Academic Global Surgery
Surgery has often been known as the ‘neglected stepchild of global health,’ says Lily Gutnik, MD, during this primer on the emergence of academic global surgery. The field of global academic surgery has only begun to cohere over the past 6-to 7 years in order to address the diverse needs that stand in the way of access to surgical care across the world. She explains the challenges of collecting meaningful data in such a cross-cutting field. Because the organization of health care varies greatly by region, Gutnik recommends a collaborative approach that begins with listening and understanding the needs of local administrators and providers.
Featuring:
Learn more about Lily Gutnik, MD
Release Date: May 31, 2022
Expiration Date: May 30, 2025
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no relevant financial relationships with ineligible companies to disclose.
Faculty:
Lily Gutnik, MD, MPH
Assistant Professor, Breast Surgery
Dr. Gutnik has no relevant financial relationships with ineligible companies to disclose.
There is no commercial support for this activity.
Lily Gutnik, MD
Assistant Professor whose specialties include Breast Surgery.Learn more about Lily Gutnik, MD
Release Date: May 31, 2022
Expiration Date: May 30, 2025
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no relevant financial relationships with ineligible companies to disclose.
Faculty:
Lily Gutnik, MD, MPH
Assistant Professor, Breast Surgery
Dr. Gutnik has no relevant financial relationships with ineligible companies to disclose.
There is no commercial support for this activity.
Transcription:
Melanie Cole (Host): Welcome to UAB Med Cast. I'm Melanie Cole and joining me today is Dr. Lily Gutnick. She's a Breast Surgeon and an Assistant Professor at UAB Medicine. And she's here to highlight academic global surgery, an emerging field gaining popularity among trainees and faculty. What is it? Where are we and where are we going? Dr. Gutnick, I love this topic, such an interesting topic. Welcome to the show. There's a large unmet need for surgical care worldwide. We've heard about this and with surgical conditions and treatments being poorly reorganized you and I just did one on Sub-Saharan Africa and breast cancer and resources as public health priorities around the world. Can you tell us a little bit about academic global surgery? What is this emerging field that's gaining popularity among trainees and faculty? Tell us a little bit about that.
Lily Gutnik, MD (Guest): Absolutely. And again, thank you so much for having me here today. First I really want to just start with a definition, right? I mean, we all, when you think about global health and when we talk about global health, people have different sort of thoughts and frameworks in their mind about what that means and what that means for them.
A lot of, I find just in my own personal experience, as I talk to people and say, you know, kind of, this is my academic niche or area of work, people automatically ask if I'm affiliated with doctors without borders. Or if I do sort of short-term mission work. Which that is certainly one aspect of global health and one aspect of global surgery, but it's not really kind of how I view and how most people view and define more of academic global surgery and global surgery as a true sort of field within global health.
And so I'd like to just briefly share this definition. And this was published in the Lancet, at the time when we were working on the Lancet Commission on Global Surgery, we had published a paper sort of saying that even titled Global Surgery Defining an Emerging Global Health Field.
And so global surgery is an area of study, research, practice and advocacy that seeks to improve the health outcomes and achieve health equity for all people who require surgical care with a special emphasis on underserved populations and populations in crisis. It uses collaborative, cross sectional and transnational approaches and is a synthesis of population based strategies with individual surgical care.
And again, one of the things I actually really love about this definition is notice how it doesn't talk about geography, right? So it's not about a group of people going to another place to perform surgery. It's really about focusing on vulnerable populations, which we know exist worldwide rather, you know, even in our own country here in the US we have tons of access to care issues and disparities in our own country.
And then of course, kind of more other lower income countries that kind of have more of these issues that may be a larger scale. And sort of with that definition in mind, I can take you through a, sort of a brief history of this academic global surgery as its own emerging field, because I think it's actually quite fascinating.
So, the first time that global surgery was actually really vocalized and supported in a large public and noteworthy former was in 1980. And at that time, Dr. Halfdan Mahler who's the, was the Executive Director of the WHO had said that the majority of the world's population have no access whatsoever to skilled surgical care and little is being done to find a solution. I beg of you to give serious consideration, this most serious manifestation of social inequity in health care. Right? So that's in 1980. Interestingly in the WHO it wasn't until 2005, where there was actually an initiative within the WHO on essential and emergency surgical care. Following that in 2008, there was a really famous publication, by two giants in global health.
