Ideally, global surgery refers to all efforts aimed at providing adequate access to optimal and affordable surgical care in all regions of the world. Examples of such efforts include, but are not limited to, research, creation of data registries, advocacy, education for all personnel involved in the surgical patient care, efforts to prevent surgical diseases, and volunteerism.
In recent years, many young surgeons have expressed a growing interest in helping to address the global surgical disease burden. This article is intended to serve as a primer for young surgeons interested in exploring global surgery opportunities.
Why surgeons should be involved
The World Health Organization (WHO) and The Lancet Commission on Global Surgery have determined that approximately 5 billion people around the world lack access to care and that this inability to receive necessary surgical care is one of the major causes of preventable morbidity and mortality. According to the WHO and The Lancet Commission, most of the preventable deaths are secondary due to non-compressible bleeding and lack of access to emergency surgery. In other words, in some areas of the world, patients are dying from the lack of resources that are regarded as basic necessities in high-income countries.
It is imperative that clinically active surgeons contribute to a sustainable effort to improve access to surgical care in economically disadvantaged countries. The first step in that direction is an understanding of surgical diseases as not only treatable, but also preventable.
Inequities in training, a paucity of surgeons, and a lack of resources for the surgical patient can be found in nations around the world. Surgeons who provide care in low- and middle-income countries (LMICs) often encounter wide variations in resources. This disparity, once seen as a drawback to providing surgical care in underserved regions, is now viewed differently because LMICs provide opportunities to become experienced in how to be resourceful in challenging circumstances at home and abroad. Indeed, participating in global surgery initiatives can be rewarding both personally and professionally. Serving in LMICs brings perspective to what is truly essential in the care of the surgical patient.
Increasing awareness of our cultural surroundings and our appreciation for the local health care system are some examples of nontechnical experiences that providing care in resource-poor settings can offer young surgeons. Recognizing surgeons’ capacity to develop innovative solutions to problems, as well as their skill set for treating complex patients without the resources available in high-income countries, is both humbling and inspiring.
Guidelines for participating in a global surgery program
Before deciding to participate in a global surgery initiative, surgeons should consider the following guidelines.
Understand your role, the composition of the team, and the environment
Providing surgical care involves far more than the technical skills required to perform an operation. In addition to properly equipped operating rooms, safe surgery requires making the most of all team members’ competencies, ranging from nurses to anesthesiologists. Combining these skills with those from ancillary services such as phlebotomy, pathology, and microbiology allows for the development of the robust infrastructure essential to optimal surgical outcomes.
When traveling to a different area of the world, it is imperative to understand the health care gaps in the nation or region you are visiting in order to effect change and avoid exacerbating existing localized problems. The importance of performing a needs analysis before embarking on a global surgery initiative cannot be overemphasized. Understanding the local needs and the capabilities of the team will allow surgeons to appropriately tailor resources to meet the needs of the community and optimize surgical care. This cache includes the equipment and tools necessary not only during the operation, but also in the ongoing management of surgical diseases.
Surgeons who provide care in austere environments need to use cost-effective techniques and be capable of providing a range of clinical services that extend beyond the operating room, such as taking and documenting vital signs, triaging patients, transporting patients, and obtaining lab tests and results.
In summary, when planning to participate in a global surgery opportunity, prepare to act in the following ways:
- Functioning in a team-based setting with health care professionals who bring a wide range of skill sets.
- Understanding the local environment and potential limitations of resources.
- Maintaining an open mind to how dynamic situations may arise in LMICs. Be flexible. Teaching and learning may happen on the go, in many busy situations.
Ethical considerations
When engaging in global outreach, surgeons should maintain the same patient safety standards they follow in their home institutions and ensure that all team members practice within their scope of training. Although it might seem easy to uphold these values regardless of the setting, the reality is that working within one’s scope of practice in LMICs can often be difficult. The spectrum of surgical pathology in these countries is broad, whereas the number of local clinicians and specialists is limited. The desire of wanting to meet patients’ needs must be balanced with our pledge to “above all, do no harm.” While trainees can be of significant value in bolstering the availability of care in underserved areas, they also must provide only services in which they have been adequately trained and uphold the same ethical standards as they would in their native countries.
Global surgery during training and reciprocity
A global surgery rotation has become a powerful means of attracting residents and fellows to training programs in recent years. Surgical outreach is appealing to trainees because it allows them to develop technical proficiency while increasing their cultural awareness.
