Surgical disease makes up one of the top 15 causes of global disability,26 yet the role of subspecialty surgical care in global public health has only recently been widely recognized.1,14,27 Subspecialty surgical care is unavailable to many in the developing world,35,36 but even where facilities exist, insurmountable financial barriers place ready access to care out of reach for many.2,44 Despite an increase in the number of neurosurgical training programs worldwide, the gap between neurosurgical capacity and need remains wide.38 In some regions, a single pediatric neurosurgeon is burdened with providing care for a population of millions, with coverage areas in the thousands of square miles.12,13
Neurosurgical services, particularly in the management of pediatric hydrocephalus and trauma, are increasingly recognized as essential components of surgical care worldwide,25,39 and the sustained presence of visiting surgical teams can have a meaningful impact on local capacity building.19,43 However, the degree of interest among neurosurgeons regarding international work, and barriers to involvement in global neurosurgical outreach, are largely unexplored. Here we discuss the results of a survey that we distributed to members of the American Association of Neurological Surgeons/Congress of Neurological Surgeons (AANS/CNS) Joint Section on Pediatric Neurosurgery to assess the state of global outreach efforts among North American pediatric neurosurgeons and to identify barriers to involvement.
Methods
An 11-question, internet-based questionnaire was developed by the International Education Subcommittee of the AANS/CNS Pediatric Section (Table 1). The questionnaire was pilot tested among all members of the International Education Subcommittee, and the survey design and questions included were approved by all members prior to distribution. The questionnaire was distributed to pediatric neurosurgeons in North America via the AANS/CNS Joint Pediatric Section email listserv. Attending-level pediatric neurosurgeons in North America were asked to complete the survey, whereas other members of the listserv, such as trainees and individuals based outside of North America, were asked to disregard the survey. Reminder emails were sent at 2 weeks and 1 month to initial nonresponders to improve the response rate. Approval was obtained from the Pediatric Section to conduct this survey.
Questionnaire distributed to AANS/CNS Pediatric Section members
| Survey Questions |
|---|
| Have you ever performed/taught neurosurgery in a developing country? |
| In what regions have you performed/taught neurosurgery in a developing country? |
| How frequently do you travel internationally to teach or perform neurosurgery? |
| Was your travel associated with an organizing entity? If so, what entity? |
| What type of conditions did you primarily treat? |
| How did you obtain follow up information on patients you treated? |
| Do you feel that your international experience improved your practice or surgical skills? |
| Did your family join you during any of these trips? |
| Are you interested in performing/teaching neurosurgery elsewhere in the world? |
| In your opinion, what are the major barriers to participation in global neurosurgery projects? |
| To what extent do you agree with the following statement: International training (for 1 month or greater) should be required during neurosurgery residency or pediatric neurosurgery fellowship |
Participants were surveyed on their previous and current involvement in global neurosurgical outreach, geographic location, nature of the participation, and barriers to further involvement. An attempt was made to include both neurosurgeons who had engaged in global neurosurgical outreach and those without prior experience. The following questions allowed binary Yes/No answers without comment: “Have you ever performed or taught neurosurgery in a developing country?” and “Did your family join you during any of these trips?” Geographic region of outreach, organizing entity, mechanism for obtaining postoperative follow-up, conditions treated, and perceived barriers to participation in global neurosurgery projects were assessed using a multiple-choice format in which multiple answers and typed-in comments were allowed. Frequency of outreach was queried using the following options: more than once per year; once per year; every few years; or only occasionally (1 or 2 trips ever). Participants were queried on whether their international experience improved their practice or surgical skills and responded via a 5-point Likert scale, in which 1 = strongly disagree; 2 = disagree; 3 = neutral; 4 = agree; and 5 = strongly agree. The same scale was used for the question “To what extent do you agree with the following statement: International training (for 1 month or greater) should be required during neurosurgery residency or pediatric neurosurgery fellowship.” Participants were queried on their interest in performing or teaching neurosurgery in the developing world and responded via a 5-point Likert scale, in which 1 = not at all interested; 2 = slightly interested; 3 = moderately interested; 4 = very interested; and 5 = extremely interested.
Results
Of a cohort of 329 active Pediatric Section members, 116 respondents completed the survey, resulting in a 35% response rate. Seventy-one respondents (61%) had performed or taught neurosurgery in a developing country, whereas 45 respondents (39%) had not. Of these, 49% traveled at least annually, 22% every few years, and 29% had taken only 1 or 2 international trips.
