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Omondi MP, Mwangi Chege J, Ong’ang’o H, Sitati FC. Effect of enforcement of the national referral guidelines on patterns of orthopedic admissions to Kenyatta National Hospital, Kenya: Pre-post intervention study. PLoS One 2024; 19:e0290195. [PMID: 39137196 PMCID: PMC11321550 DOI: 10.1371/journal.pone.0290195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 05/07/2024] [Indexed: 08/15/2024] Open
Abstract
BACKGROUND Inappropriate utilization of higher-level health facilities and ineffective management of referral processes in resource-limited settings are becoming increasingly a concern in health care management in developing countries. This is characterized by self-referral and frequent bypassing of the nearest health facilities coupled with low formal referral mechanisms. This scenario lends itself to a situation where uncomplicated medical conditions are unnecessarily managed in a high-cost health facility. On July 1, 2021, Kenyatta National Hospital (KNH) enforced the Kenya Health Sector Referral Implementation Guidelines, 2014, which required patients to receive approval from the KNH referral office and a formal referral letter to be admitted at KNH to reduce the number of walk-ins and allow KNH to function as a referral facility as envisioned by the Kenya 2010 Constitution and KNH legal statue of 1987. OBJECTIVE To determine the effect of enforcing the national referral guidelines on patterns of orthopaedic admissions to the KNH. This was a pre-post intervention study. Data abstraction was done for 459 and 446 charts before and after the enforcement of the national referral guidelines, respectively. RESULTS Enforcement of the national referral guidelines reduced the proportion of walk-in admissions from 54.9% to 45.1%, while the proportion of facility referrals increased from 46.6% to 53.4% (p = 0.013). The percentage of non-trauma orthopaedic admissions doubled from 12.0% to 22.4% (p<0.001). There was also an increase in admissions through the Outpatient Clinic and Corporate Outpatient Clinic. The proportion of emergency admissions declined, while that of elective admissions increased. The increase in elective cases was mainly driven by the increase in female admissions with active insurance cover, tertiary education, non-trauma-related conditions and older age groups. However, the use of official formal written referral letters did not change despite the enforcement of the national referral guidelines. CONCLUSION The enforcement of the national referral guidelines reduced the proportion of walk-ins' admissions to KNH. While the enforcement of the national referral guidelines had no effect on the use of official formal written referral letters, it did limit access and utilization of inpatient orthopedic services for young male patients with no active insurance cover and in need of emergency orthopedic care.
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Affiliation(s)
| | - Joseph Mwangi Chege
- Orthopedics Unit, Department of Surgery, University of Nairobi, Nairobi, Kenya
| | | | - Fred Chuma Sitati
- Orthopedics Unit, Department of Surgery, University of Nairobi, Nairobi, Kenya
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Yankunze Y, Mwachiro MM, Lando JO, Bachheta N, Mangaoang D, Bekele A, Parker RK. Laparoscopy experience in East, Central, and Southern Africa: insights from operative case volume analysis. Surg Endosc 2024; 38:4415-4421. [PMID: 38890173 PMCID: PMC11289058 DOI: 10.1007/s00464-024-10960-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 05/24/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND With the primary objective of addressing the disparity in global surgical care access, the College of Surgeons of East, Central, and Southern Africa (COSECSA) trains surgeons. While sufficient operative experience is crucial for surgical training, the extent of utilization of minimally invasive techniques during COSECSA training remains understudied. METHODS We conducted an extensive review of COSECSA general surgery trainees' operative case logs from January 1, 2015, to December 31, 2020, focusing on the utilization of minimally invasive surgical procedures. Our primary objective was to determine the prevalence of laparoscopic procedures and compare this to open procedures. We analyzed the distribution of laparoscopic cases across common indications such as cholecystectomy, appendicitis, and hernia operations. Additionally, we examined the impact of trainee autonomy, country development index, and hospital type on laparoscopy utilization. RESULTS Among 68,659 total cases, only 616 (0.9%) were laparoscopic procedures. Notably, 34 cases were conducted during trainee external rotations in countries like the United Kingdom, Germany, and India. Gallbladder and appendix pathologies were most frequent among the 582 recorded laparoscopic cases performed in Africa. Laparoscopic cholecystectomy accounted for 29% (276 of 975 cases), laparoscopic appendectomy for 3% (76 of 2548 cases), and laparoscopic hernia repairs for 0.5% (26 of 5620 cases). Trainees self-reported lower autonomy for laparoscopic (22.5%) than open cases (61.5%). Laparoscopy usage was more prevalent in upper-middle-income (2.7%) and lower-middle-income countries (0.8%) compared with lower-income countries (0.5%) (p < 0.001). Private (1.6%) and faith-based hospitals (1.5%) showed greater laparoscopy utilization than public hospitals (0.5%) (p < 0.001). CONCLUSIONS The study highlights the relatively low utilization of minimally invasive techniques in surgical training within the ECSA region. Laparoscopic cases remain a minority, with variations observed based on specific diagnoses. The findings suggest a need to enhance exposure to minimally invasive procedures to ensure well-rounded training and proficiency in these techniques.