In turn, for allowing residents and fellows to attain this experience, some institutions engage in reciprocal relationships with health care providers in LMICs by creating opportunities for them to observe operations in the U.S. and to participate in educational activities. Creating and, more importantly, maintaining these reciprocal relationships are crucial to the success of global health care initiatives. Collaborative research projects, the creation of data registries for underserved areas, and programs that allow international visitors from LMICs to travel abroad and observe new technologies in use are all results of successful reciprocal relationships in global surgery.
Research and funding
Despite growing interest in global surgery in the last decade, funding opportunities for surgical research have been limited. Yet, institutional support is crucial in generating seed funding for global surgery programs. Creating an infrastructure that allows young surgeons to pursue both clinical and academic interests will facilitate the professional development of junior faculty. Institutional buy-in also allows young surgeons to establish a track record that will be useful when exploring other sources for global surgery outreach funding.
Achieving institutional buy-in requires persistence and resilience. Success does not happen overnight and entails a slow, steady progression of building relationships, getting published, and attaining practical experience.
Mentorship
Establishing an environment in which young surgeons can build successful careers in academic global surgery is timely and essential. Not only are young surgeons interested in participating in global surgery initiatives, but they also are creating greater awareness about the lack of access to surgical care in many parts of the world.
Surgery departments, universities, and societies that prioritize global surgery should foster the development of young surgeons with an interest in providing care in underserved areas. Mentorship during the first several years of a surgical career is critical in generating academic credibility and in developing relationships with global surgery leaders.
Many surgical societies offer opportunities for mentorship and networking, including the American College of Surgeons (ACS) Young Fellows Association (YFA) and the Operation Giving Back (OGB) program. Other organizations that are active in global health also can provide these resources (see below).
The College’s role
OGB provides the tools necessary to facilitate humanitarian outreach among ACS members of all specialties, at all stages of their career, who are interested in domestic and/or international service. Through a network of high-impact partner organizations, OGB directs surgeons to volunteer opportunities that align with an individual’s skills, passions, and beliefs.
OGB rolled out a number of educational programs at Clinical Congress 2016 that were aimed at young surgeons who are interested in global surgery, including a one-day didactic course, Global Health Competencies for Surgeons: Cognitive and System Skills. This course was designed to educate international volunteers about a variety of relevant issues, including what to expect in low-resource surgical environments, situational ethics, cultural competency, and information regarding tropical diseases. The Global Health Competencies for Surgeons course also provides didactic and hands-onCreating an infrastructure that allows young surgeons to pursue both clinical and academic interests will facilitate the professional development of junior faculty. skills training in key areas of need such as orthopaedics, general surgery, neurosurgery, plastic surgery, and obstetrics and gynecology.
Conclusion
Young surgeons who are interested in developing a niche in global surgery have access to a wealth of opportunities. The need to advance collaboration internationally in order to ensure access to safe surgical care, enhance training, and increase research opportunities exists throughout the global community. The ACS supports involvement in global surgery initiatives via OGB, and the YFA stands ready to assist young Fellows who are interested in learning more about how they can become involved in global surgery initiatives.
Other resources
Most academic health care institutions have an office of global health. Developing partnerships to carry out projects already in place within these departments can be a good start for the young surgeon seeking experience in this area.
In addition to the ACS, many organizations and associations provide opportunities for surgeons at all stages of their career to gain global health care experience, including the following:
- The Association for Academic Surgery offers international courses, a listing of international fellowships and travel grants for visiting professors, and sponsors a Global Surgery Research Fellowship Award.
- The Bethune Round Table, which takes place annually in Canada, is an international conference devoted entirely to the discussion of surgical issues in the developing world.
- The Brigham and Women’s Hospital Global Surgery Program, Boston, MA, is designed to ensure patients have access to surgical care by developing a cadre of global surgery leaders, offering deep capacity building, and providing connections to broad international surgical assessments and advocacy.
- The Duke Global Health Institute (DGHI), Durham, NC, works to reduce domestic and international health care disparities. Recognizing that global health problems stem from economic, social, environmental, political, and health care inequities, DGHI brings together interdisciplinary teams to solve complex health problems and to train the next generation of global health leaders.
- Harvard Medical School’s Program in Global Surgery and Social Change, Boston, and the Paul Farmer Global Surgery Fellowship at Boston Children’s Hospital address disparities in global surgical and anesthesia care.