Africa was the most common region where pediatric neurosurgeons had traveled (54%), followed by South America (30%), Central America (29%), and South Asia (22%). Respondents traveled through a total of 29 separate organizing entities, with CURE Uganda (10 respondents), the World Pediatric Project (5 respondents), and the Foundation for International Education in Neurological Surgery (FIENS; 5 respondents) being the most commonly used agencies. The largest number of respondents worked without any overseeing entity (27 respondents).
Hydrocephalus was the most commonly treated condition (88%), followed by spinal dysraphism (74%), tumor (68%), trauma (37%), craniofacial (35%), and spine (26%). Most respondents obtained follow-up through communication from local surgeons (77%), but 21% received follow-up through local nonneurosurgeon physicians or nurses, and 18% obtained no follow-up information on the patients they treated. (The values in the previous sentence total more than 100% because some surgeons obtained follow-up information from multiple sources.)
Seventy-one percent (47 of 66 respondents) agreed or strongly agreed that their international experience improved their practice, and 74% were at least moderately interested in working in a different region. Twenty-nine percent (19 of 66 respondents) had family members join them on at least one outreach trip. Additionally, 31% (33 of 107 respondents) either agreed or strongly agreed that international neurosurgical experiences of more than 1-month duration should be a required component of a neurosurgical residency or pediatric neurosurgery fellowship.
Interference with current practice (61%, 62 of 101 respondents), cost (44%), difficulty identifying international partners (43%), and lack of supporting team and/or equipment (38%) were the most commonly cited barriers to participation. Table 2 demonstrates the full range of coordinating agencies used by survey respondents, and Table 3 lists typed-in comments made in response to questioning on the most significant barriers to participation in global neurosurgical outreach. Figure 1 displays current regions of activity, the scope of neurosurgical practice and patient follow-up, and perceived barriers to global neurosurgical practice among survey respondents.
Coordinating agencies used by survey respondents
| Coordinating Agencies | No. of Respondents |
|---|---|
| None | 27 |
| CURE Uganda | 10 |
| World Pediatric Project | 5 |
| FIENS | 5 |
| Project Medishare | 4 |
| ISPN | 4 |
| World Medical Mission | 2 |
| BethanyKids | 2 |
| AMPATH Consortium Kenya | 2 |
| WFNS | 1 |
| World Craniofacial Foundation | 1 |
| Visiting Professor | 1 |
| Solidarity Bridge | 1 |
| Smiles International | 1 |
| Shriners | 1 |
| Samaritans Purse | 1 |
| Project Perfect World | 1 |
| Neurosurgery Outreach Foundation | 1 |
| Maghreb-American Health Foundation | 1 |
| Local Government | 1 |
| INCA | 1 |
| Indian Society of Pediatric Neurosurgery | 1 |
| Healing the Children | 1 |
| HaitiHealthyKids | 1 |
| Global Neuro Rescue | 1 |
| ESPN | 1 |
| Children’s of Alabama Global Health | 1 |
| Children’s China Foundation | 1 |
| ASPN | 1 |
| AANS/CNS Pediatric Section | 1 |
AMPATH = Academic Model Providing Access to Healthcare; ASPN = American Society of Pediatric Neurosurgeons; ESPN = European Society for Pediatric Neurosurgery; INCA = International Neurosurgical Children’s Association; ISPN = International Society for Pediatric Neurosurgery.
Comments on top barriers to global neurosurgical outreach
| Comment |
|---|
| Funding is always a problem but family needs of team members is significant. |
| I would only go somewhere where I could teach a surgeon to perform surgery. I have no interest in medical tourism. |
| Reaction from fully trained and even foreign trained (US/North America/Europe) local neurosurgeons. |
| Finding a way to make a meaningful contribution given limited time of provider and unknown needs of local population. |
| It would take months, not a week or two, to transform thinking and practices in many situations. |
| Coverage while I am away. |
| Concerns about ethics and whether in some cases it’s more for “us” than for “them” - big picture considerations. |
| Not understanding the political/social system and the degree of personal/family risk. |
| General travel risk for US citizens. Kidnapping, terrorism, and so on.* |
| Lack of coordination among NGOs and providers. |
| Family support. |
| Inability to do real follow-up, difficulty mentoring after return home. |
| So little can really be done, and usually the medical problems related to infectious disease and clean water are far more significant than neurosurgery. |
| Time away from family.† |
| Haven’t been invited to participate. |
| Attitudinal issues among local neurosurgeons.† |
NGO = nongovernmental organization.
Comment reported 4 times.
Comment reported 2 times.
Bar graphs showing current regions of activity, scope of neurosurgical practice and patient follow-up, and perceived barriers to global neurosurgical practice among survey respondents. Figure is available in color online only.
