The American Surgical Association (ASA) Working Group on Global Surgery published a consensus statement in 2018 that outlined broad recommendations on ways that the US academic surgical community could most effectively engage in global surgery.1 In the statement a strong case was made that global surgery contributions by faculty members could advance the mission of academic surgery and should be considered a viable path for academic promotion and tenure. A similar publication from the Society of University Surgeons (SUS) Global Academic Surgery Committee provided a rationale for the importance of research in this new academic discipline as well as outlining specific types of research as well as challenges when conducting research in lower resourced environments typically encountered in low- and middle-income countries (LMICs).2 Each department has its own priorities and will decide whether global surgery is going to be part of their academic portfolio. At the present time, an increasing number of departments have developed robust academic global surgery programs that successfully collaborate with international partners. These programs benefit from both significant interest from trainees and faculty research and publications. A challenge for departments can be the lack of a framework to evaluate global surgery contributions, especially for appointment and promotion criteria.
Global surgery was defined by Dare in 2014 as “an area of study, research, practice, and advocacy that seeks to improve health outcomes and achieve health equity for all people who require surgical care, with a special emphasis on underserved populations and populations in crisis.”3 Academic global surgery contributions must integrate into the departmental portfolio. The field is broad and typically contributions would be in one of the following general areas of scholarly activity and research: basic and translational, health services, outcomes, population, education, health, innovation, policy, and advocacy. Global surgery faculty members must achieve an academic portfolio similar to other faculty members within their department to qualify for promotion and tenure.
Criteria for promotion and/or tenure are unique to each institution and vary widely. Faculty are judged by their universities’ criteria for their specific appointment. Metrics generally encompass measures of some or all of the following components: research, published scholarship, education, clinical care, and service to the institution. Academic global surgery is a relatively new field, departments may have minimal experience in having a schema by which to evaluate faculty contributions and how they fit into the well-understood academic paradigm centered on discovery and dissemination of new knowledge, as well as leadership in sustaining, growing, and supporting the academic enterprise. This manuscript was developed by the ASA Working Group for Global Surgery, representative chairs of surgery, and international leaders in global surgery. It is intended to provide guidance to assist promotion committees in the evaluation of the academic global surgeon.
There has been no extensive study of academic contributions in global surgery. The field is undergoing rapid change with the number of publications increasing substantially in the past 10 years, from 497 in 1991 to 1999 to 3385 in 2009 to 2017.4 The largest survey was done by the SUS and Association of Academic Surgery (AAS) joint taskforce where 62 “academic global surgeons” defined, not through published scholarship, but through their participation in the global committees of SUS and AAS, or attendance at the 2016 ACS Global Health Competencies Course. There were a total of 36 respondents, the majority of whom agreed that the definition of an academic global surgeon is “someone with an appointment in a medical school” and spends time in a LMIC (81%) or spends vacation time doing mission work (58%).5 The manuscript listed potential measures in global surgery that could be considered for the appointment and promotion of surgical faculty. These measurements include the domains of education, clinical service including short or long-term missions, research, leadership, and advocacy. In addition, they outlined that departmental support via protected time, funding, and administrative support were necessary to make global surgery a viable academic pathway.
There is also increasing recognition that academic global surgery programs truly need to be bidirectional and benefit both the US and international institution. LMICs only produce approximately 4% of surgical research for a variety of reasons including time, training, and lack of access to research methodologists such as biostatisticians.6 Unfortunately, US researchers may collect data, pursue research questions not of value to the international site, and publish findings without including local contributors. In addition, projects often end once the researcher returns to the United States.7 Lastly, there remains the question of what benefits do the international partners gain from the relationship. Opportunities for clinical and research mentorship and academic recognition through grants and publications would be excellent examples of how a successful collaboration would be beneficial to both institutions. Recognition of key international partners via adjunct or affiliated faculty appointments can also strengthen the relationship. Having formal partnerships also enables the US home institution to request direct information from the host country or host institution regarding a faculty member's efforts and evaluate their impact.
