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Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Global opportunities on 239 general surgery residency Web sites Joel J. Wackerbarth, MPH,a,b,* Timothy D. Campbell, BA,c Sherry Wren, MD, FACS,d Raymond R. Price, MD, FACS,e,f Ronald V. Maier, MD, FACS,g Patricia Numann, MD,h and Adam L. Kushner, MD, MPH, FACSi,j,k a
Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland University of Washington School of Medicine, Seattle, Washington c The Johns Hopkins University School of Medicine, Baltimore, Maryland d Center for Global Health and Innovation, Stanford University, Stanford, California e Center for Global Surgery, University of Utah, Salt Lake City, Utah f Education Intermountain Medical Center, Intermountain Healthcare, Salt Lake City, Utah g Harborview Medical Center, University of Washington, Seattle, Washington h Department of Surgery Emerita, SUNY Upstate Medical University, Syracuse, New York i Surgeons OverSeas, New York, New York j Department of Surgery, Columbia University, New York, New York k Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland b
article info
abstract
Article history:
Background: Many general surgical residency programs lack a formal international
Received 7 April 2015
component. We hypothesized that most surgery programs do not have international
Received in revised form
training or do not provide the information to prospective applicants regarding electives or
11 May 2015
programs in an easily accessible manner via Web-based resources.
Accepted 13 May 2015
Materials and methods: Individual general surgery program Web sites and the American
Available online 18 May 2015
College of Surgeons residency tool were used to identify 239 residencies. The homepages were examined for specific mention of international or global health programs. Ease of
Keywords:
access was also considered. Global surgery specific pages or centers were noted. Programs
Global surgery
were assessed for length of rotation, presence of research component, and mention of
International surgery
benefits to residents and respective institution.
Resident education
Results: Of 239 programs, 24 (10%) mentioned international experiences on their home page
Global health
and 42 (18%) contained information about global surgery. Of those with information
General surgery residency
available, 69% were easily accessible. Academic programs were more likely than independent programs to have information about international opportunities on their home page (13.7% versus 4.0%, P ¼ 0.006) and more likely to have a dedicated program or pathway Web site (18.8% versus 2.0%, P < 0.0001). Half of the residencies with global surgery information did not have length of rotation available. Research was only mentioned by 29% of the Web sites. Benefits to high-income country residents were discussed more than benefits to low- and middle-income country residents (57% versus 17%). Conclusions: General surgery residency programs do not effectively communicate international opportunities for prospective residents through Web-based resources and
* Corresponding author. 1136B 15th Ave, Seattle, WA 98122. Tel.: þ1 425 280 7283. E-mail addresses: [email protected], [email protected] (J.J. Wackerbarth). 0022-4804/$ e see front matter ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2015.05.023
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should seriously consider integrating international options into their curriculum and better present them on department Web sites. ª 2015 Elsevier Inc. All rights reserved.
1.
Introduction
Although the global health community is beginning to recognize the need to provide surgical services for the world’s poorest and most underserved populations, limited progress has been made [1]. One way to improve surgical care in lowand middle-income countries (LMICs) is by developing partnerships with surgical training programs in high-income countries (HICs). Although very important for delivering patient care, short-term private or institutional humanitarian missions do not often provide the forum for large scale and long-term collaborations. While some programs have developed partnerships and global surgery research is increasing, much of the research has been descriptive. To develop robust outcomes-based studies, there is a need for HIC surgeons to collaborate and engage in academic hypothesis-driven studies of delivery methods, cost structures, capacity building, and outcomes assessment with LMIC colleagues [2]. In recent years, global health has grown into a formal academic field in many disciplines. However, surgery has lagged behind because of lack of funding, perceived complexity of all surgical interventions, and lack of involvement by significant numbers of HIC surgeons [3,4]. Even so, there is a documented and growing interest in global health among general surgical residents [5]. Global surgery-specific surveys have been attempted to quantify the number of programs that offer international electives, programs, or experiences; however, it is unknown what information is available through Web-based resources to prospective students before starting residency as well as the impact that this has on program selection [6]. The goal of this study was to assess surgical department Web sites to determine if international programs were profiled and what type of opportunities are advertized.
