Competency based education in low resource settings: design and implementation of a novel surgical training program

2018-05-01Background: The unmet burden of surgical disease represents a major global health concern, and a lack of trained providers is a critical component of the inadequacy of surgical care worldwide. Increasingly, education is being recognized as essential to addressing this human resource crisis. Competency‐based training has been advanced in high‐income countries, improving technical skills and decreasing training time, but it is poorly understood how this model might be applied to low‐ and middle‐income countries (LMICs). This manuscript outlines the existing literature on surgical education initiatives within LMICs and describes the development of a competency‐based program to accelerate specialty training of in‐country providers in cleft surgery techniques during ongoing service initiatives with the non‐profit organization Operation Smile. ❧ Methods: A systematic review of the literature was performed utilizing PubMed and Medline databases following PRISMA guidelines. Identified programs were categorized according to model and program evaluation metrics were detailed. The specific development of Operation Smile’s surgical training program and the creation and contextualization of the evaluation instrument was then outlined. The program was designed and piloted among sixteen trainees at ten international cleft lip and palate surgical mission sites in Latin America and Africa. The competency‐based evaluation form was utilized to grade general technical and procedure‐specific competencies. Pre‐ and post‐training scores were analyzed using a paired t‐test and associations between number of completed cases and improvement in scores was evaluated using Pearson’s correlation coefficient. ❧ Results: Trainees demonstrated improvement in average general technical competency scores, from 53.1% to 67.2% (p=0.01), as well as in procedure‐specific competency scores for both cleft lip repairs, from 50.6% to 64.6% (p<0.01), and cleft palate repairs, from 45.16% to 65.1% (p<0.01). Postoperative care competencies improved from 58.5% to 73.3% (p=0.01) while preoperative care competencies improved from 53.8% to 70.6% (p<0.01). There was no significant correlation between the number of cases completed over the mission and the change in self‐perceived confidence for either lip and palate procedures for either knowledge (r=-0.62, p=0.856, n=11 for lip and r=-0.057, p=0.867, n=11 for palate) or technical skill (r=-0.091, p=0.802, n=11 for lip and r=-0.059, p=0.863, n=11 for palate). There was also no correlation between improved procedure‐specific competency scores and number of cases performed for either lip or palate procedures (r=0.032, p=0.917, n=11 for lip and r=0.046, p=0.886, n=11 for palate), although inconsistency with respect to case log completion may have contributed to the lack of apparent association. A positive correlation was seen between improvement in lip and palate‐specific competencies (r=0.774, p