- Email: [email protected]
The College of Surgeons of East, Central, and Southern Africa: Successes and Challenges in Standardizing Neurosurgical Training
Journal Pre-proof The College of Surgeons of East, Central and Southern Africa: Successes and Challenges in Standardizing Neurosurgical Training Fraser Henderson, Jr., MD, Khalif Abdifatah, MD, Mahmood Qureshi, MBChB, M.Med(Surgery), FCS-ECSA, FRCSEd(SN), Avital Perry, MD, Christopher S. Graffeo, MD MS, Michael M. Haglund, MD PhD, David Oluoch Olunya, MBChB, FRCSEd(SN), Edwin Mogere, MBChB, M.Med(Surgery), FCNeurosurg(SA), Ben Okanga, MBChB, M.Med(Surgery), FCS-ECSA, William R. Copeland, III, MD PII:
S1878-8750(20)30102-9
DOI:
https://doi.org/10.1016/j.wneu.2020.01.084
Reference:
WNEU 14114
To appear in:
World Neurosurgery
Received Date: 22 November 2019 Accepted Date: 11 January 2020
Please cite this article as: Henderson Jr. F, Abdifatah K, Qureshi M, Perry A, Graffeo CS, Haglund MM, Olunya DO, Mogere E, Okanga B, Copeland III WR, The College of Surgeons of East, Central and Southern Africa: Successes and Challenges in Standardizing Neurosurgical Training, World Neurosurgery (2020), doi: https://doi.org/10.1016/j.wneu.2020.01.084. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Elsevier Inc. All rights reserved.
Title: The College of Surgeons of East, Central and Southern Africa: Successes and Challenges in Standardizing Neurosurgical Training Authors: *Fraser Henderson Jr., MD1 *Khalif Abdifatah, MD2 Mahmood Qureshi, MBChB, M.Med(Surgery), FCS-ECSA, FRCSEd(SN)2,3 Avital Perry, MD4 Christopher S Graffeo, MD MS4 Michael M. Haglund, MD PhD5 David Oluoch Olunya MBChB, FRCSEd(SN)2 Edwin Mogere, MBChB, M.Med(Surgery), FCNeurosurg(SA)2 Ben Okanga, MBChB, M.Med(Surgery), FCS-ECSA6 William R. Copeland III, MD7 *
These authors contributed equally to the preparation of the manuscript.
1
Department of Neurosurgery Medical University of South Carolina Charleston, SC 29401 2
Aga Khan University Hospital Department of Surgery, Neurosurgery Section Nairobi, Kenya 3
NED Institute, Mnazi Mmoja Hospital Zanzibar, Tanzania 4
Department of Neurologic Surgery Mayo Clinic Rochester, NY 5
Department of Neurosurgery Division of Global Neurosurgery and Neurology Duke University Durham, NC 6
Coast Province General Hospital Department of Neurosurgery Mombasa, Kenya. 7
Tenwek Hospital Bomet, Kenya Corresponding Author’s name and current institution: William R. Copeland III, MD
Tenwek Hospital Bomet, Kenya Corresponding Author’s Email: [email protected] Key Words: global neurosurgery, resident education, sub-Saharan Africa, low and middle income countries, history of neurosurgery Running Title: COSECSA Neurosurgical Training Model Declarations of Interest: none
Henderson Abstract
Background The College of Surgeons of East, Central, and Southern Africa (COSECSA) is a regional accrediting body for general and specialty surgical training programs that has recently expanded to include neurosurgery. As neurosurgical services expand in Sub-Saharan Africa, the structure of training and accreditation has become a vital issue.
Methods We review the founding and current structures of COSECSA neurosurgical training, identifying accomplishments as well as challenges facing the expansion of neurosurgical training in this region.
Results The COSECSA model has succeeded in several countries to graduate qualified neurosurgeons, but challenges remain. Programs must balance the long duration of training required to promote surgical excellence against an overwhelming clinical need that seeks immediate solutions.
Conclusion Harnessing global collaboration, rapidly expanding local infrastructure, and a robust multinational training curriculum, COSECSA has emerged as a leader in the effort to train neurosurgeons, and is anticipated to dramatically improve upon the markedly unmet need for neurosurgical care in Sub-Saharan Africa.
1
Henderson
2
Henderson Introduction In 2015 the Lancet Commission released its landmark Global Surgery 2030 report, highlighting the sobering need for surgical care in low- and middle-income countries (LMICs). Nine out of ten people in LMICs lack access to basic surgical care, resulting in at least 17 million avoidable mortalities annually, which represents more than three times the deaths due to HIV/AIDS, tuberculosis, and malaria combined.1 The underlying disparity is particularly emphasized when the 1% of 392 million people in Eastern Sub-Saharan Africa who have access to surgery are compared to the 99.8% access-to-care noted in high-income North America.2
An organization called The College of Surgeons of East, Central, and Southern Africa (COSECSA) has developed an accreditation pathway for postgraduate surgical education across Sub-Saharan Africa to address this unmet need. COSECSA oversees a standardized surgical training program through a common examination and accreditation system. Training occurs primarily in the trainees’ countries-of-origin, and by utilizing locally-led, locally-delivered systems, retention of trained surgeons has increased. COSECSA currently operates surgical training programs in fourteen Sub-Saharan countries, including Burundi, Ethiopia, Kenya, Malawi, Mozambique, Namibia, South Sudan, Rwanda, Tanzania, Uganda, Zambia, Zimbabwe, Sudan, and Botswana.
In a first-of-its-kind study of worldwide neurosurgical capacity that focused on “essential” neurosurgical cases, it was estimated that 13.8 million new operative cases and 22.6 million new consultative cases arise globally per year, more than 80% of which are in LMICs.3 Notably excluded in the definition of “essential” were important conditions such as degenerative spine
3
Henderson disorders, pain disorders, and spasticity, for which neurosurgical treatment can alleviate disability and restore productivity. neurosurgeons.