2.
Material and methods
During July 2014, the American College of Surgeons “So You Want to be a Surgeon” (SYWTBAS) online tool was used to identify all United States general surgery residency program Web sites [7]. Each Web site was visited and data collected on whether there were global surgery programs, defined as surgical experience in a low or middle-income country for surgical residents, on the home page for the US-based general surgery residency. In addition, accessibility of information was quantified as easily accessible if international surgery-specific experience could be identified within two links from the home page. Programs were graded accessible with difficulty if information regarding international programs or electives was available after more than two links from the home page or if only accessible using the search function of the home page, using search query: “global surgery” and “international electives.” Individual Web sites
were searched for a maximum of 10 min, and if no programs or electives could be identified in this time, the program was deemed not to have information available. Ten minutes was arbitrarily chosen by the authors as an estimate of how long an applicant would search; true estimates of this variable are unknown, and it may not reflect an average due to other factors such as internet connection speed, particularly if potential residents are accessing the information from a LMIC. For those programs that demonstrated an international component, it was noted if the program had a dedicated international surgery Web site, global surgery tract, or global surgery center. Academic programs were identified based on their association with a university and selfreported status on the Web site. Web sites were revisited between November 2014 and February 2015, and quality of opportunities were assessed by length of rotation, inclusion of research component, discussions of benefits to HIC institution, HIC residents, LMIC Institution, and LMIC residents. All statistical analysis was completed using STATA 13.1 (STATA Corp, College Station, TX).
3.
Results
Of the 239 surgical residencies surveyed, 138 (58%) were academic and 101 (42%) were independent. Overall, 16% (n ¼ 42) of programs had information about international opportunities available through Web-based resources (Table 1). Stratified by the type of program, 27% (n ¼ 37) of academic programs and 5% (n ¼ 5) of independent programs had any global surgery information (P < 0.0001). Dedicated pathways, centers, or global surgery-specific Web sites were found on 12% (n ¼ 28) of residency pages; however, academic programs were more likely to have this feature (18.8% versus 2.0%, P < 0.0001). With regard to ease of accessibility, 10.5% of programs (n ¼ 25) had evidence of international programs, rotations, or electives directly on the main surgery residency home page, with academic programs having a higher proportion compared with independent programs (13.7% versus 4.0%, P ¼ 0.006). Of programs with global surgery information available, 69% (n ¼ 29) were evaluated as “easily accessible” (representing 12% of residencies overall). The
Table 1 e Programs with global surgery information by ease of access and type of program. Type of program
Academic Independent Total
Number of programs (% row) Easily
With difficulty
No information
25 (18.1) 4 (4.0) 29 (12.2)
12 (8.7) 1 (1.0) 13 (5.4)
101 (73.2) 96 (95.0) 197 (82.4)
Total
138 101 239
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Table 2 e List of specific general surgery residency programs with global surgery opportunities information available, by accessibility category. Easily Available (n ¼ 29)
Difficult to access information (n ¼ 13)
Beth Israel Deaconess Medical Center Brigham and Women’s Hospital Emory University Greenville Hospital System/University of South Carolina School of Medicine Indiana University Johns Hopkins University Loma Linda University Massachusetts General Hospital Monmouth Medical Center Mount Sinai School of Medicine New York Presbyterian Hospital (Columbia Campus) Oregon Health Sciences University St Luke’s-Roosevelt Hospital Center SUNY Health Science Center at Brooklyn UCLA Medical Center University of California (Davis) Health System University of California (San Francisco) University of California San Francisco (East Bay) University of Chicago University of Michigan University of Minnesota University of Nebraska Medical Center College of Medicine University of Rochester University of Utah University of Virginia University of Washington Vanderbilt University Western Michigan Waterbury Hospital Health Center
specific programs listed by ease of access discovered in this study are listed alphabetically in Table 2. When investigating the characteristics of the international opportunities, half of the 42 programs were found to have no information about length of rotation, 36% detailed clinical rotations lasting less than or equal to 8 weeks, and 14% had programs greater than 1 year in length. Benefits to the resident in the HIC were mentioned 57% (n ¼ 24) of the time, whereas benefits to LMIC residents or a LMIC institution were discussed 17% and 19% of the time. Additionally, 5% of residencies (n ¼ 4) had any mention of benefit of the international program on the HIC institution. Research was mentioned as a component of the resident experience in 29% (n ¼ 12) of the cases (Table 3).
