barriers to participation in global surgery academic

CLINICAL ARTICLEJ Neurosurg 130:1157–1165, 2019

Until recently, surgery was ignored as an important aspect of global health, partially due to miscon-ceptions about the global impact of surgery and

the complexity and resource-intensive nature of surgical care.1,2 Although there is an increased awareness of the global surgical need, significant work is still needed to im-prove surgical care worldwide.12

Surgically treatable conditions make up approximately 30% of the total global burden of disease,33 and an esti-mated 5 billion people do not have adequate access to surgical care.24 Approximately 16.9 million people died in

2010 from surgically treatable conditions, and 77.2 million disability-adjusted life years are lost each year due to poor access to surgical care. This often leads to significant suf-fering during the most productive years of life. Addition-ally, the global burden of surgical disease disproportion-ately affects people in low- and middle-income countries (LMICs). The population in the 30% lowest-income coun-tries receive 3.5% of worldwide surgical procedures each year, whereas the population in the 30% highest-income countries receive almost 75%.34 These statistics have a pro-found implication for the global economy, with a projected

ABBREVIATIONS GSACs = global surgery academic collaborations; HIC = high-income country; LMIC = low- and middle-income country; POHCP = perioperative health care provider. SUBMITTED February 18, 2017. ACCEPTED October 18, 2017.INCLUDE WHEN CITING Published online April 6, 2018; DOI: 10.3171/2017.10.JNS17435.

Barriers to participation in global surgery academic collaborations, and possible solutions: a qualitative studyParisa Nicole Fallah, BSA,1 and Mark Bernstein, MD, MHSc, FRCSC2,3

1Harvard Medical School, Boston, Massachusetts; 2Division of Neurosurgery, Department of Surgery, University of Toronto; and 3Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada

OBJECTIVE There is a global lack of access to surgical care, and this issue disproportionately affects those in low- and middle-income countries. Global surgery academic collaborations (GSACs) between surgeons in high-income countries and those in low- and middle-income countries are one possible sustainable way to address the global surgical need. The objective of this study was to examine the barriers to participation in GSACs and to suggest ways to increase in-volvement.METHODS A convenience sample of 86 surgeons, anesthesiologists, other physicians, residents, fellows, and nurses from the US, Canada, and Norway was used. Participants were all health care providers from multiple specialties and multiple academic centers with varied involvement in GSACs. More than half of the participants were neurosurgeons. Participants were interviewed in person or over Skype in Toronto over the course of 2 months by using a predetermined set of open-ended questions. Thematic content analysis was used to evaluate the participants’ responses.RESULTS Based on the data, 3 main themes arose that pointed to individual, community, and system barriers for involvement in GSACs. Individual barriers included loss of income, family commitments, young career, responsibility to local patients, skepticism of global surgery efforts, ethical concerns, and safety concerns. Community barriers included insufficient mentorship and lack of support from colleagues. System barriers included lack of time, minimal academic recognition, insufficient awareness, insufficient administrative support and organization, and low political and funding support.CONCLUSIONS Steps can be taken to address some of these barriers and to increase the involvement of surgeons from high-income countries in GSACs. This could lead to a necessary scale-up of global surgery efforts that may help increase worldwide access to surgical care. https://thejns.org/doi/abs/10.3171/2017.10.JNS17435KEYWORDS global surgery; academic collaborations; capacity building; workforce; barriers

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$20.3 trillion loss between 2015 and 2030 due to lack of access to surgical care. Of that estimate, $12.3 trillion will be lost from LMICs, leading to decreased development potential for those countries.24

The Lancet Commission on Global Surgery has de-fined the most basic surgical needs worldwide as the bell-wether procedures: laparotomies, cesarean sections, and treatment of open fractures.24 With these defined needs, the surgical specialties most commonly associated with global surgery are general, trauma, orthopedics, and ob-stetrics and gynecology. However, at a time when the field of global surgery is evolving, other surgical specialties are advocating for themselves within the global surgery sphere.28 There is significant value in incorporating a global surgery perspective into every specialty, so that the standard of surgery worldwide can be raised beyond the most basic needs. Specific to global neurosurgery is that, oftentimes, if a medical center in an LMIC can provide neurosurgical care, their overall standard of care is raised. By having the capability to address neurosurgical needs, a center’s capacity for other surgical specialties, anesthesia care, ICU care, and nursing is increased, which has moti-vated work toward establishing neurosurgery (and other surgical subspecialties) in low-resource contexts.