Discussion
Here we report survey findings from 116 pediatric neurosurgeons in North America, to assess the current state of international outreach efforts and to identify potential barriers to further engagement. Our results included participants with extensive and those with no international experience. Although our findings are not necessarily reflective of the overall population of practicing pediatric neurosurgeons in the US, they provide valuable guidance on mechanisms to improve and facilitate neurosurgical outreach efforts.
The current state of global neurosurgical outreach is fragmented, with respondents traveling through 29 separate organizing entities. By way of context, the American Society of Pediatric Neurosurgeons currently has only 164 active members (https://www.aspn.org). It is also telling that the largest number of respondents worked without the benefit of an overseeing entity. This is consistent with our observation that difficulty identifying international partners, and the lack of a supporting team, were frequently cited barriers to participation.
There is growing interest among neurosurgical residency program directors to offer global neurosurgical experiences in their curriculum, as a mechanism to attract top residency applicants.33 Interestingly, only 31% of our respondents either agreed or strongly agreed that extended international training experiences should be required for all neurosurgical residents or pediatric neurosurgical fellows. This low value may reflect perceived loss of critical training time, when programs are already limited by Accreditation Council for Graduate Medical Education (ACGME) work-hour restrictions. Ethical considerations surrounding the appropriate role of trainees in low-resource settings may also be a contributing factor.34
Additional Barriers to International Efforts
The FIENS is one of the largest groups directing global neurosurgical outreach, working to provide hands-on training, didactics, and infrastructure to neurosurgeons at more than 20 sites on 6 continents, predominantly through trips lasting less than 1 month.3,8 Analysis of 178 FIENS volunteer reports indicated that successful strategies for global neurosurgical efforts included local collaboration and continuity of care, while equipment and infrastructure frailty were the most commonly cited challenges.33 Culture challenges, including language barriers and decreased operative time during holidays, were far less frequently cited. Interestingly, this study only evaluated reports from volunteers who had completed at least a 4-week trip, representing a very small subset of total neurosurgical outreach efforts. These experienced providers saw far different challenges than our study population, which included all pediatric neurosurgeons, ranging from those with many years of global outreach to those with no prior international experience. The challenges these groups appreciated, therefore, were different. It may be that the FIENS respondents were describing barriers to effective neurosurgical care, whereas our respondents were describing barriers to international neurosurgical travels. Whereas long-term FIENS volunteers saw inadequate equipment and infrastructure failure as their primary obstacles, our respondents primarily cited interference with current practice, cost, difficulty identifying international partners, and the lack of a supporting team. Additional typed-in comments emphasized travel risk (5 respondents), reactions from local neurosurgeons (3 respondents), family concerns (4 respondents), and perceived futility (4 respondents).
Effective Training Models and Opportunities for Progress
Most North America–based neurosurgeons provide international care and training through short-term visits, which have increased dramatically over the past 30 years.37 These trips can be highly cost-effective despite the expense of travel and lodging for the visiting surgical team,6 but inconsistency in postoperative follow-up and lack of emphasis on local capacity building has led to criticism of the short-term mission model.11,21
The most compelling mechanism for delivering cost-effective pediatric neurosurgical care in the developing world is centered on expanding local capacity.39,40 Hands-on training of local surgeons in their home country by using immersive learning paradigms is of paramount importance to enhancing the effectiveness of short-term neurosurgical brigades.9,20 Although neurosurgeons from developing countries may visit North American centers for long-term observerships, in-country training is the most common means of improving local care delivery. Sustainable skill transfer through targeted short-term trips has been demonstrated,10,22 and mobile training units can extend equipment and skill transfer beyond the capital cities.32 Novel telecollaboration and internet-based tools have also demonstrated potential for continuing education following departure of the visiting surgical team.4,6 As an example, HELPLightning, a tablet-based tool for mobile merged reality and virtual interaction, is currently being implemented by CURE International for mentoring of surgeons performing endoscopic third ventriculostomy–choroid plexus cauterization (https://www.helplightning.com). Such evolving technologies hold great potential for ongoing training, assessing surgical competence, and enhancing relationships among geographically isolated neurosurgeons.41,42
Challenges