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Affiliation(s)
- Yves Yankunze
- Department of Surgery, Tenwek Hospital, PO Box 39, Bomet, 20400, Kenya
| | - Michael M Mwachiro
- Department of Surgery, Tenwek Hospital, PO Box 39, Bomet, 20400, Kenya
- College of Surgeons of East, Central, and Southern Africa, Arusha, Tanzania
| | - June Owino Lando
- Department of Surgery, Tenwek Hospital, PO Box 39, Bomet, 20400, Kenya
| | - Niraj Bachheta
- College of Surgeons of East, Central, and Southern Africa, Arusha, Tanzania
| | - Deirdre Mangaoang
- Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Abebe Bekele
- College of Surgeons of East, Central, and Southern Africa, Arusha, Tanzania
- University of Global Health Equity, Kigali, Rwanda
| | - Robert K Parker
- Department of Surgery, Tenwek Hospital, PO Box 39, Bomet, 20400, Kenya.
- Department of Surgery, Alpert Medical School of Brown University, Providence, RI, USA.
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Fadipe AE, Parker RK, Tchinde MJN, Eisenhut DA, Parker AS. Assessing knowledge and confidence of surgical residents in inguinal hernia repair using a low-cost synthetic model. Hernia 2023; 27:1461-1466. [PMID: 37725187 DOI: 10.1007/s10029-023-02883-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 09/03/2023] [Indexed: 09/21/2023]
Abstract
PURPOSE Open repair of groin hernia is an essential skill for the general surgeon. This study aimed to develop a low-cost hernia model based on a validated high-fidelity model and assess its effectiveness in teaching inguinal hernia repair to surgical trainees from many institutions throughout Africa. METHODS Using inexpensive, locally available materials, a low-cost hernia model was created. Six models were constructed, and a workshop was conducted for surgical residents. Pre- and post-workshop surveys were administered to assess knowledge, confidence, and understanding. Statistical analyses were performed using paired t tests and the Wilcoxon signed-rank test. RESULTS The low-cost hernia model consisted of various readily available materials and cost an average of $5.07. Sixty-eight trainees participated in the workshop, and 59 completed the post-workshop survey. Participants reported a significant increase in confidence for both mesh and non-mesh repairs and an improved understanding of hernia anatomy after the workshop. Trainees scored an average of 5.6 (SD 1.9) out of 10 questions on the pre-workshop quiz and 7.9 (SD 1.4) out of 10 on the post-workshop quiz (p < 0.001), indicating improved knowledge. All trainees supported the use of the model for education. CONCLUSION The low-cost hernia model demonstrated its effectiveness in enhancing trainees' understanding of hernia anatomy and increasing their confidence in hernia repair. Integrating low-cost hernia models into training programs can help improve trainees' knowledge and confidence in a safe and affordable environment.
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Affiliation(s)
- A E Fadipe
- Department of Surgery, Tenwek Hospital, P.O. Box 39, 20400, Bomet, Kenya
| | - R K Parker
- Department of Surgery, Tenwek Hospital, P.O. Box 39, 20400, Bomet, Kenya.
