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OBJECTIVE: General surgical training in Australia has undergone considerable change in recent years with less exposure to other areas of surgery. General surgeons from many high-income countries have played important roles in assisting with the provision of surgical care in low- and middle-income countries during sudden-onset disasters (SODs) as part of emergency medical teams (EMTs). It is not known if contemporary Australian general surgeons are receiving the broad surgical training required for work in EMTs. DESIGN: Logbook data on the surgical procedures performed by Australian general surgical trainees were obtained from General Surgeons Australia (GSA) for the time period February 2008 to February 2017. Surgical procedures performed by Médecins sans Frontières (MSF) surgeons during 5 projects in 3 SODs (the 2010 Haiti earthquake, the 2013 Philippines typhoon and the 2015 Nepal earthquake) were obtained from previously published data for 6 months following each disaster. SETTING AND PARTICIPANTS: This was carried out at the University of Sydney with input from MSF Operational Centre Brussels and GSA. RESULTS: Australian general surgical trainees performed a mean of 2107 surgical procedures (excluding endoscopy) during their training (10 6-month rotations). Common procedures included abdominal wall hernia repairs (268, 12.7%), cholecystectomies (247, 11.8%), and specialist colorectal procedures (242, 11.5%). MSF surgeons performed a total of 3542 surgical procedures across the 5 projects analyzed. Common procedures included Caesarean sections (443, 12.5%), wound debridement (1115, 31.5%), and other trauma-related procedures (472, 13.3%). CONCLUSIONS: Australian general surgical trainees receive exposure to both essential and advanced general surgery but lack exposure to specialty procedures including the obstetric and orthopedic procedures commonly performed by MSF surgeons after SODs. Further training in these areas would likely be beneficial for general surgeons prior to deployment with an EMT.

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OBJECTIVE: The burden of musculoskeletal disease remains high in low-income countries, with a high rate of pediatric disease. Efforts continue for orthopedic education, but there is little guidance on local needs and desires. Our aim was to determine the specific content and modalities that would be most useful for pediatric orthopedic educational programs abroad, and we demonstrate a practical method of identifying country-specific educational deficits through a self-reported needs survey in Haiti. DESIGN: A cross-sectional survey was administered using an automated response system. We obtained demographic information as well as training and practice patterns, comfort levels with pediatric diagnoses, and desired topics for education using a 5-point Likert Scale. SETTING: Haitian Annual Assembly for Orthopaedic Trauma (HAAOT), the only national, continuing medical education conference for orthopedic providers in Haiti. PARTICIPANTS: Of 60 eligible participants, 51 were included in the final analysis. RESULTS: Time spent on pediatric orthopedics varied widely, centered at 10% to 25%. Median comfort level with pediatric orthopedics was 3 of 5. Skills with lowest self-reported competence included spica casting, clubfoot casting, and management of supracondylar humerus fractures. Skills with highest self-reported competence were long-leg casting and Salter-Harris classification. Modes of education highly requested included didactics/lectures, hands-on sessions, dedicated rotations, and exchanges with foreign peers/mentors. Diagnoses most encountered were osteomyelitis, trauma, and clubfoot; lowest comfort levels were in neuromuscular, spine, lower extremity deformity, congenital hip, and clubfoot; and most requested for future teaching were congenital hip, neuromuscular, and spine. CONCLUSIONS: Haitian orthopedic providers express a strong desire and need for ongoing pediatric orthopedic education. They describe a high prevalence of trauma and infection, but convey a requirement for more comprehensive, multimodal teaching that also includes congenital deformities/dysplasias, neuromuscular, and spine. Our results demonstrate the importance of assessing country-specific needs and involving local care providers in curriculum development.

