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Academic global surgery consists of collaborative partnerships that address surgical inequities through research, training, education, advocacy, and diplomacy. It has been characterized by increased scholastic production through global surgery publications, dedicated global surgery sessions within scientific conferences, global surgery-specific research grants, database development to support global surgery research, global surgery research fellowships, and global surgery-based academic promotion paradigms. The increased emphasis on global surgery research has been accompanied by multiple ethical challenges. This article reviews critical ethical dilemmas presented by global surgery research efforts and proposes interventions on the partnership, infrastructural, and policy levels to enhance fidelity within research partnerships.
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Advanced surgical technologies consist of remote and virtual platforms that facilitate surgical care and education. It also includes the infrastructure necessary to utilize these platforms (e.g., internet access, robotic systems, and simulators). Given that 5 billion people lack access to safe and timely surgical care, the appeal of these technologies to the field of global surgery lies primarily in its ability to eliminate geographical barriers and address surgeon shortages. This article discusses the use of virtual and remote technologies in resource-limited settings, the potential applications of these technologies, the possible barriers to their integration, and the impact these technologies may have on access to surgical care and education. Specifically, it will explore how robotic surgery, telesurgery, virtual education platforms, and simulations have the potential to be instrumental in enhancing worldwide access to safe surgical care.
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Global surgery is a medical field dedicated to the facilitation of timely access to safe, affordable, and high-quality surgical healthcare worldwide, including support for necessary surgery and anesthesia infrastructure. Standard surgical training in the US does not provide necessary exposure to the range of surgical operations and nontechnical skills critical to practice in resource-limited contexts. Therefore, academic medical institutions have sought to bridge this training gap by establishing global surgery-focused rotations, fellowships, and integrated global surgery residencies. However, the presence of trainees pursuing education for careers in resource-variable settings presents an added layer of ethical complexity that must be carefully considered on the individual, programmatic, and institutional level. This article reviews the complexities relevant to global surgery trainees across these levels and offers potential mechanisms for addressing these ethical challenges.
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Cirugía General , Internado y Residencia , Cirujanos , Curriculum , Educación de Postgrado en Medicina , Becas , Cirugía General/educación , Humanos , Cirujanos/educación , Estados UnidosRESUMEN
Investment in healthcare infrastructure in resource-limited settings is a vital and cost-effective approach for diminishing world-wide disease burden, increasing quality of life, and lengthening life expectancy. Graduate medical trainees enthusiastically express interest in supporting global health efforts that expand healthcare access and capacity in resource-limited settings. Academic institutions are responding by developing training programs to equip graduate medical trainees with the technical, interpersonal, scholastic, and ethical skillsets necessary for the pursuit of global health efforts. Drawn from real-world experience and current literature, the following twelve tips will strengthen a global health curriculum in graduate medical training programs with dedicated global health education.
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Salud Global , Calidad de Vida , Curriculum , Educación de Postgrado en Medicina , Escolaridad , Educación en Salud , HumanosRESUMEN
OBJECTIVE: To describe the clinical features, therapeutic interventions, and patient outcomes of gastrointestinal (GI) hemorrhage in individuals with a telomere biology disorder, including dyskeratosis congenita, Hoyeraal-Hreidarsson syndrome, Revesz syndrome, and Coats plus. STUDY DESIGN: Clinical Care Consortium for Telomere Associated Ailments members were invited to contribute data on individuals with telomere biology disorders at their institutions who experienced GI bleeding. Patient demographic, laboratory, imaging, procedural, and treatment information and outcomes were extracted from the medical record. RESULTS: Sixteen patients who experienced GI hemorrhage were identified at 11 centers. Among 14 patients who underwent genetic testing, 8 had mutations in TINF2, 4 had mutations in CTC1 or STN1, and 1 patient each had a mutation in TERC and RTEL1. Ten patients had a history of hematopoietic cell transplantation. The patients with Coats plus and those without Coats plus had similar clinical features and courses. Angiodysplasia of the stomach and/or small bowel was described in 8 of the 12 patients who underwent endoscopy; only 4 had esophageal varices. Various medical interventions were trialed. No single intervention was uniformly associated with cessation of bleeding, although 1 patient had a sustained response to treatment with bevacizumab. Recurrence was common, and the overall long-term outcome for affected patients was poor. CONCLUSIONS: GI bleeding in patients with telomere biology disorders is associated with significant morbidity and with vascular ectasias rather than varices.