And Jim Kim and Paul Farmer who published a piece in the World Journal of Surgery called Surgery and Global Health a View Beyond the OR, and that was actually where this very famous phrase was coined about surgery being the stepchild of global health. In 2011, the ACGME actually approved international resident rotations.
And then in 2012, there was a first textbook called global surgery and public health which was essentially published by a team of academic general surgeons and urologists. And then fast forward to 2014, there was a first global advocacy group called the G4 Alliance, which was surgical, obstetric, trauma and anesthesia care, which is still a really great and prominent organization, really focusing on advocacy for the neglected surgical patient. And then came 2015 and now 2015 is known as the golden year for global surgery. And that is when the Lancet Commission on Global Surgery came out. The DCP 3, which stands for disease control and priorities three, which is a publication from the world bank, which is really important in terms of sort of economic evaluation and priority setting for ministry of healths around the world.
They now came up with a whole volume on essential surgery. And then the World Health Assembly happened, which adopted the resolution that's saying strengthening emergency and essential surgical care and anesthesia is a component of universal health coverage. In 2016, there's a well-respected Success in Academic Surgery, sort of handbook series and they published a volume called Academic Global Surgery. And then in 2020, the Global Surgery Foundation was formed, which is the first kind of exclusive multiple, you know, public, private foundation that is dedicated to global surgery. So you could see here, you know, most of this work has really been seeing the most rapid rise in the last sort of six, seven years or so.
Host: Wow. That was such a comprehensive description of such a large issue. So as you're telling us that long neglected as a topic within the global and public health arenas, you're describing this increasing awareness of those extreme disparities. Can you speak a little bit how metrics, data, definitions, underlying issues of workforce and training, equipment, infrastructure is huge and funding certainly funding that need to be addressed.
I read that that these may be synthesized around three interdependent pillars, Dr. Gutnick of need access and quality. Can you speak a little bit about that? And some of the barriers to those that you see.
Dr. Gutnik: Yeah, absolutely. So that's a great, great point. And actually one of, sort of the goals of the Lancet Commission was exactly to address that because until that, you know, report and process and everything came up; there was a huge realization that there really is no data. There's no line item. When you look at sort of even big multilateral organizations like budget lines, and which of course correlates their priority setting.
There actually is line items for things like HIV, but there's really nothing for surgery. And one of the challenges in that is because surgery in itself is cross-cutting, it is not its own sort of, you know, disease entity like HIV or malaria or COVID or something. It is a cross cutting discipline that really you know, touches all sorts of other kind of broader disease types. And so a lot of the big goal of the Lancet Commission was to try to synthesize data, have common metrics and have common vocabulary and have it be included in various of these multilateral unilateral organizations. And so one of the things, you know, the Lancet Commission did come up with six indicators. You know, and things like around these topics about access.
So being, you know, number, being able to get to safe and effective surgery within two hours was one sort of indicator. Peri-operative mortality rate is another example of another indicator, workforce density and workforce being you know, both anesthesia, surgical and obstetric provider. The most common surgical procedure performed worldwide is actually a C-section, which you know, kind of here in the US US is within the realm of obstetrics and gynecology. Although in some of these other settings, particularly for example, in Sub-Saharan Africa and in more rural parts, they are really done by clinical officers, which are sort of, you know, skilled surgical technicians that perform a wide range of procedures.
So, those are just some of the examples on it, but I think there's definitely ongoing discussions about what to measure, how to measure it and making sure that there is this sort of common definitions and agreed upon metrics.
Host: Okay then along those lines and if that is what the vision is and what you're looking to do, I feel that this need for this multidisciplinary approach, as you were just talking about providers and as global surgery must engage a multidisciplinary range of individuals. I mean, we're seeing that in our country more and more and more, but including academics and clinicians, politicians, economists and patients at the local, national and international levels. Can you speak about that and how you're bringing these teams together and, and that unmet need?
Dr. Gutnik: Yeah, absolutely. And that's a huge, huge thing. And I think, you know, that even stems back from that famous quote about surgery being the neglected stepchild of global health, right. And global health is really a subsection of public health. And I think we are seeing more and more of this intersection. For example, there are a number of centers for surgery and public health around the country or within global health departments. Within schools of public health, for example, there are sort of surgery niches, or surgery groups, initiatives within these.
