In 2014, the Lancet Commission on Global Surgery drew widespread attention to the global need for surgical care, predicting that ∼5 billion people lack access to quality, timely, and safe surgery1,2. Further, the lack of access to surgical care is predicted to lead to a loss of 77 million DALYs and 17 million lives each year, with a disproportionate burden on the world’s poorest patient populations2,3.
Since the Lancet report, the field of global surgery has come to embrace sustainable interventions geared toward capacity-building in surgical care2. However, these advances have not led to significant changes to medical curricula, as global surgery remains a relatively under-represented and under-resourced component of formal medical education. Furthermore, medical student interest in global surgery has not yet translated into formal expansions of the global health curriculum in medical schools4. Previous studies identified upwards of 50% of medical students as expressing dissatisfaction with their institution’s global surgery-related didactic offerings5.
Given the inadequacies of current global health curricula, academic conferences have been proposed as a strategy to allow students to gain exposure to global surgery. A study conducted at the Bethune Round Table found significant gains in both self-perceived global surgery knowledge and interest among student attendees5. The relative role of global surgery conferences targeted specifically to the student population, however, has yet to be described.
Therefore, we wanted to investigate the impact of such conferences on student perceptions of global surgery. In this study, we seek to evaluate the impact of the Boston Global Surgery Symposium, a student-led global surgery conference held at Harvard Medical School on March 4, 2017. By gauging attendees’ experiences and attitudes toward global surgery before and after their participation in the conference, we hope to demonstrate the role of our conference model in meeting the demonstrated educational demands of medical students and trainees as well as cultivating the next generation of global surgery leaders.
The 2017 Boston Global Surgery Symposium was hosted by the Global Surgery Student Alliance (GSSA) to promote global surgery education and awareness among medical students. GSSA is a newly formed, national organization operated by medical students as a resource for students and trainees interested in global surgery (www.globalsurgerystudents.org). The conference was held on Saturday March 4, 2017 and consisted of a keynote address followed by lectures, panel discussions, and a Q&A session.
This IRB-approved survey was administered to conference participants in 2 parts. Surveys were administered digitally using the online survey platform Typeform (www.typeform.com/). To the authors knowledge, a validated survey tool to assess the question at hand does not exist. Therefore, the authors designed a proprietary survey tool to assess participant perceptions and interest. The first part of the survey was administered to conference attendees when they arrived at registration to collect demographic information and evaluate preconference attitudes and beliefs. Participants were asked if they would like to participate in the study and if so, to complete surveys on their mobile phones or on laptop computers provided at the registration desk. The second part of the survey sought to collect postconference attitudes and beliefs and was accessible to conference participants via a link sent to their emails after the conference. The participants were given up to 2 weeks after the conference to complete the survey. To ensure only responses were included in the analysis from participants who attended the conference, postconference survey entries required a participant ID assigned at the conference that matched a corresponding ID on the preconference survey. Participation in the study was voluntary and no financial incentives were provided for completing surveys. No personal identifiers were collected in the study. Administered surveys are presented in Supplemental Digital Content 1 and 2 (http://links.lww.com/IJSGH/A0).
Quantitative variables were analyzed using χ2 tests, independent samples T tests, and Wilcoxon Signed-Rank tests. Categorical responses were analyzed using the Test of Marginal Homogeneity. Statistics were compiled in Stata and Microsoft Excel.
There were a total of 136 conference participants, of whom 116 completed the preconference survey (85.3% response rate) and 70 completed the postconference survey (52.2% response rate). Of 136 conference participants, there were 75 women and 54 men. Seven attendees did not report their gender at registration.
Preconference survey results
Of the 116 participants who completed the preconference survey, 70 were female and 46 were male. The majority of participants were medical students (64%), of which 91% were in their first or second years. The remaining respondents were college students (21%), nonmedical graduate students (7%), resident physicians (3%), and miscellaneous participants (5%) (Table 1).