Africa, with a population of 990 million, counted 488
In order to manage the annual incidence of nearly 2 million “essential”
neurosurgical cases, this workforce must increase to 8400 neurosurgeons—an expansion of 1700%. In addition to a humanitarian crisis, this dramatically unmet need also represents a major source of economic losses due to neurosurgical diseases, with profound potential for adverse impacts in LMICs.4
Interrelated challenges for advancing neurosurgery in Sub-Saharan Africa have been enumerated to include equipment shortages, insufficient primary care infrastructure, and physician burnout but one of the most significant challenges has been the training of a workforce to meet an overwhelming burden of surgical disease.5
In this report, we review the major successes,
impending challenges, and potential areas for growth in neurosurgical training, as provided through COSECSA.
The History of COSECSA and Its Current Scheme for Neurosurgical Training Although the visibility of global neurosurgery as a critical area of need has markedly increased in recent years, seeds for today’s growth in East Africa were sewn decades ago, following the inauguration of the Association of Surgeons of East Africa (ASEA) on November 9, 1950.6 In 1996, the ASEA steering committee recognized a need for improved quality and quantity of surgical services. Prior to that point, surgical specialty training in the region was limited to select University Teaching Hospitals, which featured few positions and inconsistent curricula. The core mission of the ASEA committee was to implement a standardized surgical training pathway,
4
Henderson with a common exam, and a shared, internationally-recognized accreditation body. Amidst increasing support in 1997, the Ministers of Health of numerous African nations met with stakeholders from their respective Medical Colleges, ultimately approving the establishment of a new regional College with a primary emphasis on education. Publication of the first examination syllabus in 1999 coincided with the official inauguration of the College in Nairobi, Kenya, and the Ministers of Health and Education of the participating countries joined forces to endorse the new organization, modeling its format on the British Colleges. In December 2000, attendees gathered for the first Annual General Meeting in Lusaka, Zambia, and the Foundation Fellows elected the College’s Council and approved its constitution. The name College of Surgeons of East Central & Southern Africa (COSECSA) was formally adopted, fulfilling a longstanding vision, and since 2009 the COSECSA Secretariat has been headquartered in Arusha, Tanzania.6
The Neurosurgical Training Program of East Central and Southern Africa (NSTP-ECSA) was developed under the supervision of numerous surgeons from Africa, Europe, and North America. Some of the initial leaders included Mahmood Qureshi and Paul Young, and quickly included Ben Warf in Uganda, and from much collaboration emerged a curriculum for neurosurgical training (“educate a few to save many”) under the auspices of the Neurosurgical Society of Kenya.7 Building on this groundwork, the Society—which lacked accreditation authority— collaborated with COSESCA to formalize the addition of a neurosurgical training program. Following valuable input from the College Education and Training Committee Chairman Chris Lavy, as well as Secretary General Jimmy James, the Neurosurgical Curriculum was approved in 2005, at the Council meeting in Blantyre, Malawi.
5
Henderson In order to pursue surgical training through COSECSA, an applicant must have graduated from an accredited medical school, and be registered with the medical board of their respective country. They are then able to apply for acceptance into the College’s Membership Program at any of the 120 accredited training hospitals across COSECSA’s network. If accepted, the trainee begins a two-year training period designed to teach a broad range of basic surgical skills, completed in English, and encompassing at least six months each of general and orthopedic surgery. In addition, trainees attend required surgical skills courses, complete a number of online modules, and maintain an electronic case log. At the conclusion of this two-year period, trainees are eligible to sit for the membership examination, which is comprised of both written and oral components, and must be passed in order to obtain Member of the College of Surgeons (MCS) status. Membership confers on graduates an acknowledgement that they are equipped to take responsibility for surgical emergencies, manage life-threatening situations resulting from trauma or critical illness, and diagnose and plan treatment for a variety of common surgical conditions. Although Membership status does not confer specialist status, it does qualify graduates to apply for higher-level surgical training, which is referred to as the College’s Fellowship Program. While MCS forms the prerequisite for candidacy to Fellowship, those already bearing surgical qualifications (M.Med Surgery or equivalent) are exempted from an MCS requirement. Offered COSECSA fellowship programs include general surgery, orthopaedic surgery, paediatric surgery, plastic surgery, urology, otorhinolaryngology, cardiothoracic surgery, and neurosurgery.
COSECSA first offered neurosurgical “fellowship” training in 2006. The program currently requires four years of dedicated specialty training, which is required to be based at one of the program’s main teaching locations, but may include rotations at a number of neurosurgically
6
Henderson accredited hospitals in COSECSA’s region. In addition, trainees have the option of spending up to six months outside the region at an approved international training location. Similar to the MCS level, trainees must complete a sequence of online modules and maintain an electronic case log, with demonstration of a minimum of 500 cases performed prior to sitting for the fellowship examination. Additionally, trainees are required to submit at least one peer-reviewed journal article during their fellowship. A trainee’s regular schedule incorporates clinical conferences such as didactic sessions, journal clubs, and morbidity and mortality meetings, and culminates in the fellowship examination after four years of service and the satisfaction of all requirements. Both written and oral examinations must be passed in order to advance to Fellow of the College of Surgeons (FCS) status, designated by the post-nominal letters FCS-ECSA (Neuro). At this point a trainee graduates with credentials to practice neurosurgery in any of the College’s member countries. (Table 1) (Video 1)
Successes of COSECSA’s Neurosurgical Training In addition to COSECSA, there are several other neurosurgical training programs in the region. However, graduates of many of these programs are only attested to by an internal board of examiners. This may introduce bias on the part of the examiners, potentially compromising the level of competence to which graduating neurosurgeons are held. By contrast, prospective COSECSA graduates must pass an oral exam administered by a group of external examiners from a number of different countries, many of whom come from outside of Africa. While COSECSA has sought to provide a standardized training model for the region, if a member country has a separate neurosurgical program, its trainees are still eligible to sit for the fellowship examination, so long as that program’s curriculum meets the comparable COSECSA
7
Henderson requirements. Fortunately, some of the programs outside of COSECSA recognize these shortcomings, and have encouraged their graduating trainees to sit for COSECSA’s fellowship examination. Today, the countries in the COSECSA region with neurosurgery fellowship programs has increased to include Ethiopia, Kenya, Malawi, Rwanda, Tanzania, Uganda, and Zambia. At the conclusion of the 2018 academic year, a total of 23 neurosurgeons have graduated via the COSECSA trainee pathway, all of whom remain in practice in the East African region. (Figure 1)
International collaboration has been critical to the success of neurosurgical programs in the COSECSA region. Duke Health’s Division of Global Neurosurgery and Neurology led by Michael Haglund has developed a twinning program with Mulago National Referral Hospital in Uganda.8,9 Other examples include the University of Bergen and Haukeland University Hospital in Norway, which has partnered with Black Lion Hospital in Ethiopia, as well as Weill Cornell Medicine, which has developed a formal relationship with the Muhimbili Orthopaedic and Neurological Institute in Tanzania.10-12
These partnerships provide educational resources
including visiting faculty, and video conferencing, and educational opportunities for clinical rotations outside the COSECSA region. Such collaborations have enabled COSECSA trainees to rotate in Egypt (Cairo), India (Mumbai), Norway (Bergen), Spain (Valencia & Alicante), Turkey (Izmir), and the United Kingdom (Bristol). Attributable to the extensive international support, COSECSA neurosurgery trainees have the potential to benefit from a remarkable and diverse range of training experiences.
