Encore careers: a solution to the unmet need in global neurosurgical care

Jacquelyn A. Corley Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts;
Duke Department of Neurosurgery, Duke University, Durham, North Carolina; and

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Gail Rosseau George Washington University School of Medicine and Health Sciences, Washington, DC

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In 2008, Bill Gates stepped down from his day-to-day duties at Microsoft to focus his efforts exclusively on his philanthropic endeavors within the Bill and Melinda Gates Foundation. He was only 53 at the time and still the world’s richest living person.10 His organization’s goals are ambitious and include tackling extreme poverty in developing countries and addressing the failures of the American education system. Through this channeling of the founders’ energy and wealth, the Gates Foundation has partnered with hundreds of other collaborators and donated billions of dollars to initiatives that range from polio eradication, to water sanitation, to tuberculosis treatment across the globe (https://www.gatesfoundation.org). Without a doubt, countless lives have been saved.

Gates is not alone. Current baby boomers are the first generation in the history of the world who are likely to have both healthy years and financial resources that permit meaningful work, or even a second career, after transitioning from one’s main career. Beyond famous encore careerists like Gates, former New York Mayor Michael Bloomberg, and retired United States Army General Stanley McCrystal, many others have embarked on these so-called “encore careers” or “second acts” as a way to enhance their work before retirement with a new directed purpose of “giving back.” Individuals and professional associations are involved in many new opportunities that require experienced practitioners and thoughtful philanthropists.

Neurosurgery is no different, and the world can benefit from the expertise and skills of the large and dynamic workforce of humanitarian neurosurgeons. Global neurosurgery is a new field that has gained attention, particularly since the publication of the Lancet Commission Report on Global Surgery in 2015.9 The subsequent unanimous adoption of World Health Assembly Resolution 68.15, which calls for all member states of the United Nations to strengthen emergency and essential surgeries, led to efforts to correct the large worldwide disparity that exists for neurosurgical care.16 Every year, an estimated 22.6 million people across the globe suffer from neurological conditions that need a specialist’s evaluation, and about half of these cases require surgery. It has been determined that there is a deficit of close to 23,000 neurosurgeons who are needed to address this need in low- and middle-income countries (LMICs).6 The myth that neurosurgical interventions in LMICs are a luxury has been debunked: there is a projected $4.4 trillion in gross domestic product losses from 2015 to 2030 in LMICs due to neurosurgical disease.14 Within organized neurosurgery, there has been a call to action to develop a committed global neurosurgical community. Neurosurgical Focus devoted an entire issue to this topic: “Reducing Inequities in Global Neurosurgery” in October 2018.2 This transformation of the duties of the neurosurgeon now includes a responsibility to advocate for enhanced access to quality neurosurgical care for everyone, everywhere.3,11,13

So, what is the vision of an encore career in global neurosurgery? Seasoned neurosurgeons can provide surgical skills education to trainees via visiting professorships; trauma or elective rotational coverage at hospitals; in-person or telemedicine mediated consultation, mentorship, and guidance for local and international medical students and residents; and guided research and methodology training on global health topics. Senior residents can provide models for best practices in the conduct of ward rounds, sign-outs, journal clubs, and graduated independent decision-making.

There are numerous programs already in place to aid in directing the flow of skills and time toward global health efforts. Rocque and colleagues have published the results of their international collaboration model in Vietnam that utilizes in-country and US-based training, augmented by long-distance telecommunication as a means to increase specialized epilepsy care.12 Haglund et al.7 describe their twinning program at Duke University Medical Center with New Mulago Hospital in Uganda. In addition to donating useable surplus supplies, the Duke teams facilitate surgical camps several times a year to provide a platform for training all providers, including anesthesiologists and perioperative nurses. In the first 2 years since implementation, an increase in neurosurgical cases, as well as cases from other surgical specialties, was observed at New Mulago Hospital.7 In Haiti, the first-ever neurosurgical residency has been established through a collaboration between the Haitian Ministry of Health, the medical school of the State University, and the Department of Neurosurgery at University of Miami, and two non-profits, Project Medishare and Haiti Healthy Kids Inc. The foundation of the curriculum is based on teleconferences and visiting professorships, most of which are supported mainly by US-based neurosurgeons.15 Spanish neurosurgeons from Valencia have established the NED Foundation (Neurosurgery, Education and Development), which promotes scientific, technical, and cultural training in Eastern and Central Africa. Their success has led to the construction of a freestanding neurosurgical department in Zanzibar.8