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Hemorragia Gastrointestinal/etiología , Telómero/genética , Adolescente , Adulto , Ataxia/complicaciones , Ataxia/genética , Enfermedades Óseas Metabólicas/complicaciones , Enfermedades Óseas Metabólicas/genética , Médula Ósea/anomalías , Neoplasias Encefálicas/complicaciones , Neoplasias Encefálicas/genética , Calcinosis/complicaciones , Calcinosis/genética , Quistes del Sistema Nervioso Central/complicaciones , Quistes del Sistema Nervioso Central/genética , Niño , Preescolar , Disqueratosis Congénita/complicaciones , Disqueratosis Congénita/genética , Femenino , Retardo del Crecimiento Fetal/genética , Hemorragia Gastrointestinal/genética , Humanos , Discapacidad Intelectual/complicaciones , Discapacidad Intelectual/genética , Leucoencefalopatías/complicaciones , Leucoencefalopatías/genética , Masculino , Microcefalia/complicaciones , Microcefalia/genética , Espasticidad Muscular/complicaciones , Espasticidad Muscular/genética , Mutación , Retina , Enfermedades de la Retina/complicaciones , Enfermedades de la Retina/genética , Convulsiones/complicaciones , Convulsiones/genética , Telómero/metabolismo , Telómero/patología , Adulto JovenRESUMEN
PROBLEM: The World Health Organization and the World Bank have identified improvement in access to surgical care as an urgent global health challenge and a cost-effective investment in public health. However, trainees in standard U.S. general surgery programs do not have adequate exposure to the procedures, technical skills, and foundational knowledge essential for providing surgical care in resource-limited settings. APPROACH: The Michael E. DeBakey Department of Surgery at Baylor College of Medicine (BCM) created a 7-year global surgery track within its general surgery residency in 2014. Individualized rotations equip residents with the necessary skills, knowledge, and experience to operate in regions with low surgeon density and develop sustainable surgical infrastructures. BCM provides a formal, integrated global surgery curriculum-including 2 years dedicated to global surgery-with surgical specialty rotations in domestic and international settings. Residents tailor their individual experience to the needs of their future clinical practice, region of interest, and surgical specialty. OUTCOMES: There have been 4 major outcomes of the BCM global surgery track: (1) increased exposure for trainees to a broad range of surgeries critical in resource-limited settings, (2) meaningful international partnerships, (3) contributions to global surgery scholarship, and (4) establishment of sustainable global surgery activities. NEXT STEPS: To better facilitate access to safe, timely, and affordable surgical care worldwide, global surgeons should pursue expertise in topics not currently included in U.S. general surgical curricula, such as setting-specific technical skills, capacity building, and organizational collaboration. Future evaluations of the BCM global surgery track will assess the effect of individualized education on trainees' professional identities, clinical practices, academic pursuits, global surgery leadership preparedness, and comfort with technical skills not encompassed in general surgery programs. Increasing availability of quality global surgery training programs would provide a critical next step toward contributing to the delivery of safe surgical care worldwide.
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Educación de Postgrado en Medicina/organización & administración , Salud Global/economía , Especialidades Quirúrgicas/organización & administración , Cirujanos/provisión & distribución , Competencia Clínica , Análisis Costo-Beneficio/estadística & datos numéricos , Curriculum/normas , Becas/métodos , Cirugía General/educación , Accesibilidad a los Servicios de Salud/normas , Humanos , Cooperación Internacional , Internado y Residencia , Conocimiento , Desarrollo de Programa/métodos , Especialidades Quirúrgicas/estadística & datos numéricos , Estados Unidos/epidemiologíaRESUMEN
To prepare global surgeons, academic institutions have created training programs that provide opportunities to develop foundational clinical knowledge, pursue academic inquiry, build surgical infrastructure and capacity, and become advocates and collaborators in resource-limited settings. Academic institutions can create a short course in global surgery, global surgery rotation, global surgery fellowship, or integrated global surgery residency. Global surgery training programs must account for ethics of global surgery engagement, sources of funding, structures for professional advancement, and trainee-appropriate partnerships. Global surgery training must include the establishment of accreditation systems, development of integrated training programs, and institutional investment in global surgery education.
