‘Piggy-Back’ Short-Term Engagements in Global Health for Surgical Residents: A Rapid Qualitative Analysis

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Zivanov, Colleen Witty, Paul E. Wise This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6970087/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Purpose: Supportive policy changes from graduate medical education bodies have prompted growing development of short-term experiences in global health (STEGHs), particularly in resource-limited settings. Due to a lack of internal global surgery experts, our general surgery residency program “piggybacks” on two structurally distinct surgical STEGHs hosted by other US programs: 1-week mission trips to Central America with a non-profit organization and an 8-week Residency Review Committee-approved surgical rotation in Eastern Africa. We performed a rapid qualitative assessment exploring our residents’ changing perspectives on global surgery through participation in these diverse external STEGHs. Methods: Current and former trainees who participated in at least one STEGH during residency were purposively sampled for participation in semi-structured interviews or focus group discussions (FGD). Recordings were summarized independently by at least two research team members using an iteratively refined template of domains mirroring the facilitation guide. Reconciled summaries were aggregated into a matrix, and rapid qualitative analysis was used to triangulate salient themes. Results: Twenty-six trainees participated in surgical STEGHs from 2009-2024, of which 13 (50%) participated in seven IDIs and three FGDs about their experiences. Rapid analysis revealed significant maturation of trainee perspectives on global surgery practice models, cultural humility, and healthcare delivery following STEGHs. However, trainees also faced many challenges during this period of growth, including dilemmas involving fulfilment of the social contract with the local hosting community and adapting to different health systems. Structural differences between two STEGHs – including scope of practice, trainee role, and duration – influenced the type and extent of impact on trainee growth. Trainees expressed a desire for more sustainable engagement and noted the importance of their home institution’s engagement across all phases of the STEGH. Longitudinal investment in global surgery leaders was viewed as a responsible and powerful method of engagement in global surgery efforts, both domestically and internationally. Conclusions: General surgery residency programs that seek to “piggyback” off of existing global surgery partnerships can maximize trainee and host community benefits by shifting trainee mindset from service to education and emphasizing programmatic and individual sustainability to help support effective, ethical and sustainable collaborations. Introduction The field of global surgery has garnered heightened attention among academic surgeons, particularly following approval of international electives for credit towards graduation requirements by the Residency Review Committee (RRC), American Board of Surgery, and Accreditation Council for Graduate Medical Education (ACGME) ( 1 , 2 ). More recently, the ACGME required that residents participate in a clinical rotation in a “resource-limited environment”, which may include international settings ( 3 ). In response to growing interest in global surgery, many residency programs and institutions in high-income countries (HIC) have developed global health tracks and international surgery rotations, often in low- and middle-income countries (LMIC) ( 4 – 6 ). Recent studies have estimated that over half of general surgery programs in the United States (US) offer clinical short-term engagements in global health (STEGHs), ranging from days to weeks in duration ( 5 , 7 , 8 ). However, complex logistics and high costs are frequent barriers to establishing an international surgical elective. Thus, programs without existing global surgery partnerships may choose to “piggyback” off established collaborations between other US and international institutions. A 2015 survey of surgery residency program directors with established surgical STEGHs demonstrated that over 40% would be willing to allow external trainees to participate ( 1 ). At our large academic general surgery training program, residents have two opportunities to participate in “piggyback” surgical STEGHs. The first is a 1-week surgical mission trip organized by Surgical Outreach for the Americas (“SOfA STEGH”), a nonprofit organization established in 2008 that aims to address unmet global surgical needs with a specialization in hernia repairs. This began as a collaboration with the Institute for Latin American Concern (ILAC) in the Dominican Republic and has since expanded to multiple Central American countries including El Salvador and Belize ( 9 , 10 ). The second surgical STEGH available to our residents is an 8-week RRC-approved global surgery elective at a tertiary referral hospital in Northern Malawi managed and organized by the XXX (“Malawi STEGH”). Established in 2015, this STEGH aims to facilitate resident exposure to a broad range of surgical pathology and procedures in an austere environment while also improving the surgical capacity of the region through investment in workforce training and materials ( 11 ). While these two opportunities offer surgical residents a unique opportunity to experience surgical care outside of their accustomed setting, there have been no formal reviews of the impact of this “piggyback” model of engagement in global surgery. Using rapid qualitative analysis, our study aims to explore residents’ experiences with this unique STEGH model and how this impacts residents’ understanding and further pursuit of global surgery engagements. Methods Study Design and Population This qualitative needs assessment was considered exempt from ethical review by the XXX Institutional Review Board (IRB #202308185) and adhered to the consolidated criteria for reporting qualitative research ( 12 ). With approval from the residency program director, all current and former general surgery residents from our institution who participated in the SOfA or Malawi STEGHs during their residency training were purposively recruited via email to participate in voluntary focus group discussions (FGDs) or in-depth interviews (IDIs) about their experiences. Data Collection and Analysis IDIs and FGDs took place between December 2023 – February 2025 and were conducted in English using an open-ended, semi-structured facilitation guide (Supplemental) developed by study team members with a background in global surgery and reviewed by program leadership and qualitative methods specialists according to established guidelines.