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.

Global surgery, obstetric, and anaesthesia indicator definitions and reporting: An Utstein consensus report.

BACKGROUND: Indicators to evaluate progress towards timely access to safe surgical, anaesthesia, and obstetric (SAO) care were proposed in 2015 by the Lancet Commission on Global Surgery. These aimed to capture access to surgery, surgical workforce, surgical volume, perioperative mortality rate, and catastrophic and impoverishing financial consequences of surgery. Despite being rapidly taken up by practitioners, data points from which to derive the indicators were not defined, limiting comparability across time or settings. We convened global experts to evaluate and explicitly define-for the first time-the indicators to improve comparability and support achievement of 2030 goals to improve access to safe affordable surgical and anaesthesia care globally. METHODS AND FINDINGS: The Utstein process for developing and reporting guidelines through a consensus building process was followed. In-person discussions at a 2-day meeting were followed by an iterative process conducted by email and virtual group meetings until consensus was reached. The meeting was held between June 16 to 18, 2019; discussions continued until August 2020. Participants consisted of experts in surgery, anaesthesia, and obstetric care, data science, and health indicators from high-, middle-, and low-income countries. Considering each of the 6 indicators in turn, we refined overarching descriptions and agreed upon data points needed for construction of each indicator at current time (basic data points), and as each evolves over 2 to 5 (intermediate) and >5 year (full) time frames. We removed one of the original 6 indicators (one of 2 financial risk protection indicators was eliminated) and refined descriptions and defined data points required to construct the 5 remaining indicators: geospatial access, workforce, surgical volume, perioperative mortality, and catastrophic expenditure. A strength of the process was the number of people from global institutes and multilateral agencies involved in the collection and reporting of global health metrics; a limitation was the limited number of participants from low- or middle-income countries-who only made up 21% of the total attendees. CONCLUSIONS: To track global progress towards timely access to quality SAO care, these indicators-at the basic level-should be implemented universally as soon as possible. Intermediate and full indicator sets should be achieved by all countries over time. Meanwhile, these evolutions can assist in the short term in developing national surgical plans and collecting more detailed data for research studies.

Factors affecting job choice among physician anesthesia providers in Uganda: a survey of income composition, discrete choice experiment, and implications for the decision to work rurally.

BACKGROUND: One of the biggest barriers to accessing safe surgical and anesthetic care is lack of trained providers. Uganda has one of the largest deficits in anesthesia providers in the world, and though they are increasing in number, they remain concentrated in the capital city. Salary is an oft-cited barrier to rural job choice, yet the size and sources of anesthesia provider incomes are unclear, and so the potential income loss from taking a rural job is unknown. Additionally, while salary augmentation is a common policy proposal to increase rural job uptake, the relative importance of non-monetary job factors in job choice is also unknown. METHODS: A survey on income sources and magnitude, and a Discrete Choice Experiment examining the relative importance of monetary and non-monetary factors in job choice, was administered to 37 and 47 physician anesthesiologists in Uganda, between May-June 2019. RESULTS: No providers worked only at government jobs. Providers earned most of their total income from a non-government job (50% of income, 23% of working hours), but worked more hours at their government job (36% of income, and 44% of working hours). Providers felt the most important job attributes were the quality of the facility and scope of practice they could provide, and the presence of a colleague (33% and 32% overall relative importance). These were more important than salary and living conditions (14% and 12% importance). CONCLUSIONS: No providers accepted the salary from a government job alone, which was always augmented by other work. However, few providers worked only nongovernment jobs. Non-monetary incentives are powerful influencers of job preference, and may be leveraged as policy options to attract providers. Salary continues to be an important driver of job choice, and jobs with fewer income generating opportunities (e.g. private work in rural areas) are likely to need salary augmentation to attract providers.

Assessment of Anesthesia Capacity in Public Surgical Hospitals in Guatemala.