Table 3 e Research and benefits mentioned in 42 program Web sites with any global surgery information. Research and benefits
Research as component of the international rotation Benefits to HIC institution Benefits to HIC residents Benefits to LMIC institution Benefits to LMIC residents
Present
Absent
n
%
n
%
12
29
30
71
2 24 8 7
5 57 19 17
40 18 34 35
95 43 81 83
4.
Boston University Medical Center College of Medicine, Mayo Clinic (Arizona) College of Medicine, Mayo Clinic (Jacksonville) Duke University Hospital Medical University of South Carolina Rush University Medical Center Stanford University Swedish Medical Center/First Hill University of California (Irvine) University of Colorado Denver University of Texas Southwestern Medical School University of Wisconsin Wake Forest University School of Medicine
Discussion
General surgery residents and potential applicants have demonstrated a strong interest in international surgery electives and programs; however, we found that fewer than 20% of programs overall have global surgery on their program Web sites and even fewer had specific information about length of rotation or availability of research opportunities. Although programs in global health for residency training are still lacking among many specialties, surveys have found that surgery has among the fewest global health programs for its trainees [8]. Increasingly, residencies in other specialties such as medicine, pediatrics, or OB/GYN have included international tracts, electives, and information for residents and potential applicants [9,10]. With the progressive development of the global health care infrastructure and growing recognition of surgical needs in LMICs, it is imperative that surgery residencies adapt to the interest of their applicants to attract and foster bright and internationally focused students. Including an international residency option has been shown to increase the chances of applicants ranking a specific program higher in studies of both family medicine and emergency medicine residencies [11,12]. Generation and better advertisement of international opportunities could potentially provide a similar benefit to surgery programs. A survey completed in 2004 found that most internal medicine residents used Web-based methods for assessing residency options, and in particular,
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the quality of the Web site and the information contained were reported to be important when choosing which residency programs to apply to [13]. Given that the Internet has grown greatly in popularity over the past 10 years this dependence is likely only increased. Incorporating international experiences into surgical residency training provides added benefits to a program and residents in various ways. Studies have found increases in understanding of operating in resource-constrained areas, cultural competency, and reported likelihood of participating internationally during their active surgical career [14,15]. Participation surveys indicate that many surgical residents find their international experience to be the most valuable elective experience of their surgical residency [16]. Still surgical residents encounter strong administrative and financial constraints on international electives, despite numerous calls for additional programs and collaborations as well as stated interest from program directors to develop and market these programs [1719]. Moving programs away from short-term medical trips toward institutionalized projects with longterm collaboration and investment could be essential to ensure that global surgery training for residents is not solely used as a recruitment tool for the sake of the HIC residency program. Although funding and accreditation are challenges for a program to overcome, there are examples of successful programs to model after, and a recent survey published by Knudson et al. found that most program directors who reported global surgery electives have been able to secure Accreditation Council for Graduate Medical Education accreditation after the development and release of Accreditation Council for Graduate Medical Education guidelines for global surgery in 2011 [2024]. Additionally, Knudson et al. found that 20% of programs required at least some personal financial investment from the resident and that the most important factor for sustainability of the programs was a dedicated faculty member. Only one-quarter of academic programs in this study had any global surgery information available for current or prospective residents. Academic programs can provide opportunities for collaboration and research between HIC and LMIC surgeons as well as provide interdisciplinary resources (such as public health professionals or existing partnerships) in a unique way and likely will be the catalyst for improving global surgery access. Academic programs were much more likely to have global surgery information and dedicated programs, but there remains much room for improvement, particularly in visibility and elucidation of the opportunities. There was a strong focus on the benefit to the HIC resident but much less of a discussion of benefit to the LMIC program or potential exchanges. Similarly, there was a lack of research opportunities, which should be a priority to improve. Additionally, as global surgery continues to work toward enhancing the surgical capacity and training of LMIC partner sites, more intentional discussion and thought regarding the benefits to LMIC partners (residents and institutions) is likely necessary and could be reflected in residency program Web sites. More information or opportunities may be available with a more indepth investigation; however, the aim of this study was to estimate the prevalence of information readily