There are some institutions that are doing global surgery as for example, Vanderbilt University, their global surgery initiative is a multidisciplinary approach within the school of medicine that engages you know, people that are more public health experts especially within the school of public health, as well, as well as across you know, providers of anesthesia, surgery, obstetrics, and then of course nursing and then other allied health professionals as well.
If you kind of like even think about like, how do you build a surgical system, right? There's a lot of work and interest happening about surgical system strengthening. And again, working very much with health economists and you know, health policy experts, because the concept is you don't want to just perform a surgery. You want to build a safe surgical system around it, which engages all these people from all these different levels. So yes, there's definitely a lot of exciting and interesting work happening around that space right now.
Host: As we wrap up with this fascinating topic, what do you think is involved in implementing improvement? Global surgery has an expansive remet. If you were to let other providers know that are interested in getting involved, in getting more information from you, speak about some of the key parameters that would make a real difference, if someone wanted to get involved, whether it's advocacy, education, research, clinical components that can involve surgeons and anesthesiologists and nurses, allied healthcare professionals, all working together with non-clinicians, including policy makers to really get this thing going. Speak to other providers, give them your final thoughts, key takeaways in what you want them to know if they're interested in getting involved in academic global surgery.
Dr. Gutnik: Absolutely. I think that's great. I mean, I think one approach is definitely a lot of, you know, professional societies whether surgical subspecialties, or even for example, the American College of Surgeons have great initiatives. And I think that is kind of one sort of place to start. I mean, you could start to see what's available within your own institution and then kind of looking to your own professional society, because a lot of them have working groups on global surgery that have various levels of opportunities and involvement.
So that is definitely a great place I would say to start is in your own institution and then turning to your professional societies. The other thing I would just always you know, encourage people to have in mind, as they engage in global surgery activities is to really kind of think about the purpose and who you're partnering with.
And really, you know, particularly if you are working with either vulnerable communities in your own backyard, or if you're working with more vulnerable communities in a different country, it's important to really partner with them and to understand what it is that they need. And how is it that you with your skillset are able to fit their need.
I think, unfortunately I have seen that a lot of that gets lost where people and, and, and from, you know, people are coming from a good place. People are excited. People want to do good. People have a lot of empathy. They want to try to help, but I think the best way to try to help is to first ask the question, what is it that you need and how is it that I could use my skillset and my opportunities to help you.
Host: What an excellent way to end this podcast. Thank you so much, Dr. Gutnick, that was excellent. And so interesting. Thank you. And please come on and update us as things progress in this initiative and let us know what's going on. We would really appreciate that. And a physician can refer a patient to UAB Medicine by calling the mist line at 1-800-UAB-MIST. Or by visiting our website at UABmedicine.org/physician. That concludes this episode of UAB Med Cast. For more updates on the latest medical advancements, breakthroughs and research, follow us on your social channels. I'm Melanie Cole.
Melanie Cole (Host): Welcome to UAB Med Cast. I'm Melanie Cole and joining me today is Dr. Lily Gutnick. She's a Breast Surgeon and an Assistant Professor at UAB Medicine. And she's here to highlight academic global surgery, an emerging field gaining popularity among trainees and faculty. What is it? Where are we and where are we going? Dr. Gutnick, I love this topic, such an interesting topic. Welcome to the show. There's a large unmet need for surgical care worldwide. We've heard about this and with surgical conditions and treatments being poorly reorganized you and I just did one on Sub-Saharan Africa and breast cancer and resources as public health priorities around the world. Can you tell us a little bit about academic global surgery? What is this emerging field that's gaining popularity among trainees and faculty? Tell us a little bit about that.
Lily Gutnik, MD (Guest): Absolutely. And again, thank you so much for having me here today. First I really want to just start with a definition, right? I mean, we all, when you think about global health and when we talk about global health, people have different sort of thoughts and frameworks in their mind about what that means and what that means for them.
A lot of, I find just in my own personal experience, as I talk to people and say, you know, kind of, this is my academic niche or area of work, people automatically ask if I'm affiliated with doctors without borders. Or if I do sort of short-term mission work. Which that is certainly one aspect of global health and one aspect of global surgery, but it's not really kind of how I view and how most people view and define more of academic global surgery and global surgery as a true sort of field within global health.