There clearly are many avenues for neurosurgeon volunteers to contribute their skills and talents, with the potential for a far-reaching impact. It should be understood that these interventions are not meant to replace or be a substitute for providers in LMICs. Rather, the interventions should be designed to increase capacity, strengthen the quality of surgical training, and empower local workforce to tackle these formidable neurosurgical issues. With the introduction of National Surgical, Obstetric, and Anesthesia Plans (NSOAPs) in WHO member nations, there is potential for surgical care to be integrated into national health systems of universal health coverage; scale-up of these services may soon be a reality.1 As these processes take place, it is essential for the neurosurgery community to boost these efforts and make better use of the collective years of experience of senior neurosurgeons. Encore careers can be the gateway to this critical development of our field on a global scale.

As part of this effort, the American Association of Neurological Surgeons (AANS) is offering an innovative new course at its 2019 annual meeting. Developed by the Foundation for International Education in Neurosurgery at the request of potential neurosurgeon volunteers, the course makes use of a successful template for similar courses for general surgeons developed at Stanford University and offered at the American College of Surgeons Clinical Congress. This Continuing Medical Education workshop will help prepare the neurosurgical volunteer to function effectively in a low-resource environment (https://www.aans.org/en/Annual-Scientific-Meeting/2019). Through didactic sessions as well as skill stations and simulations, this 1-day course will provide an overview of the scope of procedures one may be called upon to teach or perform in resource-limited conditions. Participants will familiarize themselves with essential elements of surgical safety, ethics, and cultural considerations in such settings. The world-class faculty all have experience in operating and teaching in LMICs.

There are more benefits to pursing encore careers than simply the obvious humanitarian reasons. Neurosurgeons from high-income countries have much to gain, and the flow of knowledge, skills, and ingenuity can and should be bidirectional. Co-development is a term now widely accepted in global health; it makes intuitive sense that some of the best and most efficient innovations in the world could be born out of constrained settings, where the need is great and resources are limited.4 In the litigious and expensive environment of the US healthcare system, stepping outside of these bounds and practicing our craft with novel approaches can provide new insights that will benefit our patients here at home. The accomplishment of neurosurgeon Ben Warf and his team in Uganda, who pioneered and reported on the usefulness of endoscopic third ventriculostomy/choroid plexus cauterization for the treatment of postinfectious hydrocephalus, is one example of practice in an LMIC setting that can lead to real progress for the specialty as a whole.5

The Lancet Commission on Global Surgery was launched in 2015 and documented the sad fact that 5 billion people worldwide do not have access to safe and affordable surgical and anesthesia care. The commission’s subsequent work in Global Surgery 2030 shows that an investment in surgical systems is safe, saves lives, and promotes economic growth.9 Inherent in this message is a mission and opportunity for all providers to contribute to this cause and join a field that is rapidly growing but that is in need of more funding and manpower. Neurosurgeons have a chance to enrich their careers, even after years of practice, and explore this new frontier of global neurosurgery.

Disclosures

Dr. Rosseau is a former officer of the AANS and is Director of the AANS Global Neurosurgical Practice Course, and a faculty member for a similar course at Stanford University and the American College of Surgeons Clinical Congress.

