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Comment & Response
October 23, 2019

The Realities of External Validity in Global Surgery Research—Reply

Author Affiliations
  • 1Center for Global Health and Innovation, Stanford University School of Medicine, Palo Alto, California
  • 2Clinical Surgery, Palo Alto Veterans Hospital, Palo Alto, California
  • 3Surgeons OverSeas, New York, New York
JAMA Surg. Published online October 23, 2019. doi:10.1001/jamasurg.2019.4090

In Reply The letter by Goldstein in response to our Invited Commentary1 highlights concerns about the transition of medical roles to nonphysician clinicians (NPCs). Debates about anesthesia and surgical task sharing typically revolve around “perceived erosion of safety and quality of care, change in power dynamics, and ethical concerns.”2 We believe that task shifting has a role in modern medical care, can be done safely, and augments medical and surgical practice. For example, in response to work-hour restrictions, NPCs routinely deliver quality patient care, including night coverage, in US intensive care units.3 World experience demonstrates that procedural training of NPCs to competence can result in quality care, often with significant cost savings, and increased access in rural areas.4,5 Training goes beyond basic procedures (circumcision) to cesarean sections and laparotomies. Nonphysician clinicians provide most surgeries in Africa outside of urban centers.4 Selected transplant centers in the US quietly moved to this model for donor organ procurements, a complex procedure that combines significant technical skills and intraoperative decision-making. A Columbia University report6 concluded “our model has come from the mindset that although professional credentials are important, the real proven factor rests on an individual’s unique abilities and level of proven and demonstrable experience.”6 We too echo these sentiments; competence, not necessarily degree initials, are what patients and colleagues are interested in. Practitioner, patient, and procedural selection coupled with demonstration and maintenance of competency are all critically important. Just as every medical student cannot be trained to be a surgeon, not every NPC is suitable for this type of training. It is time for a trial to compare outcomes of ambulatory open uncomplicated inguinal hernia repairs performed by surgeons or NPCs trained and credentialed through a competency-based program. This would answer patient risks, benefits, and acceptance in a procedure where surgical volume has been linked to higher recurrence rates and health care costs.7

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