( 13 ) Trainees who were unable to participate in FGDs were invited to participate in IDIs using the same facilitation guide. The facilitation guide was designed to explore trainees’ motivation to pursue international surgical experiences, the impact of these experiences on trainees, as well as any needs or desires for future international surgical opportunities. Verbal informed consent was obtained prior to study participation. FGDs and IDIs were recorded using Zoom video communication platform and lasted 30–90 minutes. Qualitative data were analyzed using a rapid matrix approach which has been shown to expedite analysis while generating comparable results to traditional qualitative methods ( 14 – 16 ). Two team members who facilitated FGDs and IDIs independently prepared narrative summaries of IDI and FGD recordings with relevant verbatim quotations. Summaries were organized using an iteratively refined template of domains mirroring the facilitation guide. These summaries were then populated into an Excel data matrix where each row represented a FGD or IDI and each column represented a domain from the facilitation guide. Three team members independently reviewed the data matrix, with subsequent collation of primary themes using negotiated agreement. Results Characteristics of the two “piggyback” STEGH experiences are compared in Table 1 . Table 1 Comparison of SOfA and Malawi STEGHs SOfA STEGH Malawi STEGH Duration 1-week 8-weeks US Program with Established STEGH Non-profit organization (SOfA) Academic medical institution Location of International Partner Central America and Caribbean Malawi STEGH Structure Surgical mission trip : trainee accompanies an interdisciplinary team of surgeons, anesthesiologists, nurses, and support staff to rural hospitals to provide surgical care Apprenticeship model : trainee works one-on-one with an ABS-certified surgeon living abroad Personnel and Resources Majority from US organization Majority from local setting Typical Cases Performed Open hernia repairs General surgery cases Cases count towards ACGME requirements? No* Yes *This STEGH is not a formal RRC-approved elective. As such, participation requires use of leave/paid time off, and cases performed during this STEGH do not count towards ACGME requirements. Thus, most residents volunteer for this STEGH during their dedicated professional development (“lab”) time after their second or third year of clinical training. Abbreviations: American Board of Surgery (ABS), and Accreditation Council for Graduate Medical Education (ACGME) Residency Review Committee (RRC), short-term engagement in global health (STEGH) Table 2 Participant Demographics 1-Week STEGH (N = 7) 8-Week STEGH (N = 4) Both (N = 2) Level of Training During STEGH Lab Resident (6) Lab + Clinical PGY3 (1) Clinical PGY 3 (2) Clinical PGY 4 (2) Lab + Clinical PGY4 (1) Lab + Clinical PGY5 (1) Professional Role at Time of Interview Resident (3) Attending (4) Resident (1) Fellow (1) Attending (2) Fellow (1) Attending (1) Current or Anticipated Specialty CT Surgery (1) Colorectal Surgery (3) General Surgery (1) MIS (2) Breast Surgery (1) CT Surgery (1) MIS (1) Surgical Oncology (1) CT Surgery (1) Transplant Surgery (1) Abbreviations: Cardiothoracic surgery (CTS), minimally invasive surgery (MIS), post-graduate year (PGY), short-term engagement in global health (STEGH) Twenty-six trainees participated in these two STEGHs from 2009-2024. Of these, 13 (50%) completed an interview (seven IDIs and three FGDs) about their STEGH experiences. Seven trainees participated in the SOfA STEGH, four participated in the Malawi STEGH, and two participated in both. Eight trainees did not respond to recruitment emails, three trainees expressed interest but did not participate due to scheduling constraints, and two trainees did not have contact information. Trainee demographics are summarized in Table 2. All SOfA STEGHs occurred during trainees’ professional development “lab” years after post-graduate year (PGY)-2, and the majority (n=6) participated in multiple SOfA trips. All Malawi STEGHs occurred during PGY-3 through -5, and most trainees participated once. Themes were organized according to the five major domains from the matrix analysis template: 1) Preparation for STEGHs, 2) Growth Facilitated by STEGHs, 3) Challenges Experienced During STEGHs, 4) Individual Aspirations and Needs, and 5) to Institutional Responsibilities and Sustainability . In-text representative quotes of salient themes provided below are labeled with trainees’ training level at the time of STEGH participation and their respective STEGH. Additional representative quotes can be found in Supplemental Tables 1-5. Themes Related to Preparation for STEGHs A principal motivation that drove trainees’ participation in surgical STEGHs was the pursuit of health equity and service, including a general belief in the right to exceptional surgical care regardless of geographic location. Trainees who had personal experiences with differently resourced healthcare systems or an aspiration to serve domestic underserved communities reported a desire to participate in surgical STEGHs as an opportunity to prepare for future work within their own communities. “Many of the motivations come selfishly because of the lived experiences that we’ve had…we want to give back to the places we come from. I grew up in [LMIC], and I saw first-hand in my family how limited access to care impacts our health, or lack of health.” (SOfA STEGH) All trainees expressed motivation to prepare for their STEGH, but trainees had mixed feelings regarding the adequacy of formal preparatory materials. Many pursued additional independent learning, however, trainees were limited in their self-guided efforts as they didn’t know what they didn’t know about global surgery, resource-limited health systems, local culture, or geopolitical context. “I guess I should have read up on the medical training or resources available, but that didn’t really occur to me.” (SOfA STEGH) Themes Related to Growth Facilitated by STEGHs The scope of operations performed during the STEGH influenced trainees’ sense of preparedness and their operative growth. The SOfA STEGH involved mostly outpatient hernia repairs. The high volume of repetitive cases facilitated increased operative confidence after a relatively short time, though only within this narrow scope. Conversely, the Malawi STEGH, offered a broader scope of surgical procedures within an austere environment which challenged trainees to consider aspects of surgery beyond the operation alone. Its apprenticeship model with graduated autonomy facilitated growth and creativity in operative skills, clinical reasoning, leadership, and education. “I took more of a senior resident role early on and then very much transitioned into a junior faculty role, leading rather than following.” (PGY3, Malawi) The different roles that