available to an applicant who is likely looking through many different programs and is limited in time. Other studies have assessed the availability of electives through surveys of program directors, which demonstrated higher levels of global heath experience availability than were found in this evaluation; however, those studies were limited by response rates of less than 40% of programs overall [2]. Department Web sites are often slow to change and remain un-updated, which is likely reflected in our results. There are further noted limitations to this study. Although the information was collected in a systematic way, it likely does not represent the true availability of electives or programs particularly as faculty at different institutions may be involved in international work and research on an informal level. Future efforts should be made to describe what proportion of international opportunities exist, which are not available through Web-based methods. There is potential for subjective misclassification of program type and misunderstanding or missing international information. This is most likely minimal, and misclassification or misunderstanding of opportunities available is certainly part of a potential applicants’ process when personally assessing programs of interest. In spite of increased interest and documented need, less than one in five programs have information on international opportunities on their respective Web sites, and half of the programs that do advertise global surgery do not have information about the length of rotation. To attract strong candidates and potential future global surgery leaders and address the growing global surgery need, residency programs should continue to invest more resources in making global surgery electives and research collaborations available, as well as provide more easily available information about these opportunities on their department Web sites.
Acknowledgment Authors’ contributions: J.J.W. was responsible for the original data collection. J.J.W. and A.L.K. completed the writing and manuscript preparation. T.D.C. was responsible for the secondary data collection. S.W., P.N., R.R.P., and R.V.M. were all responsible for the content conception and advice. A.L.K. was responsible for the concept. T.D.C., S.W., P.N., R.R.P., A.L.K., and R.V.M. completed editing of the final manuscript.
Disclosure The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article.
references
[1] Farmer P, Meara JG. Commentary: the agenda for academic excellence in “global” surgery. Surgery 2013;153:321. [2] Bowman KG. Research in global surgery: what is true science? Surgery 2013;154:646.
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[3] Calland JF, Petroze RT, Abelson J, Kraus E. Engaging academic surgery in global health: challenges and opportunities in the development of an academic track in global surgery. Surgery 2013;153:316. [4] Farmer PE, Kim JY. Surgery and global health: a view from beyond the OR. World J Surg 2008;32:533. [5] Powell AC, Casey K, Liewehr DJ, et al. Results of a national survey of surgical resident interest in international experience, electives, and volunteerism. J Am Coll Surg 2009;208:304. [6] Jayaraman SP, Ayzengart AL, Goetz LH, et al. Global health in general surgery residency: a national survey. J Am Coll Surg 2009;208:426. [7] Online Guide to Choosing a Surgical Residency. Available from: https://www.facs.org/education/resources/medicalstudents. Accessed 13 Oct 2014. [8] Kerry VB, Walensky RP, Tsai AC, et al. US medical specialty global health training and the global burden of disease. J Glob Health 2013;3:020406. [9] Anspacher M, Frintner MP, Denno D, et al. Global health education for pediatric residents: a national survey. Pediatrics 2011;128:e959. [10] Hung KJ, Tsai AC, Johnson TR, et al. Scope of global health training in U.S. obstetrics and gynecology residency programs. Obstet Gynecol 2013;122:1101. [11] Dey CC, Grabowski JG, Gebreyes K, et al. Influence of international emergency medicine opportunities on residency program selection. Acad Emerg Med 2002;9:679. [12] Bazemore AW, Henein M, Goldenhar LM, et al. The effect of offering international health training opportunities on family medicine residency recruiting. Fam Med 2007;39:255. [13] Embi PJ, Desai S, Cooney TG. Use and Utility of web-based residency program information: a survey of residency applicants. J Med Internet Res 2003;5:e22. [14] Henry JA, Groen RS, Price RR, et al. The benefits of international rotations to resource-limited settings for U.S. surgery residents. Surgery 2013;153:445.