A majority of global surgery work in LMICs has been focused on achieving short-term goals through interven-tions such as brief surgical missions and provision of re-sources.12 However, lack of access to surgery is an issue that requires more than clinical interventions; it requires training, teams, systems, and resources aimed at build-ing capacity and working toward long-term results.23 More recently, these sustainable interventions have in-creased, including individual teaching efforts and twin-ning between hospitals in high-income countries (HICs) and LMICs.5,9,19 Global surgery academic collaborations (GSACs) involve surgeons and perioperative health care providers (POHCPs) from HICs working with those in LMICs to build on clinical training, advance current knowledge through research, develop residency pro-grams, and strengthen infrastructure for the provision of surgical care.6,18 Global surgery academic collaborations involve continuous collaborations, with some time spent working directly on the ground and the remaining time spent maintaining relationships via online communica-tions and interactions.

Several models exist for participation in global surgery, ranging from provision of resources to online video con-ferences to long-term partnerships.19 Unfortunately, in-volvement in long-term global health endeavors (such as GSACs) can be difficult and inaccessible for surgeons and POHCPs.3,7,17,19,27 However, there is a need to increase sur-gical care based on a growing population with an increas-ing burden of noncommunicable diseases.36 A movement toward more global health partnerships can help achieve this,20 and given the increasing interest in global surgery, it is critical that involvement in GSACs is facilitated. We aimed to identify barriers to participation in GSACs for those in HICs and to propose solutions that can facilitate involvement. Our hope is that the results of this study can lead to increased involvement in GSACs and a scale-up in global surgery efforts.

MethodsStudy Participants and Sample Size

Study participants included surgeons from multiple specialties (Fig. 1), anesthesiologists, other physicians, residents or fellows, and nurses from 20 academic medi-cal institutions in the US, Canada, and Norway. Partici-pants were recruited through convenience sampling. The majority of potential participants recruited were known by the senior author, and a small number were known by the first author. Of the 124 health care providers emailed, 86 agreed to do an interview. Of the 32 who did not agree to an interview, 23 did not respond to the email and the other 9 were unable to schedule a time to be interviewed during the data collection period. The remaining 6 people who responded to the email were not health care providers and were not included in this analysis.

The final sample size was 86. Of the sample, 62 par-ticipants were involved in global medical or surgical aca-demic collaborations (40 surgeons, 5 anesthesiologists, 11 additional physicians, 4 surgery residents, and 2 nurses). “Involvement” included a range of commitments to global health, but all of the participants in this category were peo-ple who had a current sustained commitment, rather than only past experience, and have focused their efforts on ca-pacity building in global health and surgery. The remain-ing 24 participants were not involved in global health work (20 surgeons and 4 surgery fellows). Seventy percent of the sample was surgeons, whereas the remaining 30% was composed of anesthesiologists, other physicians, nurses, and residents or fellows. More than half (52%) of the sur-geons in the overall sample were neurosurgeons. This was due to the fact that the senior author is a neurosurgeon and had more neurosurgery contacts to recruit for the study. However, the remaining 48% of surgeons in the sample came from a wide range of surgical specialties (Fig. 1).

Study Aim, Design, Setting, and AnalysisBetween June 1 and August 1, 2015, in Toronto, Canada,

P.N.F. conducted 86 semistructured interviews in person, over the phone, or over Skype, which was sufficient to reach data saturation. Questions were based on an interview guide and were intended to be open-ended to gain more in-depth responses. Demographic data, including age, sex, specialty, and number of years in practice, were collected. Sample interview questions are shown in Table 1. Interviews were 30 minutes on average and were audio-recorded and tran-scribed. Transcripts of the audio files were analyzed using thematic analysis. This included finding, examining, and recording patterns in the data.16,30 Themes were then deter-mined inductively after coding and organizing the data. A theme constitutes an idea that is articulated by a significant number of the study participants. Numerical values and percentages are generally not used in qualitative studies; however, in this study, designated themes were mentioned by 50% or more of the respondents.

Ethics Approval and ConsentEach participant gave either written or oral informed

consent to participate in the study. All data were de-iden-tified and stored confidentially, and the recordings and


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transcripts were kept in a secure location. The study was approved both by the research ethics board at the Univer-sity Health Network in Toronto, Ontario, Canada, and by the institutional review board at the University of Texas at Austin.

ResultsFindings from the study showed 3 major themes: in-

dividual, community, and system barriers. The barriers within each theme are explained below, with accompa-nying descriptive quotes that are representative of par-ticipants’ overall responses. A summary of the results has been included in Table 2.

Individual BarriersIndividual barriers are those that affect only the indi-

vidual and/or that the individual imposes on themselves.

Loss of IncomeStudy participants reported that the lost income while

they are away is significant. They mentioned that this is often due to the need to take an unpaid leave of absence to travel as a part of GSACs. This poses a barrier because participants often have significant financial obligations in supporting themselves and their families.

Financially, I’ve always covered my own expenses, and the expenses tend not to be very onerous, but it’s actually the lost income for the time that you are away. It’s pretty significant.