BACKGROUND: International standards for safe anesthetic care have been developed by the World Federation of Societies of Anaesthesiologists (WFSA) and the World Health Organization (WHO). Whether these standards are met is unknown in many nations, including Guatemala, a country with universal health coverage. We aimed to establish an overview of anesthesia care capacity in public surgical hospitals in Guatemala to help guide public sector health care development. METHODS: In partnership with the Guatemalan Ministry of Public Health and Social Assistance (MSPAS), a national survey of all public hospitals providing surgical care was conducted using the WFSA anesthesia facility assessment tool (AFAT) in 2018. Each facility was assessed for infrastructure, service delivery, workforce, medications, equipment, and monitoring practices. Descriptive statistics were calculated and presented. RESULTS: Of the 46 public hospitals in Guatemala in 2018, 36 (78%) were found to provide surgical care, including 20 district, 14 regional, and 2 national referral hospitals. We identified 573 full-time physician surgeons, anesthesiologists, and obstetricians (SAO) in the public sector, with an estimated SAO density of 3.3/100,000 population. There were 300 full-time anesthesia providers working at public hospitals. Physician anesthesiologists made up 47% of these providers, with an estimated physician anesthesiologist density of 0.8/100,000 population. Only 10% of district hospitals reported having an anesthesia provider continuously present intraoperatively during general or neuraxial anesthesia cases. No hospitals reported assessing pain in the immediate postoperative period. While the availability of some medications such as benzodiazepines and local anesthetics was robust (100% availability across all hospitals), not all hospitals had essential medications such as ketamine, epinephrine, or atropine. There were deficiencies in the availability of essential equipment and basic intraoperative monitors, such as end-tidal carbon dioxide detectors (17% availability across all hospitals). Postoperative care and access to resuscitative equipment, such as defibrillators, were also lacking. CONCLUSIONS: This first countrywide, MSPAS-led assessment of anesthesia capacity at public facilities in Guatemala revealed a lack of essential materials and personnel to provide safe anesthesia and surgery. Hospitals surveyed often did not have resources regardless of hospital size or level, which may suggest multiple factors preventing availability and use. Local and national policy initiatives are needed to address these deficiencies.

Design, implementation and long-term follow-up of a context specific trauma training course in Uganda: Lessons learned and future directions.

BACKGROUND: The Kampala Advanced Trauma Course (KATC) was developed in 2007 due to a locally identified need for an advanced trauma training curriculum for the resource-constrained setting. We describe the design, implementation and evaluation of the course. METHODS: The course has been delivered to over 1,000 interns rotating through surgery at Mulago National Referral Hospital. Participants from 2013 to 2016 were surveyed after completion of the course. RESULTS: The KATC was developed with local faculty and includes didactic and simulation modules. Over 50% of survey respondents reported feeling confident performing and teaching 7 of 11 course skills and felt the most relevant skill was airway management(30.2%). Participants felt least confident managing head trauma(26.4%). Lack of equipment(52.8%) was identified as the most common barrier to providing trauma care. CONCLUSIONS: Providers are confident with most skill sets after taking the KATC. Minimal dependence on instructors from high-income countries has kept the course sustainable and maximized local relevance.

Feasibility of Simulation-Based Medical Education in a Low-Income Country: Challenges and Solutions From a 3-year Pilot Program in Uganda.

STATEMENT: Simulation is relatively new in many low-income countries. We describe the challenges encountered, solutions deployed, and the costs incurred while establishing two simulation centers in Uganda. The challenges we experienced included equipment costs, difficulty in procurement, lack of context-appropriate curricula, unreliable power, limited local teaching capacity, and lack of coordination among user groups. Solutions we deployed included improvisation of equipment, customization of low-cost simulation software, creation of context-specific curricula, local administrative support, and creation of a simulation fellowship opportunity for local instructors. Total costs for simulation setups ranged from US $165 to $17,000. For centers in low-income countries trying to establish simulation programs, our experience suggests that careful selection of context-appropriate equipment and curricula, engagement with local and international collaborators, and early emphasis to increase local teaching capacity are essential. Further studies are needed to identify the most cost-effective levels of technological complexity for simulation in similar resource-constrained settings.

Pulmonary mechanics and gas exchange characteristics in uncommon etiologies of acute respiratory distress syndrome.