| | - M J N Tchinde
- Department of Surgery, Mbingo Baptist Hospital, Baingo, Cameroon
| | - D A Eisenhut
- Department of Surgery, Mbingo Baptist Hospital, Baingo, Cameroon
| | - A S Parker
- Department of Surgery, Tenwek Hospital, P.O. Box 39, 20400, Bomet, Kenya
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Mwachiro MM, Yankunze Y, Bachheta N, Scroope E, Mangaoang D, Bekele A, White RE, Parker RK. Operative Case Volumes and Variation for General Surgery Training in East, Central, and Southern Africa. World J Surg 2023; 47:3032-3039. [PMID: 37697170 PMCID: PMC10694114 DOI: 10.1007/s00268-023-07164-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND Operative experience is a necessary part of surgical training. The College of Surgeons of East, Central, and Southern Africa (COSECSA), which oversees general surgery training programs in the region, has implemented guidelines for the minimum necessary case volumes upon completion of two (Membership) and five (Fellowship) years of surgical training. We aimed to review trainee experience to determine whether guidelines are being met and examine the variation of cases between countries. METHODS Operative procedures were categorized from a cohort of COSECSA general surgery trainees and compared to the guideline minimum case volumes for Membership and Fellowship levels. The primary and secondary outcomes were total observed case volumes and cases within defined categories. Variations by country and development indices were explored. RESULTS One hundred ninety-four trainees performed 69,283 unique procedures related to general surgery training. The review included 70 accredited hospitals and sixteen countries within Africa. Eighty percent of MCS trainees met the guideline minimum of 200 overall cases; however, numerous trainees did not meet the guideline minimum for each procedure. All FCS trainees met the volume target for total cases and orthopedics; however, many did not meet the guideline minimums for other categories, especially breast, head and neck, urology, and vascular surgery. The operative experience of trainees varied significantly by location and national income level. CONCLUSIONS Surgical trainees in East, Central, and Southern Africa have diverse operative training experience. Most trainees fulfill the overall case volume requirements; however, further exploration of how to meet the demands of specific categories and procedures is necessary.
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Affiliation(s)
- Michael M Mwachiro
- Department of Surgery, Tenwek Hospital, PO Box 39, Bomet, 20400, Kenya
- College of Surgeons of East, Central, and Southern Africa, Arusha, Tanzania
| | - Yves Yankunze
- Department of Surgery, Tenwek Hospital, PO Box 39, Bomet, 20400, Kenya
| | - Niraj Bachheta
- College of Surgeons of East, Central, and Southern Africa, Arusha, Tanzania
| | - Emma Scroope
- Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Deirdre Mangaoang
- Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Abebe Bekele
- College of Surgeons of East, Central, and Southern Africa, Arusha, Tanzania
- University of Global Health Equity, Kigali, Rwanda
| | - Russell E White
- Department of Surgery, Tenwek Hospital, PO Box 39, Bomet, 20400, Kenya
- Department of Surgery, Alpert Medical School of Brown University, Providence, RI, USA
| | - Robert K Parker
- Department of Surgery, Tenwek Hospital, PO Box 39, Bomet, 20400, Kenya.
- Department of Surgery, Alpert Medical School of Brown University, Providence, RI, USA.
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Bidwell SS, Gates R, Mwachiro MM, Parker AS, Sylvester K, Sandhu G, George BC, Kim GJ, Parker RK. Implementation of a Smartphone-Based Platform for Operative Feedback at Tenwek Hospital in Kenya: A Mixed Methods Study. World J Surg 2023; 47:2617-2625. [PMID: 37689597 DOI: 10.1007/s00268-023-07160-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2023] [Indexed: 09/11/2023]
Abstract
BACKGROUND The SIMPL operative feedback tool is used in many U.S. surgical residency programs. However, the challenges of implementation and benefits of the web-based platform in low- and middle-income countries are unknown. The aim of this study was to evaluate implementation of SIMPL in a general surgery residency training program in Kenya. METHODS SIMPL was pilot tested at Tenwek Hospital from January through December 2021. Participant perspectives of SIMPL were elicited through a survey and semi-structured interviews. Descriptive statistics were used to analyze survey data. Inductive qualitative content analysis of interview responses was performed by two independent researchers. RESULTS Fourteen residents and six faculty (100% response rate) were included in the study and completed over 600 operative assessments. All respondents reported numerical evaluations and dictated feedback were useful. Respondents felt that SIMPL was easy to use, improved quality and frequency of feedback, helped refine surgical skills, and increased resident autonomy. Barriers to use included participants forgetting to complete evaluations, junior residents not submitting evaluations when minimally involved in cases, and technological challenges. Suggestions for improvement included expansion of SIMPL to surgical subspecialties and allowing senior residents to provide feedback to juniors. All respondents wanted to continue using SIMPL, and 90% recommended use at other programs. CONCLUSION Residents and faculty at Tenwek Hospital believed SIMPL were a positive addition to their training program. There were a few barriers to use and suggestions for improvement specific to the training environment in Kenya, but this study demonstrates it is feasible to use SIMPL in settings outside the U.S. with the appropriate resources.