— Cardiac surgeon, Canada

Family CommitmentsFamily commitments make it difficult to give time to

GSACs. Participants reported difficulty in leaving their children for long periods of time. Additionally, having spouses who are concerned with the perceived dangers of traveling discourages involvement.

FIG. 1. Pie chart showing percentage of different surgical specialties represented by surgeons in the sample, not including other study participants. Fifty-two percent of the surgeons in the sample were neurosurgeons, followed by 7% general surgeons, 6% orthopedic surgeons, 6% surgical oncologists, and 4% cardiac surgeons. Breast surgeons, trauma surgeons, pediatric neurosur-geons, pediatric plastic surgeons, and pediatric thoracic surgeons were each represented as 3% of the surgeons in the sample. Thoracic surgeons, endocrine surgeons, ophthalmologists, vascular surgeons, plastic surgeons, and urologists were each repre-sented as 1% of the surgeons in the sample. Seventy percent of the overall sample was surgeons, whereas the remaining 30% was composed of anesthesiologists, other physicians, nurses, and residents or fellows. Figure is available in color online only.




So personally, I’m young. I have three young children. My wife did not sign on to this. She wants me to parent my chil-dren, so to leave them for a long period of time is a big deal for me.

— Anesthesiologist, Canada

Being Junior in One’s CareerYounger study participants stated that they were not

heavily involved in GSACs because they believed that teaching and learning in low-resource settings requires significant confidence, credibility, and experience that they do not yet have. Additionally, junior faculty thought that they were pressured to focus on advancing their aca-demic career and clinical reputations before becoming involved in GSACs. Participants who were older men-tioned that they were content with when they started their involvement in GSACs, because they had freedom in their career and expertise in their field.

As a young surgeon, you don’t have the credibility or the con-fidence to go to places where the surgery you’re going to do is going to require you to be super flexible since they may not have all the equipment or technology you usually use to make a diagnosis.

— Neurosurgeon, USA

Feeling Greater Responsibility to Local Patients at Home Than to Those Abroad

Participants not involved in GSACs stated that they did not understand the need to help people abroad when there are many patients within their own country that need sur-gical care. Those involved in GSACs felt a responsibility to be available for their local patients, which limits their desire to make time for international work.

When I think about where I am best suited to help people, where I am of most value, I feel like there is a lot of work to do [in my own country]. I feel like there are lots of problems to solve here.

— Surgical oncologist, Canada

Skepticism About Whether Surgery Is a Major, Cost-Effective, Global Health Issue

Participants not involved in GSACs believed that sur-

gery is not a global health priority. They were not con-vinced that global surgical interventions are helpful and wanted evidence of their efficacy. A common perception was that preventive medical and public health interven-tions are more cost-effective and impactful than surgery. There were concerns that without the basic requirements for surgery (i.e., sterile operating rooms, clean water), building surgical infrastructure is nearly impossible.

I’d like to know what the impact of teaching brain surgery is in countries where the most important health problems are fixed with a mosquito net and clean water.

— Neurosurgeon, Canada

Concerns Regarding the Ethics and Intentions of GSACsParticipants were concerned over whether GSACs

actually helped develop surgery in LMICs or if involve-ment was just for personal satisfaction. They questioned whether GSACs could be more harmful than beneficial, and they did not want to infringe on other surgical prac-tices abroad. Participants additionally stated that surgery in LMICs can be complicated with advanced clinical presentations, and there are often not enough resources to support successful surgical outcomes. There was hesi-tancy over teaching and doing second-best work without the proper resources, and there were concerns over the follow-up care that patients would receive after complex surgical care in LMICs.

It seems to be more beneficial for the people that are going to feel good about themselves than actually beneficial for the community that they are supposed to be helping. If I knew that I would go [to LMICs] and it would really, really make an impact, then I would definitely go, but right now, there’s no way of knowing what’s happening and what’s going on.


Concern for Physical and Emotional Well-Being When Traveling Participants reported a fear of war and terrorism in po-

litically unstable LMICs. They also worried about travel-ing to unsafe areas and/or areas with high rates of infec-tious diseases. There was concern over lack of access to safe water and food, as well as having to give up personal standards of hygiene to work in LMICs.

I have an education-based model that doesn’t work well in

TABLE 1. Sample questions from interview guides

Participant Characteristic Sample Questions

Involved in global surgery 1. What do you know about the global need for surgery?2. What do you think is the most effective way to address this need?3. Please describe your involvement in global surgery efforts, including global surgery academic collaborations.4. When did you begin your involvement and why?5. What do you see as obstacles to your involvement in global surgery academic collaborations?6. In what ways do you think these obstacles could be removed?

Not involved in global surgery 1. What do you know about the global need for surgery?2. What do you think should be done to alleviate this need?3. Have you considered being involved in global surgery efforts, such as global surgery academic collaborations?4. What obstacles make it difficult to be involved in global surgery academic collaborations?5. What changes would need to be made to facilitate your involvement?




a war zone, because the people you train or the people that you’re responsible for are put at risk. One of the first things is that there must be a stable local environment that we can work.