8
Henderson Acknowledging these great strides in training opportunities, a number of international bodies have formally endorsed the COSESCA neurosurgical training pathway. For example, the World Federation of Neurosurgical Societies (WFNS) has accredited the consortium of COSECSA neurosurgery training programs as only the second training center on the continent of Africa eligible for its fellowship program. This affords a total of four trainees in the program an annual stipend of $5,400 to support international travel to neurosurgical conferences.
Challenges While the early successes of COSECSA neurosurgery training have been highly encouraging, several key challenges remain.
Among the most important hurdles to the growth of
neurosurgical training in Sub-Saharan Africa are the limitations on faculty and resource availability. These shortages are offset in part via collaborations between COSECSA sites and institutions in more developed countries, which provide avenues for visiting faculty, as well as for material support in the way of supplies and equipment. An anticipated source of additional faculty in the future is neurosurgeons who have achieved financial independence in their home countries within the developed world, and have elected to dedicate a portion of their career to service in the global neurosurgery space. Such surgeons can find fulfillment in a “second career” serving as faculty and educators in COSECSA programs, until the ultimate goal of a full complement of African neurosurgeons has been met.13
In addition to human resources, the financial and material needs of COSECSA programs have been sustained in part by generous philanthropic support, a model which will ultimately prove unsustainable. A major driver of cost is the need to import supplies; correspondingly, long-term
9
Henderson financial independence will depend at least on part in developing reliable supply lines within the COSECSA region countries where neurosurgical care is being delivered. Some early signs of growth in the medical supply sectors in Africa are encouraging, yet at present, the high prices associated with these resources leaves them persistently cost-prohibitive for the vast majority of neurosurgical centers.
This has highlighted the need for cost-effective neurosurgical
innovation.14 Further, it emphasizes the need for advocacy at the industry level, with particular attention to emphasizing the humanitarian considerations, and the mandate to provide genuinely needed medical goods at a reasonable, low-margin cost.
In a recent national survey, the vast majority of US residents reported a strong interest in performing research during training, yet funding and allotment of time for research were limiting factors.15 COSECSA trainees have contributed relatively few research publications, suggesting they may be experiencing similar and more insurmountable barriers. In addition to the routine obstacles of limited time, energy, and mentorship, research methodology has historically been neglected in African medical education, and few resources are available to expedite research education during the already challenging neurosurgical training programs. Correspondingly, increasing research productivity is another major challenge and key goal for COSECSA, which the organization is attempting to meet through such efforts as the now mandatory research methodology course for fellowship trainees, and the new graduation requirement that trainees submit a peer-reviewed publication. Additionally, COSECSA now has an Institutional Review Board registered with the United Nations Department of Health and Human Resources. While COSECSA’s Annual Scientific Conference provides a platform for trainees to disseminate their
10
Henderson research findings, the College is seeking to obtain Pub-Med indexing for its peer-reviewed East and Central African Journal of Surgery, which is published three times annually.
Two lurking challenges could stunt the maturation of the development of neurosurgery training in Sub-Saharan Africa. First, because of the region’s desperate need for neurosurgeons, there has been the tendency among training programs to adopt a mindset of “something is better than nothing.” While we recognize that trainees will not have access to many of the educational tools that their peers in more developed countries have, program directors and their faculty cannot fall prey to this fatalistic attitude, but must require the highest standards of their graduates. The safety of the patients they will be treating and the competence of future trainees who will learn from them remain at stake.
Second, because many of COSECSA’s training programs are located at government or mission hospitals, faculty compensation is poor, particularly as compared to peer salaries in private practice environments. Some academic faculty therefore pursue locum tenens work, or split time for coexisting private practices. As a result, these faculty develop competing interests that may detract from their ability to completely fulfill their educational responsibilities to trainees. As such, we emphasize the importance of identifying and recruiting faculty who are passionate about and committed to education, while also seeking new avenues for more robust and appropriate faculty remuneration, to continue attracting highly qualified individuals to the academic setting.
Future Opportunities
11
Henderson The recent addition of COSECSA-approved neurosurgical training programs in Malawi and Rwanda confirms that interest in neurosurgical training is growing, as is the infrastructure required to maintain adequate educational support. Additional nations within the COSECSA region that may be candidates for COSECSA neurosurgical training program approvals in the relatively near future include Botswana, Namibia, Sudan, and Zimbabwe.
In addition to
spreading into new countries, COSECSA has also expanded to include new neurosurgery training sites within previously involved countries. In Kenya, recent graduates of the COSECSA program at Aga Khan University Hospital in Nairobi are now practicing in Embu, Mombasa, and Nyeri, generating exciting new opportunities for neurosurgical rotations in those regions. The group at Aga Khan may also begin offering full-time neurosurgical care in Kisumu. Of particular note, at Tenwek Hospital in Bomet, Kenya, the Pan-African Academy of Christian Surgeons (PAACS)—a long-time partner of COSECSA—is establishing its first neurosurgical program, which would be accredited via COSECSA, and provide local training as well as an important opportunity for a neurosurgical rotation site for trainees throughout the region.
