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Medical Student Perceptions of Global Surgery at an Academic Institution: Identifying Gaps in Global Health Education

Mehta, Ambar MPH; Xu, Tim MD, MPP; Murray, Matthew MA; Casey, Kathleen M. MD

doi: 10.1097/ACM.0000000000001832
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Purpose Robust global health demands access to safe, affordable, timely surgical care for all. The long-term success of global surgery requires medical students to understand and engage with this emerging field. The authors characterized medical students’ perceptions of surgical care relative to other fields within global health.

Method An optional, anonymous survey was given to all Johns Hopkins medical students from February to March 2016 to assess perceptions of surgical care and its role in global health.

Results Of 480 students, 365 (76%) completed the survey, with 150 (41%) reporting global health interests. One-third (34%) of responding students felt that surgical care is one of two fields with the greatest potential global health impact in the future, second to infectious disease (49%). A minority (28%) correctly identified that trauma results in more deaths worldwide than obstetric complications or HIV/AIDS, tuberculosis, and malaria combined. Relative to other examined fields, students perceived surgical care as the least preventive and cost-effective, and few students (3%) considered adequate surgical care the best indicator of a robust health care system. Students believed that practicing in a surgical field was least amenable to pursuing a global health career, citing several barriers.

Conclusions Medical students have several perceptions of global surgery that contradict current evidence and literature, which may have implications for their career choices. Opportunities to improve students’ global health knowledge and awareness of global surgery career paths include updating curricula, fostering meaningful international academic opportunities, and creating centers of global surgery and global health consortia.

Supplemental Digital Content is available in the text.

A. Mehta is a fourth-year medical student, Johns Hopkins School of Medicine, Baltimore, Maryland.

T. Xu is a recent graduate, Johns Hopkins School of Medicine, Baltimore, Maryland.

M. Murray is a fourth-year medical student, Johns Hopkins School of Medicine, Baltimore, Maryland.

K.M. Casey is president-elect, Alliance for Surgery and Anesthesia Presence, Newport, Rhode Island.

Funding/support: None reported.

Other disclosures: None reported.

Ethical approval: The Johns Hopkins Institutional Review Board approved this study (IRB00085700) on January 22, 2016.

Previous presentations: Preliminary data for this study were presented at the American College of Surgeons Medical Student Program, October 16, 2016, Washington, DC.

Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A469.

Correspondence should be addressed to Kathleen Casey, 15A Harrington St., Newport, RI 02840; telephone: (401) 841-5351; e-mail: kathleencaseymd@gmail.com.

More than 5 billion individuals currently lack access to safe, affordable, and timely surgical care,1–3 resulting in an estimated 17 million preventable deaths and a loss of 77 million disability-adjusted life years annually.2 The vast majority of these deaths occur in low- and middle-income countries (LMICs), where morbidity and mortality for common surgical conditions have plateaued or increased.2,3 To address this need, the World Health Assembly formally acknowledged the critical importance of access to surgery for universal health care with the passage of Resolution 68.15.1,2,4

Until recently, surgical care has not held a prominent role within the global health agenda for several reasons. Surgical interventions do not easily fit within the conventional paradigm of global health, which has focused on widespread and easily reproducible population-based medical care.2,3 Many believed that surgical care was too complex as it necessitates diverse personnel across multiple specialties, sterile environments, complicated equipment, and specialized skillsets, all of which are limited in LMICs.5 Furthermore, surgical care was viewed as neither cost-effective nor preventive, which are two commonly ascribed characteristics of care provision within global public health.2,3,6

Recent landmark publications have provided convincing evidence that surgical care can be both cost-effective and preventive, even in low resource settings.2,3,7 The average cost for averting a disability-adjusted life year with surgical procedures is often significantly lower than other common interventions.2 Regarding prevention, surgical care plays a critical role, especially in LMICs, where the majority of surgical procedures are performed for traumatic injuries. Affordable and prompt surgical treatment for patients suffering traumatic injuries can reduce mortality, prevent secondary disabilities, and help avoid the poverty cycle.2,7 Still, millions remain untreated or undertreated, resulting in up to six million trauma deaths annually.8,9 The scope of surgical prevention further magnifies when accounting for elective or emergent surgical conditions.2 Overall, LMICs may lose up to 12.3 trillion dollars in gross domestic product between 2015 and 2030 without adequate investment in surgical care.2

With the growing interest in global health among medical professionals and those planning to enter the profession,10,11 it is important to understand how medical students perceive both surgical care and its role within global health. Students’ perceptions of different fields can influence their preclinical and clinical experiences, affect their research opportunities, and ultimately have an enormous impact on their careers. Ideally, students’ perceptions of global surgery could inform content of global health curricula. In this study, we sought to characterize these perceptions among medical students at a single academic institution with a strong global health profile. We hypothesized that students would not recognize the importance of surgical care in global health, that they would not view surgical care as either preventive or cost-effective, and that these perceptions would not differ between preclinical and clinical students.