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Affiliation(s)
- Serena S Bidwell
- University of Michigan Medical School, 1301 Catherine Street, 3960 Preserve Drive, Dexter, Ann Arbor, MI, 48130, USA.
| | - Rebecca Gates
- Department of Surgery, Center for Surgical Training and Research, University of Michigan, Michigan Medicine, 1500 E. Medical Center Drive, Ann Arbor, MI, USA
| | - Michael M Mwachiro
- Department of General Surgery and Endoscopy, Tenwek Hospital, 39 Bomet, Bomet, Kenya
| | - Andrea S Parker
- Department of General Surgery and Endoscopy, Tenwek Hospital, 39 Bomet, Bomet, Kenya
| | - Kimutai Sylvester
- Department of General Surgery and Endoscopy, Tenwek Hospital, 39 Bomet, Bomet, Kenya
| | - Gurjit Sandhu
- Department of Surgery, University of Michigan, Michigan Medicine, 1500 E. Medical Center Drive, Ann Arbor, MI, USA
| | - Brian C George
- Department of Surgery, Center for Surgical Training and Research, University of Michigan, Michigan Medicine, 1500 E. Medical Center Drive, Ann Arbor, MI, USA
| | - Grace J Kim
- Department of Surgery, University of Michigan, Michigan Medicine, 1500 E. Medical Center Drive, Ann Arbor, MI, USA
| | - Robert K Parker
- Department of General Surgery and Endoscopy, Tenwek Hospital, 39 Bomet, Bomet, Kenya
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Zadey S, Leraas H, Gupta A, Biswas A, Hollier P, Vissoci JRN, Mugaga J, Ssekitoleko RT, Everitt JI, Loh AHP, Lee YT, Saterbak A, Mueller JL, Fitzgerald TN. KeyLoop retractor for global gasless laparoscopy: evaluation of safety and feasibility in a porcine model. Surg Endosc 2023; 37:5943-5955. [PMID: 37074419 PMCID: PMC10338623 DOI: 10.1007/s00464-023-10054-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 03/26/2023] [Indexed: 04/20/2023]
Abstract
BACKGROUND Many surgeons in low- and middle-income countries have described performing surgery using gasless (lift) laparoscopy due to inaccessibility of carbon dioxide and reliable electricity, but the safety and feasibility of the technique has not been well documented. We describe preclinical testing of the in vivo safety and utility of KeyLoop, a laparoscopic retractor system to enable gasless laparoscopy. METHODS Experienced laparoscopic surgeons completed a series of four laparoscopic tasks in a porcine model: laparoscopic exposure, small bowel resection, intracorporeal suturing with knot tying, and cholecystectomy. For each participating surgeon, the four tasks were completed in a practice animal using KeyLoop. Surgeons then completed these tasks using standard-of-care (SOC) gas laparoscopy and KeyLoop in block randomized order to minimize learning curve effect. Vital signs, task completion time, blood loss and surgical complications were compared between SOC and KeyLoop using paired nonparametric tests. Surgeons completed a survey on use of KeyLoop compared to gas laparoscopy. Abdominal wall tissue was evaluated for injury by a blinded pathologist. RESULTS Five surgeons performed 60 tasks in 15 pigs. There were no significant differences in times to complete the tasks between KeyLoop and SOC. For all tasks, there was a learning curve with task completion times related to learning the porcine model. There were no significant differences in blood loss, vital signs or surgical complications between KeyLoop and SOC. Eleven surgeons from the United States and Singapore felt that KeyLoop could be used to safely perform several common surgical procedures. No abdominal wall tissue injury was observed for either KeyLoop or SOC. CONCLUSIONS Procedure times, blood loss, abdominal wall tissue injury and surgical complications were similar between KeyLoop and SOC gas laparoscopy for basic surgical procedures. This data supports KeyLoop as a useful tool to increase access to laparoscopy in low- and middle-income countries.
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Affiliation(s)
- Siddhesh Zadey
- Department of Surgery, Duke University School of Medicine, Durham, NC, USA.
