Cultural competency and ethical behavior for collaboration in limited-resource settings: Guidelines from the Society of University Surgeons Academic Global Surgery Committee and the Association for Academic Global Surgery.

BACKGROUND: There are an increasing number of global surgery activities worldwide. With such tremendous growth, there is a potential risk for untoward interactions between high-income country members and low-middle income country members, leading to programmatic failure, poor results, and/or low impact. METHODS: Key concepts for cultural competency and ethical behavior were generated by the Academic Global Surgery Committee of the Society for University Surgeons in collaboration with the Association for Academic Global Surgery. Both societies ensured active participation from high-income countries and low-middle income countries. RESULTS: The guidelines provide a framework for cultural competency and ethical behavior for high-income country members when collaborating with low-middle income country partners by offering recommendations for: (1) preparation for work with low-middle income countries; (2) process standardization; (3) working with the local community; (4) limits of practice; (5) patient autonomy and consent; (6) trainees; (7) potential pitfalls; and (8) gray areas. CONCLUSION: The article provides an actionable framework to address potential cultural competency and ethical behavior issues in high-income country - low-middle income country global surgery collaborations.

Evaluating Global Surgery Partnerships From Low and Middle Income Country Perspectives.

INTRODUCTION: Little is known about perceptions of low-income and middle-income country (LMIC) partners regarding global surgery collaborations with high-income countries (HICs). METHODS: A survey was distributed to surgeons from LMICs to assess the nature and perception of collaborations, funding, benefits, communication, and the effects of COVID-19 on partnerships. RESULTS: We received 19 responses from LMIC representatives in 12 countries on three continents. The majority (83%) had participated in collaborations within the past 5 y with 39% of collaborations were facilitated virtually. Clinical and educational partnerships (39% each) were ranked most important by respondents. Sustainability of the partnership was most successfully achieved in domains of education/training (78%) and research (61%). The majority (77%) of respondents reported expressing their needs before HIC team arrival. However, 54% of respondents were the ones to initiate the conversation and only 47% said HIC partners understood the overall environment well at arrival to LMIC. Almost all participants (95%) felt a formal process of collaboration and a structured partnership would benefit all parties in assessing needs. During the COVID-19 pandemic, 87% of participants reported continued collaborations; however, 44% of partners felt that relationships were weaker, 31% felt relationships were stronger, and 25% felt they were unchanged. CONCLUSIONS: Our study provides a snapshot of LMIC surgeons' perspectives on collaboration in global surgery. Independent of location, LMIC partners cite inadequate structure for long-term collaborations. We propose a formal pathway and initiation process to assess resources and needs at the outset of a partnership.

Academic global surgical competencies: A modified Delphi consensus study.

Academic global surgery is a rapidly growing field that aims to improve access to safe surgical care worldwide. However, no universally accepted competencies exist to inform this developing field. A consensus-based approach, with input from a diverse group of experts, is needed to identify essential competencies that will lead to standardization in this field. A task force was set up using snowball sampling to recruit a broad group of content and context experts in global surgical and perioperative care. A draft set of competencies was revised through the modified Delphi process with two rounds of anonymous input. A threshold of 80% consensus was used to determine whether a competency or sub-competency learning objective was relevant to the skillset needed within academic global surgery and perioperative care. A diverse task force recruited experts from 22 countries to participate in both rounds of the Delphi process. Of the n = 59 respondents completing both rounds of iterative polling, 63% were from low- or middle-income countries. After two rounds of anonymous feedback, participants reached consensus on nine core competencies and 31 sub-competency objectives. The greatest consensus pertained to competency in ethics and professionalism in global surgery (100%) with emphasis on justice, equity, and decolonization across multiple competencies. This Delphi process, with input from experts worldwide, identified nine competencies which can be used to develop standardized academic global surgery and perioperative care curricula worldwide. Further work needs to be done to validate these competencies and establish assessments to ensure that they are taught effectively.

The Impact of Global Collaboration on the Academic Focus of the West African College of Surgeons: Are Worldwide Efforts Aligning with Local Priorities?

