The Tsao Fellowship in Global Health: A Model for International Fellowships in a Surgery Residency

Effect of Training Backgrounds on Plastic Surgery Leadership: A Logistic Regression Analysis

Background

Although career choices are often shaped by training and mentors, it is not clear how training backgrounds have influenced whether plastic surgeons pursue leadership positions. Analysis of these training pathways can serve as a key component of career planning for future leaders.

Methods

The American Board of Plastic Surgery's annual Newsletter to Diplomates was used to collate surgeons receiving board certification between 2002 and 2013. Online public profiles were used to collect training background data about each surgeon, including fellowship training, board certification year, MBA degree, otolaryngology or maxillofacial surgery training before commencing plastic surgery training, and leadership positions in surgery. A logistic multinomial regression was used to test the effect of training backgrounds on different types of leadership positions.

Results

In total, 2190 plastic surgeons were included in the analysis. Factors increasing the probability of holding any type of position included fellowships in microsurgery, craniofacial, and hand; an international fellowship; multiple fellowships; a fellowship not otherwise specified; and MBA degree. Training background factors affected probabilities differently for each of the studied positions including chair/chief, vice chair/vice chief, program director, plastic surgery medical director, other institutional positions, and national society positions.

Conclusions

Training backgrounds of plastic surgeons in leadership positions are multifaceted, involving a mix of intrinsic and extrinsic factors such as additional educational pursuits, subspecialty training, duration of practice, and practice setting. This analysis can help direct current trainees who aspire to future leadership in plastic surgery.

Interest in global surgery rotations among oral and maxillofacial surgical residents in the United States

PURPOSE

This study sought to assess interest in global surgery rotations among current United States (US)-based oral and maxillofacial surgery (OMS) residents.

METHODS

An anonymous 23-question survey was distributed to 633 current OMS residents in the US to examine resident interest in global surgery rotations during residency. The primary outcome variable was resident interest in participating in global OMS rotations during residency training, whereas the primary predictor variable was the presence of residency faculty involved in global OMS work. Descriptive statistics were calculated for all study variables and univariate/multivariate logistic regression analyses were conducted to identify predictors of interest in global OMS rotations.

RESULTS

A total of 120 residents with an average age of 30.4 ± 3.2 years responded to the survey. At present, 22 (18.5%) residents stated that their residency programs offer some sort of global OMS rotation and 21 (95.5%) of these claimed they were willing to participate in global OMS rotations at their residency program. Out of the residents who stated their program did not offer a global OMS rotation, 86 (87.8%) respondents stated they would be interested in adding a dedicated global OMS rotation to their residency curriculum. The presence of OMS residency faculty involved in global OMS work (p = 0.030) and a resident's willingness to dedicate vacation time to participate in a global surgery rotation (p = 0.005) were associated with increased interest in a global surgery rotation.

CONCLUSION

The majority of respondents would welcome a dedicated global OMS rotation during their residency training.

Publishing Trends in International Humanitarian Cleft Lip and Palate Care: A Systematic Review

Background: Humanitarian outreach delivers essential cleft lip and palate (CLP) care in low- and middle-income countries. Objective: To review the literature regarding humanitarian CLP care and determine if a shift toward more sustainable care delivery is observed. Methods: A systematic review was performed on articles describing CLP repair in humanitarian settings from 1985 to 2020. Publications were categorized into trip reports, outcomes, teaching, and public health. Articles were stratified into three 12-year intervals (T1-T3) for analysis. Results: A total of 246 publications were included. Average annual publications increased 15.4-fold from T1 to T3 (p < 0.001). Among publications focused on delivering CLP-related care, descriptive trip report articles trended downward (58% in T1 vs. 42% in T3), whereas outcome-focused publications trended upward (42% in T1 vs. 58% T3). Public health research represented the greatest percentage of publications in T3 (50%). There were 22 teaching-related publications in T3 and only one in prior years. Conclusion: Research trends demonstrate a shift away from focusing solely on the number of surgical cases completed and toward more sustainable models of care delivery that address barriers to receiving longitudinal care.

Academic Global Surgery Curricula: Current Status and a Call for a More Equitable Approach

INTRODUCTION

We aimed to search the literature for global surgical curricula, assess if published resources align with existing competency frameworks in global health and surgical education, and determine if there is consensus around a fundamental set of competencies for the developing field of academic global surgery.

METHODS

We reviewed SciVerse SCOPUS, PubMed, African Medicus Index, African Journals Online (AJOL), SciELO, Latin American and Caribbean Health Sciences Literature (LILACS) and Bioline for manuscripts on global surgery curricula and evaluated the results using existing competency frameworks in global health and surgical education from Consortium of the Universities for Global Health (CUGH) and Accreditation Council for Graduate Medical Education (ACGME) professional competencies.