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Method

Survey development and content

We performed a literature review to inform several characteristics of the survey, including the questions referring to specific research findings,2,12 common global health fields,6,8,13 and previously cited barriers to surgical careers.14 In the survey, we defined surgical care as elective, urgent, or obstetric operations with associated care, and specified that obstetrics–gynecology (OB/GYN) pertained to maternal and fetal health. We piloted our survey with nonmedical students at Johns Hopkins.

The survey was divided into four parts that measured student demographic information such as medical school year, gender, and age; assessed student perceptions about the global health impact of various medical and surgical specialties; characterized student perceptions about the role of surgery in global health; and evaluated student perceptions of obstacles to surgical and other careers in global health (Supplemental Digital Appendix 1, http://links.lww.com/ACADMED/A469). The survey consisted of a mix of multiple-choice questions, free text, and use of a five-point Likert scale.

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Study population, survey implementation, and data analysis

The study population comprised 480 current medical students (240 preclinical, 240 clinical) graduating between 2016 and 2019 from the Johns Hopkins School of Medicine. At Johns Hopkins, preclinical education occurs during the first and second years of medical school, and clinical education occurs during the third and fourth years. The authors did not participate in the survey.

We distributed printed surveys to students during February and March 2016 by targeting classes with mandatory attendance. The survey was optional, had no incentives, and explicitly stated that completion of the survey served as consent to be included in this study. We verbally described the survey as a research study to assess student perceptions of global health, and collected the surveys at the end of each class.

We analyzed preclinical and clinical students separately; the structured global health course work that students take at Johns Hopkins occurs during the second year, and career interests may change after starting on the wards. For completeness, we also analyzed results by student year. When collecting information on which rotations clinical students had completed, we defined surgery and OB/GYN as the two surgical rotations. Several survey responses, written in by students, were also categorized as a surgical field (anesthesiology, cardiothoracic surgery, interventional radiology, neurosurgery, ophthalmology, orthopedic surgery, otolaryngology, plastic surgery, surgical oncology, trauma surgery, urology, vascular surgery). We used STATA statistical software, version 13.1 (StataCorp, College Station, Texas) for tabulating and chi-square tests (alpha < 0.05 represented significance). The Johns Hopkins Institutional Review Board approved this study (IRB00085700) on January 22, 2016.

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Results

Of 480 students, 365 (76%) completed the survey. Of these, 177 (48%) were preclinical and 188 (52%) were clinical (Table 1). The majority of respondents (74% total: 71% preclinical, 78% clinical) were born in the United States, and approximately a third (36% total: 38% preclinical, 34% clinical, 0.38) had lived internationally for at least one year. A greater proportion of clinical students relative to preclinical students identified that their primary mentor was from a surgical field (total, 22%; preclinical, 11%; clinical, 32%).

Table 1

Table 1

While 150 students (41%) envisioned including global health work in their career, there was a significant decrease between preclinical and clinical students; fewer clinical students projected that they would spend greater than 10% of their career in global health. More students with an interest in surgical careers were interested in a global health career (90/150; 60%) relative to those interested in nonsurgical careers (88/203; 43%). Of the 150 students interested in surgical careers, 72 (48%) had a mentor in a surgical field (16 preclinical, 56 clinical).

Half of all students (179; 49%) felt that infectious disease was one of the two medical fields that will have the greatest impact in global health in the next 25 years (Figure 1). Surgical care ranked second with 123 students (34%). There was no difference in this response between the 177 preclinical and 188 clinical students (Figure 2A). In contrast, one in five students (20% preclinical, 21% clinical) selected surgical care as one of two fields having had the greatest impact in global health over the past 25 years (Figure 2B). Thirteen percent of students (14% preclinical, 12% clinical) considered surgical care as being one of the largest voids in the global health agenda (Figure 2C). Finally, 3% of students (3% preclinical, 2% clinical) selected surgical care as being the best indicator of an adequate health care system; the majority (75%) selected primary care (Figure 2D). Analyzing the above responses by student year yielded similar results.

Figure 1

Figure 1

Figure 2

Figure 2

A minority (166/353; 28%) correctly identified trauma as the greater cause of mortality in comparison with obstetric complications or HIV/AIDS, tuberculosis, and malaria combined (Figure 3).2 Twice as many clinical students (67/182; 37%) recognized this fact relative to preclinical students (31/171; 18%).