trainees were assigned in each STEGH impacted their growth as clinicians more broadly. During the SOfA STEGH, a major priority was to maximize efficiency, so trainees functioned as part of the larger organizational team and often performed logistical tasks in the operating room (OR) with minimal patient interactions. While many SOfA STEGH participants felt their operative and resource management skills improved, fewer described growth in broader clinical decision making. “You would operate the entire day. Sometimes you would have a little bit of a clinic scenario, but most of the time these were patients that had already been worked up previously and were literally just showing up for surgery... it was just a rapid turnover of operating.” (SOfA STEGH) Trainees believed that the SOfA STEGH had an important role in providing high-quality clinical services, which are otherwise inaccessible to local patients. However, they worried about patients they could not help, and expressed concerns about the increased burden on local providers. “I think we had one patient where…he had a duodenal leak or a bile leak after an open cholecystectomy…that patient had to be followed for some time, and I think [local surgeon] and his team helped with that.” (SOfA STEGH) Themes Related to Challenges Experienced During STEGHs Given the greater emphasis on learning rather than service provision in the Malawi STEGH, trainees often felt disempowered in their ability to impact the local community as individuals. “I knew going into it that service was a part of it, but it was going to be a situation where they didn’t really need me… I knew that my lack of cultural competency and independent practice ability would probably make me more of a liability than an asset.” (PGY4, Malawi) Trainees described ethical dilemmas that stemmed from the recognition of their inability to uphold the “social contract”, defined as the exchange of physician status, respect and autonomy for competent and ethical care between providers and communities (17). They appreciated the significant impact stemming from the longitudinal presence of the expatriate surgeon leading the STEGH but struggled with uncertainties about unintentional consequences related to their short-term presence in hosting communities. Trainees frequently relied on feedback from local communities to navigate the acceptability of their position as a visitor. “It was also very helpful to hear the point of view of the staff [in Malawi]...they felt like they did take something away from us being there, and not just me taking away the experience of going somewhere cool to do cool cases by myself.” (PGY3, Malawi) As trainees adjusted to varying levels of exposure to different systems and practices, they also gained perspective into the consequences of such differences. Those who felt able to accommodate these differences and maintain a personally acceptable standard of care for patients experienced personal growth. “I think allocation of resources and knowing what to use…and how can you troubleshoot things, not with the best technology but with the resources that you have at hand, is something that changed my surgical perspective.” (PGY4, Malawi) However, trainees experienced moral hazard or helplessness if they felt unable to accommodate differences in standards of care, particularly if this resulted in poor patient outcomes. “Can I teach these people anything they don’t already know? Not from where I sit, no…I saw the things they say about how international health efforts can threaten local capacity…it’s not that my enthusiasm [for global surgery] was decreased, it was that my assessment of my own ability to contribute decreased.” (PGY4, Malawi) The duration of trainee engagement with a STEGH impacted trainees’ perceptions of the local health system and community. First-time participants often had a preliminary understanding of the local system, commonly characterized by preconceived biases and initial culture shock, regardless of self-perceived preparedness. “I had read a lot…about the global distribution of wealth and things like that. I thought I knew! But then I get into the hospital and soap is restricted to the scrub sinks in the operating room...because the government couldn’t afford to provide soap outside of the operating room...I had no idea that it was like that, and that was my experience with the culture shock.” (PGY4, Malawi) As trainees spent more time engaging with STEGHs, particularly at the same site, they were able to develop deeper insight into global surgery and its complexities, often recognizing the need to learn more. “I think the second and third time I went back, in terms of personal goals, maybe not formally. I was a little bit more interested in figuring out what kind of preparation goes into making those weeks successful, how [SOfA co-founder] networks with donors beforehand to make sure we have all of the equipment and supplies we need.” (SOfA STEGH) As trainees were exposed to different health systems, they also gained new perspectives on the strengths and weaknesses of their home systems. Trainees often reflected on differences in the distribution, perception and utilization of resources in the US compared to international settings. They also appreciated the flexibility and intentionality of care in settings with limited resources, viewing these as beneficial traits which could be applied to their own future practice. “I started to see [US hospital] better for what it was. The ways in which it’s strong, the ways in which it’s limited…our brand [in the US] is based on projecting to people that we have essentially unlimited resources and skills, and it’s not true…seeing that through the lens of having worked at [Malawi hospital] was helpful to me” (PGY4, Malawi) Themes Related to Individual Aspirations and Needs Through the STEGHs, trainees developed a deeper understanding of their needs when considering engagement in future global surgery opportunities. Some of these needs were personal preferences like connection with the hosting community, feeling empowered to make positive change, or having competent language skills. “The cultural impact of being in a space where you look like the people that you go to work with every single day…for many [minority] trainees, it might be the only opportunity they have to be respected every single day and to not have to prove that they deserve to be respected or even treated as an equal…that was a profound impact for me. I didn’t walk into an OR and I was [name], the Black girl. I was [name]. And it felt good.” (PGY3, Malawi) Other needs were related to factors external to the trainees’ control, including the presence of accessible opportunities or mentors, geopolitical circumstances, or family or career responsibilities. “It’s hard enough being a surgery resident and