RESULTS

Our search generated 250 publications, of which 18 were eligible: (1) a total of 10 reported existing competency-based curricula that were concurrent with international experiences, (2) two reported existing pre-departure competency-based curricula, (3) six proposed theoretical competency-based curricula for future global surgery education. All, but one, were based in high-income countries (HICs) and focused on the needs of HIC trainees. None met all 17 competencies, none cited the CUGH competency on "Health Equity and Social Justice" and only one mentioned "Social and Environmental Determinants of Health." Only 22% (n = 4) were available as open-access.

CONCLUSION

Currently, there is no universally accepted set of competencies on the fundamentals of academic global surgery. Existing literature are predominantly by and for HIC institutions and trainees. Current frameworks are inadequate for this emerging academic field. The field needs competencies with explicit input from LMIC experts to ensure creation of educational resources that are accessible and relevant to trainees from around the world.

Global Surgery Fellowships-An Investigation of Opportunities, Outcomes, and Applicants

Following the Lancet Commission on Global Surgery in 2015, the Global Surgery Fellowships have risen in popularity, advertised as formalized opportunities for surgical trainees who have an interest in international surgical care. There is currently no up-to-date review of all fellowships available and an urgently needed overview of these opportunities is presented, including critical appraisal of their accessibility, funding, and outcomes. Detailed searches were conducted on the web engine Google, using the term "global surgery fellowship" and iterations. From the 547 resulting links, after applying exclusion criteria, 69 relevant fellowships were included in analysis. The majority of fellowships based in the United States (55%) and arranged by non-governmental organizations (NGOs) or universities (>70%). Also, 60% of fellowships had a duration of 1 year or longer. Only a quarter of the fellowships was open solely to trainees from low- or middle-income countries (LMIC), with over 80% of these being full funded. But 40% of the fellowships were advertised as open to trainees from any country, though only one-third of these provided full funding. Key themes across the fellowships' outcomes included "Professional Development," "Research," and "LMIC Quality Improvement." Almost all of the fellowships (95%) stated international travel opportunities. Twelve of the fellowships offered higher degrees, with the most common being a Masters of Public Health. The global distribution of fellowships and reduced funding opportunities for trainees from LMIC limit accessibility of the Global Surgery Fellowships. It is, however, still promising that most of key themes and high rates of international work are in line with The Lancet Commission's recommendations. This overview of the Global Surgery Fellowships highlights the need for collaboration between institutions and has illustrated points for consideration when introducing new and the value of established fellowships.

Trainee Perspectives Regarding Advanced Clinical Global Health Fellowships in North America

Postgraduate clinical global health (GH) training is a rapidly evolving field. To understand and improve training opportunities, we sought the perspectives of current and former trainees related to their advanced clinical training or global health fellowships and the anticipated impact on their careers. Clinical GH fellowships across North America were identified through websites and previous studies. An e-mail was sent to program directors to invite all current and former GH fellows to complete a web-based questionnaire. We contacted 100 GH fellowship programs. Fifty-two fellows from 10 different specialties completed the survey. The median fellowship length was 23.3 months, with an annual median of 4.8 months spent in low-income and middle-income countries, which was less than their reported ideal of 6 months. The majority reported satisfaction, the anticipation of career benefits, and that they would recommend fellowship training to others. Challenges included insufficient funding, mentorship, and formal curricula. Conducting research in high-income countries was a significant negative predictor of fellowship satisfaction. Most fellows (73.1%) were not at all or only a little concerned about the absence of fellowship accreditation, with only 17.3% desiring accreditation. Survey respondents were largely satisfied with their training and valued program flexibility and educational opportunities, including advanced tropical medicine certificates or diplomas. However, to improve fellowship training, improvements are needed in mentorship, standardized curricula, institutional support, and funding. For GH fellowship training to be effective and sustainable, institutions will need to balance the needs of fellows, training programs, and the communities (low-, middle-, and high-income countries) where the fellows serve.

Global Health Education Programs in the Americas: A Scoping Review

Background:

The interest in Global Health (GH) as an academic discipline has increased in the last decade. This article reports the findings of a scoping review of studies about Global Health education in the Americas.

Objective:

To analyse educational programs on global health in the Americas.

Method:

Five electronic databases were used in a scoping review: PubMed, Scopus, Web of Knowledge, CINAHL, and Lilacs. Data collection happened in November 2017–March 2018. The following stages were rigorously observed: identification, selection, charting, and summarizing the studies that were included. To process the data, we used IRaMuTeQ software.

Findings:

Forty-six studies were identified and organized in categories: 1) diversity of the topics addressed in GH; 2) models of teaching; 3) emotional, cultural, and collaborative aspects in teaching GH; 4) student preparation for GH experiences; and 5) structures required for a GH course.