- Association for Socially Applicable Research (ASAR), Pune, MH, India.
| | - Harold Leraas
- Department of Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Aryaman Gupta
- Department of Biomedical Engineering, Pratt School of Engineering, Duke University, Durham, NC, USA
| | - Arushi Biswas
- Department of Biomedical Engineering, Pratt School of Engineering, Duke University, Durham, NC, USA
- Duke Global Health Institute, Durham, NC, USA
| | | | - Joao Ricardo Nickenig Vissoci
- Department of Surgery, Duke University School of Medicine, Durham, NC, USA
- Duke Global Health Institute, Durham, NC, USA
| | - Julius Mugaga
- Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Jeffrey I Everitt
- Department of Pathology, Duke University of School of Medicine, Durham, NC, USA
| | - Amos H P Loh
- Duke-NUS Medical School, SingHealth Duke-NUS Global Health Institute, Singapore, Singapore
| | - York Tien Lee
- Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore, Singapore
| | - Ann Saterbak
- Department of Biomedical Engineering, Pratt School of Engineering, Duke University, Durham, NC, USA
| | - Jenna L Mueller
- Fischell Department of Bioengineering, University of Maryland, College Park, MD, USA
- Marlene and Stewart Greenebaum Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Tamara N Fitzgerald
- Department of Surgery, Duke University School of Medicine, Durham, NC, USA
- Duke Global Health Institute, Durham, NC, USA
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Implementation of a Surgical Critical Care Service Reduces Failure to Rescue in Emergency Gastrointestinal Surgery in Rural Kenya. Ann Surg 2023; 277:e719-e724. [PMID: 34520427 DOI: 10.1097/sla.0000000000005215] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE We aimed to evaluate the implementation of a dedicated Surgical critical care service (SCCS) on failure to rescue (FTR) rates in rural Kenya. SUMMARY BACKGROUND DATA FTR adversely impacts perioperative outcomes. In the resource-limited contexts of low- and middle-income countries, emergency gastrointestinal surgery carries high morbidity and mortality rates. Quality improvement initiatives that decrease FTR rates are essential for improving perioperative care. METHODS All patients who underwent emergency gastrointestinal surgery between January 2016 and June 2019 at Tenwek Hospital in rural Kenya were reviewed. Critical care capabilities were constant throughout the study period. A supervised surgical resident was dedicated to the daily care of critically ill surgical patients beginning in January 2018. The impact of the SCCS initiation on the outcome of FTR was evaluated, controlling for patient complexity via the African Surgical Outcomes Study Surgical Risk Score. RESULTS A total of 484 patients were identified, consisting of 278 without and 206 with an active SCCS. A total of 165 (34.1%) patients experienced postoperative complications, including 49 mortalities (10.1%) yielding an FTR rate of 29.7%. The FTR rate decreased after SCCS implementation from 36.8% (95% CI: 26.7%-47.8%) to 21.8% (95% CI: 13.2%-32.6%) ( P = 0.035) despite an increase in the average patient African Surgical Outcomes Study score from 14.5 (95% CI, 14.1-14.9) to 15.2 (95% CI, 14.7-15.7) ( P =0.03). CONCLUSIONS The implementation of an SCCS in rural Kenya resulted in decreased rates of FTR despite an increase in patient complexity and severity of critical illness.
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Parker AS, Hill KA, Steffes BC, Mangaoang D, O’Flynn E, Bachheta N, Bates MF, Bitta C, Carter NH, Davis RE, Dressler JA, Eisenhut DA, Fadipe AE, Kanyi JK, Kauffmann RM, Kazal F, Kyamanywa P, Lando JO, Many HR, Mbithi VC, McCoy AJ, Meade PC, Ndegwa WY, Nkusi EA, Ooko PB, Osilli DJ, Parker ME, Rankeeti S, Shafer K, Smith JD, Snyder D, Sylvester KR, Wakeley ME, Wekesa MK, Torbeck L, White RE, Bekele A, Parker RK. Design of a Novel Online, Modular, Flipped-classroom Surgical Curriculum for East, Central, and Southern Africa. ANNALS OF SURGERY OPEN 2022; 3:e141. [PMID: 37600110 PMCID: PMC10431259 DOI: 10.1097/as9.0000000000000141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 01/31/2022] [Indexed: 11/26/2022] Open
Abstract
Objective We describe a structured approach to developing a standardized curriculum for surgical trainees in East, Central, and Southern Africa (ECSA). Summary Background Data Surgical education is essential to closing the surgical access gap in ECSA. Given its importance for surgical education, the development of a standardized curriculum was deemed necessary. Methods We utilized Kern's 6-step approach to curriculum development to design an online, modular, flipped-classroom surgical curriculum. Steps included global and targeted needs assessments, determination of goals and objectives, the establishment of educational strategies, implementation, and evaluation. Results Global needs assessment identified the development of a standardized curriculum as an essential next step in the growth of surgical education programs in ECSA. Targeted needs assessment of stakeholders found medical knowledge challenges, regulatory requirements, language variance, content gaps, expense and availability of resources, faculty numbers, and content delivery method to be factors to inform curriculum design. Goals emerged to increase uniformity and consistency in training, create contextually relevant material, incorporate best educational practices, reduce faculty burden, and ease content delivery and updates. Educational strategies centered on developing an online, flipped-classroom, modular curriculum emphasizing textual simplicity, multimedia components, and incorporation of active learning strategies. The implementation process involved establishing thematic topics and subtopics, the content of which was authored by regional surgeon educators and edited by content experts. Evaluation was performed by recording participation, soliciting user feedback, and evaluating scores on a certification examination. Conclusions We present the systematic design of a large-scale, context-relevant, data-driven surgical curriculum for the ECSA region.
