outcomes which can be to increase safe surgeries. One of the preconditions will be to build the capacity of LMIC surgeons using hands-on training. Likewise, the TOC can help to establish potential causal pathways between the AGSPs’ inputs and the expected outcomes and help identify effective interventions. However, TOCs were rarely described in the papers that we reviewed. We propose that future AGSP research should share the TOC and explicitly state the factors that cause the outcomes and why in the evaluation.

Increased LMIC participation in monitoring and evaluation and research

We suggest that the AGSPs must carefully review and continue evaluations of the bilateral education model by using the appropriate TOC. Our review showed that the AGSP’s delivery was considerably skewed in favor of the HIC residents. Skewed participation and data collection do not provide a complete picture of the entire AGS landscape. It may also jeopardize the sustainability of the programs (8). Considering that partnership building is a crucial factor in implementing AGSPs, securing trust and maintaining the interests of LMIC institutions in AGSPs is also important. For instance, the bilateral method that balances reciprocal advantages, by inviting more LMIC trainees to HICs, will allow both sides to gain exposure to both resource-limited to resource-abundant settings. Collecting appropriate data from the participants and stakeholders in LMICs will provide greater insight. Moreover, this balanced delivery will provide more opportunities for collaborative research, resulting in a synergistic and sustainable partnership between LMIC and HIC institutions (8). Hence, future bilateral methods for AGSPs should be extended: inviting LMIC trainees to HICs, and these programs must include rigorous monitoring and evaluation in both HIC and LMIC contexts. In addition, we recommend research training programs as a global surgery program bonds with a major partner in an LMIC. Building research capacity will stimulate locally relevant research and strengthen partnerships of both trainers and trainees from HIC and LMIC.

Developing the standardized metrics of outcomes

Our review found that most studies looked at initial outcomes (i.e., attitude toward global surgery training, evaluation of the training program), excluding the long-term impact of the program evaluations. We believe that having a thorough TOC will greatly help in developing metrics to monitor and evaluate the AGSPs with an increased focus on sustainability measures. Similarly, Rickard and the team mentioned that academic institutions fail to use standardized AGS metrics to measure social impact, equity, and access (9). The standardization process can also help measures to be quick and easy to administer across institutions. Accordingly, a collaborative effort is necessary to develop principles for establishing standardized metrics to evaluate both short-term and long-term outcomes of AGSPs across institutions and countries.

Study limitations

Our study may be limited by publication bias. This study did not include non-peer-reviewed articles, such as gray literature or program reports, and articles written in languages other than English. Additionally, the conclusions of this scoping review are limited to interventions that focused on HIC residents, as we did not find many AGSPs publications that focused on training LMIC students.

Conclusions

Our findings can serve as a foundation for further development of AGSPs in academic medical institutions. With interest in global surgery increasing among residents, faculty, and program directors, future research would be best served by producing reliable and contextually relevant data, and ultimately developing a robust global surgery educational program to increase access to safe and affordable surgical care.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editor (Dominique Vervoort) for the series “Global Surgery” published in Journal of Public Health and Emergency. The article has undergone external peer review.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/jphe-20-80). The series “Global Surgery” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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