The Impact of Colonialism on Surgical Training Structures in Africa Part 1: Contextualizing the Past, Present, and Future.

Since the first African country attained independence from colonial rule, surgical training on the continent has evolved along 3 principal models. The first is a colonial, local master-apprentice model, the second is a purely local training model, and the third is a collegiate intercountry model. The 3 models exist currently and there are varied perceptions of their relative merits in training competent neurosurgeons. We reviewed the historical development of training and in an accompanying study, seek to describe the complex array of surgical training pathways and explore the neocolonial underpinnings of how these various models of training impact today the development of surgical capacity in Africa. In addition, we sought to better understand how some training systems may contribute to the widely recognized "brain drain" of surgeons from the African continent to high income countries in Europe and North America. To date, there are no published studies evaluating the impact of surgical training systems on skilled workforce emigration out of Africa. This review aims to discover potentially addressable sources of improving healthcare and training equity in this region.

The Impact of Colonialism on Surgical Training Structures In Africa Part 2: Surveying Current and Past Trainees.

BACKGROUND: As a result of gradual independence from colonial rule over the course of the past century, Africa has developed and evolved 3 primary surgical training structures: an extracontinental colonial model, an intracontinental college-based model, and several smaller national or local models. There is consistent evidence of international brain drain of surgical trainees and an unequal continental distribution of surgeons; however there has not, to date, been an evaluation of the impact colonialism on the evolution of surgical training on the continent. This study aims to identify the etiologies and consequences of this segmentation of surgical training in Africa. METHODS: This is a cross-sectional survey of the experience and perspectives of surgical training by current African trainees and graduates. RESULTS: A surgeon's region of residence was found to have a statistically significant positive association with that of a surgeon's training structure (P <0.001). A surgeon's professional college or structure of residency has a significantly positive association with desire to complete subspecialty training (P = 0.008). College and structure of residency also are statistically significantly associated with successful completion of subspecialty training (P < 0.001). CONCLUSIONS: These findings provide evidence to support the concept that the segmentation of surgical training structures in Africa, which is the direct result of prior colonization, has affected the distribution of trainees and specialists across the continent and the globe. This maldistribution of African surgical trainees directly impacts patient care, as the surgeon-patient ratios in many African countries are insufficient. These inequities should be acknowledged addressed and rectified to ensure that patients in Africa receive timely and appropriate surgical care.

Barriers Encountered Toward Pursuing a Neurosurgical Career: A Cross-Sectional Study Among Medical Students, Interns, and Junior Doctors in Africa.

BACKGROUND: Africa has an increased burden of neurosurgical diseases with an estimate of 1,986,392 neurosurgical cases, 108,824 neurosurgical case capacity, and 1,877,568 case deficits yearly. Literature suggests that about 8420 neurosurgeons are needed to fill this vast gap. The main objective of this study is to elucidate barriers encountered in pursuing neurosurgery training in the African context. METHODS: A cross-sectional electronic survey, developed in English and subsequently translated into French, was utilized. This was disseminated among medical students, medical interns, and junior doctors in all 5 African regions. RESULTS: A total of 491 responses were received from the following 5 African regions: West Africa (30.5%), East Africa (30.3%), Central Africa (18.1%), North Africa (11.8%), and Southern Africa (9.2%). Of the participants, 55.2% were men and 44.8% were women. Seventy-six percent of respondents were aware of the neurosurgery deficit in Africa. Barriers to pursuing neurosurgery included discouragement from others over lack of an "ideal personality" trait, culture/cultural beliefs as related to gender roles, lack of mentorship, inadequate neurosurgical training opportunities, poor health infrastructure for neurosurgical practice in Africa, poor patient outcomes, and challenges with work/life balance were some of the barriers highlighted to pursuing neurosurgical career on the continent. CONCLUSION: Even with its robust population growth, Africa is not producing enough neurosurgeons to meet the demands of the population due to several barriers. Delineating these challenges and barriers represents an important step in developing sustainable mechanisms for recruitment, training, mentorship, and support of burgeoning African neurosurgeons.

Evaluating the impact of neurosurgical rotation experience in Africa on the interest and perception of medical students towards a career in neurosurgery: a protocol for a continental, cross-sectional study.

Introduction: Africa has the second highest neurosurgical workforce deficit globally. Despite the many recent advancements in increasing neurosurgical access in Africa, published reports have shown that the vast majority of undergraduate students have little or no exposure to neurosurgery. The lack of exposure may pose a challenge in reducing the neurosurgical workforce deficit, which is one of the long-term strategies of tackling the unmet burden of disease. Students may also miss the opportunity to appreciate the specialty and its demands as well as nurture their interest in the field. This study aims to assess the impact of a neurosurgical rotation during medical school in shaping the perception and interest of students towards a career in neurosurgery. Methods: The cross-sectional study will be conducted through the dissemination of a self-administered e-survey hosted on Google Forms from 21st February 2021 to 20th March 2021. The survey will contain five-point Likert scale, multiple-choice and free-text questions. The structured questionnaire will have four sections with 27 items: (i) socio-demographic background, (ii) neurosurgical experience, (iii) perception towards a neurosurgical career and (iv) interest in a neurosurgical career. All consenting medical students in African medical schools who are in their clinical years (defined as fourth to sixth years or higher years of study) will be eligible. Odds ratios and their 95% confidence intervals, Wilcoxon rank-sum test, Welch t-test and adjusted logistic regression models will be used to test for associations between independent and dependent variables. Statistical significance will be accepted at P < 0.05.

Evaluating the Impact of Neurosurgical Rotation Experience in Africa on the Interest and Perception of Medical Students Towards a Career in Neurosurgery: A Continental, Multi-Centre, Cross-Sectional Study.

OBJECTIVE: Africa has the second highest neurosurgical workforce deficit globally and many medical students in Africa lack exposure to the field. This study aims to assess the impact of a neurosurgical rotation during medical school in shaping the perception and interest of students toward a career in neurosurgery. STUDY DESIGN: Cross-sectional study. METHODS: A Google form e-survey was disseminated to African clinical medical students between February 21st and March 20th, 2021. Data on exposure and length of neurosurgical rotation and perception of, and interest in, neurosurgery were collected. Data was analyzed using descriptive statistics and adjusted logistic regression modeling. RESULTS: Data was received from 539 students in 30 African countries (30/54, 55.6%). The majority of participants were male and were from Kenya, Nigeria and South Africa. Most students had undertaken a formal neurosurgery rotation, of which the majority reported a rotation length of 4 weeks or less. Students who had more than 4 weeks of neurosurgical exposure were more likely to express a career interest in neurosurgery than those without [odds ratio (OR) = 1.75, p < 0.04] and men were more likely to express interest in a neurosurgical career compared to women (OR = 3.22, p < 0.001), after adjusting for other factors. CONCLUSION: Neurosurgical exposure is a key determinant in shaping the perception and interest of medical students toward a career in neurosurgery. Our findings support the need: i) for a continent-wide, standardized curriculum guide to neurosurgical rotations and ii) to advocate for gender inclusivity in education and policy-making efforts across the African continent.