NextBillion - An Initiative of the William Davidson Institute at the University of Michigan

Editor’s note: This is part of a series on NextBillion Health Care regarding the lack of safe, basic surgery in much of the developing world. The first installment can be found here, the second here, and the third here.

In this final article of our series on essential surgery, we turn our attention to the grave human resources challenge contributing to the global surgery gap. The inadequate distribution of surgeons worldwide, long reported and recently quantified, makes it abundantly clear that the scale-up of people able to perform surgery in low- and middle-income countries must be a priority for any global surgery initiative.

This fact should not surprise – there are few professions that have historically required as rigorous, expensive and prolonged a certification process as surgery, in order to achieve qualified status. That this historical circumstance may be inappropriate, ill-conceived or counterproductive does not garner much attention. But any practical solution to this rapidly expanding problem requires jettisoning habit and history.

Not many in the developing world have access to the Halstedian standard of surgical education and training, and those who do are drawn to markets where the salaries, professional incentives, stature and infrastructure (such as sterilization and anesthesia capabilities) allow them to use their training at its highest income-producing level.

As one of us (Bernstein) pointed out in the past, requiring the designation of “surgeon” as it is traditionally defined as a prerequisite for holding a scalpel in the developing world is simply untenable, given the relentless growth in population, the rapidly changing landscape of illness from acute to chronic, and the increasingly well-documented need for, and value of, essential surgery.

The concept of “task-shifting” – training health workers who are not surgeons or physicians to perform basic, lifesaving surgeries – has been championed by many (including Bernstein) as the solution to this problem. The term “task-shifting” might better be described as surgeon leveraging; i.e. increasing the productivity of surgeons by providing them teams of surgical technicians just like partners leverage their time with associates in law firms. A study in the Lancet asserted that “task-shifting” can reduce costs and training times for the provision of surgical personnel by 40 percent, and other studies have shown that well-trained surgical technicians can have surgical outcomes on par with those of surgeons for specific procedures like cesarean sections.

Given the current global surgery crisis, such a shortcut to solving the human resource problem can seem like a no-brainer. But the challenges of successfully implementing this solution have yet to be fully acknowledged, let alone adequately addressed. Think back to a time when you needed surgery, or imagine being in a position where someone needed to cut you open while you were unconscious in order to save your life. Would you ever consent to such a daunting prospect without absolute confidence in the individual performing the procedure and the system that validated that individual? Even the bestowal of the “surgeon” title is not enough to assure many patients who devote substantial effort to the task of finding the best surgeon available.

This effort is understandable – the simplest surgical procedures still carry significant risks and the potential for complications. In the U.S. and other places of relative abundance, when it comes to surgeon density, who are we to say that patients in any other part of the world should be forced to accept a lower standard?

Of course, “the best surgeon” may be a poor term. Do we mean best to carry out the surgery, or best to care for the patient after the operation? These are two dramatically different skill sets. Doing surgery, for the basic operations that may be categorized as “essential surgery,” is technically straightforward and requires little informed judgment. Post-operative care requires a wholly different set of knowledge and behaviors. (Modern airplane pilots are not required to maintain their airplanes but must know how to fly them.)

When starting with countries that may only have a few surgeons for the entire population, it is tempting to focus on immediate scale-up of people able to perform procedures. Objections to this approach correctly point out that this begs the question of proper anesthesia and post-operative care. If we take as a starting point that surgery and surgical care are synonymous, then this argument carries the day. However, if  moving away from the rigidity of academic surgical requirements for the procedure itself is coupled with surgical care by those with deeper experience and training, we can avoid a decline in standards and outcomes.

We cannot talk about leveraging surgeons without establishing a new system of training practices, tools for supervision and monitoring, methods of validation, and strict boundaries for which surgeries can be performed at a certain level of training. This is not to say that this new system should be one-size-fits-all for all of the areas of the world that could benefit from such a model. Training and supervision might differ depending on available resources and local needs. But if we are to solve global surgery’s personnel problem, these are issues that leaders in global health must confront promptly and aggressively.

One of us (Sampson) has already started to apply advanced simulation technologies to rapid training of anesthesia technicians, compressing the time required to gain supervised experience.

Another challenge facing increased access to essential surgery relates to perception, authority and responsiveness. Maintenance of supply chains and procurement of resources, supplies and medicines necessary for surgery are challenges for medical professionals all over the world, but they are particularly difficult in under-resourced regions. People who perform surgeries but do not have the title of “surgeon” may carry less clout, and therefore not be able to advocate for their patients’ needs as successfully to hospital administrators or government officials. With this disadvantage, even the most capable and well-trained surgical technician will be unable to provide needed surgical care. Having a surgeon who manages a team of surgical technicians (a leveraged surgeon) will ameliorate this frequently encountered problem.

Now that surgery has the chance to shed its “neglected stepchild” status and emerge as a priority for global health, local and international health leaders are working together to agree upon goals and define outcomes for the global surgery movement.  Determining which procedures qualify as “essential surgery” is an important step forward, but further delineation and strict boundaries will be needed for identifying which operations can be done by trained technicians.

Technologies and techniques specific to training, certification and maintenance of skills must go hand-in-hand with technological innovations that facilitate surgical procedures in low-resource settings. Surgery cannot happen without people to do it, just as it cannot happen without sterilization or anesthesia. Persisting in replicating yesterday’s models guarantees a catastrophic failure to meet  the growing need. Focusing on leverage, training, certification and rewriting the rules for surgery must be a part of every effort to bring basic surgery to the 5 billion people around the world in need.

Dr. James Bernstein is the co-founder, chairman and CEO of Eniware and Dr. John B. Sampson is founder and president of Doctors for United Medical Missions.