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[15] Oliphant JL, Ruhlandt RR, Sherman SR, et al. Do international rotations make surgical residents more resource-efficient? A preliminary study. J Surg Educ 2012;69:311. [16] Sawatsky AP, Rosenman DJ, Merry SP, McDonald FS. Eight years of the Mayo International Health Program: what an international elective adds to resident education. Mayo Clin Proc 2010;85:734. [17] Birnberg JM, Lypson M, Anderson RA, et al. Incoming resident interest in global health: occasional travel versus a future career abroad? J Grad Med Educ 2011;3:400. [18] Grigorian A, Sicklick JK, Kingham TP. International surgical residency electives: a collaborative effort from trainees to surgeons working in low- and middle-income countries. J Surg Educ 2014;71:694. [19] Mitchell KB, Tarpley MJ, Tarpley JL, Casey KM. Elective global surgery rotations for residents: a call for cooperation and consortium. World J Surg 2011;35:2617. [20] Knudson MM, Tarpley MJ, Numann PJ. Global surgery opportunities for U.S. Surgical residents: an interim report. J Surg Educ 2015;72:e60. [21] Tarpley M, Hansen E, Tarpley JL. Early experience in establishing and evaluating an ACGME-approved international general surgery rotation. J Surg Educ 2013;70: 709. [22] Ozgediz D, Wang J, Jayaraman S, et al. Surgical training and global health: initial results of a 5-year partnership with a surgical training program in a low-income country. Arch Surg 2008;143:860. discussion 865. [23] Klaristenfeld DD, Chupp M, Cioffi WG, White RE. An international Volunteer program for general surgery residents at Brown medical School: the Tenwek Hospital Africa experience. J Am Coll Surg 2008;207: 125. [24] Silverberg D, Wellner R, Arora S, et al. Establishing an international training program for surgical residents. J Surg Educ 2007;64:143.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Global opportunities on 239 general surgery residency Web sites Joel J. Wackerbarth, MPH,a,b,* Timothy D. Campbell, BA,c Sherry Wren, MD, FACS,d Raymond R. Price, MD, FACS,e,f Ronald V. Maier, MD, FACS,g Patricia Numann, MD,h and Adam L. Kushner, MD, MPH, FACSi,j,k a
Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland University of Washington School of Medicine, Seattle, Washington c The Johns Hopkins University School of Medicine, Baltimore, Maryland d Center for Global Health and Innovation, Stanford University, Stanford, California e Center for Global Surgery, University of Utah, Salt Lake City, Utah f Education Intermountain Medical Center, Intermountain Healthcare, Salt Lake City, Utah g Harborview Medical Center, University of Washington, Seattle, Washington h Department of Surgery Emerita, SUNY Upstate Medical University, Syracuse, New York i Surgeons OverSeas, New York, New York j Department of Surgery, Columbia University, New York, New York k Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland b
article info
abstract
Article history:
Background: Many general surgical residency programs lack a formal international
Received 7 April 2015
component. We hypothesized that most surgery programs do not have international
Received in revised form
training or do not provide the information to prospective applicants regarding electives or
11 May 2015
programs in an easily accessible manner via Web-based resources.
Accepted 13 May 2015
Materials and methods: Individual general surgery program Web sites and the American
Available online 18 May 2015
College of Surgeons residency tool were used to identify 239 residencies. The homepages were examined for specific mention of international or global health programs. Ease of
Keywords:
access was also considered. Global surgery specific pages or centers were noted. Programs
Global surgery
were assessed for length of rotation, presence of research component, and mention of
International surgery
benefits to residents and respective institution.