A majority of participants (80%) indicated an interest in surgery or a surgical subspecialty. The most frequently indicated surgical subspecialties included general surgery (23%, 21/93), neurosurgery (18%, 17/93), and orthopedics (13%, 12/93). Participant interests are detailed in Supplemental Digital Content 3 and 4 (http://links.lww.com/IJSGH/A0).
A majority of participants (57%) endorsed prior experience in global health or global surgery. Among these, a majority indicated <1 year of prior experience (61%) and experience in only a single country (69%) (Supplemental Digital Content 5, http://links.lww.com/IJSGH/A0).
The most frequently cited reason for conference participation was the opportunity to attend panel discussions (46%, 54/116), followed by the networking session (30%, 35/116), and the keynote address (19%, 22/116) (Supplemental Digital Content 6, http://links.lww.com/IJSGH/A0).
Postconference survey results
Of the 70 participants who completed the postconference survey, 58 were matched via participant code to a corresponding preconference survey. The remaining 12 participants were not matched to a corresponding preconference survey owing to errors in participant code reporting. There was no difference in the distribution of unmatched postconference survey responses as compared with that of matched postconference survey responses (Supplemental Digital Content 7 and 8, http://links.lww.com/IJSGH/A0).
As an assessment of internal validity, quantitative demographic variables were compared between the 58 matched participants and the 12 participants who either did not fill out a postconference survey or could not be matched to their postconference survey responses. Analyses were performed using χ2 tests and Mann-Whitney U tests. Results of this comparison are presented in Supplemental Digital Content 9 and 10 (http://links.lww.com/IJSGH/A0).
Quantitative differences between matched participant preconference and postconference survey results were evaluated using the Wilcoxon Signed-Rank tests due to the nonparametric distribution of the responses. Results are presented in Table 2.
Categorical responses to survey questions were evaluated using the Test of Marginal Homogeneity. Participants were asked the following questions on both the preconference and postconference survey.
- What aspect of global surgery interests you the most?
- What aspects of global surgery do you think are most important for improving surgical care and access in the developing world?
- What aspects of global surgery do you think experience the greatest need for further work, resources, and/or personnel?
Participants could respond by choosing one of the following options to respond to each question: capacity building and education, policy development and reform, research, surgical mission trips, and technology innovation. No significant differences in survey responses to categorical questions were found (Supplemental Digital Content 11, http://links.lww.com/IJSGH/A0).
Surgery not only has an impact on global health, but also has profound implications for addressing major inequities in the global economy6. The multi-faceted nature of global surgery requires a wide range of skills, including those focused on implementation of surgical infrastructure, surgical innovation, investigation of surgical needs, and more. Unfortunately, many students and trainees are unaware of the field of global surgery and have limited access to educational opportunities to learn. While prior studies have identified the educational potential for the conference model in global surgery, the role of such conferences targeted specifically to students and trainees has not been characterized. Consequently, the goal of our study was to analyze the impact of the Boston Global Surgery Symposium, a symposium geared toward students and trainees, and to assess the value of global surgery conferences on engaging students in global surgery and the importance of the conference model in influencing perspectives on the field.
In total, 136 participants attended the conference, including 75 women and 54 men. Of 70 postconference survey respondents, 42 women and 16 men were matched to their preconference survey results. Furthermore, women were more likely to complete both preconference and postconference surveys (60.0% women vs. 34.8% men, z=2.6572, Holm-Bonferroni corrected P-value=0.032). A preponderance of women attending our conference, coupled with a greater participation in the survey, suggests that interest in global surgery at our conference was driven to a large part by women, transcending the observed gender imbalance that has pervaded modern surgical training since its inception. The gender distribution at our conference would seem to challenge the well-established gender imbalance within surgical specialties, in which upwards of 60% of surgical trainees are men7,8.
The top 3 subspecialty interests endorsed by conference participants were, in descending order, general surgery (21), neurosurgery (17), and orthopedic surgery (12). This distribution was significantly different from the reported distribution of US seniors applying in surgical subspecialties (χ2=22.45; P-value=0.000013)9. It is unclear if this difference represents a true phenomenon reflective of global surgery trainees or stochastic variation due to low sample size. Furthermore, conference participants are a somewhat imperfect proxy for US trainees interested in global surgery. However, this result does raise the possibility of a disproportionate distribution of global surgery trainees across the various surgical subspecialties.