BACKGROUND: Global collaboration has the potential to induce a shift in research focus away from the priorities of those in low- and low-middle-income countries (LICs and LMICs). This study quantified international collaboration among surgery publications by Fellows of the West African College of Surgeons (WACS) and investigated if collaboration with upper-middle-income and high-income countries (UMICs and HICs) decreases the homophily of research focus. METHODS: Publications by WACS surgery Fellows from 1960 to 2019 were characterized as local WACS publications, collaborative publications without UMIC/HIC participation, or collaborative publications with UMIC/HIC participation. Research topics were determined for each publication, and topic percentages were compared between collaboration groups. RESULTS: We analyzed 5065 publications. Most (3690 publications, 73%) were local WACS publications, while 742 (15%) were collaborative publications with UMIC/HIC participation and 633 (12%) were collaborative publications without UMIC/HIC participation. UMIC/HIC collaborations contributed to 49% of the increase (378 out of 766 publications) from 2000 to 2019. Topic homophily was significantly lower between local WACS publications and collaborations with UMIC/HIC participation (differed in nine research topics) than it was between local WACS publications and collaborations without UMIC/HIC participation (differed in two research topics). CONCLUSIONS: Publications without international collaboration comprise most WACS research, but the rate of UMIC/HIC collaborations is rapidly increasing. We found that UMIC/HIC collaborations decreased the homophily of topic focus in WACS publications, indicating that global collaborations need to have greater emphasis on the priorities of those in LICs and LMICs.

The First Two Years of the Association of Pediatric Surgery Training Program Directors (APSTPD) Transition to Fellowship Course: Lessons Learned and Future Directions.

OBJECTIVE: The first transition to fellowship course for incoming pediatric surgery fellows was held in the US in 2018 and the second in 2019. The course aimed to facilitate a successful transition in to fellowship by introduction of the professional, patient care, and technical aspects unique to pediatric surgery training. The purpose of this study was to evaluate the feasibility and effectiveness of the first two years of this course in the US and discuss subsequent evolution of this endeavor. DESIGN: This is a descriptive and qualitative analysis of two years' experience with the Association of Pediatric Surgery Training Program Directors' (APSTPD) Transition to Fellowship course. Course development and curriculum, including clinical knowledge, soft skills, and hands-on skills labs, are presented. Participating incoming fellows completed multiple choice, boards-style pre- and post-tests. Scores were compared to determine if knowledge was effectively transferred. Participants also completed post-course evaluations and subsequent 3- or 12-month surveys inquiring on the lasting impact of the course on their transition into fellowship. Standard univariate statistics were used to present results. SETTING: The first APSTPD Transition to Fellowship course was held at the Johns Hopkins Hospital in Baltimore, Maryland in 2018, and the second course was held at the Oregon Health and Science University in Portland, Oregon in 2019. PARTICIPANTS: All fellows entering ACGME-certified Pediatric Surgery fellowships in the United States were invited to participate. Twenty fellows accepted and attended in 2018, and fourteen fellows participated in 2019. RESULTS: There were 34 incoming pediatric surgery fellow participants over 2 years. Faculty represented more than 10 institutions each year. Pre- and post-test scores were similar between years, with a significant improvement of scores after completion of the course (67±10% vs 79±8%, p < 0.001). Feedback from participants was overwhelmingly positive, with skills labs being attendees' favorite component. When asked about usefulness of individual course sessions, more attendees found clinical sessions more useful than soft skills (93% vs 73%, p = 0.011). Almost all (90%) of participants reported the course met its stated purpose and would recommend the course to future fellows. This was further reflected on 3 and 12 month follow up surveys wherein 85% stated they found the course helpful during the first few months of fellowship and 90% would still recommend it. CONCLUSIONS: A transition to fellowship course in the US for incoming pediatric surgery fellows is logistically feasible, effective in transfer of knowledge, and highly regarded among attendees. Feedback from each course has been used to improve the subsequent courses, ensuring that it remains a valuable addition to pediatric surgical training in the US.

Virtual curriculum delivery in the COVID-19 era: the pediatric surgery boot camp v2.0.

PURPOSE: We evaluated the impact of a virtual Pediatric Surgery Bootcamp curriculum on resource utilization, learner engagement, knowledge retention, and stakeholder satisfaction. METHODS: A virtual curriculum was developed around Pediatric Surgery Milestones. GlobalCastMD delivered pre-recorded and live content over a single 10-h day with a concluding social hour. Metrics of learner engagement, faculty interaction, knowledge retention, and satisfaction were collected and analyzed during and after the course. RESULTS: Of 56 PS residencies, 31 registered (55.4%; 8/8 Canadian and 23/48 US; p = 0.006), including 42 learners overall. The virtual BC budget was $15,500 (USD), 54% of the anticipated in-person course. Pre- and post-tests were administered, revealing significant knowledge improvement (48.6% [286/589] vs 66.9% [89/133] p < 0.0002). Learner surveys (n = 14) suggested the virtual BC facilitated fellowship transition (85%) and strengthened peer-group camaraderie (69%), but in-person events were still favored (77%). Program Directors (PD) were surveyed, and respondents (n = 22) also favored in-person events (61%). PDs not registering their learners (n = 7) perceived insufficient value-added and concern for excessive participants. CONCLUSIONS: The virtual bootcamp format reduced overall expenses, interfered less with schedules, achieved more inclusive reach, and facilitated content archiving. Despite these advantages, learners and program directors still favored in-person education. LEVEL OF EVIDENCE: III.

