Global surgery ‘the trainees’ perspective’: Ten things we have learnt so far...

Alice Campion, Matthew Arnaouti, William M Nabulyato, James Archer, Alex Schade and James Berwin

Global surgery can be defined as “an area of study, research, practice, and advocacy that seeks to improve health outcomes and achieve health equity for all people who require surgical care” [1]. The perspectives and insights of trainees have been described as ‘crucial’ in promoting advancements and addressing challenges in global surgery [2].

As a cohort of trainees from the World Orthopaedic Concern-UK (WOC-UK) network, we wish to share ten key insights from our collective experience in the multifaceted landscape of global surgical practice. We hope these insights offer guidance for navigating the complexities inherent in global surgical endeavours and highlight the role of trainees in shaping the future trajectory of this critical field.

1. Orthopaedic surgeons are urgently required

Nearly a decade after the Lancet Commission on Global Surgery highlighted the extensive burden of musculoskeletal trauma, and its disproportionate impact on low- and middle- income countries (LMIC), the allocation of healthcare personnel and resources remains inequitable. Traumatic injury results in the premature death of over four million people annually [3], and renders millions more either transiently or permanently disabled. This perpetuates a downward spiral of poverty with local, regional and global ramifications [4].

Analysis of surgical workforce statistics comparing the NHS and data presented at the College of Surgeons of East, Central and Southern Africa (COSECSA) 2023 Conference, reveals a striking discrepancy, with a ratio of 48:1 orthopaedic consultant per million population (Table 1) [5,6].

The scarcity of orthopaedic consultants encapsulates a critical gap in healthcare provision and underscores the urgent need for collaborative interdisciplinary strategies that bolster surgical capacity, enhance training programmes, and improve access for patients. By fostering partnerships between healthcare institutions, governments and independent organisations, concerted efforts can be made to improve care for all.

2. Meaningful clinical work is possible but needs to be conducted carefully

At the WOC-UK 2022 Conference, four ‘pillars’ of global surgery were discussed: Clinical, Advocacy, Research and Education (CARE). These pillars must be actualised within a Specific, Measurable, Attainable, Realistic and Time-bound (SMART) framework, to ensure transparent and accountable goal-completion [7]. Clinical work is often the fire that ignites long-term personal investment in global surgery, but to be conducted meaningfully, careful preparation is required. This should be guided by the department hosting the initiative, with appropriate oversight. At all levels, trainees should strive to positively affect and foster sustainable health-system collaboratives.

The British Orthopaedic Trainees Association (BOTA) and WOC-UK strongly support orthopaedic trainees who wish to pursue clinical opportunities in low-resource settings, and contribute to a number of trainee bursaries every year8. There are many excellent partnerships that trainees have been involved with, including the British Society for Surgery of the Hand’s partnership with the Lilongwe Institute of Orthopaedics and Neurosurgery in Malawi [9], and the Kadoorie Senior Orthopaedic Fellowship in Cambodia [10]. Other trainees have engaged with collaborations within their local trusts, such as the ‘Cambridge Global Health Partnerships Fellowship’ scheme [11] and the ‘Poole-Africa Link’ [12]; or with international organisations such as the ‘Primary Trauma Care Foundation’ [13] and ‘Mercy Ships’ [14].

We believe that a bidirectional transfer of knowledge and skills benefits both the trainee and host institution. Trainees across the UK describe their experiences working in low-resource settings as incredibly valuable, sharing innovation, developing leadership skills and nurturing international relationships with overseas peers.

3. Working in global surgery can count towards training

As seen in other medical specialties, and parallel orthopaedic training programmes in other high-income countries, surgical placements in low-resource settings are rightly becoming increasingly formalised – and in some cases, count towards a ‘Certificate of Completion of Training’. Surgeons previously trailed behind our anaesthetic and emergency medicine colleagues, but fortunately the Speciality Advisory Committee (SAC) guidelines, not only state that trainees are permitted to take up to two-weeks of study leave for orthopaedic projects in lowresource settings, but that longer periods may be undertaken as an ‘Out of Programme Experience’ (OOPE). They have stipulated that this may be considered towards achieving training competencies [15]. There is a growing recognition that clinical work in low-resource settings is valuable and can contribute towards achieving curriculum competencies.