Participants also mentioned emotional stress from see-ing conditions abroad and feeling unable to make a mea-surable impact. There was also frustration stemming from the slow nature of establishing and continuing GSACs.

It just seems like anyone’s efforts are just like a drop in the ocean, which then becomes overwhelming and hard to know if any individual can actually make a difference.

— General surgeon, Canada

Community BarriersCommunity barriers are those that are based on inter-

actions between surgeons and POHCPs in an academic or medical institution.

Insufficient Mentorship and Early Exposure to Global Surgery During Training

Participants said that it would have been significantly easier to incorporate GSACs into their careers if they had early exposure during training, and that without mentors, it was difficult to know how to become involved in GSACs and what that involvement entailed. There are structural limitations on how training programs are incentivized to involve their trainees in such work, even though the value of this work for trainees is immense. Additionally, par-ticipants pointed out that mentors provided inspiration for involvement in global surgical work.

I think definitely when you start early, it just becomes easier to make it a part of your life perspective. The more you see it,

the more you are able to distinguish whether or not it’s some-thing for you.

— Pediatric neurosurgeon, Canada

Lack of Support From ColleaguesParticipants felt discouraged by their colleagues when

doing global surgical work. Although they are not directly told to discontinue their involvement, there is a notion among their colleagues that involvement in GSACs is not difficult and is synonymous with a vacation. Participants felt that their practice partners are not aware of the im-portance of GSACs, and some are unwilling to cover call while their colleagues travel as a part of these collabora-tions.

I think not all of your colleagues really appreciate what you’re doing. Some people think you’re just going on a glorified hol-iday in a new part of the world, so that’s a challenge as well.

— Pediatric thoracic surgeon, Canada

Participants were also concerned about putting signifi-cant strain on their practice partners each time they leave for global surgery–related work. Combined with their col-leagues’ other academic work that also requires traveling, participants worried that there is inadequate coverage for their patients.

Well I think that for any of us to leave for an extended time, our work partners have to be understanding and invariably they have to do a little more clinical load.

— Plastic surgeon, Canada

System BarriersSystem barriers are those that are related to hospital,

institution, funding, or government infrastructure.

TABLE 2. Barriers and possible solutions to increase involvement in GSACs

Category Barriers Possible Solutions

Individual Loss of income Income support through new payment plansFamily commitments Providing time for global surgery work outside of vacation timeJunior in career Options for academic advancement through global surgery workResponsibility to local patients Ensuring adequate coverage for local patients while others in a department engage in

GSACsSkepticism about global surgery More education on global surgery, including in medical schools, residencies, and grand

roundsUnclear ethics and intentionsConcerns for physical and emotional well-

beingImproved guidance and planning prior to travel for GSACs

Community Insufficient mentorship and early exposure Global surgery options during training; increased mentorship from those already involvedLack of support from colleagues Flexible scheduling and job sharing

System Minimal time Dedicated academic time for global surgery workPoor academic recognition Creation of an academic promotion track in global surgeryMinimal awareness of opportunities Increased publicity around GSACs; centralized data bank of global surgery efforts; global

surgery department headsInsufficient administrative support Paid administrative positions dedicated to organizing GSACsLack of funding and political support Increased scholarly work to legitimize global surgery; increased availability of grants from

funding agencies; contributions from national surgery organizations




Minimal TimeParticipants mentioned a lack of time for involvement

in GSACs. They pointed out that they often use their vaca-tion time to travel for GSACs, which creates professional and personal strain. Due to the academic responsibilities of surgeons and POHCPs at their own institutions, par-ticipants reported difficulty in being able to pause activi-ties, such as research and teaching, to become involved in GSACs. Those who hold significant administrative roles mentioned that stepping away from their administrative duties for long periods of time could rarely be done. The amount of time participants currently spend on GSACs is less than what they would consider ideal.

Time, it’s a big commitment. Since starting this, I have no free time. My vacations are missions, which I do little of. So the amount of involvement I have in extracurricular [universi-ty] activities is zero right now, and in terms of home vacation time, it’s been hard.

— Plastic surgeon, Canada

Insufficient Academic Recognition and Institutional SupportParticipants reported the lack of a promotion track that

recognizes global surgery as an important academic en-deavor. There is no career value or incentive to be involved in GSACs. This deters surgeons and POHCPs from want-ing to engage in global surgery work, and also prevents them from devoting time to GSACs due to having to fulfill their other academic requirements (i.e., research, teaching).

All of the work I have done and still do is academically, on paper, of extremely little value in terms of my development in the department and professionally.