buckling up and doing your 80-hours…but then you’re fully going away for a few months…if you do have a family...it’s just another burden on them when it’s already tough.” (SOfA STEGH) Trainees’ perceptions on whether they would anticipate participating in future global surgery opportunities depended on alignment with these identified needs. Some trainees appreciated how having the option to participate in an existing STEGH lowered the threshold for participation which they may not have otherwise been able to overcome. Without existing opportunities, trainees felt they would be likely to disengage or pursue selective engagement in the future. “You have [STEGH faculty] who is out there full time, but you also have attendings who were there for a month, taking one of their trainees and also teaching the medical students and clinical officers at [Malawi Hospital] as part of their career…there are many ways to incorporate global surgery into your career…what do I want my career to look like?” (PGY5, Malawi) Additional feedback from trainees included a desire for more frequent opportunities to debrief and about their experiences. Some participants expressed frustrations related to re-integration and their inability to apply new leadership skills and lessons learned to their home system. Many also requested additional opportunities for international engagement. “There are so many ways to be involved in global surgery… And after being in Malawi…it made it easier for me to have better conversations about global surgery…it opened up my understanding – it didn’t complete it at all.” (PGY4, Malawi) Themes Related to Institutional Responsibilities and Sustainability However, trainees acknowledged that beyond the limited scope of their individual impact, institutional investment in sustainable methods of global surgery engagement, even beyond direct engagement, can have significant positive impact on a hosting community. “The thing that [US institution] contributes to that I think is really important is supporting this as a horizontal rather than vertical global health intervention…providing financial support for [STEGH faculty]’s presence…is making a difference. He is a pillar of the community in that hospital.” (PGY4, Malawi) Trainees’ views of responsible institutional engagement are reminiscent of the standards which they apply to themselves regarding the pursuit of health equity and service. “I think our responsibility lies in recruiting people with really diverse interests and promoting people who may be a little more unconventional. And that takes a lot of guts from a leadership position…I don’t know if global surgery makes money for an institution…but is it important? Absolutely” (PGY5, Malawi) Trainees also emphasized the need for institutional involvement in domestic, underserved communities as an essential component of global surgical practice. “Part of what makes us such a powerhouse clinically and academically is that we have an abundance of resources…we should feel a responsibility to care about the less resourced areas, whether in [our city], in the US or globally…our primary responsibility is in the city in which we work, but the extension of that responsibility is to address inequities worldwide.” (SOfA STEGH) Discussion This rapid qualitative analysis revealed that our trainees gained deeper insights into global surgery practices, cultural awareness and flexibility, and nuanced perspectives of care provision, domestically and abroad, following their STEGH experiences. Beyond these positive gains, we noted that trainees struggled with concerns related to their position within the local social contract, adapting to different health systems, and the sustainability of engagements. We provide recommendations for institutions engaging in “piggyback” STEGHs who lack internal global surgery experts to promote both longitudinal engagements for trainees and sustainable partner engagement to better foster alignment of goals and productive progress (18–21). These recommendations are informed by trainee feedback as well as best practices guidelines from collaborations who have more experience navigating the complex power dynamics and the historically extractive context frequently associated with STEGH experiences (18–20). One major motivating factor our trainees expressed for engaging with STEGHs was a commitment to equity and service. Following the STEGH many trainees recognized their limited scope of impact and inability to uphold the ‘social contract’ with the local community. Trainees worried about their inability to ensure adequacy of long-term outcomes or ensure competency of care when practicing in an unfamiliar system. The Advocacy for Global Health Partnerships (AGHP) coalition identifies this conflict in balancing service and learning as a common phenomenon in many who participate in STEGHs, and recommend shifting the trainee mindset towards learning role (22). This shift in perspective can alleviate unreasonable expectations of personal responsibility to create change as an individual. It can also avoid the unintentional shift of focus away from collaboration with host communities to favoring the presence of visiting volunteers (22). The Brocher Declaration is a series of six foundational principles for guiding STEGHs towards more “appropriate, equitable sustainable, and ethical practices”, that may also be a helpful guideline for institutions of all backgrounds engaging in STEGHS to appropriately prioritize the needs of the community in which the STEGH occurs (22). Within a learning context, however, many trainees identified unmet needs related to their understanding of and role within global surgery. Given the nature of piggyback STEGHs, returning trainees may lack the opportunity to debrief or participate in structured global surgery curricula beyond the short-term engagement. Adopting a long-term perspective on a trainee’s global surgery journey can reframe a STEGH within the context of more enduring individual development. Examples of such curricula can be found from existing programs and implemented to support trainees participating in STEGHs (24,25). Encouraging trainees to build multidisciplinary mentorship panels who can contribute to their long-term development as global health providers can also help address the lack of immediate experts within home institutions (26). In both STEGHs, our trainees expressed admiration for the programmatic sustainability stemming from the longitudinal engagements of STEGH leaders within local communities, becoming ‘pillars of the community’. In contrast, trainees struggled with their own short-term roles in the program, frequently only developing insight into the larger goals of the STEGH experiences upon completion. This concern for sustainable practices on both programmatic and individual levels is a