Increasing and Retaining African Surgeons Working in Rural Hospitals: An Analysis of PAACS Surgeons with Twenty-Year Program Follow-Up

Abstract

Background

African surgical workforce needs are significant, with largest disparities existing in rural settings. Pan-African Academy of Christian Surgeons (PAACS), a primarily rural-based general surgery training program, has published successes in producing rural African surgeons; however, long-term follow-up data are unreported. The goal of our study was to define characteristics of PAACS alumni surgeons working in rural hospitals, documenting successes and illuminating strategies for trainee recruitment and retention.

Method

PAACS’ twenty-year surgery residency database was reviewed for 12 programs throughout Africa regarding trainee demographics and graduate outcomes. Characteristics of PAACS’ graduate surgeons were further analyzed with a 42-question survey.

Results

Among active PAACS graduates, 100% practice in Africa and 79% within their home country. PAACS graduates had 51% short-term and 35% long-term (beyond 5 years) rural retention rate (less than 50,000 population).

Conclusion

Our study shows that PAACS general surgery training program has a high retention rate of African surgeons in rural settings compared to all programs reported to date, highlighting a multifaceted, rural-focused approach that could be emulated by surgical training programs worldwide.

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Acknowledgements

We appreciate PAACS and AIC Kijabe staff: Evelyn Mbugua, MD, Steve Doane, MD, Thomas Robey, MD and Carol Mwangi, acquiring data and performing survey. COSECSA data by Deirdre Mangaoang–RCSI/COSECSA Collaboration Program. Statistical support was made possible by James M. Scanlan, Providence Health and Services, USA and graphics from Kalie Wolfinger.

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Correspondence to Caleb Van Essen.

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The authors declare that they have no conflict of interest.

Appendix A: PAACS rural African surgeon study survey

Appendix A: PAACS rural African surgeon study survey

  • Q1: What is your age?

  • Q2: What is your sex?

  • Q3: What country did you grow up in?

  • Q4: What size was the town you grew up in?

    1. 1.

      Less than 50,000

    2. 2.

      50,000–100,000

    3. 3.

      100,000–250,000

    4. 4.

      250,000–500,000

    5. 5.

      Greater than 500,000

  • Q5: Was your medical school training outside country of your current surgical practice?

    1. 1.

      Yes, within an African country

    2. 2.

      Yes, Non-African country

    3. 3.

      No

  • Q6: During your year working as a medical officer, how many months did you spend at a rural hospital setting (less than 50,000 people).

    1. 1.

      0 months

    2. 2.

      1–2 months

    3. 3.

      3–4 months

    4. 4.

      4–6 months

    5. 5.

      More than 6 months

  • Q7: Did you have an occupation prior to attending medical school? If so, what field?

    1. 1.

      Medicine (nursing, OR technician, etc.)

    2. 2.

      Religious (pastor, clergy, etc.)

    3. 3.

      Governmental

    4. 4.

      Agriculture

    5. 5.

      Business

    6. 6.

      No previous occupation

    7. 7.

      Other: please list ___________

  • Q8: What PAACS program did you graduate from?

  • __________________

  • Q9: What month and year did you graduate? (example September 2007)

  • Q10: In what country and hospital are you currently practicing?

  • Q11: Did your spouse move with you to your current practice location?

    1. 1.

      Yes, living in same household

    2. 2.

      No, lives separate within 20 km of current location

    3. 3.

      No, lives separate within 50 km of current location

    4. 4.

      No, lives separate within 100 km of current location

    5. 5.

      No, lives separate more than 100 km of current location

    6. 6.

      Decline to answer

  • Q12: Does your spouse work outside the home?

    1. 1.

      Yes, full time (40 or more h/week)

    2. 2.

      Yes, part time (20–40 h/week)

    3. 3.

      Yes, part time (less than 20 h/week)

    4. 4.

      No

    5. 5.

      Not applicable, am not married

    6. 6.

      Decline to answer

  • Q13: How far away does your spouse’s family (mother, father, siblings) live from current job site posting?

    1. 1.

      Less than 50 km

    2. 2.

      50–100 km

    3. 3.