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Affiliation(s)
- Andrea S. Parker
- From the Department of Surgery, Tenwek Hospital, Bomet, Kenya
- Department of Surgery, Alpert Medical School of Brown University, Providence, RI
- College of Surgeons of East, Central, and Southern Africa, Arusha, Tanzania
| | - Katherine A. Hill
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | - Deirdre Mangaoang
- Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Eric O’Flynn
- Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Niraj Bachheta
- College of Surgeons of East, Central, and Southern Africa, Arusha, Tanzania
| | - Maria F. Bates
- Department of Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | - Caesar Bitta
- Department of Surgery, Maseno University, Kisumu, Kenya
| | | | | | | | | | | | - John K. Kanyi
- Department of Surgery, AIC Litein Hospital, Litein, Kenya
| | - Rondi M. Kauffmann
- Department of Surgery, Vanderbilt University Medical Center, Division of Oncologic and Endocrine Surgery, Nashville, TN
| | - Frances Kazal
- Warren Alpert Medical School at Brown University, Providence, RI
| | - Patrick Kyamanywa
- Department of Surgery, Kampala International University, Kampala, Uganda
| | - Justus O. Lando
- From the Department of Surgery, Tenwek Hospital, Bomet, Kenya
| | - Heath R. Many
- Department of Surgery, University of Tennessee Medical Center, Knoxville, TN
| | | | - Amanda J. McCoy
- Department of Orthopedic Surgery, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | | | - Wairimu Y.B. Ndegwa
- Department of Surgery, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Emmy A. Nkusi
- Department of Surgery, Rwanda Military Hospital, Kigali, Rwanda
| | - Philip B. Ooko
- Department of Surgery, AIC Litein Hospital, Litein, Kenya
| | - Dixon J.S. Osilli
- Department of Surgery, Barking, Havering, and Redbridge University Hospitals NHS Trust, Romford, England, UK
| | | | | | | | - James D. Smith
- Department of Surgery, Oregon Health & Science University, Portland, OR
| | - David Snyder
- Pan-African Academy of Christian Surgeons, Palatine, Illinois
| | | | - Michelle E. Wakeley
- Department of Surgery, Alpert Medical School of Brown University, Providence, RI
| | | | - Laura Torbeck
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Russell E. White
- From the Department of Surgery, Tenwek Hospital, Bomet, Kenya
- Department of Surgery, Alpert Medical School of Brown University, Providence, RI
- College of Surgeons of East, Central, and Southern Africa, Arusha, Tanzania
| | - Abebe Bekele
- College of Surgeons of East, Central, and Southern Africa, Arusha, Tanzania
- University of Global Health Equity, Kigali, Rwanda
- Department of Surgery, Addis Ababa University, Addis Ababa, Ethiopia
| | - Robert K. Parker
- From the Department of Surgery, Tenwek Hospital, Bomet, Kenya
- Department of Surgery, Alpert Medical School of Brown University, Providence, RI
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A thematic review of the use of electronic logbooks for surgical assessment in sub-Saharan Africa. Surgeon 2021; 20:57-60. [PMID: 34922837 DOI: 10.1016/j.surge.2021.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 10/26/2021] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Ensuring that surgical training programmes in low- and middle-income countries (LMICs) provide high quality training, including adequate operative experience, is of crucial importance in meeting the goals set out in the Lancet Global Surgery 2030. Electronic logbooks (eLogbooks) have been adopted to monitor both individual trainee progression and the performance of surgical training programmes. METHODS We performed a thematic review of the current evidence base surrounding the use of eLogbooks for the assessment of surgeons in training in sub-Saharan Africa, with a view to identifying the learning to date and areas for future research. RESULTS Whilst there are multiple papers highlighting the use of surgical eLogbooks in high-income countries, we identified only three papers which discussed their use in sub-Saharan Africa. Four common themes emerged which related to the use of surgical eLogbooks throughout sub-Saharan Africa: ease of analysis, centralised databases, discrepancies in reporting and technology limitations. CONCLUSIONS Robust data to demonstrate trainee progression and the quality of surgical training programmes are of crucial importance in ensuring that surgical training programmes can rapidly scale up to deliver large numbers of well-trained surgical providers to address the unmet patient need in LMICs in the next decade. The limited data on the use of well designed, centralised electronic surgical logbooks indicate that this tool may play an important role in providing key data to underpin these training programmes.
