Fidelity in Academic Global Surgery and Research: Incorporating Trustworthiness in the Development of Research Partnerships, Infrastructure, and Policy

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.

Correction: Academic global surgical competencies: A modified Delphi consensus study

[This corrects the article DOI: 10.1371/journal.pgph.0002102.].

Remote Robotic Surgery and Virtual Education Platforms: How Advanced Surgical Technologies Can Increase Access to Surgical Care in Resource-Limited Settings

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.

Academic global surgical competencies: A modified Delphi consensus study

Academic global surgery is a rapidly growing field that aims to improve access to safe surgical care worldwide. However, no universally accepted competencies exist to inform this developing field. A consensus-based approach, with input from a diverse group of experts, is needed to identify essential competencies that will lead to standardization in this field. A task force was set up using snowball sampling to recruit a broad group of content and context experts in global surgical and perioperative care. A draft set of competencies was revised through the modified Delphi process with two rounds of anonymous input. A threshold of 80% consensus was used to determine whether a competency or sub-competency learning objective was relevant to the skillset needed within academic global surgery and perioperative care. A diverse task force recruited experts from 22 countries to participate in both rounds of the Delphi process. Of the n = 59 respondents completing both rounds of iterative polling, 63% were from low- or middle-income countries. After two rounds of anonymous feedback, participants reached consensus on nine core competencies and 31 sub-competency objectives. The greatest consensus pertained to competency in ethics and professionalism in global surgery (100%) with emphasis on justice, equity, and decolonization across multiple competencies. This Delphi process, with input from experts worldwide, identified nine competencies which can be used to develop standardized academic global surgery and perioperative care curricula worldwide. Further work needs to be done to validate these competencies and establish assessments to ensure that they are taught effectively.

Establishing a baseline for surgical care in Mongolia: a situational analysis using the six indicators from the Lancet Commission on Global Surgery

OBJECTIVES

To inform national planning, six indicators posed by the Lancet Commission on Global Surgery were collected for the Mongolian surgical system. This situational analysis shows one lower middle-income country's ability to collect the indicators aided by a well-developed health information system.

DESIGN

An 11-year retrospective analysis of the Mongolian surgical system using data from the Health Development Center, National Statistics Office and Household Socio-Economic Survey. Access estimates were based on travel time to capable hospitals. Provider density, surgical volume and postoperative mortality were calculated at national and regional levels. Protection against impoverishing and catastrophic expenditures was assessed against standard out-of-pocket expenditure at government hospitals for individual operations.

SETTING

Mongolia's 81 public hospitals with surgical capability, including tertiary, secondary and primary/secondary facilities.

PARTICIPANTS

All operative patients in Mongolia's public hospitals, 2006-2016.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcomes were national-level results of the indicators. Secondary outcomes include regional access; surgeons, anaesthesiologists and obstetricians (SAO) density; surgical volume; and perioperative mortality.

RESULTS

In 2016, 80.1% of the population had 2-hour access to essential surgery, including 60% of those outside the capital. SAO density was 47.4/100 000 population. A coding change increased surgical volume to 5784/100 000 population, and in-hospital mortality decreased from 0.27% to 0.14%. All households were financially protected from caesarean section. Appendectomy carried 99.4% and 98.4% protection, external femur fixation carried 75.4% and 50.7% protection from impoverishing and catastrophic expenditures, respectively. Laparoscopic cholecystectomy carried 42.9% protection from both.

CONCLUSIONS

Mongolia meets national benchmarks for access, provider density, surgical volume and postoperative mortality with notable limitations. Significant disparities exist between regions. Unequal access may be efficiently addressed by strengthening or building key district hospitals in population-dense areas. Increased financial protections are needed for operations involving hardware or technology. Ongoing monitoring and evaluation will support the development of context-specific interventions to improve surgical care in Mongolia.

A Nationwide Assessment of Pediatric Surgical Capacity in Mongolia

BACKGROUND

Mongolia is a country characterized by its vast distances and extreme climate. An underdeveloped medical transport infrastructure makes patient transfer from outlying regions dangerous. Providing pediatric surgical care locally is crucial to improve the lives of children in the countryside. This is the first structured assessment of nationwide pediatric surgical capacity.

METHODS

Operation rates were calculated using data from the Mongolian Center for Health Development and population data from the Mongolian Statistical Information Service. The Pediatric Personnel, Infrastructure, Procedures, Equipment, and Supplies (PediPIPES) survey tool was used to collect data at all survey sites. Descriptive data analyses were completed using Excel. Studies of association were completed using Stata. All reported percentages are of the hospitals outside of the capital (n = 21).

