Training low-middle-income (LMIC) pediatric surgeons in a high-income country (HIC) program.

BACKGROUND: A popular paradigm to support surgical education for low- and middle-income countries (LMICs) is partnering with high-income country (HIC) surgeons. These relationships may, however, be asymmetric and fail to optimally address the most pressing curricular needs. We explored the effectiveness of our LMIC-HIC educational partnership. METHODS: Through a partnership between a HIC (Canada) and a LMIC (Uganda), three candidate surgeons were commissioned for a custom designed 1-year training experience at our HIC accredited pediatric surgical training centre as part of their overall formal education. The training curriculum was developed in collaboration with the LMIC pediatric surgeon and utilized competency-based medical education principles. A Likert and short-answer survey tool was administered to these trainees upon completion of their training. RESULTS: All prescribed milestones as well as specialty certification by examination of the College of Surgeons of East, Central and Southern Africa was achieved by participating fellows, each of whom have begun clinical practice, leadership and teaching roles in their home country. Although several obstacles were identified by fellows, all agreed that the experience boosted their clinical and teaching abilities, and was worth the effort. CONCLUSION: This endeavour in global pediatric surgical training represents a significant innovation in surgical education partnerships and would be reproducible across different surgical subspecialties and contexts. Such collaborative efforts represent a feasible upskilling opportunity towards addressing global surgical service capacity. LEVEL OF EVIDENCE: V.

Assessing the Social Determinants of Health and Adverse Childhood Experiences in Patients Attending a Children's Hospital Cleft Palate-Craniofacial Program.

This study aimed to describe the social determinants of health (SDoH) for patients receiving multidisciplinary team care in a Cleft Palate-Craniofacial program, develop responsive and consistent processes to include trauma-informed psychosocial histories, promote discussions about additional "non-medical" factors influencing health and surgical outcomes, and demonstrate that these activities are feasible in the context of multidisciplinary patient-provider interactions.Single-site, cross-sectional study using a questionnaire.Participants were recruited from a provincial quaternary care Cleft Palate-Craniofacial program at British Columbia Children's Hospital in Vancouver, BC, Canada.290 families completed the questionnaire.34% of families experience significant barriers to accessing primary health care, 51% struggle financially, and 11% scored four or more on the Adverse Childhood Experiences scale. Furthermore, 47% reported not having adequate social support in their lives, and 5% reported not feeling resilient at the time of the survey.Patients with cleft and craniofacial anomalies have complex needs that extend beyond the surgical and medical care they receive. It is critical that all Cleft and Craniofacial teams incorporate social histories into their clinic workflow and be responsive to these additional needs. Discussions surrounding SDoH and adversity are welcomed by families; being involved in the care and decision-making plans is highly valued. Healthcare providers can and should ask about SDoH and advocate for universal access to responsive, site-based, social work support for their patients.

Evaluation of Interventions Addressing Timely Access to Surgical Care in Low-Income and Low-Middle-Income Countries as Outlined by the LANCET Commission 2030 Global Surgery Goals: A Systematic Review.

BACKGROUND: In 2015, the Lancet Commission on Global Surgery published six global surgery goals, one of which was to provide 80% of the world's population with timely access to the Bellwether Surgical procedures. Little is known about the prevalence or efficacy of subsequent interventions implemented in under-resourced countries to increase timely access to Bellwether surgical procedures. METHODS: A systematic review of articles and grey literature published in MEDLINE, Embase, Cochrane, CINAHL, and Web of Science databases was conducted. Two independent reviewers evaluated 1923 captured abstracts using explicit inclusion and exclusion criteria. Following a thematic analysis, two reviewers conducted data extraction on the eleven manuscripts included in the final review. RESULTS: The studied innovations, sparse in number, centred on improved educational resources, the development of orthopaedic devices, and models for assessing surgical access disparity. Eight papers were centred around timely access to caesarean sections, three around open fracture reduction, and three around laparotomy; all focused on adult populations. Five papers addressed innovations in West Africa, two in East Africa, two in South Asia, and one in Southeast Asia. Common outcome metrics were not used to assess improvements to timely surgical access. CONCLUSIONS: Few published interventions have been implemented since the publication of the 2015 Lancet Commission on Global Surgery goals that have or will longitudinally increase the availability of timely surgical access in Low and Middle-Income Countries (LMIC). Tangible outcome measures in existing literature are lacking. An up-scaling and wider adoption of successful strategies is necessary and possible.