Neurosurgeons delivering care in developing countries face unique challenges. Well-developed anesthesia, intensive care unit, radiology, nursing, and oncology teams are prerequisites for the delivery of neurosurgical care in any country.5 Geopolitical stability, strong referral networks, dependable electricity, adequate equipment, and reliable postoperative follow-up are additionally required.20,21 Furthermore, even though such care is typically delivered through philanthropic efforts, the most destitute patients may be quite simply too poor to obtain even “free” subspecialty care, leading to delays in referral, poor postoperative follow-up, and delays in identifying and managing postoperative complications.17,18,24 Visiting surgeons must be attentive to the additional resources required to identify patients at highest risk. Adding yet another layer of complexity, prevailing local conception and stigmatization of pediatric neurological disability, and confidence in the local health care system, have wide variability and sometimes a dramatic influence on care delivery.5,15,29,31 All of these obstacles have hampered evaluation of the efficacy of delivering high-complexity neurosurgical care in the developing world.16,23,28,40
Many neurosurgical groups have identified and overcome these barriers through a process of trial and error. The recent ascent of surgical care as a global health priority may soon bring a more coordinated approach to the widespread, inefficient, and disjointed efforts. The “Global Surgery” movement is advocating incorporating surgical care as part of health systems strengthening—a paradigm widely accepted as the most sustainable solution. And they are succeeding—at the World Health Assembly last year, resolution 68.15, calling for “strengthening essential and emergency surgical care and anesthesia,” passed unanimously. The neurosurgical correlate to the Global Surgery movement, Global Neurosurgery, is still in its infancy.30 Yet, important and foundational work is already in progress. For example, a worldwide neurosurgery workforce and capacity mapping project is underway as a joint project of the World Federation of Neurosurgical Societies (WFNS) and the WHO, to establish a baseline and identify the areas of most need. Additionally, neurosurgeons at the Harvard Program in Global Surgery and Social Change are working to provide a centralized forum for international collaboration (https://globalneurosurgery.org/), and FIENS and the WFNS continue to improve networking and matching of experienced neurosurgeons with international partners. Repeated short-term trips by rotating surgeons, combining resources from multiple institutions with ongoing follow-up, can provide a continuity of care that a single neurosurgeon is unable to provide. In addition, short-term trips in conjunction with visiting observerships and remote telecollaboration have also proved successful for sustained partnerships and capacity building.6 Results of this survey suggest that development of an accessible, comprehensive, and updated online community of existing and potential collaborations would be valuable for surgeons seeking to initiate new relationships and find creative solutions to providing care in low-resource settings.
Limitations of the Study
There are several limitations based on our cross-sectional survey study design. Although the 35% response rate compares favorably to typical response rates in online survey studies, response bias remains a potential concern. Additionally, because we used an anonymous survey, we were unable to obtain detailed information on individual respondents. Although we could not account for potential completion of the survey by unintended participants, we believed that willful completion by individuals other than attending-level pediatric neurosurgeons in North America was unlikely and was outweighed by the value of contacting all potential participants through the AANS/CNS Pediatric Section email list. Furthermore, the objective of this study was not necessarily to reflect the full spectrum of views of the Pediatric Section membership, but rather to survey the range of ongoing international outreach efforts, and to determine perceived barriers to outreach. The selected study design was sufficient for this purpose. Although responses were most likely obtained at a higher rate from individuals with interest in and history of global neurosurgery work, we do not view this as a limitation. People who have participated in international outreach have insight and perspective that differs from those who do not engage in such outreach efforts and may be better suited to identify barriers to involvement. Nevertheless, future studies would be valuable to compare regional and practice pattern differences between neurosurgeons’ involvement in international neurosurgical outreach, to more effectively target specific groups of neurosurgeons and to increase international involvement.
Conclusions
Pediatric neurosurgeons based in North America are currently involved in a wide range of international outreach efforts. Although interference with current practice is the most commonly cited barrier to participation, difficulty identifying international partners and lack of support are common, modifiable barriers. Broadening the range of US-based neurosurgical outreach and facilitating educational efforts requires high-level coordination across a large number of organizing entities. A centralized online community of existing projects with facilitated introductions between prospective partners would lower one barrier to participation and potentially increase the number of neurosurgeons participating in the worldwide effort to increase surgical capacity.
Acknowledgments
Dr. Davis completed this work as a Women’s Leadership Council Clinical Scholar in the Department of Neurosurgery at the University of Alabama at Birmingham, supported by the Kaul Foundation.
Disclosures
The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
Author Contributions
Conception and design: all authors. Acquisition of data: Davis, Johnston. Analysis and interpretation of data: Davis, Johnston. Drafting the article: Davis, Rocque. Critically revising the article: all authors. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Davis. Statistical analysis: Davis. Administrative/technical/material support: Rocque, Singhal, Ridder, Pattisapu, Johnston. Study supervision: Rocque, Singhal, Ridder, Pattisapu, Johnston.
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