RESULTS

All provincial hospitals have general surgeons; seven (33.3%) of them have pediatric surgeon(s). One facility has no anesthesiologist. All facilities perform basic procedures and provide anesthesia. Four (19%) can treat common congenital anomalies. All facilities have basic operating room equipment. Nine hospitals do not have pulse oximetry available. Twelve hospitals do not have pediatric surgical instruments always available. Pediatric supplies are lacking.

CONCLUSIONS

Provincial hospitals in Mongolia can perform basic procedures. However, essential pediatric supplies are lacking. Consequently, certain life-saving procedures are not available to children outside of the capital. Only a few improvements would be amendable to low-cost process improvement adjustment, and the majority of needs require resource additions. Procedure, equipment, and supply availability should be further explored to develop a comprehensive nationwide pediatric surgical program.

Global Surgery 2030: a roadmap for high income country actors

The Millennium Development Goals have ended and the Sustainable Development Goals have begun, marking a shift in the global health landscape. The frame of reference has changed from a focus on 8 development priorities to an expansive set of 17 interrelated goals intended to improve the well-being of all people. In this time of change, several groups, including the Lancet Commission on Global Surgery, have brought a critical problem to the fore: 5 billion people lack access to safe, affordable surgical and anaesthesia care when needed. The magnitude of this problem and the world's new focus on strengthening health systems mandate reimagined roles for and renewed commitments from high income country actors in global surgery. To discuss the way forward, on 6 May 2015, the Commission held its North American launch event in Boston, Massachusetts. Panels of experts outlined the current state of knowledge and agreed on the roles of surgical colleges and academic medical centres; trainees and training programmes; academia; global health funders; the biomedical devices industry, and news media and advocacy organisations in building sustainable, resilient surgical systems. This paper summarises these discussions and serves as a consensus statement providing practical advice to these groups. It traces a common policy agenda between major actors and provides a roadmap for maximising benefit to surgical patients worldwide. To close the access gap by 2030, individuals and organisations must work collectively, interprofessionally and globally. High income country actors must abandon colonial narratives and work alongside low and middle income country partners to build the surgical systems of the future.

Expansion of laparoscopic cholecystectomy in a resource limited setting, Mongolia: a 9-year cross-sectional retrospective review

BACKGROUND

The benefits of laparoscopic cholecystectomy have been largely unavailable to most people in developing countries. Mongolia has an extremely high incidence of gallbladder disease. In 2005, only 2% of cholecystectomies were being done laparoscopically. Open cholecystectomies were associated with high rates of wound infections, complications, and increased recovery time. Because of the unacceptable complications associated with open cholecystectomies, and nearly 50% of the nomadic population needing faster post-operative recovery times, a national project for the development of laparoscopic surgery was organised. Multi-institutional collaboration between the Mongolia Health Sciences University, the Dr W C Swanson Family Foundation (SFF), the University of Utah, Intermountain Healthcare, and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) led to the promulgation of a formalised countrywide laparoscopic training programme during the past 9 years. This is a retrospective review of the transition from open to laparoscopic cholecystectomy throughout Mongolia.

METHODS

Demographic patient data, diagnosis, and operation preformed-laparoscopic versus open cholecystectomy, between January, 2005, and September, 2013, were collected and trends were analysed from seven regional diagnostic referral and treatment centres, and two tertiary academic medical centres from six of the 21 provinces (Aimags) throughout Mongolia. Data were analysed by individual training centre, by year, and then compared between rural and urban centres.

FINDINGS

Nearly 16 000 cholecystectomies were analysed and compared (4417 [28·2%] men; 11 244 [71·8%] women). Men and women underwent laparoscopic cholecystectomy with the same frequency (41·2% men, 43·2% women) and had similar age (men, mean 52·2 years [SD 14·8]; women, mean 49·4 years [SD 15·7]). By 2013, 62% of gallbladders were removed laparoscopically countrywide as opposed to only 2% in 2005. More than 315 Mongolian practitioners have received laparoscopic training in 19 of 21 Aimags. On average 60% of cholecystectomies are done laparoscopically in urban surgical centres, up from 2%, versus 55% in rural surgical centres, up from 0%, in 2005. Laparoscopic cholecystectomy surpassed open cholecystectomy as the primary method for gallbladder removal countrywide in 2011.

INTERPRETATION

By 2013, 62% of cholecystectomies countrywide were done laparoscopically, a great increase from 9 years ago. Despite being a resource limited country, the expansion of laparoscopic cholecystectomy has transformed the care of biliary tract disease in Mongolia.

FUNDING

The University of Utah Center for Global Surgery.