commonly emphasized need in the global surgery community. Loh and colleagues (2015) proposed a taxonomy of STEGH programs according to the number of involved partners and frequency of visits and noted that programs with fewer partners and continuous presence create less burden on hosting communities (23). Although STEGHs are inherently short-term, continuity can be enhanced by framing short-term visits around longitudinal program goals. Expanding trainee exposure to the inner workings and long-term goals of STEGHs prior to the rotation can help align this transient group into a more cohesive presence prior to engagement with the hosting community. Additionally, the “piggyback” partnership model may allow for institutions without long-term international collaborations to contribute to the longitudinal mission of existing collaborations to maximize benefits and minimize disruptions in local hosting communities. Limitations This is a single-center study with a limited sample size. While we were able to identify key emerging themes within our interviews, we recognize the limitations associated with our inability to enroll all prior STEGH participants from our institution. This may limit achievement of true thematic saturation within our full cohort. Despite this, we believe the perspectives we collected across a 15-year period of our institution’s involvement in a “piggyback” model of global surgery partnership may remain a useful case study for other institutions seeking to engage in similar collaborations. As in all qualitative studies, we also recognize the cultural, confirmation, and reflexivity biases within our research team. We attempted to mitigate these biases by engaging team members with varying cultural backgrounds and global health experiences in independent coding and analysis of interviews. Conclusion As surgical trainees are increasingly encouraged by the ACGME to gain experiences in low-resource settings, whether domestically or internationally, all institutions involved in the trainee’s experience have a shared responsibility to ensure they are adequately prepared to engage in patient care in an unfamiliar setting. “Piggyback” STEGHs are particularly complex experiences which require a higher level of attention and intention to ensure mutual benefit for all parties involved. We hope our findings can provide a case study for institutions seeking to engage in this space and lend advice for how to approach STEGH experiences with an emphasis on humility, reciprocity and sustainability. Institutions and trainees must remain accountable to their patients, regardless of setting, and investment in training global surgeons who are effective clinicians and citizens across diverse settings will only continue to grow in importance. Declarations Conflict of Interest Statement On behalf of all authors, the corresponding author states that there is no conflict of interest. Data Availability Statement Due to the sensitive and potentially identifiable nature of our qualitative interviews, particularly within our limited cohort, we are unable to make our full transcripts publicly available in order to protect participant privacy and confidentiality. However, all relevant quotes have been directly de-identified in text and additional samples of representative quotes are available in Supplementary Tables. Further de-identified textual data can be made available upon reasonable request to the corresponding author. References Knudson MM, Tarpley MJ, Numann PJ. Global surgery opportunities for U.S. surgical residents: an interim report. J Surg Educ. 2015;72(4):e60-65. American Board of Surgery [Internet]. [cited 2025 Jun 17]. International Rotations Policy. 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Supplementary Files SupplementalTable15.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 18 Jul, 2025 Reviewers invited by journal 13 Jul, 2025 Editor invited by journal 12 Jul, 2025 Editor assigned by journal 07 Jul, 2025 First submitted to journal 30 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6970087","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":484676259,"identity":"f660b3e8-b954-46ad-8c88-8694979923c0","order_by":0,"name":"Helen Wu Li","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAx0lEQVRIiWNgGAWjYBACAwbmBgaGAgk5MO8BAwNjA2EtIDUGEsYMINUJJGhhSGwgWos5e2Pj4wIDi/QNN9KfP0hgsJHdcICAFsueg83GMwwkcjfcyDEE2pJmTFCLwY3ENmkeoJZtN3JADjucSFjL/Yftv4Fa0s1upD8EavlPhJYbjG3MQC0JZjcSQA47QISWM4nNIIcZ7j/zxnBGgkGy8UyCWo4fPviZp6JOXrI9/cGHDxV2sn2EtKCbQJryUTAKRsEoGAU4AACTZEbuBNsuAgAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0003-1437-2668","institution":"Washington University in St Louis Department of Surgery","correspondingAuthor":true,"prefix":"","firstName":"Helen","middleName":"Wu","lastName":"Li","suffix":""},{"id":484676260,"identity":"b5362f8c-0821-47ad-b408-f78f084b9b1e","order_by":1,"name":"Catherine N. Zivanov","email":"","orcid":"","institution":"Washington University in St Louis Department of Surgery","correspondingAuthor":false,"prefix":"","firstName":"Catherine","middleName":"N.","lastName":"Zivanov","suffix":""},{"id":484676261,"identity":"ee4408e2-97be-4573-a94f-b90e9f2b6ddc","order_by":2,"name":"Colleen Witty","email":"","orcid":"","institution":"Washington University in St Louis Department of Surgery","correspondingAuthor":false,"prefix":"","firstName":"Colleen","middleName":"","lastName":"Witty","suffix":""},{"id":484676262,"identity":"49b22161-16cb-41fd-8400-54b9782d685e","order_by":3,"name":"Paul E. Wise","email":"","orcid":"","institution":"Washington University in St Louis Department of Surgery","correspondingAuthor":false,"prefix":"","firstName":"Paul","middleName":"E.","lastName":"Wise","suffix":""}],"badges":[],"createdAt":"2025-06-25 03:22:45","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6970087/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6970087/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":86795418,"identity":"daf41cb6-1ae7-425e-9c70-d186349bfb7c","added_by":"auto","created_at":"2025-07-15 15:34:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":523313,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6970087/v1/146a4a0e-6394-4a8b-ad11-c9cba3c84774.pdf"},{"id":86794977,"identity":"816f55a0-b2e3-46de-85a1-1c34b0f03aee","added_by":"auto","created_at":"2025-07-15 15:26:21","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":28387,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementalTable15.docx","url":"https://assets-eu.researchsquare.com/files/rs-6970087/v1/8185461a346d8dd14c570791.docx"}],"financialInterests":"","formattedTitle":"‘Piggy-Back’ Short-Term Engagements in Global Health for Surgical Residents: A Rapid Qualitative Analysis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe field of global surgery has garnered heightened attention among academic