Resident education
Results: Of 239 programs, 24 (10%) mentioned international experiences on their home page
Global health
and 42 (18%) contained information about global surgery. Of those with information
General surgery residency
available, 69% were easily accessible. Academic programs were more likely than independent programs to have information about international opportunities on their home page (13.7% versus 4.0%, P ¼ 0.006) and more likely to have a dedicated program or pathway Web site (18.8% versus 2.0%, P < 0.0001). Half of the residencies with global surgery information did not have length of rotation available. Research was only mentioned by 29% of the Web sites. Benefits to high-income country residents were discussed more than benefits to low- and middle-income country residents (57% versus 17%). Conclusions: General surgery residency programs do not effectively communicate international opportunities for prospective residents through Web-based resources and
* Corresponding author. 1136B 15th Ave, Seattle, WA 98122. Tel.: þ1 425 280 7283. E-mail addresses: [email protected], [email protected] (J.J. Wackerbarth). 0022-4804/$ e see front matter ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2015.05.023
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should seriously consider integrating international options into their curriculum and better present them on department Web sites. ª 2015 Elsevier Inc. All rights reserved.
1.
Introduction
Although the global health community is beginning to recognize the need to provide surgical services for the world’s poorest and most underserved populations, limited progress has been made [1]. One way to improve surgical care in lowand middle-income countries (LMICs) is by developing partnerships with surgical training programs in high-income countries (HICs). Although very important for delivering patient care, short-term private or institutional humanitarian missions do not often provide the forum for large scale and long-term collaborations. While some programs have developed partnerships and global surgery research is increasing, much of the research has been descriptive. To develop robust outcomes-based studies, there is a need for HIC surgeons to collaborate and engage in academic hypothesis-driven studies of delivery methods, cost structures, capacity building, and outcomes assessment with LMIC colleagues [2]. In recent years, global health has grown into a formal academic field in many disciplines. However, surgery has lagged behind because of lack of funding, perceived complexity of all surgical interventions, and lack of involvement by significant numbers of HIC surgeons [3,4]. Even so, there is a documented and growing interest in global health among general surgical residents [5]. Global surgery-specific surveys have been attempted to quantify the number of programs that offer international electives, programs, or experiences; however, it is unknown what information is available through Web-based resources to prospective students before starting residency as well as the impact that this has on program selection [6]. The goal of this study was to assess surgical department Web sites to determine if international programs were profiled and what type of opportunities are advertized.
2.
Material and methods
During July 2014, the American College of Surgeons “So You Want to be a Surgeon” (SYWTBAS) online tool was used to identify all United States general surgery residency program Web sites [7]. Each Web site was visited and data collected on whether there were global surgery programs, defined as surgical experience in a low or middle-income country for surgical residents, on the home page for the US-based general surgery residency. In addition, accessibility of information was quantified as easily accessible if international surgery-specific experience could be identified within two links from the home page. Programs were graded accessible with difficulty if information regarding international programs or electives was available after more than two links from the home page or if only accessible using the search function of the home page, using search query: “global surgery” and “international electives.” Individual Web sites
were searched for a maximum of 10 min, and if no programs or electives could be identified in this time, the program was deemed not to have information available. Ten minutes was arbitrarily chosen by the authors as an estimate of how long an applicant would search; true estimates of this variable are unknown, and it may not reflect an average due to other factors such as internet connection speed, particularly if potential residents are accessing the information from a LMIC. For those programs that demonstrated an international component, it was noted if the program had a dedicated international surgery Web site, global surgery tract, or global surgery center. Academic programs were identified based on their association with a university and selfreported status on the Web site. Web sites were revisited between November 2014 and February 2015, and quality of opportunities were assessed by length of rotation, inclusion of research component, discussions of benefits to HIC institution, HIC residents, LMIC Institution, and LMIC residents. All statistical analysis was completed using STATA 13.1 (STATA Corp, College Station, TX).
3.