Figure 3

Figure 3

Students also compared five medical fields—family medicine, OB/GYN, infectious disease, emergency medicine, and surgical care—on several characteristics using a five-point Likert scale (Figure 4). A majority (96%) of the 365 students responded that family medicine focuses on preventive medicine, followed by OB/GYN (77%), infectious disease (49%), emergency medicine (6%), and finally surgical care (5%). When asked which of these five specialties had the potential to practice preventive medicine, surgical care ranked last (46%). While half of students (54%) felt surgical care could be practiced cost-effectively in a resource-poor setting, it again ranked last. The majority of students (93%) believed that an infectious disease practice was most amenable to pursuing a global health career, with surgical care ranking last (53%).

Figure 4

Figure 4

The most commonly reported student-perceived barrier to surgical careers in global health was constrained time to travel abroad during one’s career (197/256; 77%), followed by length of training (66%), available medical resources and infrastructure in limited-resource communities (66%), difficulty with providing longitudinal patient care (62%), and a lack of established career tracks for global surgery (57%). Students also recognized additional barriers (Supplemental Digital Appendix 2, http://links.lww.com/ACADMED/A469).

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Discussion

The 2015 passage of the Resolution on Surgery and Anesthesia by the World Health Organization acknowledged the necessity of surgical care within global public health and for universal health coverage.15 While many interventions for addressing disparities in surgical care will ultimately develop within affected communities, the importance of academic, clinical, and economic partnerships is understood16 and has been described as an academic moral imperative.1 Accordingly, the long-term sustained impact of global surgery depends in part on ensuring that medical students understand its role, evolution, and impact on global health and can recognize meaningful career opportunities.

In this single-institution study, while a third of students perceived that surgical care would be among the two fields having the biggest global health impact in the future, students considered surgical care to be the least preventive and cost-effective relative to other specialties. Furthermore, while students with interests in surgical careers were more likely to report global health interests, they perceived that a surgical practice was least amenable to working in global health, citing several barriers. These findings and several other perceptions warrant further examination, for both understanding career interests and designing global health curricula.

Inadequate access to quality surgical care results in worse health outcomes for individuals, families, and communities.2,4 While more lives are lost from trauma each year than from obstetric complications or HIV/AIDS, tuberculosis, and malaria combined, only a minority of the medical students we surveyed (28%) appreciated the scale of trauma mortality. The long-standing emphasis on infectious diseases and reproductive health by governments,17 the media, and the public,18 as well as the significant successes demonstrated in these realms, may partially explain these perceptions. Nevertheless, misconceptions about the impact of trauma in LMICs may cause students to undervalue the role of surgical care in global health.

Public health paradigms traditionally have not included surgical care, and we suspect this may continue to influence student perceptions.19 In our study, surgical care was least perceived to almost always or always incorporate preventive and cost-effective practices, recapitulating previously documented misconceptions about surgical care2,3,6 at the student level. While a focus on prevention is central to fields such as infectious disease and family medicine, it is also an important but underrecognized component of surgical care.2,3 Furthermore, while some have argued that quality surgical care is the best indicator of a robust health care system,2 as it demands intact infrastructure, trained personnel, interdisciplinary cooperation, established referral practices, and cost-efficient practices, only 3% of students agreed; the majority selected family medicine. Students likely recognized that family medicine provides longitudinal medical care for patients, but may hold a U.S.-based understanding of primary care that is neither inclusive of basic surgical care nor immediately translatable to LMICs.

Understanding the trajectory of global health education in the United States may offer insight into why students hold these perceptions. In the 1990s, a national consensus report identified five core components of international health education for medical schools.20 While these components emphasized community-based primary health care, interdisciplinary teams, and culturally sensitive curricula,20 topics such as general surgery and disaster health care were only recommended as optional topics.20 Recently, the increasing demand for immersive global health experiences from surgical residents21,22 has revealed the lack of educational opportunities in global surgery.11 The American Board of Surgery (ABS) and the Accreditation Council for Graduate Medical Education (ACGME) began addressing this in 2011 by jointly developing guidelines for international general surgery rotations.23 These rotations satisfy ACGME competencies for surgical residents.24 Unfortunately, medical schools have been slow to respond to medical student interest in global health,13,25 in particular global surgery.26–29 At Johns Hopkins, the formal weeklong global health curriculum devotes only a few hours to surgical care.

While this survey focused on student perceptions of global surgical care, our findings also provide insights into how students perceive the importance of psychiatry, oncology, and other fields within global health. These findings invite an opportunity to review medical school global health curricula and identify opportunities for updating them. We focus our comments on the surgical elements and describe three proposals for improving medical school training in global surgery: refining preclinical medical education to incorporate key learning points, enhancing the efficacy of immersive international opportunities, and ensuring adequate resources and mentorship for longitudinal opportunities and global surgery research.