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OBJECTIVE: To evaluate the quality of the Mexican Board of Pediatric Surgery (MBPS) certifying system, using contemporary international guidelines. DESIGN: Retrospective assessment of evidence collected during the design and implementation processes of 2 consecutive applications of the MBPS certifying examination, using Cizek's checklist for evaluating credential-testing programs. It includes the relevant guidelines from the American Education Research Association, the American Psychological Association, the National Council on Measurement in Education, and the National Commission for Certifying Agencies. Four independent and previously trained raters used the checklist. They underwent a 2-week training using frame-of-reference and performance dimensions methodologies. SETTING: Certification examinations of MBPS. POPULATION: The 2013 and 2014 MBPS certification examinations, with 111 evidence items of the processes, followed for the assessment of 86 examinees. RESULTS: The checklist internal consistency was 0.89. Absolute interrater agreement was 0.34 for the 2013 and 0.66 for the 2014 editions of the examination. The 2013 examination complied with 55 (64%) of the checklist 86 items, in 2014 with 72 (84%). CONCLUSION: In 2014, the certifying system reached a quality of 84%. For optimal fulfillment of its social responsibility, the MBPS is required to maintain its level of quality and attempt to improve its performance.

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BACKGROUND: Intensive training programs arose from limitations in access to simulation centers. The aim of this study is to evaluate the effect and associated factors involved in an intensive course for learning advanced laparoscopic skills, which include validated teaching techniques. METHODS: General surgeons and final-year residents were analyzed after completing an intensive 5-session advanced laparoscopy course. Initial (IA) and final assessment (FA) consisted in performing a jejunojejunal anastomosis in a live porcine model, measured using objective structured assessment of technical skill (OSATS) (GRS and SRS, that is, global rating scale and specific rating scale, respectively) and operative time (OT). The 3-session training was structured in a bench model with an ex vivo bowel. For the demographic analysis, 3 groups were defined according to the presentation of relevant changes in OSATS and in OT between IA and FA: group A, no changes; group B, change in 1 variable; and group C, change in both variables. RESULTS: After the course, all 114 participants presented a significant improvement in OT (37 vs 24.6min, p < 0.001) and in OSATS; global rating scale (10.5 vs 16 points; p < 0.001) and Specific Rating Scale (8.5 vs 12.7 points; p < 0.001). In the IA, 70 (61%) participants completed the jejunojejunal anastomosis and 105(92%) in the FA (p < 0.01). In the FA, 56% of participants presented relevant changes in both variables (group C). This group was significantly younger (34 vs 45 vs 40y old; p < 0.001), had fewer years of surgical experience (2 vs 9 vs 5y; p < 0.001), and had a proportionally higher concentration of residents (p = 0.01). CONCLUSIONS: This intensive course is set out as a viable alternative to teach basic skills in advanced laparoscopy in a short period of time, which is ideal for surgeons with difficult access to training centers. It remains necessary to establish the participant profile for which this type of course is most beneficial.

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OBJECTIVES: Since 1996, 1 to 4 annual training missions have been carried out to train Haitian otorhinolaryngology (ENT) and cervicofacial surgery residents by the association Liens Otorhinolaryngology Ayti (LOA). Until 1996, ENT was practiced and taught by ophthalmologists. The aim of this article is to describe the contributions and limitations of LOA in training of Haitian resident physicians and the creation of the ENT specialty in Haiti. DESIGN: Retrospective analysis of clinical consultation and surgical interventions records and didactics carried out during missions from 1996 through 2014. PARTICIPANTS: A total of 37 missions were made during the 19-year period in which 29 senior ENT specialists participated, with an average of 3.37 missions per physician. RESULTS: A total of 10,300 consultations and 173 surgical procedures were made jointly by a senior LOA physician and a Haitian resident physician. Totally 16 Haitian ENT residents were trained, 81% of whom are still practicing in Haiti. ENT became a surgical specialty in 2001 after the nomination of a Haitian ENT specialist as Assistant Director of the ENT-Ophthalmology service. The latter benefitted from dual training by LOA in Haiti and abroad. CONCLUSION: The Haitian population experiences significant difficulties with access to medical care owing to very low number of resident medical personnel. LOA's work has contributed over 19 years to the training of ENT physicians now practicing in Haiti and to the creation of a local ENT specialty.