The prevalence of common neurosurgical conditions including as trauma, hydrocephalus, spina bifida, epilepsy, and degenerative spine disease highlights the possibility of future “super specialty qualification,” such as the previously developed COSECSA Paediatric Orthopedic tract. Lastly, the fact that COSECSA accredits neurosurgical graduates throughout the eastern, central, and southern parts of Africa puts the College in a unique position to unify the region’s existing neurosurgical bodies, which make up in part the Continental Association of African Neurosurgical Societies (CAANS), one of the five continental associations of the WFNS. Wise leaders within COSECSA will take advantage of this opportunity to strengthen comradery, not
12
Henderson only because it has the potential to greatly improve neurosurgical training in Africa, but because it stands to amplify the voice of CAANS at the international level.
Conclusions Harnessing global collaboration, rapidly expanding local infrastructure, and a robust multinational training curriculum, COSECSA has emerged as a leader in the effort to train neurosurgeons, and is anticipated to dramatically improve upon the markedly unmet need for neurosurgical care in Sub-Saharan Africa.
Acknowledgements The authors kindly thank Abenezer Tirsit, Lydia Nanjula, Gerald Mayaya, Japhet Ngerageza, Justin Onen, and Emmanuel Nkusi for providing confirmatory information regarding neurosurgical practice in the COSECSA member countries.
References
1.
Meara JG, Leather AJ, Hagander L, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386(9993):569624.
13
Henderson 2.
Alkire BC, Raykar NP, Shrime MG, et al. Global access to surgical care: a modelling study. Lancet Glob Health. 2015;3(6):e316-323.
3.
Dewan MC, Rattani A, Fieggen G, et al. Global neurosurgery: the current capacity and deficit in the provision of essential neurosurgical care. Executive Summary of the Global Neurosurgery Initiative at the Program in Global Surgery and Social Change. J Neurosurg. 2018:1-10.
4.
Rudolfson N, Dewan MC, Park KB, Shrime MG, Meara JG, Alkire BC. The economic consequences of neurosurgical disease in low- and middle-income countries. J Neurosurg. 2018:1-8.
5.
Santos MM, Qureshi MM, Budohoski KP, et al. The Growth of Neurosurgery in East Africa: Challenges. World Neurosurg. 2018;113:425-435.
6.
Kodwavwala Y. History of the Association of Surgeons of East Africa (ASEA) and the College of Surgeons of East, Central and Southern Africa (COSECSA). http://www.cosecsa.org/sites/default/files/History%20of%20ASEA%20and%20COSECS A_0.pdf. Published 2009. Accessed October 1, 2019, 2019.
7.
Warf BC. Educate one to save a few. Educate a few to save many. World Neurosurg. 2013;79(2 Suppl):S15.e15-18.
8.
Fuller A, Tran T, Muhumuza M, Haglund MM. Building neurosurgical capacity in low and middle income countries. eNeurologicalSci. 2016;3:1-6.
9.
Haglund MM, Warf B, Fuller A, et al. Past, Present, and Future of Neurosurgery in Uganda. Neurosurgery. 2017;80(4):656-661.
10.
Budohoski KP, Ngerageza JG, Austard B, et al. Neurosurgery in East Africa: Innovations. World Neurosurg. 2018;113:436-452.
14
Henderson 11.
Leidinger A, Extremera P, Kim EE, Qureshi MM, Young PH, Piquer J. The challenges and opportunities of global neurosurgery in East Africa: the Neurosurgery Education and Development model. Neurosurg Focus. 2018;45(4):E8.
12.
Lund-Johansen M, Laeke T, Tirsit A, et al. An Ethiopian Training Program in Neurosurgery with Norwegian Support. World Neurosurg. 2017;99:403-408.
13.
Corley JA, Rosseau G. Encore careers: a solution to the unmet need in global neurosurgical care. J Neurosurg. 2019:1-3.
14.
Ravindra VM, Kraus KL, Riva-Cambrin JK, Kestle JR. The Need for Cost-Effective Neurosurgical Innovation--A Global Surgery Initiative. World Neurosurg. 2015;84(5):1458-1461.
15.
Karsy M, Henderson F, Tenny S, et al. Attitudes and opinions of US neurosurgical residents toward research and scholarship: a national survey. J Neurosurg. 2018:1-12.
Legends:
Video 1: A current COSECSA neurosurgery trainee describes the requirements for certification to practice neurosurgery in East Africa.
Figure 1: COSECSA Member Countries with Neurosurgery Training Sites. Most recent population data obtained by country from: “World Bank Open Data”. https://data.worldbank.org. Accessed October 26, 2019.
15
Table 1: Flow of Requirements for Certification in Neurosurgery in East Africa STEPS I. II. III. IV. V. VI. VII. VIII. IX. X. XI.