surgeons, particularly following approval of international electives for credit towards graduation requirements by the Residency Review Committee (RRC), American Board of Surgery, and Accreditation Council for Graduate Medical Education (ACGME) (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). More recently, the ACGME required that residents participate in a clinical rotation in a “resource-limited environment”, which may include international settings (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). In response to growing interest in global surgery, many residency programs and institutions in high-income countries (HIC) have developed global health tracks and international surgery rotations, often in low- and middle-income countries (LMIC) (\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e–\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eRecent studies have estimated that over half of general surgery programs in the United States (US) offer clinical short-term engagements in global health (STEGHs), ranging from days to weeks in duration (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). However, complex logistics and high costs are frequent barriers to establishing an international surgical elective. Thus, programs without existing global surgery partnerships may choose to “piggyback” off established collaborations between other US and international institutions. A 2015 survey of surgery residency program directors with established surgical STEGHs demonstrated that over 40% would be willing to allow external trainees to participate (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAt our large academic general surgery training program, residents have two opportunities to participate in “piggyback” surgical STEGHs. The first is a 1-week surgical mission trip organized by Surgical Outreach for the Americas (“SOfA STEGH”), a nonprofit organization established in 2008 that aims to address unmet global surgical needs with a specialization in hernia repairs. This began as a collaboration with the Institute for Latin American Concern (ILAC) in the Dominican Republic and has since expanded to multiple Central American countries including El Salvador and Belize (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e The second surgical STEGH available to our residents is an 8-week RRC-approved global surgery elective at a tertiary referral hospital in Northern Malawi managed and organized by the XXX (“Malawi STEGH”). Established in 2015, this STEGH aims to facilitate resident exposure to a broad range of surgical pathology and procedures in an austere environment while also improving the surgical capacity of the region through investment in workforce training and materials (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eWhile these two opportunities offer surgical residents a unique opportunity to experience surgical care outside of their accustomed setting, there have been no formal reviews of the impact of this “piggyback” model of engagement in global surgery. Using rapid qualitative analysis, our study aims to explore residents’ experiences with this unique STEGH model and how this impacts residents’ understanding and further pursuit of global surgery engagements.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cem\u003eStudy Design and Population\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThis qualitative needs assessment was considered exempt from ethical review by the XXX Institutional Review Board (IRB #202308185) and adhered to the consolidated criteria for reporting qualitative research (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). With approval from the residency program director, all current and former general surgery residents from our institution who participated in the SOfA or Malawi STEGHs during their residency training were purposively recruited via email to participate in voluntary focus group discussions (FGDs) or in-depth interviews (IDIs) about their experiences.\u003c/p\u003e\u003cp\u003e\u003cem\u003eData Collection and Analysis\u003c/em\u003e\u003c/p\u003e\u003cp\u003e IDIs and FGDs took place between December 2023 – February 2025 and were conducted in English using an open-ended, semi-structured facilitation guide (Supplemental) developed by study team members with a background in global surgery and reviewed by program leadership and qualitative methods specialists according to established guidelines.(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) Trainees who were unable to participate in FGDs were invited to participate in IDIs using the same facilitation guide. The facilitation guide was designed to explore trainees’ motivation to pursue international surgical experiences, the impact of these experiences on trainees, as well as any needs or desires for future international surgical opportunities. Verbal informed consent was obtained prior to study participation. FGDs and IDIs were recorded using Zoom video communication platform and lasted 30–90 minutes.\u003c/p\u003e\u003cp\u003eQualitative data were analyzed using a rapid matrix approach which has been shown to expedite analysis while generating comparable results to traditional qualitative methods (\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e–\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Two team members who facilitated FGDs and IDIs independently prepared narrative summaries of IDI and FGD recordings with relevant verbatim quotations. Summaries were organized using an iteratively refined template of domains mirroring the facilitation guide. These summaries were then populated into an Excel data matrix where each row represented a FGD or IDI and each column represented a domain from the facilitation guide. Three team members independently reviewed the data matrix, with subsequent collation of primary themes using negotiated agreement.