Participants also felt frustrated that institutions use GSACs for advertisement but do not support the work aca-demically.

This is not a holiday project. It has to have academic merit, and it needs to be part of our institution’s strategic model. It must be mainstream. It needs to be recognized as a priority and not just as an advertising point or a bullet point on a pro-motional slide.


Minimal Awareness of Opportunities to ParticipateParticipants reported difficulty in accessing informa-

tion about current projects and international work related to GSACs. Participants also stated that it was difficult to find ways to get involved in global surgery or to find out what work is being done unless someone approached them directly.

There is just a lack of awareness of the opportunities that exist and the mechanisms that can be put in place to help these sur-geons get to regions of the world to assist in global outreach.

— Pediatric neurosurgeon, Canada

Insufficient Administrative Support and OrganizationParticipants reported having to organize their own

trips abroad, including for all members of their team. This

meant doing paperwork for international travel, organiz-ing schedules and flights, coordinating with the institution abroad, and other work. Additionally, participants men-tioned dealing with unnecessary hospital bureaucracy. Also, a lack of communication and organization limits their ability to coordinate with others who are also in-volved in GSACs.

One of the biggest [barriers] is that [surgeons and POHCPs] just don’t know how to do it. They feel like they are going to spend a lot of energy figuring out how to arrange travel and do they have to bring sterile gloves and all of these questions that would result in them not knowing what to do, and that uncertainty, I think, is as much of a barrier as anything else.


Lack of Funding and Political SupportSurgeons and POHCPs reported a low availability of

funding for GSACs. There are minimal grants available and minimal funding through chairs and endowments. Some had to use their own money to cover expenses, and others needed to aggressively pursue funding from their departments. Participants pointed out that having adequate funding is crucial to the success and continuity of GSACs. They also mentioned frustration with how their institu-tions publicize their global work for better hospital ratings, but do not contribute funding. Participants additionally reported the need for more political will and government support to back global surgery.

There’s tons of money for research and basic science, but they need to have unrestricted funding for charitable work and have long-term goals for deliverables—goals that are five or ten years out—because you’re not going to be able to do grant funding and then produce something in a year.


DiscussionMost of the currently available published work on bar-

riers to involvement in global health is generally editori-als about personal experiences. For example, Palazuelos and Dhillon reported encountering a “global health tax” during their careers due to the lack of academic recogni-tion of global health work.27 They pointed out that aca-demic careers only support clinical, education, research, and administrative duties, and that it is difficult to add on global health work. Additionally, they mentioned global health career “wild cards,” such as issues with work-life balance and families, lost income, dealing with conditions in LMICs, and difficulty in obtaining credentials and in planning travel for global health work.

Additionally, Calland et al. point out the serious chal-lenges to developing an academic track in global surgery, as well as the opportunities to be gained from overcoming those challenges.7 Their editorial confirms the funding and structural barriers that inhibit development of global sur-geons in the academic arena. However, it also points out the significant effort by students and residents to develop global surgery opportunities, as well as the unique oppor-tunity for global surgeons to learn and share knowledge with their other academic colleagues.




The points that both Palazuelos and Dhillon and Cal-land et al. make, similar to other editorials, are consistent with the findings of our study and provide a basis for un-derstanding the results.7,27 Fortunately, many of the barri-ers found in our study can be addressed to help increase involvement in GSACs and other global surgery capacity-building efforts. Although not much research is available on the practical issues related to involvement, we drew suggestions from participants’ responses and have em-phasized the mechanisms by which we can move beyond current limitations in the system toward solutions. A sum-mary of these suggestions has been included in Table 2.

Addressing Individual BarriersIncome loss, sometimes referred to as the “global

health tax,” is a barrier for those involved in GSACs.27 Calland et al. also point out the significant cost to global surgeons involved in long-term efforts, as well as the cost to academic institutions were they to support global sur-gery work.7 However, there is a need to provide income support for those participating in GSACs, either by par-tially covering income or by modifying payment plans. Fee-for-service payment plans cause difficulties for sur-geons and POHCPs, because time spent abroad for GSACs generally means lost income.32 Possibilities could include institutions providing partial income coverage or practice partners helping cover for their colleagues who are abroad doing global surgery work.

Family commitments are difficult to balance with glob-al surgery work,27 particularly for younger participants. Having older children, a supportive spouse,4 and a stable family life more easily allows surgeons and POHCPs to commit time for global surgery work. It may be possible to create options for participants to take their family with them when traveling. Additionally, not forcing participants to use vacation time for GSACs will allow them to use vacations to honor family commitments.