REQUIREMENT Completion of a medical degree in one’s native country Registration as MD through medical boards of respective countries Completion of 1-2 years’ internship service Application to Provisional Member (provisional MCS) – “Member of the College of Surgeons of East, Central and Southern Africa” Completion of two years of general surgical training at designated sites, including rotations in general and orthopedic surgery
Qualifying examination for full membership in COSECSA (MCS) - Parts I and II written examination Four years of neurosurgical training at accredited COSECSA centers, of which one year incorporates basic sciences, including neurology & neuroradiology Submission of a thesis prior to sitting the final FCS examinations (requirement since 2019) Qualifying written (Part I multiple choice, Part II free response) examination for FCS Neuro “Fellow of the College of Surgeons of East, Central and Southern Africa” Qualifying clinical and oral examination for FCS Neuro Application for surgical privileges as an attending neurosurgeon at a hospital
Henderson et al., COSECSA Neurosurgical Training Model Abbreviations COSECSA - College of Surgeons of East, Central, and Southern Africa LMICs - low- and middle-income countries ASEA - Association of Surgeons of East Africa NSTP-ECSA - Neurosurgical Training Program of East Central and Southern Africa MCS - Member of the College of Surgeons FCS - Fellow of the College of Surgeons WFNS - World Federation of Neurosurgical Societies PAACS - Pan-African Academy of Christian Surgeons
S1878-8750(20)30102-9
DOI:
https://doi.org/10.1016/j.wneu.2020.01.084
Reference:
WNEU 14114
To appear in:
World Neurosurgery
Received Date: 22 November 2019 Accepted Date: 11 January 2020
Please cite this article as: Henderson Jr. F, Abdifatah K, Qureshi M, Perry A, Graffeo CS, Haglund MM, Olunya DO, Mogere E, Okanga B, Copeland III WR, The College of Surgeons of East, Central and Southern Africa: Successes and Challenges in Standardizing Neurosurgical Training, World Neurosurgery (2020), doi: https://doi.org/10.1016/j.wneu.2020.01.084. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Elsevier Inc. All rights reserved.
Title: The College of Surgeons of East, Central and Southern Africa: Successes and Challenges in Standardizing Neurosurgical Training Authors: *Fraser Henderson Jr., MD1 *Khalif Abdifatah, MD2 Mahmood Qureshi, MBChB, M.Med(Surgery), FCS-ECSA, FRCSEd(SN)2,3 Avital Perry, MD4 Christopher S Graffeo, MD MS4 Michael M. Haglund, MD PhD5 David Oluoch Olunya MBChB, FRCSEd(SN)2 Edwin Mogere, MBChB, M.Med(Surgery), FCNeurosurg(SA)2 Ben Okanga, MBChB, M.Med(Surgery), FCS-ECSA6 William R. Copeland III, MD7 *
These authors contributed equally to the preparation of the manuscript.
1
Department of Neurosurgery Medical University of South Carolina Charleston, SC 29401 2
Aga Khan University Hospital Department of Surgery, Neurosurgery Section Nairobi, Kenya 3
NED Institute, Mnazi Mmoja Hospital Zanzibar, Tanzania 4
Department of Neurologic Surgery Mayo Clinic Rochester, NY 5
Department of Neurosurgery Division of Global Neurosurgery and Neurology Duke University Durham, NC 6
Coast Province General Hospital Department of Neurosurgery Mombasa, Kenya. 7
Tenwek Hospital Bomet, Kenya Corresponding Author’s name and current institution: William R. Copeland III, MD
Tenwek Hospital Bomet, Kenya Corresponding Author’s Email: [email protected] Key Words: global neurosurgery, resident education, sub-Saharan Africa, low and middle income countries, history of neurosurgery Running Title: COSECSA Neurosurgical Training Model Declarations of Interest: none
Henderson Abstract
Background The College of Surgeons of East, Central, and Southern Africa (COSECSA) is a regional accrediting body for general and specialty surgical training programs that has recently expanded to include neurosurgery. As neurosurgical services expand in Sub-Saharan Africa, the structure of training and accreditation has become a vital issue.
Methods We review the founding and current structures of COSECSA neurosurgical training, identifying accomplishments as well as challenges facing the expansion of neurosurgical training in this region.
Results The COSECSA model has succeeded in several countries to graduate qualified neurosurgeons, but challenges remain. Programs must balance the long duration of training required to promote surgical excellence against an overwhelming clinical need that seeks immediate solutions.
Conclusion Harnessing global collaboration, rapidly expanding local infrastructure, and a robust multinational training curriculum, COSECSA has emerged as a leader in the effort to train neurosurgeons, and is anticipated to dramatically improve upon the markedly unmet need for neurosurgical care in Sub-Saharan Africa.
1
Henderson
2
Henderson Introduction In 2015 the Lancet Commission released its landmark Global Surgery 2030 report, highlighting the sobering need for surgical care in low- and middle-income countries (LMICs). Nine out of ten people in LMICs lack access to basic surgical care, resulting in at least 17 million avoidable mortalities annually, which represents more than three times the deaths due to HIV/AIDS, tuberculosis, and malaria combined.1 The underlying disparity is particularly emphasized when the 1% of 392 million people in Eastern Sub-Saharan Africa who have access to surgery are compared to the 99.8% access-to-care noted in high-income North America.2
An organization called The College of Surgeons of East, Central, and Southern Africa (COSECSA) has developed an accreditation pathway for postgraduate surgical education across Sub-Saharan Africa to address this unmet need. COSECSA oversees a standardized surgical training program through a common examination and accreditation system. Training occurs primarily in the trainees’ countries-of-origin, and by utilizing locally-led, locally-delivered systems, retention of trained surgeons has increased. COSECSA currently operates surgical training programs in fourteen Sub-Saharan countries, including Burundi, Ethiopia, Kenya, Malawi, Mozambique, Namibia, South Sudan, Rwanda, Tanzania, Uganda, Zambia, Zimbabwe, Sudan, and Botswana.
In a first-of-its-kind study of worldwide neurosurgical capacity that focused on “essential” neurosurgical cases, it was estimated that 13.8 million new operative cases and 22.6 million new consultative cases arise globally per year, more than 80% of which are in LMICs.3 Notably excluded in the definition of “essential” were important conditions such as degenerative spine
3
Henderson disorders, pain disorders, and spasticity, for which neurosurgical treatment can alleviate disability and restore productivity. neurosurgeons.
Africa, with a population of 990 million, counted 488
In order to manage the annual incidence of nearly 2 million “essential”
neurosurgical cases, this workforce must increase to 8400 neurosurgeons—an expansion of 1700%. In addition to a humanitarian crisis, this dramatically unmet need also represents a major source of economic losses due to neurosurgical diseases, with profound potential for adverse impacts in LMICs.4
Interrelated challenges for advancing neurosurgery in Sub-Saharan Africa have been enumerated to include equipment shortages, insufficient primary care infrastructure, and physician burnout but one of the most significant challenges has been the training of a workforce to meet an overwhelming burden of surgical disease.5
In this report, we review the major successes,
impending challenges, and potential areas for growth in neurosurgical training, as provided through COSECSA.