References

  • 1

    Albutt K, Sonderman K, Citron I, Nthele M, Bekele A, Makasa E, et al.: Healthcare leaders develop strategies for expanding national surgical, obstetric, and anaesthesia plans in WHO AFRO and EMRO regions. World J Surg [epub ahead of print], 2018

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Branch CL Jr, Boop F, Haglund MM, Dempsey RJ: Introduction. Neurosurgical opportunities in global health inequities. Neurosurg Focus 45(4):E1, 2018

  • 3

    Corley JA, Haglund M, Denham SL: How neurosurgery fits into the global surgery 2030 agenda. Neurosurgery 79:E544E545, 2016 (Letter)

  • 4

    Crisp N: Turning the World Upside Down: The Search for Global Health in the Twenty-First Century. London: Royal Society of Medicine Press, 2010

  • 5

    Dewan MC, Onen J, Bow H, Ssenyonga P, Howard C, Warf BC: Subspecialty pediatric neurosurgery training: a skill-based training model for neurosurgeons in low-resourced health systems. Neurosurg Focus 45(4):E2, 2018

    • Crossref
    • PubMed
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  • 6

    Dewan MC, Rattani A, Fieggen G, Arraez MA, Servadei F, Boop FA, et al.: Global neurosurgery: the current capacity and deficit in the provision of essential neurosurgical care. Executive Summary of the Global Neurosurgery Initiative at the Program in Global Surgery and Social Change. J Neurosurg [epub ahead of print April 27, 2018. DOI: 10.3171/2017.11.JNS171500]

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Haglund MM, Kiryabwire J, Parker S, Zomorodi AR, MacLeod DB, Schroeder RA, et al.: Surgical capacity building in Uganda through twinning, technology, and training camps. World J Surg 35:11751182, 2011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Leidinger A, Extremera P, Kim EE, Qureshi MM, Young PH, Piquer J: The challenges and opportunities of global neurosurgery in East Africa: the Neurosurgery Education and Development model. Neurosurg Focus 45(4):E8, 2018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Meara JG, Leather AJ, Hagander L, Alkire BC, Alonso N, Ameh EA, et al.: Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet 386:569624, 2015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    NPR: Timeline: Bill Gates: From Geek to Gazillionaire to Do-Gooder. Washington, DC: NPR (https://www.npr.org/news/graphics/2008/june/bill_gates/gates_timeline_04.html) [Accessed December 19, 2018]

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Park KB, Johnson WD, Dempsey RJ: Global neurosurgery: the unmet need. World Neurosurg 88:3235, 2016

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    Rocque BG, Davis MC, McClugage SG, Tuan DA, King DT, Huong NT, et al.: Surgical treatment of epilepsy in Vietnam: program development and international collaboration. Neurosurg Focus 45(4):E3, 2018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Rosseau G, Johnson WD, Park KB, Sánchez MA, Servadei F, Vaughan KA: Global neurosurgery: current and potential impact of neurosurgeons at the World Health Organization and the World Health Assembly. Executive summary of the World Federation of Neurosurgical Societies–World Health Organization Liaison Committee at the 71st World Health Assembly. Neurosurg Focus 45(4):E18, 2018

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Rudolfson N, Dewan MC, Park KB, Shrime MG, Meara JG, Alkire BC: The economic consequences of neurosurgical disease in low- and middle-income countries. J Neurosurg [epub ahead of print May 18, 2018. DOI: 10.3171/2017.12.JNS17281]

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Shah AH, Barthélemy E, Lafortune Y, Gernsback J, Henry A, Green B, et al.: Bridging the gap: creating a self-sustaining neurosurgical residency program in Haiti. Neurosurg Focus 45(4):E4, 2018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    World Health Organization: WHA68.15—strengthening emergency and essential surgical care and anaesthesia as a component of universal health care coverage, presented at the Sixty-Eighth World Health Assembly, May 18–26, 2015 (http://apps.who.int/medicinedocs/documents/s21904en/s21904en.pdf) [Accessed December 19, 2018]

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    • Search Google Scholar
    • Export Citation
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Illustration from Ferrareze Nunes et al. (pp 1304–1314). Copyright Juan C. Fernandez-Miranda. Published with permission.