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Pohl L, Naidoo M, Rickard J, Abahuje E, Kariem N, Engelbrecht S, Kloppers C, Sibomana I, Chu K. Surgical Trainee Supervision During Non-Trauma Emergency Laparotomy in Rwanda and South Africa. JOURNAL OF SURGICAL EDUCATION 2021; 78:1985-1992. [PMID: 34183277 DOI: 10.1016/j.jsurg.2021.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 05/21/2021] [Accepted: 05/29/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE The primary objective was to describe the level of surgical trainee autonomy during non-trauma emergency laparotomy (NTEL) operations in Rwanda and South Africa. The secondary objective was to identify potential associations between trainee autonomy, and patient mortality and reoperation. DESIGN, SETTING, AND PARTICIPANTS This was a prospective, observational study of NTEL operations at 3 teaching hospitals in South Africa and Rwanda over a 1-year period from September 1, 2017 to August 31, 2018. The study included 543 NTEL operations performed by the acute care and general surgery services on adults over the age of 18 years. RESULTS Surgical trainees led 3-quarters of NTEL operations and, of these, 72% were performed autonomously in Rwanda and South Africa. Notably, trainee autonomy was not significantly associated with reoperation or mortality. CONCLUSIONS Trainees were able to gain autonomous surgical experience without impacting mortality or reoperation outcomes, while still providing surgical support in a high-demand setting.
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Affiliation(s)
- Linda Pohl
- Department of Surgery, University of Cape Town, Cape Town, South Africa
| | - Megan Naidoo
- Centre for Global Surgery, Department of Global Health, Stellenbosch University, Cape Town, South Africa
| | - Jennifer Rickard
- Department of Surgery, University Teaching Hospital of Kigali, Kigali, Rwanda; Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Egide Abahuje
- Department of Surgery, University of Rwanda, Kigali, Rwanda; Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Nazmie Kariem
- Department of Surgery, University of Cape Town, Cape Town, South Africa; Department of Surgery, New Somerset Hospital, Cape Town, South Africa
| | | | - Christo Kloppers
- Department of Surgery, University of Cape Town, Cape Town, South Africa
| | - Isaie Sibomana
- Department of Surgery, University of Rwanda, Kigali, Rwanda
| | - Kathryn Chu
- Centre for Global Surgery, Department of Global Health, Stellenbosch University, Cape Town, South Africa.
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Abbott KL, Kwakye G, Kim GJ, Luckoski JL, Krumm AE, Clark M, Chen X, Gupta T, Weiser TG, George BC. US general surgical trainee performance for representative global surgery procedures. Am J Surg 2021; 223:224-228. [PMID: 34119330 DOI: 10.1016/j.amjsurg.2021.05.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 05/06/2021] [Accepted: 05/31/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Many US general surgery residents are interested in global surgery, but their competence with key procedures is unknown. METHODS Using a registry managed by the Society for Improving Medical Professional Learning (SIMPL), we extracted longitudinal operative performance ratings data for a national cohort of US general surgery residents. Operative performance at the time of graduation was estimated via a Bayesian generalized linear mixed model. RESULTS Operative performance ratings for 12,976 procedures performed by 1584 residents in 52 general surgery programs were analyzed. These spanned 17 of 31 (55%) procedures deemed important for global surgical practice. For these procedures, the probability of a graduating resident being deemed competent to perform a procedure was 0.95 (95% confidence interval 0.86-1.00) but was less than 0.9 for 3 observed procedures. CONCLUSION Our results highlight gaps in the preparedness of US general surgery trainees to perform procedures deemed most important for global surgery settings.