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Academic global surgery is a nascent field focused on improving surgical care in resource-poor settings through a broad-based scholarship agenda. Although there is increasing momentum to expand training opportunities in low-resource settings among academic surgical programs, most focus solely on establishing short-term elective rotations rather than fostering research or career development. Given the complex nature of surgical care delivery and programmatic capacity building in the resource-poor settings, many challenges remain before global surgery is accepted as an academic discipline and an established career path. Brigham and Women's Hospital has established a specialized global surgery track within the general surgery residency program to develop academic leaders in this growing area of need and opportunity. Here we describe our experience with the design and development of the program followed by practical applications and lessons learned from our early experiences.

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OBJECTIVE: Visiting surgical teams are a vital aspect of capacity-building continuing medical education (CME) in low-income countries like Haiti. Imperfect understanding of the genuine needs of local surgeons limit CME initiatives. Previous paper-based needs assessment efforts have been unsuccessful because of low response rates. We explored using an electronic audience response system (ARS) during a Haitian CME conference to improve the response rates and better assess needs. METHODS: Data were prospectively collected using an ARS from 78 conference participants (57 Haitian and 21 foreign) about current and desired knowledge of 7 topic and 8 skill areas using a 5-point Likert scale presented in English and in French. The response rates using ARS vs a similar paper survey were compared using a 2-sample test of proportions. The current and desired knowledge levels were compared using paired t tests. Analysis of variance and post hoc unpaired t tests were used to compare between demographic groups. RESULTS: The response rates were significantly greater for ARS vs a paper survey (87.7 vs 63.2%, p = 0.002). The 4 areas of least self-confidence for Haitians were pelvic and articular injury, joint dislocation, and osteomyelitis. The 4 skills of least self-confidence for Haitians were arthroscopy, open reduction and internal fixation-plate, external fixation, and fasciotomy. Haitians desired improvements in knowledge and management of articular, diaphyseal, and pelvic injury, joint dislocation, and osteomyelitis to a greater extent than foreigners (p < 0.05). Participants who previously attended the conference on open fractures felt more knowledgeable about open fractures as a topic (p < 0.05), but not in its management. CONCLUSIONS: We are the first to show that an ARS improves response rates to allow for better characterization of surgeon needs in the developing world. We also demonstrate the importance of skill building paired with topic area teaching. Lastly, we show how a CME conference is an effective tool to build surgical capacity and increase confidence level.

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OBJECTIVES: The proportion of US medical students participating in global health has increased by 24%. These experiences are generally self-directed and lack a formal educational component. This article describes a structured, comprehensive, community-driven global surgery elective for senior-year students. DESIGN: "Surgery and Global Health" is a monthlong elective during which students shadow in the university hospital, lead discussions of an assigned text, attend lectures, and participate in a clinical rotation in rural Haiti. The first week is didactic and takes place in Atlanta, GA. Weeks 2 through 4 are clinical and are conducted in Haiti. Urological and general surgery procedures are performed during weeks 2 and 3, while the final week is reserved for follow-up care. This experience was institutionally supported. SETTING: Emory University Hospital, Atlanta, GA; L'Hôpital St. Thérèse, Hinche, Centre, Haiti. PARTICIPANTS: Emory University School of Medicine students, years 2 through 4, supervised by faculty from the departments of Urology, General Surgery, and Anesthesiology. Senior-year students spent 21 days in central Haiti working in a rural clinical setting. RESULTS: Students participated in all facets of surgical care including preoperative clearance, postanesthesia care, discharge planning, and follow-up. Students felt a level of supervised responsibility that was not afforded at their home institution and were able to take on more advanced clinical roles. CONCLUSIONS: Students planned and executed this innovative experience with multidisciplinary, departmental, and institutional support. Stateside components introduced students to Haitian culture, global surgery ethics, and humanitarian surgical trip logistics. Structured global health experiences such as this give students practical skills and incentive to pursue careers involving global surgery.

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