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eCharacteristics of the two \u0026ldquo;piggyback\u0026rdquo; STEGH experiences are compared in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eComparison of SOfA and Malawi STEGHs\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSOfA STEGH\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMalawi STEGH\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eDuration\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1-week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8-weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eUS Program with Established STEGH\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNon-profit organization (SOfA)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAcademic medical institution\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLocation of International Partner\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCentral America and Caribbean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMalawi\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSTEGH Structure\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurgical mission trip\u003c/strong\u003e: trainee accompanies an interdisciplinary team of surgeons, anesthesiologists, nurses, and support staff to rural hospitals to provide surgical care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eApprenticeship model\u003c/strong\u003e: trainee works one-on-one with an ABS-certified surgeon living abroad\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePersonnel and Resources\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMajority from US organization\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMajority from local setting\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTypical Cases Performed\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOpen hernia repairs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGeneral surgery cases\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCases count towards ACGME requirements?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003e*This STEGH is not a formal RRC-approved elective. As such, participation requires use of leave/paid time off, and cases performed during this STEGH do not count towards ACGME requirements. Thus, most residents volunteer for this STEGH during their dedicated professional development (\u0026ldquo;lab\u0026rdquo;) time after their second or third year of clinical training.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAbbreviations:\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eAmerican Board of Surgery (ABS), and Accreditation Council for Graduate Medical Education (ACGME) Residency Review Committee (RRC), short-term engagement in global health (STEGH)\u003c/em\u003e\u003c/p\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003eTable 2\u0026nbsp;\u003cp\u003eParticipant Demographics\u003c/p\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth\u003e\u003cbr\u003e\u003c/th\u003e\n \u003cth\u003e\n \u003cp\u003e1-Week STEGH\u003c/p\u003e\n \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;7)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth\u003e\n \u003cp\u003e8-Week STEGH\u003c/p\u003e\n \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;4)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth\u003e\n \u003cp\u003eBoth\u003c/p\u003e\n \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;2)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eLevel of Training During STEGH\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eLab Resident (6)\u003c/p\u003e\n \u003cp\u003eLab\u0026thinsp;+\u0026thinsp;Clinical PGY3 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eClinical PGY 3 (2)\u003c/p\u003e\n \u003cp\u003eClinical PGY 4 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eLab\u0026thinsp;+\u0026thinsp;Clinical PGY4 (1)\u003c/p\u003e\n \u003cp\u003eLab\u0026thinsp;+\u0026thinsp;Clinical PGY5 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eProfessional Role at Time of Interview\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eResident (3)\u003c/p\u003e\n \u003cp\u003eAttending (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eResident (1)\u003c/p\u003e\n \u003cp\u003eFellow (1)\u003c/p\u003e\n \u003cp\u003eAttending (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eFellow (1)\u003c/p\u003e\n \u003cp\u003eAttending (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCurrent or Anticipated Specialty\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eCT Surgery (1)\u003c/p\u003e\n \u003cp\u003eColorectal Surgery (3)\u003c/p\u003e\n \u003cp\u003eGeneral Surgery (1)\u003c/p\u003e\n \u003cp\u003eMIS (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eBreast Surgery (1)\u003c/p\u003e\n \u003cp\u003eCT Surgery (1)\u003c/p\u003e\n \u003cp\u003eMIS (1)\u003c/p\u003e\n \u003cp\u003eSurgical Oncology (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eCT Surgery (1)\u003c/p\u003e\n \u003cp\u003eTransplant Surgery (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAbbreviations:\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u0026nbsp;Cardiothoracic surgery (CTS), minimally invasive surgery (MIS), post-graduate year (PGY), short-term engagement in global health (STEGH)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTwenty-six trainees participated in these two STEGHs from 2009-2024. Of these, 13 (50%) completed an interview (seven IDIs and three FGDs) about their STEGH experiences. Seven trainees participated in the SOfA STEGH, four participated in the Malawi STEGH, and two participated in both. Eight trainees did not respond to recruitment emails, three trainees expressed interest but did not participate due to scheduling constraints, and two trainees did not have contact information. Trainee demographics are summarized in Table 2. All SOfA STEGHs occurred during trainees\u0026rsquo; professional development \u0026ldquo;lab\u0026rdquo; years after post-graduate year (PGY)-2, and the majority (n=6) participated in multiple SOfA trips. All Malawi STEGHs occurred during PGY-3 through -5, and most trainees participated once.\u003c/p\u003e\n\u003cp\u003eThemes were organized according to the five major domains from the matrix analysis template: 1) Preparation for STEGHs, 2) Growth Facilitated by STEGHs, 3) Challenges Experienced During STEGHs, 4) Individual Aspirations and Needs, and 5)\u003cem\u003e\u0026nbsp;\u003c/em\u003eto Institutional Responsibilities and Sustainability\u003cem\u003e.\u003c/em\u003e In-text representative quotes of salient themes provided below are labeled with trainees\u0026rsquo; training level at the time of STEGH participation and their respective STEGH. Additional representative quotes can be found in Supplemental Tables 1-5.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eThemes Related to Preparation for STEGHs\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eA principal motivation that drove trainees\u0026rsquo; participation in surgical STEGHs was the pursuit of health equity and service, including a general belief in the right to exceptional surgical care regardless of geographic location. Trainees who had personal experiences with differently resourced healthcare systems or an aspiration to serve domestic underserved communities reported a desire to participate in surgical STEGHs as an opportunity to prepare for future work within their own communities.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Many of the motivations come selfishly because of the lived experiences that we\u0026rsquo;ve had\u0026hellip;we want to give back to the places we come from. I grew up in [LMIC], and I saw first-hand in my family how limited access to care impacts our health, or lack of health.