Unifying Children's Surgery and Anesthesia Stakeholders Across Institutions and Clinical Disciplines: Challenges and Solutions from Uganda.

BACKGROUND: There is a significant unmet need for children's surgical care in low- and middle-income countries (LMICs). Multidisciplinary collaboration is required to advance the surgical and anesthesia care of children's surgical conditions such as congenital conditions, cancer and injuries. Nonetheless, there are limited examples of this process from LMICs. We describe the development and 3-year outcomes following a 2015 stakeholders' meeting in Uganda to catalyze multidisciplinary and multi-institutional collaboration. METHODS: The stakeholders' meeting was a daylong conference held in Kampala with local, regional and international collaborators in attendance. Multiple clinical specialties including surgical subspecialists, pediatric anesthesia, perioperative nursing, pediatric oncology and neonatology were represented. Key thematic areas including infrastructure, training and workforce retention, service delivery, and research and advocacy were addressed, and short-term objectives were agreed upon. We reported the 3-year outcomes following the meeting by thematic area. RESULTS: The Pediatric Surgical Foundation was developed following the meeting to formalize coordination between institutions. Through international collaborations, operating room capacity has increased. A pediatric general surgery fellowship has expanded at Mulago and Mbarara hospitals supplemented by an international fellowship in multiple disciplines. Coordinated outreach camps have continued to assist with training and service delivery in rural regional hospitals. CONCLUSION: Collaborations between disciplines, both within LMICs and with international partners, are required to advance children's surgery. The unification of stakeholders across clinical disciplines and institutional partnerships can facilitate increased children's surgical capacity. Such a process may prove useful in other LMICs with a wide range of children's surgery stakeholders.

Who is in Your Waiting Room? Social Determinants of Health and Adverse Childhood Experiences in Pediatric Surgery Clinics.

BACKGROUND: Social determinants of health (SDoH) influence overall health, although little is known about the SDoH for pediatric patients requiring surgical services. This study aims to describe SDoH for pediatric surgical patients attending out-patient, community, and outreach clinics, as well as demonstrate the feasibility of identifying and addressing SDoH and Adverse Childhood Experiences (ACEs) when appropriate. METHODS: A cross-sectional study using surveys evaluating SDoH that were distributed to families attending pediatric surgical clinics over a two-year period. The pilot survey used validated questions and was later refined to a shorter version with questions on: Barriers to care, Economic factors, Adversity, Resiliency and Social capital (BEARS). Data was analyzed with descriptive and inferential statistics. RESULTS: 851 families across 13 clinics participated. One third of families reported not having a primary health care provider or being unable to turn to them for additional support. One in four families were found to have a household income less than the Canadian after-tax low-income threshold (<$40,000 CAD). Two-thirds of families answered questions about ACEs, and those with more ACEs were more likely to report a low income. Forty percent of families rarely or only sometimes had adequate social support. CONCLUSION: This survey tool enabled discussions between families and care providers, which allowed clinicians to appropriately follow-up with families and refer them to social work for further support when indicated. Addressing concerns around SDoH within a busy surgical clinical is feasible and may positively affect long-term health outcomes and equitable resource allocation. LEVEL OF EVIDENCE: IV.

Access to pediatric surgery delivered by general surgeons and anesthesia providers in Uganda: Results from 2 rural regional hospitals.

BACKGROUND: Significant limitations in pediatric surgical capacity exist in low- and middle-income countries, especially in rural regions. Recent global children's surgical guidelines suggest training and support of general surgeons in rural regional hospitals as an effective approach to increasing pediatric surgical capacity. METHODS: Two years of a prospective clinical database of children's surgery admissions at 2 regional referral hospitals in Uganda were reviewed. Primary outcomes included case volume and clinical outcomes of children at each hospital. Additionally, the disability-adjusted life-years averted by delivery of pediatric surgical services at these hospitals were calculated. Using a value of statistical life calculation, we also estimated the economic benefit of the pediatric surgical care currently being delivered. RESULTS: From 2016 to 2019, more than 300 surgical procedures were performed at each hospital per year. The majority of cases were standard general surgery cases including hernia repairs and intussusception as well as procedures for surgical infections and trauma. In-hospital mortality was 2.4% in Soroti and 1% in Lacor. Pediatric surgical capacity at these hospitals resulted in over 12,400 disability-adjusted life-years averted/year. This represents an estimated economic benefit of 10.2 million US dollars/year to the Ugandan society. CONCLUSION: This investigation demonstrates that lifesaving pediatric procedures are safely performed by general surgeons in Uganda. General surgeons who perform pediatric surgery significantly increase surgical access to rural regions of the country and add a large economic benefit to Ugandan society. Overall, the results of the study support increasing pediatric surgical capacity in rural areas of low- and middle-income countries through support and training of general surgeons and anesthesia providers.