      100–200 km

    4. 4.

      More than 200 km

    5. 5.

      Not applicable

  • Q14: How far away does your (surgeon’s) family (mother, father, siblings) live from current job site posting?

    1. 1.

      Less than 50 km

    2. 2.

      50–100 km

    3. 3.

      100–200 km

    4. 4.

      More than 200 km

    5. 5.

      Not applicable

  • Q15: How many children do you currently have?

    1. 1.

      1

    2. 2.

      2

    3. 3.

      3

    4. 4.

      4

    5. 5.

      5 or more

    6. 6.

      Decline to answer

  • Q16: How satisfied are you with the current educational opportunities for your children at current position?

    1. 1.

      Very satisfied

    2. 2.

      Somewhat satisfied

    3. 3.

      Neutral

    4. 4.

      Somewhat unsatisfied

    5. 5.

      Very unsatisfied

  • Q17: What is the size of the town/city of your current job posting?

    1. 1.

      Less than 50 thousand

    2. 2.

      50–100 thousand

    3. 3.

      100–250 thousand

    4. 4.

      250–500 thousand

    5. 5.

      Greater than 500 thousand

  • Q18: How likely are you to continue practicing at your current location in 5 years?

    1. 1.

      Very likely

    2. 2.

      Somewhat likely

    3. 3.

      Neutral

    4. 4.

      Somewhat unlikely

    5. 5.

      Very unlikely

  • Q19: What is your surgical specialty?

  • Q20: How likely are you to pursue additional subspecialty surgical training?

    1. 1.

      Very likely—currently in subspecialty training or actively pursuing training

    2. 2.

      Somewhat likely

    3. 3.

      Neutral

    4. 4.

      Somewhat unlikely

    5. 5.

      Very unlikely—will continue to work as a General Surgeon

  • Q21: Are you a faculty member of PAACS?

    1. 1.

      Yes

    2. 2.

      No

  • Q22: How many years have you practiced as a surgeon since you graduated from PAACS?

    1. 1.

      1

    2. 2.

      2

    3. 3.

      3

    4. 4.

      4

    5. 5.

      5 or more

  • Q23: How many job postings have you had since graduating PAACS?

    1. 1.

      1

    2. 2.

      2

    3. 3.

      3

    4. 4.

      4

    5. 5.

      5 or more

  • Q24: What is the primary motivation for practicing surgery in your current environment?

    1. 1.

      _____________(fill-in-the-blank)

  • Q25: Do you anticipate you will practice rurally (town population less than 50,000) long term?

    1. 1.

      Yes, including the next 2 years

    2. 2.

      Yes, including the next 5 years

    3. 3.

      Yes, including the next 10 years

    4. 4.

      Yes, indefinitely

    5. 5.

      No

  • Q26: How often are you on call?

    1. 1.

      Every day

    2. 2.

      Every other day

    3. 3.

      Every third day

    4. 4.

      Every fourth day

    5. 5.

      Every fifth day or more

  • Q27: On average how many patients do you see in clinic per week?

    1. 1.

      Less than 25

    2. 2.

      26–50

    3. 3.

      51–100

    4. 4.

      101–150

    5. 5.

      More than 150

  • Q28: On average how many operations/procedures do you perform each week?

    1. 1.

      0–5

    2. 2.

      6–10

    3. 3.

      11–15

    4. 4.

      16–20

    5. 5.

      More than 20

  • Q29: For each surgical specialty, please tell us the percentage of cases you perform.

    • Your total should equal 100% (Example: General Surgery 50% + Gynecology 25% + Urology 15% + Head and Neck 10%.)

    • General Surgery _____%

    • Neurosurgery ______%

    • Pediatric Surgery _____%

    • Urology _____%

    • Gynecology _____%

    • Head and Neck_____%

    • Orthopedic Surgery ______%

    • Other _____%

  • Q30: Do you feel adequately trained for the healthcare delivery that is required of you?

    1. 1.

      Very adequately training

    2. 2.

      Somewhat adequately trained

    3. 3.

      Neutral

    4. 4.

      Somewhat inadequately trained

    5. 5.