BACKGROUND: Common causes of acute respiratory distress syndrome (ARDS) include pneumonia, aspiration, non-pulmonary sepsis and trauma. Little is known about pulmonary mechanics and gas exchange in less-common etiologies of ARDS, which comprises 12-23% of cases. Our hospital's ARDS quality assurance database contained a substantial number of these cases. This descriptive study examines the pulmonary mechanics, and gas exchange characteristics of this diverse cohort of ARDS subjects. METHODS: Between March 2010 and April 2017 we identified 94 subjects with less common etiologies of ARDS who had dead space fraction (VD/VT) and respiratory system compliance (CRS) measured within 24 hours of ARDS onset; 86 of whom did not have sepsis as a co-diagnosis. There were 18 identifiable sources of ARDS. For descriptive purposes these were subsumed under 10 etiologic categories: pancreatitis (n=16), hemorrhagic shock/reperfusion injury (n=9), transfusion-associated acute lung injury (TRALI) (n=3), drug overdose (n=13), inhalation injury (n=10), idiopathic (n=10), neurogenic (n=8), pulmonary toxicity (n=3), hyper-immune response (n=4), hepatic failure (n=7), and 3 other cases: 2 cutaneous burns and one case of malaria. VD/VT was measured using the Enghoff-Bohr equation. Arterial blood gases were drawn simultaneously with mixed expired CO2 using volumetric capnography and standard pulmonary mechanics measurements. Data are expressed as median (IQR). Comparisons between groups used Kruskal-Wallis and Dunn's post-tests, Mann-Whitney tests or Fisher exact tests. RESULTS: The majority of less common ARDS were from indirect sources (79%) with 9% attributed to direct causes and 11% idiopathic. Because of the small sample sizes, there were no differences in pulmonary mechanics or gas exchange between subgroups classified as indirect, direct and idiopathic, or between subgroups sharing common lung injury mechanisms. Nevertheless, salient trends were apparent particularly in CRS and VD/VT. CRS was most severely reduced in the toxicity subgroup and least impaired in the idiopathic subgroup [18 (11 to 22), and 40 (30 to 43) mL/cmH2O respectively]. VD/VT was extraordinarily high in the hepatic failure subgroup and lowest in pancreatitis [0.78 (0.57 to 0.79) and 0.54 (0.47 to 0.65) respectively]. There was less distinction in oxygenation as median values for all subgroups met moderate ARDS criteria. For the entire cohort, only VD/VT was statistically different between non-survivors and survivors: 0.66 (0.57 to 0.78) vs. 0.59 (0.51 to 0.68), P=0.012. CONCLUSIONS: Within a diverse cohort having less common presentations of ARDS, there was apparent variability in the distribution of CRS, VD/VT compared to differences oxygenation dysfunction. Elevated pulmonary dead space still identified patients with higher mortality, as is the case with more common causes of ARDS.

Lung Injury Etiology and Other Factors Influencing the Relationship Between Dead-Space Fraction and Mortality in ARDS.

BACKGROUND: In ARDS, elevated pulmonary dead-space fraction (VD/VT) is a particularly strong indicator of mortality risk. Whether the magnitude of VD/VT is modified by the underlying etiology of ARDS and whether this influences the strength of its association with mortality remains unknown. We sought to elucidate the impact of ARDS etiology on VD/VT and also to determine whether ARDS severity, as classified by the Berlin definition, has correspondence with changes in VD/VT. METHODS: This single-center, retrospective, observational study (2010-2016) measured VD/VT in 685 subjects with ARDS as part of clinical management with lung-protective ventilation. Volumetric capnography was used to measure VD/VT with 99% of measurements occurring within 48 h of ARDS onset. Demographic information as well as illness severity scores and pulmonary mechanics data also were collected. Multivariate logistic regression modeling was done to assess the strength of association between VD/VT and mortality. RESULTS: VD/VT was elevated across etiologies, with aspiration and pneumonia having significantly higher VD/VT than non-pulmonary sepsis or trauma. Differences in the magnitude of VD/VT across etiologies did not necessarily correspond with mortality between etiologies. However, within each etiology grouping, VD/VT was significantly elevated in non-survivors versus survivors. The same results were found in both moderate and severe (but not mild) ARDS using the Berlin definition. In the final adjusted model, the strongest mortality risk was VD/VT, wherein the risk of death increased by 22% for every 0.05 increase in VD/VT. CONCLUSIONS: VD/VT magnitude varies by ARDS etiology, as does mortality. Only in mild ARDS does VD/VT fail to distinguish non-survivors from survivors. Nonetheless, VD/VT has the strongest association with mortality risk in those with ARDS.

Research in surgery and anesthesia: challenges for post-graduate trainees in Uganda.