  • 1

    Albutt K, Sonderman K, Citron I, Nthele M, Bekele A, Makasa E, et al.: Healthcare leaders develop strategies for expanding national surgical, obstetric, and anaesthesia plans in WHO AFRO and EMRO regions. World J Surg [epub ahead of print], 2018

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Branch CL Jr, Boop F, Haglund MM, Dempsey RJ: Introduction. Neurosurgical opportunities in global health inequities. Neurosurg Focus 45(4):E1, 2018

  • 3

    Corley JA, Haglund M, Denham SL: How neurosurgery fits into the global surgery 2030 agenda. Neurosurgery 79:E544E545, 2016 (Letter)

  • 4

    Crisp N: Turning the World Upside Down: The Search for Global Health in the Twenty-First Century. London: Royal Society of Medicine Press, 2010

  • 5

    Dewan MC, Onen J, Bow H, Ssenyonga P, Howard C, Warf BC: Subspecialty pediatric neurosurgery training: a skill-based training model for neurosurgeons in low-resourced health systems. Neurosurg Focus 45(4):E2, 2018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Dewan MC, Rattani A, Fieggen G, Arraez MA, Servadei F, Boop FA, et al.: Global neurosurgery: the current capacity and deficit in the provision of essential neurosurgical care. Executive Summary of the Global Neurosurgery Initiative at the Program in Global Surgery and Social Change. J Neurosurg [epub ahead of print April 27, 2018. DOI: 10.3171/2017.11.JNS171500]

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Haglund MM, Kiryabwire J, Parker S, Zomorodi AR, MacLeod DB, Schroeder RA, et al.: Surgical capacity building in Uganda through twinning, technology, and training camps. World J Surg 35:11751182, 2011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Leidinger A, Extremera P, Kim EE, Qureshi MM, Young PH, Piquer J: The challenges and opportunities of global neurosurgery in East Africa: the Neurosurgery Education and Development model. Neurosurg Focus 45(4):E8, 2018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Meara JG, Leather AJ, Hagander L, Alkire BC, Alonso N, Ameh EA, et al.: Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet 386:569624, 2015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    NPR: Timeline: Bill Gates: From Geek to Gazillionaire to Do-Gooder. Washington, DC: NPR (https://www.npr.org/news/graphics/2008/june/bill_gates/gates_timeline_04.html) [Accessed December 19, 2018]

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Park KB, Johnson WD, Dempsey RJ: Global neurosurgery: the unmet need. World Neurosurg 88:3235, 2016

  • 12

    Rocque BG, Davis MC, McClugage SG, Tuan DA, King DT, Huong NT, et al.: Surgical treatment of epilepsy in Vietnam: program development and international collaboration. Neurosurg Focus 45(4):E3, 2018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Rosseau G, Johnson WD, Park KB, Sánchez MA, Servadei F, Vaughan KA: Global neurosurgery: current and potential impact of neurosurgeons at the World Health Organization and the World Health Assembly. Executive summary of the World Federation of Neurosurgical Societies–World Health Organization Liaison Committee at the 71st World Health Assembly. Neurosurg Focus 45(4):E18, 2018

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Rudolfson N, Dewan MC, Park KB, Shrime MG, Meara JG, Alkire BC: The economic consequences of neurosurgical disease in low- and middle-income countries. J Neurosurg [epub ahead of print May 18, 2018. DOI: 10.3171/2017.12.JNS17281]

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Shah AH, Barthélemy E, Lafortune Y, Gernsback J, Henry A, Green B, et al.: Bridging the gap: creating a self-sustaining neurosurgical residency program in Haiti. Neurosurg Focus 45(4):E4, 2018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    World Health Organization: WHA68.15—strengthening emergency and essential surgical care and anaesthesia as a component of universal health care coverage, presented at the Sixty-Eighth World Health Assembly, May 18–26, 2015 (http://apps.who.int/medicinedocs/documents/s21904en/s21904en.pdf) [Accessed December 19, 2018]

    • PubMed
    • Search Google Scholar
    • Export Citation

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