Surgeons, Infectious Diseases, and Twitter Hit a Home Run for Antibiotic Stewardship.

Many infectious diseases (ID) clinicians join Twitter to follow other ID colleagues or "like" people. While there is great value in engaging with people who have similar interests, there is equal value in engaging with "unlike" or non-ID people. Here, we describe how Twitter connected an ID pharmacist with a pediatric surgeon, a vice chair of surgery, a surgeon chief medical officer from Spain, and a surgical intensive care unit pharmacist. This Twitter collaboration resulted in several scholarly activities related to antibiotic resistance and antibiotic stewardship and served as a conduit for global collaboration.

Diagnosis and management of intestinal rotational abnormalities with or without volvulus in the pediatric population.

Intestinal malrotation is a congenital anomaly that can be associated with midgut volvulus, requiring an emergent operation in order to maintain blood supply to the compromised intestine. It results from an abnormal rotation of the intestines, leading to three types of malrotation. Non-rotation is complete failure of the intestines to rotate, while the most common configuration is associated with the cecum in the mid-upper abdomen, close to a malpositioned duodenal-jejunal (DJ) flexure. This configuration has a narrow mesentery that has a high risk of volvulus. The final form of malrotation is incomplete rotation, where the DJ flexure and cecum are malpositioned, but the mesentery is not narrowed. The benefits of performing a Ladd's procedure for these individuals is controversial. Workup for malrotation should be considered in all patients who present with abdominal pain/distention and bilious emesis. An upper gastrointestinal contrast study is 93-100% sensitive and will show a corkscrew appearance when a volvulus is present. While the basic tenets of the Ladd's procedure have not changed and include detorsion of a volvulus, adhesiolysis of Ladd's bands and broadening of the mesentery, how this is accomplished and in whom are controversial. Laparoscopic Ladd's is associated with shorter hospital stays but also has a higher incidence of recurrent volvulus compared to an open approach. Patients with heterotaxy syndrome also represent a controversial group with some studies showing no difference in post-operative complications despite a higher mortality due to underlying cardiac disease, while other studies show a low incidence of volvulus and question the need for Ladd's in those who are asymptomatic. This review highlights the major aspects of diagnosing and treating malrotation, including the pathophysiology, workup, surgical options and areas of controversy.

Congenital duodenal obstruction - Advances in diagnosis, surgical management, and associated controversies.

Congenital duodenal obstruction (CDO) occurs due to intrinsic and extrinsic mechanisms but is most often caused by intrinsic duodenal atresia and stenosis. This review will summarize the history, epidemiology, and etiologies associated with the most common causes of CDO. The clinical presentation, complex diagnostic considerations, and current surgical repair options for duodenal atresia and stenosis will also be discussed. Finally, both historical and recent controversies which continue to affect the surgical decision-making in the management of these patients will be highlighted.

Inclusion and representation in the pediatric surgery workforce: Strategies to mitigate bias in the fellowship application process.

Diverse perspectives are critical components of effective teams in every industry. Underrepresentation of minorities in medicine leads to worse outcomes for minority patients, and efforts to increase diversity in the health care workforce are critical. Presently, about 70% of the pediatric surgery workforce is white, and pediatric surgeons at large do not reflect the racial or ethnic diversity of the populations they serve. Pediatric surgery fellowship training programs are the gateway to the field, and fellow selection processes should be optimized to support diversity and inclusion. The Association of Pediatric Surgery Training Program Directors (APSTPD) Diversity Equity and Inclusion subcommittee compiled best practices for bias mitigation during fellow selection, drawing from published literature and personal experiences in our own programs. A list of concrete recommendations was compiled, which can be implemented in every phase from applicant screening to rank list creation. We present these as a position statement that has been endorsed by the executive committee of the APSTPD. Pediatric surgery fellowship programs can utilize this focused review of best practices to mitigate bias and support diverse applicants.

Success in pediatric surgery: An updated survey of Program Directors 2020.