And so I'd like to just briefly share this definition. And this was published in the Lancet, at the time when we were working on the Lancet Commission on Global Surgery, we had published a paper sort of saying that even titled Global Surgery Defining an Emerging Global Health Field.
And so global surgery is an area of study, research, practice and advocacy that seeks to improve the health outcomes and achieve health equity for all people who require surgical care with a special emphasis on underserved populations and populations in crisis. It uses collaborative, cross sectional and transnational approaches and is a synthesis of population based strategies with individual surgical care.
And again, one of the things I actually really love about this definition is notice how it doesn't talk about geography, right? So it's not about a group of people going to another place to perform surgery. It's really about focusing on vulnerable populations, which we know exist worldwide rather, you know, even in our own country here in the US we have tons of access to care issues and disparities in our own country.
And then of course, kind of more other lower income countries that kind of have more of these issues that may be a larger scale. And sort of with that definition in mind, I can take you through a, sort of a brief history of this academic global surgery as its own emerging field, because I think it's actually quite fascinating.
So, the first time that global surgery was actually really vocalized and supported in a large public and noteworthy former was in 1980. And at that time, Dr. Halfdan Mahler who's the, was the Executive Director of the WHO had said that the majority of the world's population have no access whatsoever to skilled surgical care and little is being done to find a solution. I beg of you to give serious consideration, this most serious manifestation of social inequity in health care. Right? So that's in 1980. Interestingly in the WHO it wasn't until 2005, where there was actually an initiative within the WHO on essential and emergency surgical care. Following that in 2008, there was a really famous publication, by two giants in global health.
And Jim Kim and Paul Farmer who published a piece in the World Journal of Surgery called Surgery and Global Health a View Beyond the OR, and that was actually where this very famous phrase was coined about surgery being the stepchild of global health. In 2011, the ACGME actually approved international resident rotations.
And then in 2012, there was a first textbook called global surgery and public health which was essentially published by a team of academic general surgeons and urologists. And then fast forward to 2014, there was a first global advocacy group called the G4 Alliance, which was surgical, obstetric, trauma and anesthesia care, which is still a really great and prominent organization, really focusing on advocacy for the neglected surgical patient. And then came 2015 and now 2015 is known as the golden year for global surgery. And that is when the Lancet Commission on Global Surgery came out. The DCP 3, which stands for disease control and priorities three, which is a publication from the world bank, which is really important in terms of sort of economic evaluation and priority setting for ministry of healths around the world.
They now came up with a whole volume on essential surgery. And then the World Health Assembly happened, which adopted the resolution that's saying strengthening emergency and essential surgical care and anesthesia is a component of universal health coverage. In 2016, there's a well-respected Success in Academic Surgery, sort of handbook series and they published a volume called Academic Global Surgery. And then in 2020, the Global Surgery Foundation was formed, which is the first kind of exclusive multiple, you know, public, private foundation that is dedicated to global surgery. So you could see here, you know, most of this work has really been seeing the most rapid rise in the last sort of six, seven years or so.
Host: Wow. That was such a comprehensive description of such a large issue. So as you're telling us that long neglected as a topic within the global and public health arenas, you're describing this increasing awareness of those extreme disparities. Can you speak a little bit how metrics, data, definitions, underlying issues of workforce and training, equipment, infrastructure is huge and funding certainly funding that need to be addressed.
I read that that these may be synthesized around three interdependent pillars, Dr. Gutnick of need access and quality. Can you speak a little bit about that? And some of the barriers to those that you see.
Dr. Gutnik: Yeah, absolutely. So that's a great, great point. And actually one of, sort of the goals of the Lancet Commission was exactly to address that because until that, you know, report and process and everything came up; there was a huge realization that there really is no data. There's no line item. When you look at sort of even big multilateral organizations like budget lines, and which of course correlates their priority setting.
There actually is line items for things like HIV, but there's really nothing for surgery. And one of the challenges in that is because surgery in itself is cross-cutting, it is not its own sort of, you know, disease entity like HIV or malaria or COVID or something. It is a cross cutting discipline that really you know, touches all sorts of other kind of broader disease types. And so a lot of the big goal of the Lancet Commission was to try to synthesize data, have common metrics and have common vocabulary and have it be included in various of these multilateral unilateral organizations. And so one of the things, you know, the Lancet Commission did come up with six indicators. You know, and things like around these topics about access.