Engaging youth in rural Uganda in articulating health priorities through Photovoice.

Youth living in rural Uganda represent over 20% of the country's population. Despite the size of this demographic segment of the population, there is a paucity of data on their health priorities. Engaging people in understanding their own health status has proven to be an effective mechanism for health promotion. The objective of this study was to use Photovoice, a community-based, participatory action research methodology, to understand the current health priorities of youth living in rural Uganda. Thirty-two students between the ages of 13 and 17 were recruited from four schools within the region of Soroti, Uganda. Participants were given a disposable camera and were asked to photograph situations that contributed or detracted from their health status. The cameras were then returned to the investigators and each photo taken by the participant was reviewed with the investigators during a semi-structured interview. Codes were applied to the photographs and organized into overarching themes. Each participant chose one to two photos that were most representative of their health priorities for a secondary analysis. Participants provided 499 photos that met the eligibility criteria. The most common themes presented in the photographs were 'hygiene' ( n = 73, 12.4%), 'nutrition' ( n = 69, 11.7%), and 'cleanliness' ( n = 48, 8%). 'Hygiene' ( n = 6, 14.6%) and 'exercise' ( n = 6, 14.6%) were the most common priorities articulated in the representative photographs. Photovoice proved to be an effective method to assess and express the health concerns of youth in rural Uganda. Study participants were able to articulate their health concerns and priorities through photographs and reflect on opportunities for health promotion through subsequent interviews.

Brighter Smiles: Service learning, inter-professional collaboration and health promotion in a First Nations community.

OBJECTIVE: The goal of Brighter Smiles was to improve children's dental health in a remote First Nations community in British Columbia in the context of a service-learning experience for pediatrics residents. SETTING AND PARTICIPANTS: The provincial Ministry of Health had competitive funds available for collaborations between remote communities and medical educators. Hartley Bay (Gitga'at), a tribe of the Tsimshian Nation, responded by declaring children's dental health to be a primary health concern. This northern community has an on-reserve population fluctuating around 200 people and is accessible only by air or water. INTERVENTION: A convenience sample of children had a baseline dental exam; parents also completed a questionnaire about dental health behaviours. Only 31% (4/13) of pre-kindergarten and 8% (2/26) of kindergarten to Grade 12 children had no dental caries. Planning of the Brighter Smiles intervention involved community leaders, teachers, parents, Elders, health care staff, pediatrics residents, and dental and medical faculty from the University of British Columbia (UBC). Brighter Smiles includes school-based brush-ins, fluoride programs, classroom presentations, and regular visits by UBC pediatrics residents to Hartley Bay to provide well-child care that includes age-appropriate dental counselling to parents at the clinic visits. OUTCOMES: An early success indicator was a significantly increased proportion of dental service provider's time scheduled for preventive maintenance services rather than dental rehabilitation (restorations and extractions). CONCLUSIONS: The goal of providing a service-learning experience for trainee pediatricians in a remote community has been achieved. In addition, early indicators demonstrate improvements in child oral health.

Pediatric surgical camps as one model of global surgical partnership: a way forward.

BACKGROUND/PURPOSE: A uniquely Ugandan method of holding surgical "camps" has been one means to deal with the volume of patients needing surgery and provides opportunities for global partnership. METHODS: We describe an evolved partnership between pediatric surgeons in Uganda and Canada wherein Pediatric Surgical Camps were organized by the Ugandans with team participation from Canadians. The camp goals were to provide pediatric surgical and anesthetic service and education and to foster collaboration as a way forward to assist Ugandan health delivery. RESULTS: Three camps were held in Uganda in 2008, 2011, and 2013. A total of 677 children were served through a range of operations from hernia repair to more complex surgery. The educational mandate was achieved through the involvement of 10 Canadian trainees, 20 Ugandan trainees in surgery and anesthesia, and numerous medical students. Formal educational sessions were held. The collaborative mandate was manifest in relationship building, an understanding of Ugandan health care, research projects completed, agreement on future camps, and a proposal for a Canadian-Ugandan pediatric surgery teaching alliance. CONCLUSION: Pediatric Surgical Camps founded on global partnerships with goals of service, education, and collaboration can be one way forward to improve pediatric surgery access and expertise globally.