BACKGROUND: One of the most competitive surgical sub-specialty fellowships remains Pediatric Surgery (PS), which requires candidates to develop a strong and research-oriented curriculum vitae. Although some objective factors of matriculation are known, factors for the interview selection and ranking per the program directors (PDs) have not been reviewed in over a decade. METHODS: A web-based survey of US and Canadian PS program directors (PDs) (n = 58) was used to evaluate a comprehensive list of factors in the selection criteria for PS fellowships. A mix of dichotomous, ranking, five-point Likert scale, and open-ended questions evaluated applicant characteristics, ABSITE scores, research productivity, interview day, and rank order criteria. RESULTS: Fifty-five programs responded to the survey for a 95% participation rate. PDs desired an average of two years in dedicated research and weighted first authorship and total number of publications heavily. Only 38% of programs used an ABSITE score cutoff for offering interviews; however, the majority agreed that an overall upward trend was important. Quality letters of recommendation, especially from known colleagues, carried weight when deciding to offer interviews. Interview performance, being a team player, observed interpersonal interactions, perceived operative skills and patient care, and leadership were some of the notable factors when finalizing rank lists. CONCLUSIONS: A multitude of factors define a successful matriculant, including quality of letters of recommendation, quality and quantity of publications, supportive phone calls, observed interactions, interview performance, perceptions of being team player with leadership skills as well as perceptions of good operative skills and patient care. LEVEL OF EVIDENCE: Type II. TYPE OF STUDY: Prognostic (retrospective).

Is the changing landscape of fellowship recruitment during COVID-19 here to stay?

BACKGROUND: The 2020 Pediatric Surgery (PS) fellowship selection process was heavily impacted by the COVID-19 pandemic. A review of lessons learned can help determine best practices for the future. The purpose of the study was to analyze the virtual interview experience and assess opportunities to improve the post-pandemic fellowship recruitment process. STUDY DESIGN: Using a 28-question survey of Program Directors (PDs) of PS fellowships as well as a 44-question survey of applicants to PS fellowships in the US and Canada, we gathered information on the recruitment process during the COVID-19 pandemic (2020). Dichotomous, multiple choice and open-ended questions about the changes in process, platforms used, format, comparison to on-site interviews and overall satisfaction were used for objective and subjective feedback. RESULTS: A 95% participation rate was recorded for the PD survey. 24 out of 55 programs (44%) changed their on-site interviews to virtual format due to the pandemic. Most PDs described their overall impression of virtual interviews as satisfactory (66%, 16/24) and did not have an impact on the applicant's success in the match (35/54; 65%). About 50% of PDs preferred to have on-site interviews with virtual screening in the future. While the participation rate from applicants was much less (26 of 70), responses confirmed our survey results. Majority preferred on-site interviews (17/26), 6 of which preferred virtual screening followed by on-site interviews. CONCLUSION: Components of virtual screening and interviews were found to have benefits financially and from both time and stress perspectives, and thus might survive past the pandemic. LEVELS OF EVIDENCE LEVEL IV: .

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.

Surgical subspecialists in West Africa: Workforce size, training opportunities, and contributing factors.

BACKGROUND: The global burden of disease treatable by surgical subspecialists remains an outstanding area of need, and yet little is known about the subspecialist workforce worldwide, especially in sub-Saharan Africa. This study aims to quantify the subspecialty surgical workforce and number of subspecialty training programs in West Africa and to identify socioeconomic factors predicting the number of subspecialists in West African countries. METHODS: West African subspecialists and accredited fellowship training programs in 17 West African countries were quantified using membership data from the West African College of Surgeons and compared with publicly available workforce data from the United States, the United Kingdom, and East, Central, and Southern Africa. Spearman's coefficients were calculated to identify socioeconomic predictors of subspecialist surgical workforce. RESULTS: Of 2,181 surgeons, 712 (32.6%) were surgical subspecialists. Three (18%) of 17 West African countries had greater than 11 subspecialists. There were 174 subspecialty training programs in the region, though 13 countries (76%) had no programs. The number of subspecialists correlated most strongly with the number of subspecialty training programs (rS = 0.68, P = .003) but also correlated significantly with gross population and number of medical schools (rS = 0.50-0.52, P ≤ .05). CONCLUSION: Subspecialist surgeons represent one third of surgeons in West Africa, though most countries have fewer than 12 providers. The number of subspecialists is significantly correlated with the number of subspecialty training programs, and yet many West African countries lack accredited programs. These results suggest that investing in training programs is the most valuable potential strategy to address the shortage of surgical subspecialists in West Africa.

