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Global Neurosurgery: Models for International Surgical Education and Collaboration at One University

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Global Neurosurgery: Models for International Surgical Education and Collaboration at One University NEUROSURGICAL FOCUS Neurosurg Focus 45 (4):E5, 2018 Global neurosurgery: models for international surgical education and collaboration at one university Joao Paulo Almeida, MD,1 Carlos Velásquez, MD,1,2 Claire Karekezi, MD,1 Miguel Marigil, MD, PhD,1 Mojgan Hodaie, MD, PhD,1 James T. Rutka, MD, PhD, FRCSC,1 and Mark Bernstein, MD, MHSc, FRCSC1 1Division of Neurosurgery, Toronto Western Hospital/University Health Network, University of Toronto, Ontario, Canada; and 2Hospital Universitario Marqués de Valdecilla and Fundación Instituto de Investigación Marqués de Valdecilla, Santander, Spain OBJECTIVE International collaborations between high-income (HICs) and low- and middle-income countries (LMICs) have been developed as an attempt to reduce the inequalities in surgical care around the world. In this paper the authors review different models for international surgical education and describe projects developed by the Division of Neurosur- gery at the University of Toronto in this field. METHODS The authors conducted a review of models of international surgical education reported in the literature in the last 15 years. Previous publications on global neurosurgery reported by the Division of Neurosurgery at the University of Toronto were reviewed to exemplify the applications and challenges of international surgical collaborations. RESULTS The most common models for international surgical education and collaboration include international surgical missions, long-term international partnerships, fellowship training models, and online surgical education. Development of such collaborations involves different challenges, including limited time availability, scarce funding/resources, socio- cultural barriers, ethical challenges, and lack of organizational support. Of note, evaluation of outcomes of international surgical projects remains limited, and the development and application of assessment tools, such as the recently pro- posed Framework for the Assessment of International Surgical Success (FAIRNeSS), is encouraged. CONCLUSIONS Actions to reduce inequality in surgical care should be implemented around the world. Different mod- els can be used for bilateral exchange of knowledge and improvement of surgical care delivery in regions where there is poor access to surgical care. Implementation of global neurosurgery initiatives faces multiple limitations that can be ameliorated if systematic changes occur, such as the development of academic positions in global surgery, careful se- lection of participant centers, governmental and nongovernmental financial support, and routine application of outcome evaluation for international surgical collaborations. https://thejns.org/doi/abs/10.3171/2018.7.FOCUS18291 KEYWORDS education; international; global; neurosurgery; collaboration CCESS to surgical care is disproportional around the rosurgical care.8,29 While China and Japan have approxi- world. According to current data, the population mately 18,000 neurosurgeons, the African continent has in the 30% of the lowest-income countries receive only approximately 990. To balance the current case A3.5% of the worldwide surgical procedures each year, deficit in neurosurgical care (5.2 million), it is estimated whereas the population in the 30% of the high-income that an additional 22,626 neurosurgeons would be neces- countries (HICs) receive almost 75%.35,38 An estimated 5 sary. 9 Aside from the shortage of qualified surgeons, the billion people do not have adequate access to surgical care, infrastructure for surgical care in many low- and middle- leading to significant social and economic impact.26,27 income countries (LMICs) is limited and impacts the de- This inequality is even more striking in terms of neu- livery of adequate care. ABBREVIATIONS FAIRNeSS = Framework for the Assessment of International Surgical Success; HIC = high-income country; LMIC = low- and middle-income country; NED = Neurosurgery, Education and Development. SUBMITTED June 1, 2018. ACCEPTED July 12, 2018. INCLUDE WHEN CITING DOI: 10.3171/2018.7.FOCUS18291. ©AANS 2018, except where prohibited by US copyright law Neurosurg Focus Volume 45 • October 2018 1 Unauthenticated | Downloaded 09/29/21 04:31 AM UTC Almeida et al. The concept of global surgery has been developed with rosurgeons coming from LMICs. It allows training in a the aim to minimize such inequality and promote academ- high-volume neurosurgical center and gives fellows the ic and clinical collaborations between HICs and LMICs opportunity to be immersed in a comprehensive academic (Table 1). Multiple neurosurgical collaborations have been program at the University of Toronto. They