- Mending Kids focuses on transformational surgical care for children by empowering communities to create self-sustaining programs.
- The Oregon Health & Science University’s Global Health Advocacy Program in Surgery, Portland, provides global surgery rotations for clinicians.
- The Panamerican Trauma Society, hosted by the division of acute care surgical services, department of surgery, Virginia Commonwealth University, Richmond, enhances collaboration in trauma and emergency surgery through North, Central, and South America. These programs are available to surgeons, students, residents, nurses, and paramedics.
- The Rutgers University division of acute care surgery and the Rutgers School of Public Health, New Brunswick, NJ, offer a master’s in public health in global health and epidemiology with global surgery tracks in Latin America. Funded opportunities exist for student, resident, and fellow research in trauma systems development. Rutgers also offers nonfunded (no compensation is provided to participants), non-accredited one- to two-year global surgery fellowships.
- The University of California, Los Angeles (UCLA), features its Global Surgery Initiative as part of the UCLA Center for World Health. The mission of the Global Surgery Initiative parallels that of the UCLA Center for World Health, with a focus specifically on bringing a standard of care to the surgical patient in all regions of the world.
- The University of Utah’s Center for Global Surgery, Salt Lake City, is a network of providers and professionals who envision a world in which safe, effective, and affordable surgical and anesthetic care is accessible to all people. Embedded within the school of medicine’s department of surgery, the center positions surgical faculty, residents, and medical students to address barriers of access to essential surgical care through innovation, research, and advocacy.
- The University of Washington (UW) Global Health Certificate for Residents and Fellows is available to all residents and fellows at UW. This certificate program draws on courses, seminars, and other global health training activities available at UW.
- WHO Programme for Emergency and Essential Surgical Care is dedicated to strengthening health systems, achieving universal health coverage, and ensuring the safety and efficacy of clinical procedures in anesthesia, surgery, orthopaedics, and obstetrics.
Bibliography
Boeck MA, Nagarajan N, Swaroop M. The role of public health in a global surgery fellowship. J Surg Educ. 2015;72(5):776-777.
Calland JF, Petroze RT, Abelson J, Kraus E. Engaging academic surgery in global health: Challenges and opportunities in the development of an academic track in global surgery. Surgery. 2013;153(3):316-320.
Chu KM, Jayaraman S, Kyamanywa P, Ntakiyiruta G. Building research capacity in Africa: Equity and global health collaborations. PLoS Medicine. March 2014. Available at: journals.plos.org/plosmedicine/article/file?id=10.1371/journal.pmed.1001612&type=printable. Accessed November 12, 2016.
Farmer PE, Kim JY. Surgery and global health: A view from beyond the OR. World J Surg. 2008;32(4):533-536.
Ferrada P, Ivatury RR, Spain DA, et al. International rotations: A valuable source to supplement operative experience for acute care surgery, trauma and surgical critical care fellows. J Trauma Acute Care Surg. 2016 Oct 25. [Epub ahead of print].
Ginwalla RF, Rustin RB. The “global surgeon”: Is it time for modifications in the American surgical training paradigm? J Surg Educ. 2015;72(4):e100-103.
Global health in 2012: Development to sustainability. Lancet. 2012;379(9812):193.
Haagsma JA, Graetz N, Bolliger I. The global burden of injury: Incidence, mortality, disability-adjusted life years and time trends from the Global Burden of Disease study 2013. Inj Prev. 2016;22(1):3-18.
The Lancet Commission on Global Surgery. Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development: Executive Summary of The Lancet Commission on Global Surgery Report. Bull Am Coll Surg. 2015;100(6):12-15. Available at: bulletin.facs.org/2015/06/global-surgery-2030-the-lancet-commission-on-global-surgery-report/. Accessed January 13, 2017.
Leow JJ, Kingham TP, Casey KM, Kushner AL. Global surgery: Thoughts on an emerging surgical subspecialty for students and residents. J Surg Educ. 2010;67(3):143-148.
Ologunde R, Marks I. Global surgery: Integrating an emerging sub-specialty within global health. J Epidemiol Glob Health. 2015;5(1):93-94.
Rao SG. Pediatric cardiac surgery in developing countries. Pediatr Cardiol. 2007;28(2):144-148.
Yorston D. High-volume surgery in developing countries. Eye (Lond). 2005;19(10):1083-1089.