Results
Of the 239 surgical residencies surveyed, 138 (58%) were academic and 101 (42%) were independent. Overall, 16% (n ¼ 42) of programs had information about international opportunities available through Web-based resources (Table 1). Stratified by the type of program, 27% (n ¼ 37) of academic programs and 5% (n ¼ 5) of independent programs had any global surgery information (P < 0.0001). Dedicated pathways, centers, or global surgery-specific Web sites were found on 12% (n ¼ 28) of residency pages; however, academic programs were more likely to have this feature (18.8% versus 2.0%, P < 0.0001). With regard to ease of accessibility, 10.5% of programs (n ¼ 25) had evidence of international programs, rotations, or electives directly on the main surgery residency home page, with academic programs having a higher proportion compared with independent programs (13.7% versus 4.0%, P ¼ 0.006). Of programs with global surgery information available, 69% (n ¼ 29) were evaluated as “easily accessible” (representing 12% of residencies overall). The
Table 1 e Programs with global surgery information by ease of access and type of program. Type of program
Academic Independent Total
Number of programs (% row) Easily
With difficulty
No information
25 (18.1) 4 (4.0) 29 (12.2)
12 (8.7) 1 (1.0) 13 (5.4)
101 (73.2) 96 (95.0) 197 (82.4)
Total
138 101 239
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Table 2 e List of specific general surgery residency programs with global surgery opportunities information available, by accessibility category. Easily Available (n ¼ 29)
Difficult to access information (n ¼ 13)
Beth Israel Deaconess Medical Center Brigham and Women’s Hospital Emory University Greenville Hospital System/University of South Carolina School of Medicine Indiana University Johns Hopkins University Loma Linda University Massachusetts General Hospital Monmouth Medical Center Mount Sinai School of Medicine New York Presbyterian Hospital (Columbia Campus) Oregon Health Sciences University St Luke’s-Roosevelt Hospital Center SUNY Health Science Center at Brooklyn UCLA Medical Center University of California (Davis) Health System University of California (San Francisco) University of California San Francisco (East Bay) University of Chicago University of Michigan University of Minnesota University of Nebraska Medical Center College of Medicine University of Rochester University of Utah University of Virginia University of Washington Vanderbilt University Western Michigan Waterbury Hospital Health Center
specific programs listed by ease of access discovered in this study are listed alphabetically in Table 2. When investigating the characteristics of the international opportunities, half of the 42 programs were found to have no information about length of rotation, 36% detailed clinical rotations lasting less than or equal to 8 weeks, and 14% had programs greater than 1 year in length. Benefits to the resident in the HIC were mentioned 57% (n ¼ 24) of the time, whereas benefits to LMIC residents or a LMIC institution were discussed 17% and 19% of the time. Additionally, 5% of residencies (n ¼ 4) had any mention of benefit of the international program on the HIC institution. Research was mentioned as a component of the resident experience in 29% (n ¼ 12) of the cases (Table 3).
Table 3 e Research and benefits mentioned in 42 program Web sites with any global surgery information. Research and benefits
Research as component of the international rotation Benefits to HIC institution Benefits to HIC residents Benefits to LMIC institution Benefits to LMIC residents
Present
Absent
n
%
n
%
12
29
30
71
2 24 8 7
5 57 19 17
40 18 34 35
95 43 81 83
4.
Boston University Medical Center College of Medicine, Mayo Clinic (Arizona) College of Medicine, Mayo Clinic (Jacksonville) Duke University Hospital Medical University of South Carolina Rush University Medical Center Stanford University Swedish Medical Center/First Hill University of California (Irvine) University of Colorado Denver University of Texas Southwestern Medical School University of Wisconsin Wake Forest University School of Medicine
Discussion
General surgery residents and potential applicants have demonstrated a strong interest in international surgery electives and programs; however, we found that fewer than 20% of programs overall have global surgery on their program Web sites and even fewer had specific information about length of rotation or availability of research opportunities. Although programs in global health for residency training are still lacking among many specialties, surveys have found that surgery has among the fewest global health programs for its trainees [8]. Increasingly, residencies in other specialties such as medicine, pediatrics, or OB/GYN have included international tracts, electives, and information for residents and potential applicants [9,10]. With the progressive development of the global health care infrastructure and growing recognition of surgical needs in LMICs, it is imperative that surgery residencies adapt to the interest of their applicants to attract and foster bright and internationally focused students. Including an international residency option has been shown to increase the chances of applicants ranking a specific program higher in studies of both family medicine and emergency medicine residencies [11,12]. Generation and better advertisement of international opportunities could potentially provide a similar benefit to surgery programs. A survey completed in 2004 found that most internal medicine residents used Web-based methods for assessing residency options, and in particular,