Global surgical volunteering is supported by the Academy of Medical Royal Colleges [16] and all four home nations [17]. The BOTA survey demonstrates a strong interest in global surgery experiences amongst UK orthopaedic trainees, which is largely supported by Training Programme Directors (TPD) [18]. Trainees have previously worked in low-resource settings for Out of Programme Research (OOPR), and currently, there is one trainee who is working overseas as part of Out of Programme Training (OOPT), rather than taking time out for an OOPE. We hope this will gain momentum with time, making it easier for trainees to benefit from valuable learning opportunities, and for TPDs to support them.

Clinical work is an ethical minefield –volunteer but don’t ‘voluntour’ [4] .

As clinical work in low-resource settings becomes possible within training, a comprehensive understanding of ethical practice is a prerequisite for any trainee seeking to engage in international global surgery development work. It is essential to embrace a model of regulated professional partnerships, where those involved are governed by minimum standards, discarding outdated practices such as ‘voluntourism’ [19] Trainees must take conscious steps to mitigate any pressure to act beyond their current competencies. Furthermore, basic requirements should not be overlooked, such as ensuring clinicians are licensed to practise within the host nation and obtaining patient consent for treatment or clinical photography. Trainees can be placed in difficult situations, nevertheless, ethical standards must be adhered to at all times [20].

5. Advocacy needs to occur at every level

Along with its ethical challenges, the field of global surgery is unfortunately marred by a lack of regulatory mechanisms and evidencebased interventions [21]. Seemingly well-meaning projects are often driven by donor agendas, rather than those of beneficiaries [22]. Care must be taken not to undermine the integrity and capabilities of local institutions, where solitary interventions – which do not form enduring partnerships with the host country – risk creating parallel health systems that do not address LMIC healthcare objectives [23-25] They significantly hinder sustainability and should be consciously avoided.

Whilst trainees are in a position to advocate for the right type of partnerships, they are also vulnerable to inadvertently perpetuating ineffective and potentially damaging practices. In order to prevent this, trainee- and studentled advocacy groups have been formed – including the ‘Global Anaesthesia, Surgery and Obstetrics Collaboration’ (GASOC) [26] and the ‘International Student Surgical Network’ (InciSioN) [27] – which facilitate responsible and impactful engagement of trainees, within global surgery education, research and fieldwork. Additionally, through providing educational resources, such as courses and conferences – they serve as platforms for uniting highand low-income trainees and promoting interdisciplinary collaboration. Following the Lancet Commission’s recommendation that trainees should develop broad competencies in global surgery, these groups are working towards its inclusion in medical school curricula nationally [28,29].

6. Listen and be accountable

In developing partnerships, actively listening to stakeholders in emerging economies is crucial [30]. Consensus meetings can be utilised to derive agendas that align with those of local health systems, ensuring that interventions are led by colleagues in host nations [31]. Without investment from local teams, courses and interventions are unlikely to be valued or sustained. Short-term programmes can be worthwhile, but demand huge amounts of planning, specialised skill sets, and consecutive visits – wherein previous work is continued [32]. Further research into their cost-effectiveness is crucial. We have a responsibility to ensure accountability of engaged parties and ensure sustainable practice with explicit objectives and robust follow-up plans [32].

7. Promote equitable engagement in research

Our colleagues in low-resource settings face myriad barriers to conducting research. Academics from emerging economies are subject to marginalisation by major journals and are under-represented amongst editorial boards. They also face practical issues, such as fewer research facilities, greater clinical burdens, and limited protected time for research [33].