First, medical students’ global health interest documented by our survey and other studies13,25 suggests that medical schools should continue advancing their global health education to reflect priorities and advances in the field, including those in global surgery. This material can be a distinct curricular element or woven into preclinical education and clinical rotations. Of note, while several reasons may account for the decline in global health interest that we saw in clinical relative to preclinical students, continuing global health education into the clinical years might sustain that interest.

Our findings suggest that incorporating specific learning objectives about global surgery may correct student misperceptions. A focus on the changing epidemiologic importance of trauma and other surgical mortality and morbidity worldwide would satisfy a core global health education competency pertaining to the global burden of diseases.20,27 Another important learning point is how surgical care can be both cost-effective and preventive. Case studies from world-renowned organizations, such as Aravind Eye Care System, can illustrate cost-effective systems that deliver preventive surgical care in LMICs without sacrificing quality.30 Relevant to other global health challenges is how surgical initiatives have used “task shifting” to cost-effectively address deficits in the surgical workforce.31,32 Students can also explore whether surgical care should be considered an essential element of primary care and if establishing adequate surgical care fosters a robust health care system.5,33 Finally, students should learn how trauma systems, prehospital care, and health policies can significantly affect surgical conditions in developing countries. For each of these points, educators should also acknowledge how students’ and their own understanding of medical care in the United States might shape their perceptions of surgical care in LMICs.

Arguably, the most comprehensive educational experience for medical students interested in global surgery is acquired through firsthand exposure.10,21 Clinical experiences may reshape student perceptions of global surgery and motivate future international career interests.34 Without thorough preparation or appropriate guidance, however, these experiences can unintentionally cause adverse effects for both the student and the host community22,34–38 and diverge into “medical tourism.”39 Accordingly, medical schools should follow a systematic approach to building reciprocally beneficial international partnerships40,41; continue to establish meaningful objectives for students42; and create predeparture workshops for addressing expectations, previously identified challenges, and the ethical ramifications for practicing surgical care in LMICs.43–46 Leeds et al47 demonstrated the feasibility of integrating global health experiences into the traditional surgical clerkship and how this yielded “equivalent outcomes as measured by standard end-of-clerkship examinations.” Furthermore, medical schools can build upon previous international partnerships, such as the Medical Education Partnership Initiative,48 to create mutually beneficial clerkships abroad. The existing ABS and ACGME guidelines developed for residents participating in international rotations could also be tailored to medical students.

Finally, numerous medical institutions have created centers of global health in response to the growing interest in the field, the majority of which focus on communicable illnesses and other nonsurgical diseases. Our study, however, showed that of the 150 students (40%) who identified a surgical field as their current medical interest, two-thirds wanted to incorporate global health in their career. Incorporating surgical components into existing centers of global health or creating distinct centers of global surgery can strengthen medical education by consolidating both information and resources pertinent to global surgery.49–51 Such centers could provide students interested in global health with valuable mentorship and address the barriers cited in this study for pursuing global surgery careers.

As global surgery gains more prominence in academic settings, incorporating international work into a surgical career is becoming more feasible. Palazuelos and Dhillon14 have provided valuable recommendations for addressing logistical challenges in global health work for faculty, including travel. Academic institutions are beginning to offer global health fellowships.49,50 Additionally, the emergence of surgical education consortia could support flexibility in travel schedules while ensuring continuity of service for the host community.16,52 As global health encompasses domestic inequities, opportunities abound for physicians to improve access to surgical care locally.

We acknowledge several study limitations. First, survey responses were from a single institution and may not be representative of students’ perceptions at other institutions. Additionally, as Johns Hopkins medical students may have more exposure to global health curricula and experiences than the average medical student in the United States, our findings may underemphasize student perceptions and misconceptions of global surgery. This is one of the first studies, however, to look at specific perceptions of global surgery from medical students. We also recognize that while some student misconceptions of factual knowledge may be amenable to intervention, some of our other findings capture subjective views. Finally, we neither included logistic regression analyses nor accounted for prior background knowledge or experience in global health among all students. These limitations prompt future research opportunities on a broader scale.

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Conclusion

We found that the majority of students interested in surgical careers desire to incorporate a global health element. However, medical students’ understanding of the role of surgical care within global health may not reflect current evidence-based data and practices. These perceptions may adversely affect their decision to pursue a global health career through a surgical field, which highlights the need for enhanced global surgery education. We propose that medical educators incorporate widely accepted data and trends on global surgery into preclinical education, enhance international electives for clinical students, and advocate for consortia models in global health and for centers of global surgery.

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Acknowledgments:

The authors acknowledge Dr. John L. Tarpley, Mrs. Margaret Tarpley, and Dr. Edward J. Wright for reviewing this manuscript and providing their insightful and thoughtful comments (no compensation). Author A.M. had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

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