The History of COSECSA and Its Current Scheme for Neurosurgical Training Although the visibility of global neurosurgery as a critical area of need has markedly increased in recent years, seeds for today’s growth in East Africa were sewn decades ago, following the inauguration of the Association of Surgeons of East Africa (ASEA) on November 9, 1950.6 In 1996, the ASEA steering committee recognized a need for improved quality and quantity of surgical services. Prior to that point, surgical specialty training in the region was limited to select University Teaching Hospitals, which featured few positions and inconsistent curricula. The core mission of the ASEA committee was to implement a standardized surgical training pathway,
4
Henderson with a common exam, and a shared, internationally-recognized accreditation body. Amidst increasing support in 1997, the Ministers of Health of numerous African nations met with stakeholders from their respective Medical Colleges, ultimately approving the establishment of a new regional College with a primary emphasis on education. Publication of the first examination syllabus in 1999 coincided with the official inauguration of the College in Nairobi, Kenya, and the Ministers of Health and Education of the participating countries joined forces to endorse the new organization, modeling its format on the British Colleges. In December 2000, attendees gathered for the first Annual General Meeting in Lusaka, Zambia, and the Foundation Fellows elected the College’s Council and approved its constitution. The name College of Surgeons of East Central & Southern Africa (COSECSA) was formally adopted, fulfilling a longstanding vision, and since 2009 the COSECSA Secretariat has been headquartered in Arusha, Tanzania.6
The Neurosurgical Training Program of East Central and Southern Africa (NSTP-ECSA) was developed under the supervision of numerous surgeons from Africa, Europe, and North America. Some of the initial leaders included Mahmood Qureshi and Paul Young, and quickly included Ben Warf in Uganda, and from much collaboration emerged a curriculum for neurosurgical training (“educate a few to save many”) under the auspices of the Neurosurgical Society of Kenya.7 Building on this groundwork, the Society—which lacked accreditation authority— collaborated with COSESCA to formalize the addition of a neurosurgical training program. Following valuable input from the College Education and Training Committee Chairman Chris Lavy, as well as Secretary General Jimmy James, the Neurosurgical Curriculum was approved in 2005, at the Council meeting in Blantyre, Malawi.
5
Henderson In order to pursue surgical training through COSECSA, an applicant must have graduated from an accredited medical school, and be registered with the medical board of their respective country. They are then able to apply for acceptance into the College’s Membership Program at any of the 120 accredited training hospitals across COSECSA’s network. If accepted, the trainee begins a two-year training period designed to teach a broad range of basic surgical skills, completed in English, and encompassing at least six months each of general and orthopedic surgery. In addition, trainees attend required surgical skills courses, complete a number of online modules, and maintain an electronic case log. At the conclusion of this two-year period, trainees are eligible to sit for the membership examination, which is comprised of both written and oral components, and must be passed in order to obtain Member of the College of Surgeons (MCS) status. Membership confers on graduates an acknowledgement that they are equipped to take responsibility for surgical emergencies, manage life-threatening situations resulting from trauma or critical illness, and diagnose and plan treatment for a variety of common surgical conditions. Although Membership status does not confer specialist status, it does qualify graduates to apply for higher-level surgical training, which is referred to as the College’s Fellowship Program. While MCS forms the prerequisite for candidacy to Fellowship, those already bearing surgical qualifications (M.Med Surgery or equivalent) are exempted from an MCS requirement. Offered COSECSA fellowship programs include general surgery, orthopaedic surgery, paediatric surgery, plastic surgery, urology, otorhinolaryngology, cardiothoracic surgery, and neurosurgery.
COSECSA first offered neurosurgical “fellowship” training in 2006. The program currently requires four years of dedicated specialty training, which is required to be based at one of the program’s main teaching locations, but may include rotations at a number of neurosurgically
6
Henderson accredited hospitals in COSECSA’s region. In addition, trainees have the option of spending up to six months outside the region at an approved international training location. Similar to the MCS level, trainees must complete a sequence of online modules and maintain an electronic case log, with demonstration of a minimum of 500 cases performed prior to sitting for the fellowship examination. Additionally, trainees are required to submit at least one peer-reviewed journal article during their fellowship. A trainee’s regular schedule incorporates clinical conferences such as didactic sessions, journal clubs, and morbidity and mortality meetings, and culminates in the fellowship examination after four years of service and the satisfaction of all requirements. Both written and oral examinations must be passed in order to advance to Fellow of the College of Surgeons (FCS) status, designated by the post-nominal letters FCS-ECSA (Neuro). At this point a trainee graduates with credentials to practice neurosurgery in any of the College’s member countries. (Table 1) (Video 1)
Successes of COSECSA’s Neurosurgical Training In addition to COSECSA, there are several other neurosurgical training programs in the region. However, graduates of many of these programs are only attested to by an internal board of examiners. This may introduce bias on the part of the examiners, potentially compromising the level of competence to which graduating neurosurgeons are held. By contrast, prospective COSECSA graduates must pass an oral exam administered by a group of external examiners from a number of different countries, many of whom come from outside of Africa. While COSECSA has sought to provide a standardized training model for the region, if a member country has a separate neurosurgical program, its trainees are still eligible to sit for the fellowship examination, so long as that program’s curriculum meets the comparable COSECSA
7
Henderson requirements. Fortunately, some of the programs outside of COSECSA recognize these shortcomings, and have encouraged their graduating trainees to sit for COSECSA’s fellowship examination. Today, the countries in the COSECSA region with neurosurgery fellowship programs has increased to include Ethiopia, Kenya, Malawi, Rwanda, Tanzania, Uganda, and Zambia. At the conclusion of the 2018 academic year, a total of 23 neurosurgeons have graduated via the COSECSA trainee pathway, all of whom remain in practice in the East African region. (Figure 1)
International collaboration has been critical to the success of neurosurgical programs in the COSECSA region. Duke Health’s Division of Global Neurosurgery and Neurology led by Michael Haglund has developed a twinning program with Mulago National Referral Hospital in Uganda.8,9 Other examples include the University of Bergen and Haukeland University Hospital in Norway, which has partnered with Black Lion Hospital in Ethiopia, as well as Weill Cornell Medicine, which has developed a formal relationship with the Muhimbili Orthopaedic and Neurological Institute in Tanzania.10-12
These partnerships provide educational resources
including visiting faculty, and video conferencing, and educational opportunities for clinical rotations outside the COSECSA region. Such collaborations have enabled COSECSA trainees to rotate in Egypt (Cairo), India (Mumbai), Norway (Bergen), Spain (Valencia & Alicante), Turkey (Izmir), and the United Kingdom (Bristol). Attributable to the extensive international support, COSECSA neurosurgery trainees have the potential to benefit from a remarkable and diverse range of training experiences.