      Very inadequately trained

  • Q31: How many times per week are you presented with a disease process/surgical procedure that you do not feel prepared to treat?

    1. 1.

      Never

    2. 2.

      1–2

    3. 3.

      3–4

    4. 4.

      5–6

    5. 5.

      More than 6

  • Q32: Do you have reliable anesthesia services?

    1. 1.

      Yes, I am never limited in my surgical scope of practice due to anesthesia

    2. 2.

      Yes, but I am occasionally limited in my surgical scope of practice due to anesthesia

    3. 3.

      Yes, but half the time I am limited in my surgical scope of practice due to anesthesia

    4. 4.

      No, but I often will administer my own anesthesia for operations

    5. 5.

      No, unreliable anesthesia services, limits my ability to operate on patients

  • Q33: Do you have Internet services?

    1. 1.

      Yes, works properly every time I need it (100%)

    2. 2.

      Yes, works properly most of the time that I need it (75%)

    3. 3.

      Yes, works properly half of the time that I need it

    4. 4.

      Yes, works properly infrequently (25%)

    5. 5.

      No, I do not have reliable internet services

  • Q34: How often are you involved in intentionally training residents, medical students or other healthcare personnel?

    1. 1.

      Daily

    2. 2.

      Weekly

    3. 3.

      Every other week

    4. 4.

      Monthly

    5. 5.

      Rarely involved in training residents, medical students or other healthcare personnel

  • Q35: Do you have a senior surgical mentor? If so, how frequently do you communicate?

    1. 1.

      Yes, weekly

    2. 2.

      Yes, monthly

    3. 3.

      Yes, quarterly

    4. 4.

      Yes, Biannually

    5. 5.

      Yes, Annually

    6. 6.

      No, I do not have a senior surgical mentor

  • Q36: How valued/appreciated do you feel by your current hospital staff and community?

    1. 1.

      Very valued and/or appreciated

    2. 2.

      Somewhat valued or appreciated

    3. 3.

      Neutral

    4. 4.

      Somewhat devalued or appreciated

    5. 5.

      Not valued or appreciated, in fact antagonistic

  • Q37: How satisfied are you with the opportunities you have for ongoing medical training?

    1. 1.

      Very satisfied

    2. 2.

      Somewhat satisfied

    3. 3.

      Neutral

    4. 4.

      Somewhat unsatisfied

    5. 5.

      Very unsatisfied

  • Q38: Besides your work as a surgeon, how many other leadership positions do you hold in your community? (Examples include leadership in church, local schools, rotary club, Non-governmental organizations, etc.)

    1. 1.

      0 roles/positions

    2. 2.

      1 role/position

    3. 3.

      2 roles/positions

    4. 4.

      3 roles/positions

    5. 5.

      4 or more roles/positions

  • Q39: Which of the following most closely describes your surgical practice?

    1. 1.

      Only work at rural hospital

    2. 2.

      Only work at urban Hospital

    3. 3.

      Work at both rural and urban hospitals

  • Q40: Which of the following most closely describes your surgical practice compensation?

    1. 1.

      Government Hospital Stipend

    2. 2.

      Mission hospital stipend

    3. 3.

      Private Practice

    4. 4.

      Other: (if combination please include) ____________

  • Q41: What is your monthly salary?

    1. 1.

      Less than $ US 500 per month

    2. 2.

      $ US 500–$1000 per month

    3. 3.

      $ US 1000–$2500 per month

    4. 4.

      $ US 2500–$5000 per month

    5. 5.

      Greater than $ US 5000 per month

    6. 6.

      Decline to answer

  • Q42: Do you regularly attend a local church?

    1. 1.

      Yes, on average weekly

    2. 2.

      Yes, on average twice a month

    3. 3.

      Yes, on average monthly

    4. 4.

      Yes on average every other month

    5. 5.

      No

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Van Essen, C., Steffes, B.C., Thelander, K. et al. Increasing and Retaining African Surgeons Working in Rural Hospitals: An Analysis of PAACS Surgeons with Twenty-Year Program Follow-Up. World J Surg 43, 75–86 (2019). https://doi.org/10.1007/s00268-018-4781-9

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