Analysis of the pediatric surgery fellowship application process using the Thalamus™ database.

BACKGROUND: The pediatric surgery fellowship interview process is costly and time intensive. We hypothesized that the increasing number of interviews completed by applicants and programs have become inefficient over time. METHODS: We analyzed pediatric surgery fellowship program and applicant interview data between 2018 and 2020. Cancellations, program fill time, regional analysis of programs and applicants, and program rank list data were also captured. Analyses were performed using descriptive statistics and Chi-Square analysis. RESULTS: Our dataset included 34, 41, and 45 programs, which represented 81%, 91%, and 97% of all programs in 2018, 2019, and 2020, respectively. The median number of interviews completed per program remained constant, while the median number of interviews per applicant increased from 9.0 in 2018 to 13.0 in 2020. For 75% of programs, a program required only 4 or less candidates to fill their position. On average, 96% of program interviews do not result in a matched candidate. CONCLUSIONS: Programs offer interviews out of proportion to the number of positions available, and most applicants attend all interviews offered. We recommend an initial program goal of 20 interviews, which may be achieved by increased use of virtual interviews and the creation of program-level data on ideal applicant profiles.

Global Surgery Pro-Con Debate: A Pathway to Bilateral Academic Success or the Bold New Face of Colonialism?

Global surgery, especially academic global surgery, is of tremendous interest to many surgeons. Classically, it entails personnel from high-income countries going to low- and middle-income countries and engaging in educational activities as well as procedures. Academic medical personnel have included students, residents, and attendings. The pervasive notion is that this is a win-win situation for the volunteers and the hosts, that is, a pathway to bilateral academic success. However, a critical examination demonstrates that it can easily become the bold new face of colonialism of a low- and middle-income country by a high-income country.

Acute histologic inflammatory activity and postoperative outcomes in pediatric patients with ulcerative colitis.

BACKGROUND: The aim of this study was to determine whether acute histologic inflammatory activity at the rectal margin predicts postoperative complications in children with ulcerative colitis following ileal pouch-anal anastomoses (IPAA). METHODS: Patients who underwent IPAA following previous total abdominal colectomy for ulcerative colitis between 2006 and 2014 were included. Data collected included demographics, operative and postoperative data, histologic grading of the rectal margin at time of IPAA, and stooling outcomes at one, six and 12 months following ileostomy closure. RESULTS: Twenty-seven patients were included. Acute inflammation scores ranged between 2 and 13. Unadjusted and adjusted models showed no statistically significant relationship between inflammation and presence of any postoperative complications, number of daily stools, nighttime stooling, soiling, or stool-altering medication usage. CONCLUSION: Acute histologic inflammatory activity at the rectal margin is not associated with increased rates of postoperative complications following IPAA creation in children, nor with poorer continence outcomes following ileostomy closure.

The pediatric surgery match by the numbers: Defining the successful application.

BACKGROUND: Pediatric surgery remains the most competitive general surgery subspecialty. The authors suspected significant inflation in academic metrics since the last published paper. This study aimed to identify factors associated with applicant success in the match. METHODS: After IRB approval, all applications to a single accredited pediatric surgery fellowship program were reviewed for match years 2014-2018. Matched and unmatched applicants were compared in an unadjusted and adjusted analysis. RESULTS: This training program received 414 of 425 total applications (97%). Match results were available for 388 (94%). Matched applicants were more likely to train in programs with pediatric surgery fellowships (64% vs. 28%) and to have dedicated research time (55% vs. 21%; all p < 0.01). Matched applicants had more total publications (median: 12 vs. 7, p < 0.01) and higher ABSITE scores (median: 64th vs. 59th percentile, p < 0.01). Training in multiple programs negatively impacted the chance to match (p < 0.01). The median number of publications per applicant increased over the study time period from 7 to 11 (p < 0.01). CONCLUSIONS: The likelihood of matching into a pediatric surgery fellowship was related to the type of residency attended, dedicated research time, ABSITE scores, and number of publications. Overall, the total number of publications reported by all applicants increased. TYPE OF STUDY: Retrospective Comparative Study. LEVEL OF EVIDENCE: Level III.

Ethics in Global Pediatric Surgery: Existing Dilemmas and Emerging Challenges.

The rapid growth of global pediatric surgery beyond direct care delivery into research, education, and advocacy necessitates re-evaluation of the traditional ethical paradigms which have governed our partnerships in low- and middle-income countries (LMIC). Within this paper, we consider current and emerging ethical challenges and discuss principles to consider in order to promote autonomous systems for pediatric surgical care in LMIC.