This is one of the most contentious areas of discussion in valuation of international work because faculty members not infrequently participate and may want departmental support of their clinical “mission” work that is not linked to their academic role. Clinical care whether in the US or overseas is not an academic activity unless it involves the pursuit and dissemination of new knowledge, either through observational or experimental means. Examples of overseas clinically related endeavors that would clearly be included in an academic portfolio for promotion are the development of innovative procedures or clinical trials.8 Another successful example is clinical care performed while collaborating with international partners to develop a dedicated surgical unit or program with subsequent publications on outcomes and recommendations for clinical care of similar or unique diseases or conditions that relate to LMICs.9
An additional area in which clinical care and academic mission may overlap occurs when the faculty member is providing clinical care combined with resident supervision for an approved international resident rotation, or as part of an institutional partnership with an institution in a LMIC. This type of activity is valuable to the department and its international partner but when not coupled with research or program building these contributions would not likely be valued any differently than any other clinical activity in their department.
Faculty members who wish to engage in clinical work overseas that is not expressly linked to the departmental academic mission should not expect to have these activities included in their academic portfolio. Clinical activities outside of the home institution can also be seen as a conflict of commitment, as departmental revenues, and faculty salaries are directly tied to clinical productivity; hence, it would be better that clinical “mission” work be done on personal time. In general, providing clinical care, regardless of location, is not a component of the academic portfolio and we recommend that faculty should not expect departments to provide financial support for clinical care “missions” not aligned with departmental programs.
Education is frequently one of the goals embedded in capacity-building programs in LMIC as outlined in the ASA Working Group on Global Surgery document.1 Contributions in these efforts should be cataloged and be part of the evaluative process. The same criteria for valuation of educational contributions should apply to both domestic and international efforts and priority given to those that produce measurable results or impact. Typically teaching is part of the core academic mission and expected of all faculty. Promotion portfolios include trainee teaching evaluations, education research, and development of educational programs or curricula. If there are teaching contributions internationally it would be optimal to gather both evaluations and measures of impact of the faculty efforts from both the US and international sites. An example of a program that would be valued in the promotion process is published research describing and evaluating the impact of a twinning partnership to build a surgery residency program in an LMIC.10 However, if faculty expect departmental support for the educational program development in a LMIC, these efforts need to be developed as part of the approved academic mission of the department.
RESEARCH AND SCHOLARLY CONTRIBUTIONS
The ASA Working Group on Global Surgery article outlines the wide areas of possible research domains as well as value of research collaborations, and joint authorship recommendations.1 Scholarship is typically valued through peer-reviewed publications. Global surgery research ideally would integrate in one of the departmental core research areas including basic, clinical, translational, innovation, education, or health service/policy research. Contributions should be valued in the same way as other research performed in the department. As global surgery is a new area there have been issues with the scientific rigor of many global surgery investigations resulting in publications that may not favorably compare to peer publications from nonglobal projects.11 This is improving as more mentorship is available and scientific methodology is improving. Novel works in high-impact journals are now being published including basic and translational research as well as cost-effectiveness and patient expenditure impact.12 The improvement in quality of research is critical since promotion committees will utilize the same criteria for all research endeavors. Departments may also need to evaluate work published in international or regional peer-reviewed journals. Consideration should be similar to work published in US-based journals as long as the international journals have similar scientific standards and validity (eg, indexed in PubMed).
One potential area of difference in a global surgery versus global health portfolio is a successful track record in acquiring external funding. At the present time, there is a paucity of funding opportunities for global surgery research and acquisition of any funding, even small grant amounts, should be valued. Significant advocacy efforts by the American College of Surgeons and other organizations are underway to try and improve the situation. Until the external funding opportunities significantly improve, it is critical for departments and university appointment and promotion committees to understand that the lack of this type of funding should not be taken as a negative attribute when considering a global surgery-oriented portfolio.
Academic evaluation committees should also recognize administrative roles that faculty have in administrating LMIC programs such as twinned academic programs, capacity-building efforts, or international research or education collaborations. International relationship building can be challenging and requires significant investment in learning and adapting to different systems and cultures. These relationships may involve regulatory challenges, security issues, different research approval processes, and difficulties in funds transfers. These issues often take significant faculty time and efforts to work through and departmental and university leadership should be made aware of these factors when evaluating faculty contributions. In addition, faculty members engaged in LMIC activities need to be cognizant of the fact that these processes may necessitate considerable time of additional departmental administrative staff that places an additional financial burden on the department.