Many participants have legitimate fears about terrorism, war, illness, hygiene, and general safety.15,21 It is important to provide education and preparation to address the practi-cal concerns of those involved or those showing interest, especially trainees.8 This could mean adequate planning and pretravel information sessions to reduce anxiety. It is also important to manage participants’ expectations about what the short- and long-term goals are, what is likely to be accomplished within a specified time period, what the schedule will be, what conditions might be at the destina-tion, and other concerns.13

Surgeons and POHCPs not involved in GSACs be-lieved that there are more important global health issues than surgery, including preventive medicine, infectious disease, public health infrastructure, and systemic is-sues, such as war and government corruption. They also thought that surgery is not cost-effective enough to war-rant participation in GSACs. Coupled with concerns over the intentions of participants in GSACs, these perceptions often lead to a lack of support for global surgery work. Although systemic issues increase the difficulty of mak-ing surgical care available, focusing solely on those issues will not eliminate the need to address lack of access to surgical care. More education about the global burden of

surgical disease and how GSACs are addressing this issue could help remedy the perceptions that prevent surgeons and POHCPs from getting involved or from supporting their colleagues’ work. Specifically, data on the global sur-gical need as well as data on outcomes of global surgery interventions such as GSACs can work toward combating skepticism toward global surgery. These data could be dis-seminated as published research, but can also be shared in conferences, grand rounds, and other venues with audi-ences that include surgical health care providers.

Addressing Community BarriersSurgeons and POHCPs reported a concern for leaving

their practice to do international work, both due to feeling responsible for their patients and due to lack of support from colleagues. Flexible scheduling is needed,27 which can be difficult in surgical careers.7 Additionally, current knowledge and attitudes of surgeons and their teams do not reflect the contributions they could make to global surgery through facilitating GSACs, including through support of a colleague’s practice while they are away doing global surgery work. Everyone in a shared practice, department, hospital, and/or institution should be in agreement on the importance of global surgery to their overall mission.11

Surgeons and POHCPs believed that being advanced in their careers is conducive to involvement in GSACs due to their increased confidence, credibility, and experience. There should be a focus on encouraging and facilitating the involvement of junior surgeons, because the new gen-eration of physicians is showing increased interest in glob-al health.7,26 Involvement in GSACs could also become an option for surgical residencies, and reforms should look at ways to incentivize residency programs to allow train-ees and young faculty to benefit from global surgery ex-periences.7 Additionally, senior surgeons and POHCPs who are involved in GSACs should take on a mentorship role for trainees or junior faculty who show interest.8,31 This can help build confidence and increase experience, as well as show younger participants how to implement global surgery in their careers. Currently, those involved in global surgery tend to have more developed careers, but to increase involvement in GSACs, it is necessary for more surgeons and POHCPs to get involved earlier.7

Addressing System BarriersLack of time is a significant barrier for involvement in

GSACs; these activities require extended travel, which de-tracts from academic and administrative duties.7 Whereas surgeons receive set time for research, conferences, and other academic activities, those involved in GSACs are often forced to use vacation time.7,27 If the hospital or aca-demic institution makes global surgery a priority, time can be allotted for work related to GSACs. As surgeons and POHCPs develop their careers, they are generally pushed into choosing a particular career track.22,29 There is a need to create an academic promotion track based on global surgical work.7,15,27 Better academic recognition of global surgery would allow surgeons to dedicate more time to GSACs. Additionally, a standardized academic track can encourage more research in global surgery,11 which would increase the legitimacy and quality of GSACs.7




There is minimal awareness of GSACs and their im-portance, which leads to a lack of holistic support for sur-gery as an important global health intervention. Increased awareness of GSACs could improve participation, overall recognition, and access to funding. It may be useful to have an accessible centralized website and/or database listing those who are involved in GSACs around the world, their specialties, their institutions, and their current and planned work. The website could also include a list of institutions in LMICs and other countries that have a surgical need and explain what that need is. Having a leader for global surgery in each department or academic institution will also allow easy access to information regarding GSACs and can streamline the process for those interested in be-coming involved.35

To help the surgical community better understand what GSACs are and to notify others of opportunities to become involved, there could be public reflection meetings after an individual or group returns from travel and GSAC-related work. Increased publicity around details of GSACs and their progress could also help garner political, donor, and institutional support.1,25,35 Additionally, as increasing re-search is done on GSACs, hosting research symposia and conferences specific to global surgery will help improve the view of this work as a significant scholarly endeavor,9 which could help legitimize the distribution of grant mon-ey for long-term global surgery projects (https://www.fic.nih.gov/FUNDING/pages/fogarty-funding-opps.aspx).7

For those who want to work in global surgery, the field is disorganized—in terms of lost opportunity costs for par-ticipants—so reforms should explore how to improve the general organization of efforts. The lack of administrative support can be addressed by creating administrative paid positions that would take on the role of organizing and planning work related to GSACs. This could significant-ly ease the process of getting involved in GSACs so that more surgeons and POHCPs will want to participate. Ad-ditionally, hospitals and institutions can work to decrease bureaucratic administrative barriers, such as extensive, ir-relevant paperwork.35