have the oppor- developed between HIC and LMIC institutions in the last tunity to exchange experiences with neurosurgeons from 15 years.4,5, 9, 17, 20, 22, 24, 25, 30–32, 34,36 Although the establishment around the world and to build long-term collaborations. of initiatives such as the Foundation for International Edu- Finally, fellows have the opportunity to participate in clini- cation in Neurological Surgery (FIENS)3 and the Neuro- cal research projects. This is an important part of training, surgery, Education and Development (NED) Foundation useful for development of a critical methodological-based have supported this cause, most projects are still being or- approach to investigate questions in neurooncology. ganized by individual or single-center initiatives, and face A similar training program has been developed at the financial, organizational, and academic challenges. Hospital for Sick Children through the Prakash Founda- In the current project, we aim to discuss the different tion Low Income Country Surgical Scholarships, where models for international surgical education and the chal- surgeons from low-income countries can apply for fellow- lenges associated with the development of international ship training in pediatric neurosurgery at the University collaborations. The experience of our Division of Neuro- of Toronto. Despite the significant and obvious advantages surgery (Toronto) is used to illustrate those models. of this postgraduate training program, some challenges arise. Fellows from LMICs may find major difficulties Methods when trying to introduce the techniques learned during training in her or his country of origin. Such procedures We reviewed the initiatives in international education usually require technological resources, which may not be developed by the Division of Neurosurgery of the Uni- available upon returning home. versity of Toronto in the past 15 years involving collabo- rations with LMICs. The initiatives were classified as 1) Neurosurgical Education Missions local-based structured training programs; 2) neurosurgi- cal education missions overseas; 3) online surgical cur- Neurosurgical education missions are probably the riculums; and 4) long-term personal mentorships. The ex- most common model of international surgical collabora- periences from each model are summarized in this paper. tion. They are based on organized, often multidisciplinary trips to LMICs with a philanthropic goal in healthcare. The objectives of the missions can include healthcare as- Results sistance, surgical training, clinical research assistance, Local-Based Structured Training Programs and a combination of all of them. In the local-based structured training program model, In our Division, missions have been organized by neu- a visiting neurosurgeon from an LMIC temporarily joins rooncology (Mark Bernstein), pediatric (James Rutka), an academic training program in an HIC. These programs and functional (Mojgan Hodaie) neurosurgeons. A total include short- or long-term fellowship programs. An ex- of 25 missions were performed in 8 LMICs from 2008 to ample of this model is the Neuro-oncology and Skull Base 2018. The main objectives, the host institutions, and the Surgery Fellowship of the University of Toronto at the number of members of the missions, among other features, Toronto Western Hospital. This is a 1-year training pro- are specified in Table 2. The rate of missions per year was gram22 that exposes trainees to a wide range of procedures about 3, which has remained stable over the years, and for intraaxial and skull base tumors. Since 2010, 27 neu- the average duration was 10–12 days with a range of 5–16 rosurgeons from different countries have been trained in days. Several local neurosurgeons, neurosurgery residents, the program and, among them, 6 came from an LMIC (2 nurses, anesthetists, and researchers participated in the ac- trainees from Egypt and 1 each from Nigeria, India, Ethi- tivities during each mission. The number of patients treat- opia, and Rwanda). The funding for the LMIC fellows was ed was approximately 8 on average per mission. A total of specifically allocated through the Greg Wilkins-Barrick 5 pediatric neurosurgery educational missions to Ukraine Chair, since it was first established in 2011. were organized in recent years, helping the development This program entails numerous advantages for neu- of pediatric neurosurgical care in that country through TABLE 1. Highlights of global surgery programs Summary of the Main Points Applied in Global Neurosurgery Solid long-term partnership btwn mentor, international trainee, & host country Adequate institutional relationships btwn the HIC & LMIC involved in the project Strategic plan defined before the visit w/ clearly defined outcomes & expected challenges Awareness & foresight of the individual, cultural, & systemic limitations in the host country Action
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