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Internado y Residencia , Cirujanos , HumanosRESUMEN
Mitochondrial neurogastrointestinal encephalomyopathy (MNGIE) is a fatal disorder characterized by progressive gastrointestinal dysmotility, peripheral neuropathy, leukoencephalopathy, skeletal myopathy, ophthalmoparesis, and ptosis. MNGIE stems from deficient thymidine phosphorylase activity (TP) leading to toxic elevations of plasma thymidine. Hematopoietic stem cell transplant (HSCT) restores TP activity and halts disease progression but has high transplant-related morbidity and mortality. Liver transplant (LT) was reported to restore TP activity in two adult MNGIE patients. We report successful LT in four additional MNGIE patients, including a pediatric patient. Our patients were diagnosed between ages 14 months and 36 years with elevated thymidine levels and biallelic pathogenic variants in TYMP. Two patients presented with progressive gastrointestinal dysmotility, and three demonstrated progressive peripheral neuropathy with two suffering limitations in ambulation. Two patients, including the child, had liver dysfunction and cirrhosis. Following LT, thymidine levels nearly normalized in all four patients and remained low for the duration of follow-up. Disease symptoms stabilized in all patients, with some manifesting improvements, including intestinal function. No patient died, and LT appeared to have a more favorable safety profile than HSCT, especially when liver disease is present. Follow-up studies will need to document the long-term impact of this new approach on disease outcome. Take Home Message: Liver transplantation is effective in stabilizing symptoms and nearly normalizing thymidine levels in patients with mitochondrial neurogastrointestinal encephalomyopathy (MNGIE) and may have an improved safety profile over hematopoietic stem cell transplant.
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Trasplante de Hígado/métodos , Mitocondrias/metabolismo , Encefalomiopatías Mitocondriales/terapia , Timidina Fosforilasa/genética , Adolescente , Adulto , Trastornos de la Motilidad Esofágica/genética , Femenino , Trasplante de Células Madre Hematopoyéticas/mortalidad , Humanos , Lactante , Trasplante de Hígado/mortalidad , Imagen por Resonancia Magnética , Masculino , Mitocondrias/enzimología , Mitocondrias/patología , Encefalomiopatías Mitocondriales/diagnóstico por imagen , Encefalomiopatías Mitocondriales/genética , Encefalomiopatías Mitocondriales/fisiopatología , Enfermedades del Sistema Nervioso Periférico/genética , Timidina/sangre , Secuenciación del ExomaRESUMEN
The provision of intestinal stoma care is challenging in austere settings due to limitations in surgical and wound care access as well as the high cost and sparsity of ostomy supplies. As a result, many surgical patients suffer from ostomy-related complications such as peristomal wounds and are unable to find relief for these complications from standard treatments and measures. This article describes the external stoma diversion, a cost-effective palliative surgical procedure that assists in the healing of peristomal wounds in resource-limited settings.
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BACKGROUND: The teaching of humanistic values is recognized as an essential component of medical education and continuing professional development of physicians. The application of humanistic values in medical care can benefit medical students, clinicians and patients. AIMS: This article presents 12 tips on fostering humanistic values in medical education. METHOD: The authors reviewed the literature and present 12 practical tips that are relevant to contemporary practices. RESULTS: The tips can be used in teaching and sustaining humanistic values in medical education. CONCLUSIONS: Humanistic values can be incorporated in formal preclinical environments, the transition into clinical settings, medical curricula and clinical clerkships. Additionally, steps can be taken so that medical educators and institutions promote and sustain humanistic values.