A systematic approach is also necessary to reduce the confusion that arises from the lack of communication and organization among all surgeons and POHCPs involved in GSACs. Guidelines are needed so that the process is more streamlined and so that complete program development would not be necessary for every GSAC and related work abroad. Communication can also improve the network-ing and availability of information for all participants in GSACs.10

As mentioned by study participants, funding is also a major barrier to global surgery work, such that there is no regular source of funding for these efforts. Currently, in-dividuals must insistently encourage their colleagues, de-partments, and/or hospitals to engage in and to contribute to global surgery work. Some funds come through grants from the National Institutes of Health and other major funding organizations; through departments that have pri-oritized global surgery; from endowed chairs; and often-times from individuals’ own pockets. A possible source of funding that has been less explored is national surgery organizations, such as the American College of Surgeons.

Some of these organizations have dedicated portions of their mission to global surgery (for example, Operation Giving Back) and, given their more centralized role in sur-gical care, have the capacity to orient their members to-ward that mission. Disseminating more data and research on the effectiveness of global surgery interventions such as GSACs can potentially increase funding toward such efforts.

Study LimitationsQualitative research is not as familiar to the medical

and surgical field. It involves generating themes without the exactitude of quantitative research. However, it holds significant value in the details that can be extracted from participants’ responses and the depth at which each theme can be understood beyond quantitative data.

Due to convenience sampling, there is slightly larger representation in the sample from one locality. Qualitative research is also more difficult to replicate, and thematic analysis can limit the generalizability of the data. How-ever, the large sample size was used to help decrease bias and address these limitations, and although the findings are less generalizable, they can be transferred to other settings and used for future quantitative studies to better understand the impact of each of these barriers and their potential solutions.

ConclusionsWe were able to identify several barriers to participa-

tion in GSACs that stem from individual, community, and system-based sources. Fortunately, there are concrete ways to address these barriers to increase participation in global surgery efforts, including through education, pub-licity, academic recognition, income coverage, adminis-trative support, and institutional prioritization. If changes are implemented and more surgeons and POHCPs become involved in GSACs, this could lead to a necessary scale-up of global surgery efforts.

Future studies are needed to further characterize these barriers, and to look at the mechanisms that can address these barriers and the effectiveness of suggested methods in increasing involvement in sustainable global surgery ef-forts. Future studies could also address barriers to global surgery work from the perspective of hospital adminis-trators, financial officers, and other institutional priority decision makers. Finally, to build on the investigation of barriers from the perspective of those in HICs, a similar study should be done to look at barriers to GSACs from the perspective of those in LMICs.

AcknowledgmentsThe Greg Wilkins-Barrick Chair in International Surgery at the

University Health Network in Toronto funded Ms. Fallah during the data collection period.

References 1. Ackerly DC, Udayakumar K, Taber R, Merson MH, Dzau VJ:

Perspective: global medicine: opportunities and challenges for academic health science systems. Acad Med 86:1093–1099, 2011




2. Bae JY, Groen RS, Kushner AL: Surgery as a public health intervention: common misconceptions versus the truth. Bull World Health Organ 89:394, 2011

3. Bernstein M: Ethical dilemmas encountered while operating and teaching in a developing country. Can J Surg 47:170–172, 2004

4. Black JS, Stephens GK: The influence of the spouse on American expatriate adjustment and intent to stay in Pacific Rim overseas assignments. J Manage 15:529–544, 1989

5. Cadée F, Nieuwenhuijze MJ, Lagro-Janssen ALM, De Vries R: The state of the art of twinning, a concept analysis of twinning in healthcare. Global Health 12:66, 2016

6. Cadotte DW, Sedney C, Djimbaye H, Bernstein M: A qualita-tive assessment of the benefits and challenges of international neurosurgical teaching collaboration in Ethiopia. World Neurosurg 82:980–986, 2014

7. Calland JF, Petroze RT, Abelson J, Kraus E: Engaging aca-demic surgery in global health: challenges and opportunities in the development of an academic track in global surgery. Surgery 153:316–320, 2013

8. Dandu M: Trainee safety in global health. J Gen Intern Med 26:826–827, 2011

9. Deckelbaum DL, Gosselin Tardif A, Taylor R, Howard A, Khwaja K, Kyamanywa P, et al: Global health conferences: are they truly “global”? The Bethune Round Table paradigm for promoting global surgery. Can J Surg 54:422–429, 2011 (Erratum in Can J Surg 56:198, 2013)

10. Fallah PN, Bernstein M: Unifying a fragmented effort: a qualitative framework for improving international surgical teaching collaborations. Global Health 13:70, 2017

11. Farmer PE: More than just a hobby. What Harvard can do to advance global health. Harvard Crimson. May 26, 2011 (http://www.thecrimson.com/article/2011/5/26/health-global-training-medical/) [Accessed December 14, 2017]