The majority of conference participants either had no or limited prior experience in global health or global surgery. This limited exposure reflects the fact that the majority of conference participants are still early in their training (21% undergraduates and 65% medical students). More importantly, this finding also reflects the dearth of opportunities for students and trainees to become involved in global surgery4,5. Global surgery remains a relatively neglected component of formal medical education, so the limited exposure witnessed in our study cohort is likely not unique.
Overall, survey respondents indicated that the conference had a measurable impact on their attitudes related to global surgery. The 58 participants who completed both preconference and postconference surveys expressed a significantly greater confidence in their understanding of what global surgery means as a career (P<0.00001). This finding was consistent across all groups when the analysis was stratified based on gender as well as on prior experience (Tables 3, 4). Furthermore, participants indicated a significantly higher likelihood of incorporating global surgery into their future careers (P=0.03572), though the significance of this finding did not remain after accounting for multiple hypothesis testing (Holm-Bonferroni correction P=0.250). Interestingly, when the analysis was stratified based on prior experience in global health and global surgery, the significance of this response was found only in the group with prior global health and global surgery experience (P=0.0096 vs P=0.5287 for the group without experience); however, this result was no longer significant after accounting for multiple hypothesis testing (Holm-Bonferroni corrected P=0.115). These findings corroborate the conclusions of the Bethune Round Table, which proposed the academic conference as an effective model for increasing self-perceived understandings of global surgery among students and trainees6.
After correcting for multiple hypothesis testing, we found no significant changes in participants’ beliefs about the importance of any of the global surgery subtopics that were queried (Table 2). Furthermore, no significant changes were found in participants’ responses to the categorical questions that were posed (Supplemental Digital Content 11, http://links.lww.com/IJSGH/A0). Given the varied exposure of participants to conference content and speakers, it is no surprise that significant changes in participant attitudes were not observed. Furthermore, creating a measurable, unilateral change in participant beliefs about global surgery was not the intention of the conference, as speakers represented a variety of surgical subspecialties and a range of approaches to the global agenda. However, the absence of a significant change does suggest 2 things. First, the lack of a unified approach to the delivery of global surgery poses a unique pedagogical challenge for educators in global surgery, as debate within the field concerning the relative importance of various global health interventions, the utility of varying global surgery care delivery models, the sustainability of such efforts, and their effectiveness must be addressed in order to provide a coherent narrative for teaching students and trainees10–13. Second, the conference model, while an important vehicle for education, may not be sufficient as an educational platform to meet the demands of students and trainees for exposure to the field. This highlights the need for a more concerted effort to provide structured global surgery learning opportunities in medical education.
Limitations and future directions
Certainly, this study is not without limitations.
First, while we sought to evaluate student understanding through survey questions that required self-reflective responses, we did not use a validated, objective tool. Consequently, the questions asked were limited in their interpretability and applicability beyond our study population. In addition, responses to our surveys may suffer from social desirability bias, which complicate the applicability of our findings further14. However, to our knowledge, a validated assessment tool does not exist. Future studies examining global surgery pedagogy would benefit from the development of such an assessment tool so that results can be interpreted more confidently, objectively, and in a manner that allows for comparison between studies.
As a cross-sectional evaluation of student perceptions, beliefs, and demographics, this study represents an observational analysis from which causality cannot be reliably established. In addition, the surveys looked at participant attitudes immediately after the conference and did not evaluate student attitudes on long-term follow-up. Therefore, it is unclear if the findings of this study are stable over time. Future evaluations of global surgery pedagogy should be designed prospectively and may consider following students over time, perhaps through a structured course, using validated assessment tools.