So being, you know, number, being able to get to safe and effective surgery within two hours was one sort of indicator. Peri-operative mortality rate is another example of another indicator, workforce density and workforce being you know, both anesthesia, surgical and obstetric provider. The most common surgical procedure performed worldwide is actually a C-section, which you know, kind of here in the US US is within the realm of obstetrics and gynecology. Although in some of these other settings, particularly for example, in Sub-Saharan Africa and in more rural parts, they are really done by clinical officers, which are sort of, you know, skilled surgical technicians that perform a wide range of procedures.
So, those are just some of the examples on it, but I think there's definitely ongoing discussions about what to measure, how to measure it and making sure that there is this sort of common definitions and agreed upon metrics.
Host: Okay then along those lines and if that is what the vision is and what you're looking to do, I feel that this need for this multidisciplinary approach, as you were just talking about providers and as global surgery must engage a multidisciplinary range of individuals. I mean, we're seeing that in our country more and more and more, but including academics and clinicians, politicians, economists and patients at the local, national and international levels. Can you speak about that and how you're bringing these teams together and, and that unmet need?
Dr. Gutnik: Yeah, absolutely. And that's a huge, huge thing. And I think, you know, that even stems back from that famous quote about surgery being the neglected stepchild of global health, right. And global health is really a subsection of public health. And I think we are seeing more and more of this intersection. For example, there are a number of centers for surgery and public health around the country or within global health departments. Within schools of public health, for example, there are sort of surgery niches, or surgery groups, initiatives within these.
There are some institutions that are doing global surgery as for example, Vanderbilt University, their global surgery initiative is a multidisciplinary approach within the school of medicine that engages you know, people that are more public health experts especially within the school of public health, as well, as well as across you know, providers of anesthesia, surgery, obstetrics, and then of course nursing and then other allied health professionals as well.
If you kind of like even think about like, how do you build a surgical system, right? There's a lot of work and interest happening about surgical system strengthening. And again, working very much with health economists and you know, health policy experts, because the concept is you don't want to just perform a surgery. You want to build a safe surgical system around it, which engages all these people from all these different levels. So yes, there's definitely a lot of exciting and interesting work happening around that space right now.
Host: As we wrap up with this fascinating topic, what do you think is involved in implementing improvement? Global surgery has an expansive remet. If you were to let other providers know that are interested in getting involved, in getting more information from you, speak about some of the key parameters that would make a real difference, if someone wanted to get involved, whether it's advocacy, education, research, clinical components that can involve surgeons and anesthesiologists and nurses, allied healthcare professionals, all working together with non-clinicians, including policy makers to really get this thing going. Speak to other providers, give them your final thoughts, key takeaways in what you want them to know if they're interested in getting involved in academic global surgery.
Dr. Gutnik: Absolutely. I think that's great. I mean, I think one approach is definitely a lot of, you know, professional societies whether surgical subspecialties, or even for example, the American College of Surgeons have great initiatives. And I think that is kind of one sort of place to start. I mean, you could start to see what's available within your own institution and then kind of looking to your own professional society, because a lot of them have working groups on global surgery that have various levels of opportunities and involvement.
So that is definitely a great place I would say to start is in your own institution and then turning to your professional societies. The other thing I would just always you know, encourage people to have in mind, as they engage in global surgery activities is to really kind of think about the purpose and who you're partnering with.
And really, you know, particularly if you are working with either vulnerable communities in your own backyard, or if you're working with more vulnerable communities in a different country, it's important to really partner with them and to understand what it is that they need. And how is it that you with your skillset are able to fit their need.
I think, unfortunately I have seen that a lot of that gets lost where people and, and, and from, you know, people are coming from a good place. People are excited. People want to do good. People have a lot of empathy. They want to try to help, but I think the best way to try to help is to first ask the question, what is it that you need and how is it that I could use my skillset and my opportunities to help you.
Host: What an excellent way to end this podcast. Thank you so much, Dr. Gutnick, that was excellent. And so interesting. Thank you. And please come on and update us as things progress in this initiative and let us know what's going on. We would really appreciate that. And a physician can refer a patient to UAB Medicine by calling the mist line at 1-800-UAB-MIST. Or by visiting our website at UABmedicine.org/physician. That concludes this episode of UAB Med Cast. For more updates on the latest medical advancements, breakthroughs and research, follow us on your social channels. I'm Melanie Cole.