12. Farmer PE, Kim JY: Surgery and global health: a view from beyond the OR. World J Surg 32:533–536, 2008

13. Foyle MF, Beer MD, Watson JP: Expatriate mental health. Acta Psychiatr Scand 97:278–283, 1998

14. Gardner A, Cohen T, Carter EJ: Tuberculosis among partici-pants in an academic global health medical exchange pro-gram. J Gen Intern Med 26:841–845, 2011

15. Gewin V: The global challenge. Nature 447:348–349, 200716. Green J, Thorogood N: Qualitative Methods for Health Re-

search. Thousand Oaks, CA: SAGE Publications Inc, 200917. Howe KL, Malomo AO, Bernstein MA: Ethical challenges in

international surgical education, for visitors and hosts. World Neurosurg 80:751–758, 2013

18. Howe KL, Zhou G, July J, Totimeh T, Dakurah T, Malomo AO, et al: Teaching and sustainably implementing awake craniotomy in resource-poor settings. World Neurosurg 80:e171–e174, 2013

19. Ibrahim GM, Bernstein M: Models of neurosurgery interna-tional aid and their potential ethical pitfalls. Virtual Mentor 17:49–55, 2015

20. Jones A: Envisioning a global health partnership movement. Global Health 12:1, 2016

21. Jones S: Medical aspects of expatriate health: health threats. Occup Med (Lond) 50:572–578, 2000

22. Levinson W, Linzer M: What is an academic general in-ternist? Career options and training pathways. JAMA 288:2045–2048, 2002

23. Loh LC, Cherniak W, Dreifuss BA, Dacso MM, Lin HC, Evert J: Short term global health experiences and local part-nership models: a framework. Global Health 11:50, 2015

24. Meara J, Leather A, Hagander L, et al: Global surgery 2030:

evidence and solution for achieving health, welfare, and eco-nomic development. Lancet 386:569–624, 2015

25. Merson MH, Leather A, Hagander L, et al: University en-gagement in global health. N Engl J Med 370:1676–1678, 2014

26. Nelson BD, Kasper J, Hibberd PL, Thea DM, Herlihy JM: Developing a career in global health: considerations for phy-sicians-in-training and academic mentors. J Grad Med Educ 4:301–306, 2012

27. Palazuelos D, Dhillon R: Addressing the “global health tax” and “wild cards”: practical challenges to building academic careers in global health. Acad Med 91:30–35, 2016

28. Park KB, Johnson WD, Dempsey RJ: Global neurosurgery: the unmet need. World Neurosurg 88:32–35, 2016

29. Periyakoil VS: What would Osler do? J Palliat Med 16:118–119, 2013

30. Saldaña J: The Coding Manual for Qualitative Research-ers. Thousand Oaks, CA: SAGE Publications Inc, 2009

31. Shah SK, Nodell B, Montano SM, Behrens C, Zunt JR: Clini-cal research and global health: mentoring the next generation of health care students. Glob Public Health 6:234–246, 2011

32. Shoeb M, Le P, Greysen SR: Global health hospitalists: the fastest growing specialty’s newest niche. J Hosp Med 8:162–163, 2013

33. Shrime MG, Bickler SW, Alkire BC, Mock C: Global burden of surgical disease: an estimation from the provider perspec-tive. Lancet Glob Health 3 (Suppl 2):S8–S9, 2015

34. Weiser TG, Regenbogen SE, Thompson KD, Haynes AB, Lipsitz SR, Berry WR, et al: An estimation of the global vol-ume of surgery: a modelling strategy based on available data. Lancet 372:139–144, 2008

35. Whitcomb ME: Promoting global health: what role should academic health centers play? Acad Med 82:217–218, 2007

36. Winchester MS, BeLue R, Oni T, Wittwer-Backofen U, Deo-bagkar D, Onya H, et al: The Pan-University Network for Global Health: framework for collaboration and review of global health needs. Global Health 12:13, 2016

DisclosuresThe authors report no conflict of interest concerning the materi-als or methods used in this study or the findings specified in this paper.

Author ContributionsConception and design: both authors. Acquisition of data: Fallah. Analysis and interpretation of data: Fallah. Drafting the article: Fallah. Critically revising the article: both authors. Reviewed submitted version of manuscript: both authors. Approved the final version of the manuscript on behalf of both authors: Bernstein. Administrative/technical/material support: Bernstein. Study supervision: Bernstein.

Supplemental InformationPrevious PresentationsPortions of this work were shared as a podium presentation at the Bethune Round Table Meeting in Halifax, Nova Scotia, Canada, on June 3, 2016.

CorrespondenceMark Bernstein: Toronto Western Hospital, Toronto, ON, Canada. [email protected].


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