Ultimately, the limitations of this study also reflect the limitations of conferences in impacting student learning. While conferences may be impactful in certain ways, they also highlight the need for innovation in undergraduate medical education to better meet demands for global surgery education. Groups such as the GSSA are attempting to fill this need and unify global surgery efforts, but ultimately require the support of the broader surgical community to improve global surgery education for students and trainees.
In summary, this study’s evaluation of the 2017 Boston Global Surgery Symposium revealed that the conference did influence participant’s perceptions of global surgery by increasing their confidence in their understanding of what global surgery means as a career. Furthermore, participants were more likely to incorporate work in global surgery into their careers in the future, though this result was no longer significant after accounting for multiple hypothesis testing. While participants’ beliefs about the importance of the specific components of global surgery did not change, the authors believe this result highlights the need for a more unified pedagogical approach from educators in global surgery and the need for a broader, more integrated educational experience in medical curricula to meet the demands of students and trainees for exposure to global surgery.
This study was approved by our institution’s IRB.
Sources of funding
J.Y. engaged in study design, data collection, analysis, and manuscript preparation. M.T. engaged in study design, data collection, and manuscript preparation. P.N.F. engaged in study design, data collection, and manuscript preparation. S.A. engaged in study design and manuscript preparation and guidance.
Conflict of interest disclosures
The authors declare that they have no financial conflict of interest with regard to the content of this report.
Research registration unique identifying number (UIN)
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Supported by Harvard Catalyst, The Harvard Clinical and Translational Science Center (National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health Award UL1 TR001102) and financial contributions from Harvard University and its affiliated academic health care centers. The content is solely the responsibility of the authors and does not necessarily represent the official views of Harvard Catalyst, Harvard University and its affiliated academic health care centers, or the National Institutes.
1. Alkire BC, Raykar NP, Shrime MG, et al. Global access to surgical care: a modeling study. Lancet 2015;3:316–323.
2. Meara J, Leather A, Hagander L, et al. Global surgery
2030: Evidence and solutions for achieving health, welfare, and economic development. Lancet 2015;386:569–624.
3. Weiser TG, Regenbogen SG, Thompson KB, et al. An estimation of the global volume of surgery: a modeling strategy based on available data. Lancet 2008;372:139–144.
4. Alkire BC, Shrime MG, Dare AJ, et al. Global economic consequences of selected surgical diseases: a modeling study. Lancet 2015;3(S2):S21–S27.
5. Hugar LA, McCullough CM, Quinn ME, et al. Scaling up short-term humanitarian surgery: a global surgery
elective for senior medical students. J Surg Educ 2014;71:871–877.
6. Gosselin-Tardif A, Butler-Laporte G, Vassiliou M, et al. Enhancing medical students’ education and careers in global surgery
. Can J Surg 2014;57:224–225.
7. Seemann NM, Webster F, Holden HA, et al. Women in academic surgery: Why is the playing field still not level? Am J Surg 2016;211:343–349.
9. National Resident Matching Program. Charting Outcomes in the Match for US Allopathic Seniors. 2016. Available at: www.nrmp.org/wp-content/uploads/2016/09/Charting-Outcomes-US-Allopathic-Seniors-2016.pdf
. Accessed September 10, 2017.
10. Shrime MG, Sleemi A, Ravilla TD. Charitable platforms in global surgery
: a systematic review of their effectiveness, cost-effectiveness, sustainability, and role training. World J Surg 2015;39:10–20.
11. Sykes KJ. Short-term medical service trips: a systematic review of the evidence. Am J Public Health 2014;104:e38–e48.
12. Green T, Green H, Scandlyn J, et al. Perceptions of short-term medical volunteer work: a qualitative study in Guatemala. Global Health 2009;5:4.
13. Heck JE, Bazemore A, Diller P. The shoulder to shoulder model-channeling medical volunteerism toward sustainable health change. Fam Med 2007;39:644–650.
14. Grimm P. Sheth J, Malhotra N, Kamakura W. Social desirability bias. Marketing Research. Wiley International Encyclopedia of Marketing. Chichester, WestSussex: Wiley; 2010:2. Doi:10.1002/9781444316568.wiem02057.