BACKGROUND: Research is critical to the training and practice of surgery and anesthesia in all settings, regardless of available resources. Unfortunately, the output of surgical and perioperative research from Africa is low. Makerere University College of Health Sciences' (MakCHS) surgical and anesthesia trainees are required to conduct research, though few publish findings or go on to pursue careers that incorporate research. We believe that early career experiences with research may greatly influence physicians' future conduct and utilization of research. We therefore sought to analyze trainee experiences and perceptions of research to identify interventions that could increase production of high-quality, locally led, surgical disease research in our resource-constrained setting. METHODS: Following ethical approval, a descriptive, cross-sectional survey was conducted among anesthesia and surgery trainees using a pretested, self-administered questionnaire. Data were tabulated and frequency tables generated. RESULTS: Of the 43 eligible trainees, 33 (77%) responded. Ninety-four percent identify research as important to career development, and 85% intend to publish their dissertations. The research dissertation is considered a financial burden by 64%. Also, 49% reported that their departments place low value on their research, and few of the findings are utilized. Trainees report that lack of protected research time, difficulty in finding research topics, and inadequate mentorship are the main challenges to conducting research projects. DISCUSSION: Our anesthesia and surgery trainees spend considerable resources on research endeavors. Most have significant interest in incorporating research into their careers, and most intend to publish their work in peer-reviewed journals. Here we identify several challenges facing trainees including research project development, financing and mentorship. We hope to use these results to improve support in these areas for our trainees and those in other resource-limited areas.

Evaluating international global health collaborations: perspectives from surgery and anesthesia trainees in Uganda.

BACKGROUND: The number of international academic partnerships and global health programs is expanding rapidly worldwide. Although the benefits of such programs to visiting international partners have been well documented, the perceived impacts on host institutions in resource-limited settings have not been assessed adequately. We sought to describe the perspectives of postgraduate, Ugandan trainees toward international collaborations and to discuss how these perceptions can be used to increase the positive impact of international collaborations for the host institution. METHODS: We conducted a descriptive, cross-sectional survey among anesthesia and surgery trainees at Makerere College of Health Sciences (Kampala, Uganda) using a pretested, self-administered questionnaire. Data were summarized as means or medians where applicable; otherwise, descriptive statistical analyses were performed. RESULTS: Of 43 eligible trainees, 77% completed the questionnaire. The majority (75%) agreed that visiting groups improve their training, mostly through skills workshops and specialist camps. A substantial portion of trainees reported that international groups had a neutral or negative impact on patient care (40%). Only 15% agreed that research projects conducted by international groups are in priority areas for Uganda. Among those surveyed, 28% reported participation in these projects, but none has published as a coauthor. Nearly one-third of trainees (31%) reported discomfort with the ethics of some clinical decisions made by visiting faculty. CONCLUSION: The current perspective from the surgery and anesthesia trainees of Makerere College of Health Sciences demonstrates rich ground for leveraging international collaborations to improve training, primarily through skills workshops, specialist camps, and more visiting faculty involvement. This survey also identified potential challenges in collaborative research and ethical dilemmas that warrant further examination.

Surgery and anesthesia capacity-building in resource-poor settings: description of an ongoing academic partnership in Uganda.

BACKGROUND: Surgery and perioperative care have been neglected in the arena of global health despite evidence of cost-effectiveness and the growing, substantial burden of surgical conditions. Various approaches to address the surgical disease crisis have been reported. This article describes the strategy of Global Partners in Anesthesia and Surgery (GPAS), an academically based, capacity-building collaboration between North American and Ugandan teaching institutions. METHODS: The collaboration's projects shift away from the trainee exchange, equipment donation, and clinical service delivery models. Instead, it focuses on three locally identified objectives to improve surgical and perioperative care capacity in Uganda: workforce expansion, research, collaboration. RESULTS: Recruitment programs from 2007 to 2011 helped increase the number of surgery and anesthesia trainees at Mulago Hospital (Kampala, Uganda) from 20 to 40 and 2 to 19, respectively. All sponsored trainees successfully graduated and remained in the region. Postgraduate academic positions were created and filled to promote workforce retention. A local research agenda was developed, more than 15 collaborative, peer-reviewed papers have been published, and the first competitive research grant for a principal investigator in the Department of Surgery at Mulago was obtained. A local projects coordinator position and an annual conference were created and jointly funded by partnering international efforts to promote collaboration. CONCLUSIONS: Sub-Saharan Africa has profound unmet needs in surgery and perioperative care. This academically based model helped increase recruitment of trainees, expanded local research, and strengthened stakeholder collaboration in Uganda. Further analysis is underway to determine the impact on surgical disease burden and other important outcome measures.

