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Comment & Response
October 23, 2019

International Consensus and External Validity in Global Surgery Research and Task Shifting—Reply

Author Affiliations
  • 1Lewis Katz School of Medicine, Division of Trauma Surgery and Surgical Critical Care, Department of Surgery, Temple University, Philadelphia, Pennsylvania
  • 2School of Medicine and Dentistry, Department of Surgery, University of Ghana, Accra, Ghana
  • 3Karolinska Institutet, Department of Molecular Medicine and Surgery, Stockholm, Sweden
JAMA Surg. 2020;155(2):171-172. doi:10.1001/jamasurg.2019.4088

In Reply We appreciate Jindal’s thoughtful comments in response to our study evaluating outcomes after inguinal hernia repair performed by medical doctors and surgeons in Ghana.1 We wholeheartedly agree that all surgical care clinicians should receive adequate training, support, continuing education, recognition, and remuneration. Standardizing methods for training and mentoring of associate clinicians and medical doctors to perform specific surgical procedures paired with ongoing support and outcomes evaluation are core principles of our work in inguinal hernia surgery capacity building in West Africa.

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    1 Comment for this article
    Global Surgery and Task-Shifting
    Eric Gokcen, M.D. | Lewis Katz School of Medicine, Department of Orthopaedic Surgery and Sports Medicine, Temple University, Philadelphia, Pennsylvania
    As with many others, I read Beard et al’s(1) study with great interest and applaud the well-done study they completed. Having personally started orthopaedic residency training programs in Kenya and Ethiopia, I have had extensive experience with global surgical education. I agree with the concept of “task-sharing” as a method of physician extenders in order to increase the capacity of low and middle income countries. “Task-shifting” is a much more controversial topic and has the potential for entry-level trained healthcare workers to inappropriately manage more complex pathologies. Task-sharing continues to provide some level of local supervision, whereas task-shifting allows the healthcare worker to function more independently as a surgeon, albeit in a supposedly limited role.
    Everyone agrees that the treating healthcare worker should have adequate training, but who decides what is adequate? The concern with an independent healthcare worker performing surgeries, is that they are the ones who ultimately decide what they will or will not treat, frequently not understanding the pathology they are treating. For example, I have come across numerous circumstances in Africa where a patient with a fracture dislocation of an ankle is treated by an orthopaedic technician with cast immobilization without reducing the ankle. The tech knows how to apply casts, the patient has an injury, thus the tech applies a cast, not realizing that the ankle must first be reduced before the cast is applied. A few months later, the patient presents to an orthopaedic surgeon with persistent pain and advanced, rapidly progressive arthritis and the only treatment is now an ankle fusion. Local orthopaedic surgeons tell me that they do more ankle fusions than open reduction and internal fixation because of poorly managed ankle fractures by orthopaedic techs.
    Although there is a need for physician extenders and task-sharing, task-shifting without adequate supervision opens the door for potential harm to patients and must be approached with caution. There is still an ongoing need for the highly trained surgical specialists to oversee the management of surgical patients(2). Without them, the level of care in low and middle income countries will continue to remain at an unacceptable level (3).

    1. Beard JH, Ohene-Yeboah M, Tabiri S, et al. Outcomes after inguinal hernia repair with mesh performed by medical doctors and surgeons in Ghana. JAMA Surg. 2019;154(9):853-859. doi:10.1001/jamasurg.2019.1744
    2. Gokcen, E, Sustainable Orthopaedic Surgery Residency Training in East Africa: A 10-Year Experience in Kenya. JAAOS Global Research & Reviews: July 2019 - Volume 3 - Issue 7 - p e035
    doi: 10.5435/JAAOSGlobal-D-19-00035
    3. Frenk J, Chen L, Bhutta ZA, et al. Health professionals for a new century: Transforming education to strengthen health systems in an interdependent world. Lancet 2010;376:1923-1958.