8
Henderson Acknowledging these great strides in training opportunities, a number of international bodies have formally endorsed the COSESCA neurosurgical training pathway. For example, the World Federation of Neurosurgical Societies (WFNS) has accredited the consortium of COSECSA neurosurgery training programs as only the second training center on the continent of Africa eligible for its fellowship program. This affords a total of four trainees in the program an annual stipend of $5,400 to support international travel to neurosurgical conferences.
Challenges While the early successes of COSECSA neurosurgery training have been highly encouraging, several key challenges remain.
Among the most important hurdles to the growth of
neurosurgical training in Sub-Saharan Africa are the limitations on faculty and resource availability. These shortages are offset in part via collaborations between COSECSA sites and institutions in more developed countries, which provide avenues for visiting faculty, as well as for material support in the way of supplies and equipment. An anticipated source of additional faculty in the future is neurosurgeons who have achieved financial independence in their home countries within the developed world, and have elected to dedicate a portion of their career to service in the global neurosurgery space. Such surgeons can find fulfillment in a “second career” serving as faculty and educators in COSECSA programs, until the ultimate goal of a full complement of African neurosurgeons has been met.13
In addition to human resources, the financial and material needs of COSECSA programs have been sustained in part by generous philanthropic support, a model which will ultimately prove unsustainable. A major driver of cost is the need to import supplies; correspondingly, long-term
9
Henderson financial independence will depend at least on part in developing reliable supply lines within the COSECSA region countries where neurosurgical care is being delivered. Some early signs of growth in the medical supply sectors in Africa are encouraging, yet at present, the high prices associated with these resources leaves them persistently cost-prohibitive for the vast majority of neurosurgical centers.
This has highlighted the need for cost-effective neurosurgical
innovation.14 Further, it emphasizes the need for advocacy at the industry level, with particular attention to emphasizing the humanitarian considerations, and the mandate to provide genuinely needed medical goods at a reasonable, low-margin cost.
In a recent national survey, the vast majority of US residents reported a strong interest in performing research during training, yet funding and allotment of time for research were limiting factors.15 COSECSA trainees have contributed relatively few research publications, suggesting they may be experiencing similar and more insurmountable barriers. In addition to the routine obstacles of limited time, energy, and mentorship, research methodology has historically been neglected in African medical education, and few resources are available to expedite research education during the already challenging neurosurgical training programs. Correspondingly, increasing research productivity is another major challenge and key goal for COSECSA, which the organization is attempting to meet through such efforts as the now mandatory research methodology course for fellowship trainees, and the new graduation requirement that trainees submit a peer-reviewed publication. Additionally, COSECSA now has an Institutional Review Board registered with the United Nations Department of Health and Human Resources. While COSECSA’s Annual Scientific Conference provides a platform for trainees to disseminate their
10
Henderson research findings, the College is seeking to obtain Pub-Med indexing for its peer-reviewed East and Central African Journal of Surgery, which is published three times annually.
Two lurking challenges could stunt the maturation of the development of neurosurgery training in Sub-Saharan Africa. First, because of the region’s desperate need for neurosurgeons, there has been the tendency among training programs to adopt a mindset of “something is better than nothing.” While we recognize that trainees will not have access to many of the educational tools that their peers in more developed countries have, program directors and their faculty cannot fall prey to this fatalistic attitude, but must require the highest standards of their graduates. The safety of the patients they will be treating and the competence of future trainees who will learn from them remain at stake.
Second, because many of COSECSA’s training programs are located at government or mission hospitals, faculty compensation is poor, particularly as compared to peer salaries in private practice environments. Some academic faculty therefore pursue locum tenens work, or split time for coexisting private practices. As a result, these faculty develop competing interests that may detract from their ability to completely fulfill their educational responsibilities to trainees. As such, we emphasize the importance of identifying and recruiting faculty who are passionate about and committed to education, while also seeking new avenues for more robust and appropriate faculty remuneration, to continue attracting highly qualified individuals to the academic setting.
Future Opportunities
11
Henderson The recent addition of COSECSA-approved neurosurgical training programs in Malawi and Rwanda confirms that interest in neurosurgical training is growing, as is the infrastructure required to maintain adequate educational support. Additional nations within the COSECSA region that may be candidates for COSECSA neurosurgical training program approvals in the relatively near future include Botswana, Namibia, Sudan, and Zimbabwe.
In addition to
spreading into new countries, COSECSA has also expanded to include new neurosurgery training sites within previously involved countries. In Kenya, recent graduates of the COSECSA program at Aga Khan University Hospital in Nairobi are now practicing in Embu, Mombasa, and Nyeri, generating exciting new opportunities for neurosurgical rotations in those regions. The group at Aga Khan may also begin offering full-time neurosurgical care in Kisumu. Of particular note, at Tenwek Hospital in Bomet, Kenya, the Pan-African Academy of Christian Surgeons (PAACS)—a long-time partner of COSECSA—is establishing its first neurosurgical program, which would be accredited via COSECSA, and provide local training as well as an important opportunity for a neurosurgical rotation site for trainees throughout the region.