Conclusions:

The existing global health curriculum in the Americas is diffuse and limited, with a greater focus on clinical aspects. Thus, a minimum curriculum for students from different areas is needed. Results evidenced that the teaching of global health in the Americas is still incipient, although it is promising. The lack of a common curriculum for the courses in the region makes it difficult to train sensitive and capable professionals to achieve the 2030 Sustainable Development Goals.

Transitions in care from pediatric to adult general surgery: Evaluating an unmet need for patients with anorectal malformation and Hirschsprung disease

BACKGROUND

The provision of timely and comprehensive transition of care from pediatric to adult surgical providers for patients who have undergone childhood operations remains a challenge. Understanding the barriers to transition from a patient and family perspective may improve this process.

METHODS

A cross-sectional survey was conducted of patients with a history of anorectal malformation (ARM) or Hirschsprung Disease (HD) and their families. The web-based survey was administered through two support groups dedicated to the needs of individuals born with these congenital abnormalities. Categorical variables were compared using Chi-squared and Fisher's exact test with Student's t test and ANOVA for continuous variables.

RESULTS

A total of 118 surveys were completed (approximately 26.2% response). The average age of patients at time of survey was 12.3years (SD 11.6) with 64.5% less than 15years old. The primary diagnosis was reported for 78.8% patients and included HD (29.0%), ARM (61.3%), and cloaca (9.7%). The average distance traveled for ongoing care was 186.6miles (SD 278.3) with 40.9% of patients traveling ≥30miles; the distance was statistically significantly greater for patients with ARM (p<0.001). With regards to ongoing symptoms, 44.1% experience constipation, 40.9% experience diarrhea, and approximately 40.9% require chronic medication for management of bowel symptoms; only 3 respondents (3.2%) reported fecal incontinence. The majority of patients, 52.7% reported being seen by a provider at least twice per year and the majority continued to be followed by a pediatric provider, consistent with the majority of the cohort being less than 18years of age. Conversations with providers regarding transitioning to an adult physician had occurred in fewer than 13% of patients. The most commonly cited barrier to transition was the perception that adult providers would be ill-equipped to manage the persistent bowel symptoms.

CONCLUSION

Patients undergoing childhood procedures for ARM or HD have a high prevalence of ongoing symptoms related to bowel function but very few have had conversations regarding transitions in care. Early implementation of transitional care plans and engagement of adult providers are imperative to transitions and may confer long-term health benefits in this patient population.

LEVEL OF EVIDENCE

Level IV, case series with no comparison group.

Characterizing pediatric surgical capacity in the Eastern Democratic Republic of Congo: results of a pilot study

PURPOSE

Characterize pediatric surgical capacity in the eastern Democratic Republic of Congo (DRC) to identify areas of potential improvement.

METHODS

The Pediatric Personnel, Infrastructure, Procedures, Equipment, and Supplies (PediPIPES) survey was used in two representative eastern DRC provinces to assess existing surgical infrastructure and capacity. We compared our results to previously published reports from other sub-Saharan African countries.

RESULTS

Fourteen hospitals in the eastern DRC and 37 in 19 sub-Saharan African (SSA) countries were compared. The average PediPIPES index for the DRC was 7.7 compared to 13.5 for SSAs. The greatest disparities existed in the areas of personnel and infrastructure. Running water was reportedly available to 57.1% of the hospitals in the DRC, and the majority of hospitals (78.6%) were dependent on generators and solar panels for electricity. Only two hospitals in the DRC (14.3%) reported a pediatric surgeon equivalent on staff, compared to 86.5% of facilities sampled in SSA reporting ≥ 1 pediatric surgeon.

CONCLUSIONS

Significant barriers in personnel, infrastructure, procedures, equipment, and supplies impede the provision of adequate surgical care to children. Further work is needed to assess allocation and utilization of existing resources, and to enhance training of personnel with specific attention to pediatric surgery.

Global Burn Care: Education and Research

Burns are an often-overlooked health indicator in global health literature, but account for a significant global health burden in lower middle income countries. This article provides an overview of burn injury from the global health perspective. It focuses on education and research, emphasizing the appropriate role of volunteerism.

Plastic and Reconstructive Surgery in Global Health: Let's Reconstruct Global Surgery

Since the inception of the Lancet Commission in 2013 and consequent prioritization of Global Surgery at the World Health Assembly, international surgical outreach efforts have increased and become more synergistic. Plastic surgeons have been involved in international outreach for decades, and there is now a demand to collaborate and address local need in an innovative way. The aim of this article was to summarize new developments in plastic and reconstructive surgery in global health, to unify our approach to international outreach. Specifically, 5 topics are explored: current models in international outreach, benefits and concerns, the value of research, the value of international surgical outreach education, and the value of technology. A “Let’s Reconstruct Global Surgery” network has been formed using Facebook as a platform to unite plastic and reconstructive surgeons worldwide who are interested in international outreach. The article concludes with actionable recommendations from each topic.