Disparities in injury mortality between Uganda and the United States: comparative analysis of a neglected disease.

BACKGROUND: The burden of global injury-related deaths predominantly affects developing countries, which have little infrastructure to evaluate these disparities. We describe injury-related mortality patterns in Kampala, Uganda and compare them with data from the United States and San Francisco (SF), California. METHODS: We created a database in Kampala of deaths recorded by the City Mortuary, the Mulago Hospital Mortuary, and the Uganda Ministry of Health from July to December 2007. We analyzed the rate and odds ratios and compared them to data from the U.S. Centers for Disease Control and Prevention and the California Department of Public Health. RESULTS: In Kampala, 25% of all deaths were due to injuries (812/3303) versus 6% in SF and 7% in the United States. The odds of dying of injury in Kampala were 5.0 times higher than in SF and 4.2 times higher than in the United States. Age-standardized death rates indicate a 93% greater risk of dying from injury in Kampala than in SF. The mean age was lower in Kampala than in SF (29 vs. 44 years). The adult injury death rate (rate ratio, or RR) was higher in Kampala than in SF (2.3) or the United States (1.5). Head/neck injury was reported in 65% of injury deaths in Kampala compared to 34% in SF [odds ratio (OR) 3.7] and 28% in the US (OR 4.8). CONCLUSIONS: Urban injury-related mortality is significantly higher in Uganda than in the United States. Injury preferentially affects adults in the prime of their economically productive years. These findings serve as a call for stronger injury prevention and control policies in Uganda.

Current patterns of prehospital trauma care in Kampala, Uganda and the feasibility of a lay-first-responder training program.

BACKGROUND: Uganda currently has no organized prehospital emergency system. We sought to measure the current burden of injury seen by lay people in Kampala, Uganda and to determine the feasibility of a lay first-responder training program. METHODS: We conducted a cross-sectional survey of current prehospital care providers in Kampala: police officers, minibus taxi drivers, and Local Council officials, and collected data on types and frequencies of emergencies witnessed, barriers to aid provision, history of training, and current availability of first-aid supplies. A context-appropriate course on basic first-aid for trauma was designed and implemented. We measured changes in trainees' fund of knowledge before and after training. RESULTS: A total of 309 lay people participated in the study, and during the previous 6 months saw 18 traumatic emergencies each; 39% saw an injury-related death. The most common injury mechanisms were road crashes, assault, and burns. In these cases, 90% of trainees provided some aid, most commonly lifting (82%) or transport (76%). Fifty-two percent of trainees had previous first-aid training, 44% had some access to equipment, and 32% had ever purchased a first-aid kit. Before training, participants answered 45% of test questions correctly (mean %) and this increased to 86% after training (p < 0.0001). CONCLUSIONS: Lay people witness many emergencies and deaths in Kampala, Uganda and provide much needed care but are ill-prepared to do so. A context-appropriate prehospital trauma care course can be developed and improve lay people's knowledge of basic trauma care. The effectiveness of such a training program needs to be evaluated prospectively.

Surgical training and global health: initial results of a 5-year partnership with a surgical training program in a low-income country.

HYPOTHESIS: Surgical trainees in the United States have a growing interest in both clinical experiences and structured training opportunities in global health. Global health training and exposure can be integrated into a surgical residency program. DESIGN: The global health activities of surgical residents and faculty in 1 department were evaluated from January 1, 1998, to June 1, 2008, using a survey and personal interviews. RESULTS: From January 1, 1998, to December 31, 2002, 4 faculty members made more than 20 overseas volunteer medical expeditions, but only 1 resident participated in global health activities. In 2003, a relationship with a surgical training program in a developing country was established. Ten residents and 12 faculty members have made overseas trips during the last 5 years, and 1 international surgeon has visited the United States. During their research block, 4 residents completed 1- to 3-month clinical rotations and contributed to mentored research projects. Three residents completed a university-based Global Health Clinical Scholars Program, and 3 obtained master's degrees in public health. A joint conference in injury-trauma research was also conducted. A faculty member is based overseas with clinical and research responsibilities, and another is completing a master's degree in public health. CONCLUSIONS: Global health training and exposure for residents can be effectively integrated into an academic surgical residency program through relationships with training programs in low-income countries. Legitimate academic experiences improve the success of these programs. Reciprocity with collaborative partners must be ensured, and sustained commitment and funding remain a great challenge to such programs. The long-term effect on the development of global health careers is yet to be determined.