The prevalence of common neurosurgical conditions including as trauma, hydrocephalus, spina bifida, epilepsy, and degenerative spine disease highlights the possibility of future “super specialty qualification,” such as the previously developed COSECSA Paediatric Orthopedic tract. Lastly, the fact that COSECSA accredits neurosurgical graduates throughout the eastern, central, and southern parts of Africa puts the College in a unique position to unify the region’s existing neurosurgical bodies, which make up in part the Continental Association of African Neurosurgical Societies (CAANS), one of the five continental associations of the WFNS. Wise leaders within COSECSA will take advantage of this opportunity to strengthen comradery, not
12
Henderson only because it has the potential to greatly improve neurosurgical training in Africa, but because it stands to amplify the voice of CAANS at the international level.
Conclusions Harnessing global collaboration, rapidly expanding local infrastructure, and a robust multinational training curriculum, COSECSA has emerged as a leader in the effort to train neurosurgeons, and is anticipated to dramatically improve upon the markedly unmet need for neurosurgical care in Sub-Saharan Africa.
Acknowledgements The authors kindly thank Abenezer Tirsit, Lydia Nanjula, Gerald Mayaya, Japhet Ngerageza, Justin Onen, and Emmanuel Nkusi for providing confirmatory information regarding neurosurgical practice in the COSECSA member countries.
References
1.
Meara JG, Leather AJ, Hagander L, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386(9993):569624.
13
Henderson 2.
Alkire BC, Raykar NP, Shrime MG, et al. Global access to surgical care: a modelling study. Lancet Glob Health. 2015;3(6):e316-323.
3.
Dewan MC, Rattani A, Fieggen G, et al. Global neurosurgery: the current capacity and deficit in the provision of essential neurosurgical care. Executive Summary of the Global Neurosurgery Initiative at the Program in Global Surgery and Social Change. J Neurosurg. 2018:1-10.
4.
Rudolfson N, Dewan MC, Park KB, Shrime MG, Meara JG, Alkire BC. The economic consequences of neurosurgical disease in low- and middle-income countries. J Neurosurg. 2018:1-8.
5.
Santos MM, Qureshi MM, Budohoski KP, et al. The Growth of Neurosurgery in East Africa: Challenges. World Neurosurg. 2018;113:425-435.
6.
Kodwavwala Y. History of the Association of Surgeons of East Africa (ASEA) and the College of Surgeons of East, Central and Southern Africa (COSECSA). http://www.cosecsa.org/sites/default/files/History%20of%20ASEA%20and%20COSECS A_0.pdf. Published 2009. Accessed October 1, 2019, 2019.
7.
Warf BC. Educate one to save a few. Educate a few to save many. World Neurosurg. 2013;79(2 Suppl):S15.e15-18.
8.
Fuller A, Tran T, Muhumuza M, Haglund MM. Building neurosurgical capacity in low and middle income countries. eNeurologicalSci. 2016;3:1-6.
9.
Haglund MM, Warf B, Fuller A, et al. Past, Present, and Future of Neurosurgery in Uganda. Neurosurgery. 2017;80(4):656-661.
10.
Budohoski KP, Ngerageza JG, Austard B, et al. Neurosurgery in East Africa: Innovations. World Neurosurg. 2018;113:436-452.
14
Henderson 11.
Leidinger A, Extremera P, Kim EE, Qureshi MM, Young PH, Piquer J. The challenges and opportunities of global neurosurgery in East Africa: the Neurosurgery Education and Development model. Neurosurg Focus. 2018;45(4):E8.
12.
Lund-Johansen M, Laeke T, Tirsit A, et al. An Ethiopian Training Program in Neurosurgery with Norwegian Support. World Neurosurg. 2017;99:403-408.
13.
Corley JA, Rosseau G. Encore careers: a solution to the unmet need in global neurosurgical care. J Neurosurg. 2019:1-3.
14.
Ravindra VM, Kraus KL, Riva-Cambrin JK, Kestle JR. The Need for Cost-Effective Neurosurgical Innovation--A Global Surgery Initiative. World Neurosurg. 2015;84(5):1458-1461.
15.
Karsy M, Henderson F, Tenny S, et al. Attitudes and opinions of US neurosurgical residents toward research and scholarship: a national survey. J Neurosurg. 2018:1-12.
Legends:
Video 1: A current COSECSA neurosurgery trainee describes the requirements for certification to practice neurosurgery in East Africa.
Figure 1: COSECSA Member Countries with Neurosurgery Training Sites. Most recent population data obtained by country from: “World Bank Open Data”. https://data.worldbank.org. Accessed October 26, 2019.
15
Table 1: Flow of Requirements for Certification in Neurosurgery in East Africa STEPS I. II. III. IV. V. VI. VII. VIII. IX. X. XI.
REQUIREMENT Completion of a medical degree in one’s native country Registration as MD through medical boards of respective countries Completion of 1-2 years’ internship service Application to Provisional Member (provisional MCS) – “Member of the College of Surgeons of East, Central and Southern Africa” Completion of two years of general surgical training at designated sites, including rotations in general and orthopedic surgery
Qualifying examination for full membership in COSECSA (MCS) - Parts I and II written examination Four years of neurosurgical training at accredited COSECSA centers, of which one year incorporates basic sciences, including neurology & neuroradiology Submission of a thesis prior to sitting the final FCS examinations (requirement since 2019) Qualifying written (Part I multiple choice, Part II free response) examination for FCS Neuro “Fellow of the College of Surgeons of East, Central and Southern Africa” Qualifying clinical and oral examination for FCS Neuro Application for surgical privileges as an attending neurosurgeon at a hospital
Henderson et al., COSECSA Neurosurgical Training Model Abbreviations COSECSA - College of Surgeons of East, Central, and Southern Africa LMICs - low- and middle-income countries ASEA - Association of Surgeons of East Africa NSTP-ECSA - Neurosurgical Training Program of East Central and Southern Africa MCS - Member of the College of Surgeons FCS - Fellow of the College of Surgeons WFNS - World Federation of Neurosurgical Societies PAACS - Pan-African Academy of Christian Surgeons