Huge changes are required to decolonise global health [34], and whilst the goal may be ‘local people writing about local issues for local audiences’, challenging the disproportionate imbalance in power in global health academia, and advocating to remove expensive article processing fees should continue [33].

Trainees have a great potential to contribute to research collaborations with LMIC colleagues whilst advocating for high quality, ethical practices. The days of high-income country surgeons ‘data mining’ in low-resource settings, and publishing their work as first author, are over. Research priorities should be driven by local stakeholders, facilitating policy and funding into areas that are important to local teams [35].

8. Perhaps the best way to be involved in global surgery is not through clinical work

Work in advocacy, training and research roles is achievable for trainees, and can provide sustained benefits which should be championed. For example, the Northwest Orthopaedic and Trauma Alliance for Africa (NOTAA) started an annual research methodologies course, at the request of trainees in Ethiopia. A collaboration between multiple organisations, it is freely available and globally accessible. They also help to run a ‘Residents’ Day’ which showcases work undertaken by Ethiopian residents, and collaborative projects with UK-based trainees, to improve clinical practice through audit and research. This pioneering initiative highlights how UK-based trainees can get involved with global surgery, without travelling overseas [36].

The trainee-led podcast ‘Global Scalpels’, showcases particular individuals who are contributing to the field of global surgery in innovative and inspiring ways [37]. Whilst online events hosted by ‘Cambridge Global Health Café’, provide trainees with the opportunity to gain exposure to diverse perspectives and evidence-based approaches to patient care interventions, as well as critical insights regarding participation.

Collaborative initiatives, such as the partnership between the Guyana Orthopaedic Training Programme and the Birmingham Orthopaedic Training Programme, exemplify a model for engaging in mentorship, regular virtual teaching sessions, and developing open-access educational resources [38]. These roles represent potent mechanisms for fostering enduring relationships that enhance innovation, mutual support, camaraderie, and ultimately the potential for positive outcomes that transcend national boundaries.

9. Involvement in global surgery is self-investment

It is clear that our involvement in global surgery as trainees strengthens our own professional skills and competencies –enabling us to develop skills to communicate across professional cultures and learn about the processes required to enact and sustain change [23,39]. Bidirectional learning and overseas volunteering facilitates access to novel approaches to healthcare delivery.

Healthcare volunteers often report having a greater confidence to challenge and change established practice in their trust based on their experiences, as well as having exposure to a wider variety of clinical conditions [29,40]. Research shows that involvement in overseas partnerships results in improved enthusiasm, better staff morale, reduced rates of sick leave, and reduced workforce attrition [41].

10. Working towards equity in global surgery is a marathon not a sprint

Quick solutions to complex problems rarely exist. As with any area of medicine, sustained engagement and commitment is required to ensure the success of international collaborations. Trainees who become involved in global surgery early on in their careers can identify areas of interest and tailor their experiences to strengthen existing skills. Ongoing participation, rather than transient contributions, is required to collectively work towards establishing equitable surgical care [32].

Conclusion

We are grateful to many orthopaedic consultants who inspire and mentor us, and we are delighted that our educational bodies now support trainees wishing to pursue experiences working in low-resource settings. We recognise the importance of avoiding surgical colonialism and facilitating equitable engagement in research [33,42]. As we progress through our careers, we hope to meet the goals of high-quality, professional, and ambitious partnerships, by consolidating and strengthening existing schemes. We aim to improve collaboration, at regional and national levels, in all four pillars of Global Surgery: Clinical, Advocacy, Research and Education [23].

If you are reading this and want to get involved in global surgery, the WOC-UK Annual Congress serves as an excellent opportunity to engage with many different projects. Many alternative global surgery based conferences exist, most of which are accessible virtually. There are also a number of relevant surgical courses available, which can lead to further opportunities. See the World Orthopaedic Concern UK webpage for more details (https://wocuk.org), follow us on twitter(@Orthoconcern), or contact globalsurgery@bota.org.uk for more information.

References

References can be found online at www.boa.ac.uk/publications/JTO.