NOVEL ACADEMIC TRACK DEVELOPMENT: GLOBAL SURGERY ACADEMIC LINE
Departments interested in recruiting academic faculty with interests in global surgery are developing specific criteria. Recently, the University of Toronto developed a Surgeon-Global Health (SGH) position: which “recognizes applied scholarly work carried out by Department members focused primarily on global health with the objective of improving the delivery of surgical care in low and middle-income countries.”13 To ensure appropriate valuation of academic contributions “activities within the scope of SGH should be captured under the relevant domains of administration, education, and research for the purposes of promotion…Academic promotion will be based on the impact of global activities in leadership, capacity building, education, and research.”13
It is critical that global surgery faculty recognize that their academic contributions will be evaluated in an identical manner as the other faculty. It is also important for faculty members to understand pathways and contributions that would be factored into their academic advancement and to develop a complete academic portfolio including their achievements. Table 1 summarizes criteria that are similar, potentially undervalued, or should not be considered in promotion actions. These recommendations can be discussed and reviewed by department promotion committees and faculty meetings to clarify faculty expectations.
Academic global surgery is a new field that is undergoing rapid evolution. The field of Global Surgery must expand beyond clinical “mission” work and must integrate into the departmental academic and educational enterprise to be considered a viable path for academic promotion. Departments should recognize a value proposition in having global surgery as an integral part of their department and should invest in faculty through start up packages and resources similar to other academic track appointments within the department. This investment must also provide value to the departmental mission through integration with the educational programs, peer-reviewed publications, and funded research. An academic path for faculty interested in global surgery will capitalize on the significant interest and energy in residents, fellows, and junior faculty members and provide opportunities for novel research endeavors in the field. Departments that develop academic global surgery as a career path will have competitive candidates interested in joining their ranks.
1. Mock C, Debas H, Balch CM, et al. Global surgery
: effective involvement of US academic surgery: report of the American Surgical Association Working Group on Global Surgery
. Ann Surg
2. Saluja S, Nwomeh B, Finlayson SRG, et al. Society of University Surgeons Global Academic Surgery CommitteeGuide to research in academic global surgery
: a statement of the Society of University Surgeons Global Academic Surgery Committee. Surgery
3. Dare AJ, Grimes CE, Gillies R, et al. Global surgery
: defining an emerging global health field. Lancet
4. Wladis A, Roy N, Löfgren J. Lessons for all from the early years of the global surgery
initiative. Br J Surg
5. Rickard J, Onwuka E, Joseph S, et al. Academic Global Surgery
TaskforceValue of global surgical activities for US academic health centers: a position paper by the Association for Academic Surgery Global Affairs Committee, Society of University Surgeons Committee on Global Academic Surgery, and American College of Surgeons’ Operation Giving Back. J Am Coll Surg
6. Steyn E, Edge J. Ethical considerations in global surgery
. Br J Surg
7. Chellam S, Ganbold L, Gadgil A, et al. Contributions of academic institutions in high income countries to anesthesia and surgical care in low- and middle-income countries: are they providing what is really needed? Can J Anaesth
8. Warf BC East African Neurosurgical Research CollaborationPediatric hydrocephalus in East Africa: prevalence, causes, treatments, and strategies for the future. World Neurosurg
9. Gallaher JR, Mjuweni S, Shah M, et al. Timing of early excision and grafting following burn in sub-Saharan Africa. Burns
10. Grudziak J, Gallaher J, Banza L, et al. The effect of a surgery residency program and enhanced educational activities on trauma mortality in Sub-Saharan Africa. World J Surg
11. Finlayson SR. How should academic surgeons respond to enthusiasts of global surgery
12. Anderson GA, Ilcisin L, Kayima P, et al. Out-of-pocket payment for surgery in Uganda: the rate of impoverishing and catastrophic expenditure at a government hospital. PLoS One