Lights, camera, surgery: a novel pilot project to engage medical students in the development of pediatric surgical learning resources.

BACKGROUND/PURPOSE: It is important to engage junior medical students in the pediatric surgical environment to showcase possible future career choices. Our aim was to assess how the students valued their experience in the realm of clinical learning, exposure to surgical careers, and development of skill sets necessary for creating learning resources. METHODS: A novel pilot project entitled Lights, Camera, Surgery engaged 13 medical students in the production of instructional videos of basic surgical procedures. An electronic survey questionnaire allowed the students to provide formal feedback on the project outcomes. RESULTS: Of the students who responded, 87.5% expressed appreciation of the enhanced clinical experience. All of the students either agreed or strongly agreed that the project afforded them valuable leadership experience, practical skills in creating educational learning resources, and opportunities to explore careers in surgery. All of the students either agreed or strongly agreed that the project allowed them to gain valuable skills in educational video production. The project videos are now available as educational tools. CONCLUSIONS: Engaging medical students in the production of surgical videos potentially improves leadership skills and promotes the use of educational resources while affording them opportunities to explore pediatric surgery as a future career choice.

Lack of Supervision and Independent Clinical Decision Making in Postgraduate Pediatric training in Australia.

OBJECTIVE: Evaluation of postgraduate pediatric training is a complex yet critical task. We aimed to review pediatric trainees' attitudes to clinical decision-making, levels of supervision and end of life issues in a tertiary pediatric teaching hospital in Sydney, Australia. METHOD: A questionnaire was devised and distributed to all trainees at Sydney Children's Hospital, Randwick. All responses were anonymous. Results were independently analyzed using SPSS statistical software. RESULTS: Forty percent of trainees spent three hours or less per week face to face with more senior colleagues and 14% spent greater than 10 hours per week with more senior colleagues. Seventy-five percent of trainees spent three hours or less on the phone with more senior colleagues while 10% spent five hours or more on the phone with more senior colleagues. There was no association (or correlation) (p>0.05) between seniority of trainee and the number of times a trainee met face to face or phoned a more senior colleague to discuss a management plan. One in three trainees felt that they made less than 10% of clinical decisions on their own and 54% felt that they made less than half of decisions on their own. There was a statistically significant difference between seniority of training and the percentage of important clinical decisions made (p<0.01). Nearly half the trainees (47.7%) have not had the occasion to inform families of the death or impending death of a child. There was a statistically significant difference between seniority of training and the opportunity of informing families of a death of a child (p<0.01).Greater than two thirds of trainees feel that they have not received formal training in clinical decision-making. At the completion of four years of pediatric training only half the trainees considered themselves to be making the majority of clinical decisions. CONCLUSION: There is a need for closer supervision of pediatric trainees by senior colleagues, who themselves, may require additional ongoing training to supervise appropriately. There should be a balanced environment where trainees can make safe, independent decisions. The perceived absence of clinical decision making training suggests a deficiency in the training program.

Making the Most of Medical Orientation - A New Approach.

Orientating new junior medical staff can be a complex and time consuming task. Traditional models have typically involved a day or longer of lectures. This involves a large number of senior staff being available on the first day of term. It also means that junior staff not present on the first day had any access to an orientation program at all. Evaluation of our program confirmed the belief that the day was dull and that there was simply too much information for new staff to absorb. As a result of this feedback we extensively updated our orientation program. Pre-reading of the junior staff manual became compulsory. We departed from the traditional lecture style program and devised a new ten- station scenario based interactive program. The stations were designed to cover aspects of the hospital's mandatory education and key educational requirements in order to function effectively on our campus. Station leaders were selected and trained in the goals of the new process. Several of our secondment sites were engaged in the development of the project topics. We hoped that our secondment sites would be relieved of some orientation responsibility if core material was delivered centrally. The strength of the new orientation is that it is portable, reproducible and uniform. It is also available via video conferencing. A single person can educate new staff in three hours if the need arises. Most importantly all new staff will have access to the program within a week of starting a term at our hospital. Key words: medical orientation; junior staff; interactive.