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Affiliation(s)
- Kenneth L Abbott
- Center for Surgical Training and Research, Department of Surgery, University of Michigan, Ann Arbor, MI, USA; University of Michigan Medical School, Ann Arbor, MI, USA
| | - Gifty Kwakye
- Center for Surgical Training and Research, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Grace J Kim
- Center for Surgical Training and Research, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - John L Luckoski
- Center for Surgical Training and Research, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Andrew E Krumm
- Center for Surgical Training and Research, Department of Surgery, University of Michigan, Ann Arbor, MI, USA; Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, USA
| | - Michael Clark
- Consulting for Statistics, Computing, and Analytics Research, University of Michigan, Ann Arbor, MI, USA
| | - Xilin Chen
- Center for Surgical Training and Research, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Tanvi Gupta
- Center for Surgical Training and Research, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Thomas G Weiser
- Stanford University School of Medicine, Department of Surgery, Division of General Surgery, Section of Trauma & Critical Care, Stanford, CA, USA; Department of Clinical Surgery, University of Edinburgh, Edinburgh, UK
| | - Brian C George
- Center for Surgical Training and Research, Department of Surgery, University of Michigan, Ann Arbor, MI, USA.
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Lemfuka AD, Huang AH. Plastic surgery within global surgery: the incidence of plastic surgery cases in a rural Gabonese hospital. EUROPEAN JOURNAL OF PLASTIC SURGERY 2021. [DOI: 10.1007/s00238-021-01837-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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13
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Parker RK, Mwachiro MM, Topazian HM, Davis R, Nyanga AF, O'Connor Z, Burgert SL, Topazian MD. Gastrointestinal endoscopy experience of surgical trainees throughout rural Africa. Surg Endosc 2020; 35:6708-6716. [PMID: 33258037 DOI: 10.1007/s00464-020-08174-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 11/15/2020] [Indexed: 01/26/2023]
Abstract
BACKGROUND Gastrointestinal endoscopy (GIE) is not routinely accessible in many parts of rural Africa. As surgical training expands and technology progresses, the capacity to deliver endoscopic care to patients improves. We aimed to describe the current burden of gastrointestinal (GI) disease undergoing GIE by examining the experience of surgical training related to GIE. METHODS A retrospective review was conducted on GIE procedures performed by trainees with complete case logs during 5-year general surgery training at Pan-African Academy of Christian Surgeons (PAACS) sites. Cases were classified according to diagnosis and/or indication, anatomic location, intervention, adverse events, and outcomes. Comparisons were performed by institutional location and case volumes. Analysis was performed for trainee self-reported autonomy by post-graduate year and case volume experience. RESULTS Twenty trainees performed a total of 2181 endoscopic procedures. More upper endoscopies (N = 1,853) were performed than lower endoscopies (N = 325). Of all procedures, 546 (26.7%) involved a cancer or mass, 267 (12.2%) involved a report of blood loss, and 452 (20.7%) reported pain as a component of the diagnosis. Interventions beyond biopsy were reported in 555 (25%) procedures. Esophageal indications predominated the upper endoscopies, particularly esophageal cancer. Trainees in high-volume centers and in East Africa performed more interventional endoscopy and procedures focused on esophageal cancer. Procedure logs documented adverse events in 39 cases (1.8% of all procedures), including 16 patients (0.8%) who died within 30 days of the procedure. Self-reported autonomy improved with both increased endoscopy experience and post-graduate year. CONCLUSIONS GIE is an appropriate component of general surgery residency training in Africa, and adequate training can be provided, particularly in upper GI endoscopy, and includes a wide variety of endoscopic therapeutic interventions.
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Affiliation(s)
- Robert K Parker
- Department of Surgery, Tenwek Hospital, PO Box 39, Bomet, 20400, Kenya. .,Department of Surgery, Alpert Medical School of Brown University, Providence, RI, USA.
| | - Michael M Mwachiro
- Department of Surgery, Tenwek Hospital, PO Box 39, Bomet, 20400, Kenya.,Department of Endoscopy, Tenwek Hospital, Bomet, Kenya
| | - Hillary M Topazian
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Richard Davis
- Department of Surgery, AIC Kijabe Hospital, Kijabe, Kenya
| | - Albert F Nyanga
- Department of Internal Medicine, Mbingo Baptist Hospital, Bamenda, Cameroon
| | | | | | - Mark D Topazian
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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14
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Operative Case Volume Minimums Necessary for Surgical Training Throughout Rural Africa. World J Surg 2020; 44:3245-3258. [DOI: 10.1007/s00268-020-05609-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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