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the quality of the Web site and the information contained were reported to be important when choosing which residency programs to apply to [13]. Given that the Internet has grown greatly in popularity over the past 10 years this dependence is likely only increased. Incorporating international experiences into surgical residency training provides added benefits to a program and residents in various ways. Studies have found increases in understanding of operating in resource-constrained areas, cultural competency, and reported likelihood of participating internationally during their active surgical career [14,15]. Participation surveys indicate that many surgical residents find their international experience to be the most valuable elective experience of their surgical residency [16]. Still surgical residents encounter strong administrative and financial constraints on international electives, despite numerous calls for additional programs and collaborations as well as stated interest from program directors to develop and market these programs [1719]. Moving programs away from short-term medical trips toward institutionalized projects with longterm collaboration and investment could be essential to ensure that global surgery training for residents is not solely used as a recruitment tool for the sake of the HIC residency program. Although funding and accreditation are challenges for a program to overcome, there are examples of successful programs to model after, and a recent survey published by Knudson et al. found that most program directors who reported global surgery electives have been able to secure Accreditation Council for Graduate Medical Education accreditation after the development and release of Accreditation Council for Graduate Medical Education guidelines for global surgery in 2011 [2024]. Additionally, Knudson et al. found that 20% of programs required at least some personal financial investment from the resident and that the most important factor for sustainability of the programs was a dedicated faculty member. Only one-quarter of academic programs in this study had any global surgery information available for current or prospective residents. Academic programs can provide opportunities for collaboration and research between HIC and LMIC surgeons as well as provide interdisciplinary resources (such as public health professionals or existing partnerships) in a unique way and likely will be the catalyst for improving global surgery access. Academic programs were much more likely to have global surgery information and dedicated programs, but there remains much room for improvement, particularly in visibility and elucidation of the opportunities. There was a strong focus on the benefit to the HIC resident but much less of a discussion of benefit to the LMIC program or potential exchanges. Similarly, there was a lack of research opportunities, which should be a priority to improve. Additionally, as global surgery continues to work toward enhancing the surgical capacity and training of LMIC partner sites, more intentional discussion and thought regarding the benefits to LMIC partners (residents and institutions) is likely necessary and could be reflected in residency program Web sites. More information or opportunities may be available with a more indepth investigation; however, the aim of this study was to estimate the prevalence of information readily
available to an applicant who is likely looking through many different programs and is limited in time. Other studies have assessed the availability of electives through surveys of program directors, which demonstrated higher levels of global heath experience availability than were found in this evaluation; however, those studies were limited by response rates of less than 40% of programs overall [2]. Department Web sites are often slow to change and remain un-updated, which is likely reflected in our results. There are further noted limitations to this study. Although the information was collected in a systematic way, it likely does not represent the true availability of electives or programs particularly as faculty at different institutions may be involved in international work and research on an informal level. Future efforts should be made to describe what proportion of international opportunities exist, which are not available through Web-based methods. There is potential for subjective misclassification of program type and misunderstanding or missing international information. This is most likely minimal, and misclassification or misunderstanding of opportunities available is certainly part of a potential applicants’ process when personally assessing programs of interest. In spite of increased interest and documented need, less than one in five programs have information on international opportunities on their respective Web sites, and half of the programs that do advertise global surgery do not have information about the length of rotation. To attract strong candidates and potential future global surgery leaders and address the growing global surgery need, residency programs should continue to invest more resources in making global surgery electives and research collaborations available, as well as provide more easily available information about these opportunities on their department Web sites.
Acknowledgment Authors’ contributions: J.J.W. was responsible for the original data collection. J.J.W. and A.L.K. completed the writing and manuscript preparation. T.D.C. was responsible for the secondary data collection. S.W., P.N., R.R.P., and R.V.M. were all responsible for the content conception and advice. A.L.K. was responsible for the concept. T.D.C., S.W., P.N., R.R.P., A.L.K., and R.V.M. completed editing of the final manuscript.
Disclosure The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article.
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