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003cem\u003e(SOfA STEGH)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAll trainees expressed motivation to prepare for their STEGH, but trainees had mixed feelings regarding the adequacy of formal preparatory materials. Many pursued additional independent learning, however, trainees were limited in their self-guided efforts as they didn\u0026rsquo;t know what they didn\u0026rsquo;t know about global surgery, resource-limited health systems, local culture, or geopolitical context.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I guess I should have read up on the medical training or resources available, but that didn\u0026rsquo;t really occur to me.\u0026rdquo; (SOfA STEGH)\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eThemes Related to Growth Facilitated by STEGHs\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe scope of operations performed during the STEGH influenced trainees\u0026rsquo; sense of preparedness and their operative growth. The SOfA STEGH involved mostly outpatient hernia repairs. The high volume of repetitive cases facilitated increased operative confidence after a relatively short time, though only within this narrow scope. Conversely, the Malawi STEGH, offered a broader scope of surgical procedures within an austere environment which challenged trainees to consider aspects of surgery beyond the operation alone. Its apprenticeship model with graduated autonomy facilitated growth and creativity in operative skills, clinical reasoning, leadership, and education.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003e\u0026ldquo;I took more of a senior resident role early on and then very much transitioned into a junior faculty role, leading rather than following.\u0026rdquo; (PGY3, Malawi)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003eThe different roles that trainees were assigned in each STEGH impacted their growth as clinicians more broadly. During the SOfA STEGH, a major priority was to maximize efficiency, so trainees functioned as part of the larger organizational team and often performed logistical tasks in the operating room (OR) with minimal patient interactions. While many SOfA STEGH participants felt their operative and resource management skills improved, fewer described growth in broader clinical decision making.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;You would operate the entire day. Sometimes you would have a little bit of a clinic scenario, but most of the time these were patients that had already been worked up previously and were literally just showing up for surgery... it was just a rapid turnover of operating.\u0026rdquo; (SOfA STEGH)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003eTrainees believed that the SOfA STEGH had an important role in providing high-quality clinical services, which are otherwise inaccessible to local patients. However, they worried about patients they could not help, and expressed concerns about the increased burden on local providers.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think we had one patient where\u0026hellip;he had a duodenal leak or a bile leak after an open cholecystectomy\u0026hellip;that patient had to be followed for some time, and I think [local surgeon] and his team helped with that.\u0026rdquo; (SOfA STEGH)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eThemes Related to Challenges Experienced During STEGHs\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eGiven the greater emphasis on learning rather than service provision in the Malawi STEGH, trainees often felt disempowered in their ability to impact the local community as individuals.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I knew going into it that service was a part of it, but it was going to be a situation where they didn\u0026rsquo;t really need me\u0026hellip; I knew that my lack of cultural competency and independent practice ability would probably make me more of a liability than an asset.\u0026rdquo; (PGY4, Malawi)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003eTrainees described ethical dilemmas that stemmed from the recognition of their inability to uphold the \u0026ldquo;social contract\u0026rdquo;, defined as the exchange of physician status, respect and autonomy for competent and ethical care between providers and communities (17). They appreciated the significant impact stemming from the longitudinal presence of the expatriate surgeon leading the STEGH but struggled with uncertainties about unintentional consequences related to their short-term presence in hosting communities. Trainees frequently relied on feedback from local communities to navigate the acceptability of their position as a visitor.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;It was also very helpful to hear the point of view of the staff [in Malawi]...they felt like they did take something away from us being there, and not just me taking away the experience of going somewhere cool to do cool cases by myself.\u0026rdquo; (PGY3, Malawi)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAs trainees adjusted to varying levels of exposure to different systems and practices, they also gained perspective into the consequences of such differences. Those who felt able to accommodate these differences and maintain a personally acceptable standard of care for patients experienced personal growth.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think allocation of resources and knowing what to use\u0026hellip;and how can you troubleshoot things, not with the best technology but with the resources that you have at hand, is something that changed my surgical perspective.\u0026rdquo; (PGY4, Malawi)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHowever, trainees experienced moral hazard or helplessness if they felt unable to accommodate differences in standards of care, particularly if this resulted in poor patient outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Can I teach these people anything they don\u0026rsquo;t already know? Not from where I sit, no\u0026hellip;I saw the things they say about how international health efforts can threaten local capacity\u0026hellip;it\u0026rsquo;s not that my enthusiasm [for global surgery] was decreased, it was that my assessment of my own ability to contribute decreased.\u0026rdquo; (PGY4, Malawi)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe duration of trainee engagement with a STEGH impacted trainees\u0026rsquo; perceptions of the local health system and community. First-time participants often had a preliminary understanding of the local system, commonly characterized by preconceived biases and initial culture shock, regardless of self-perceived preparedness.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I had read a lot\u0026hellip;about the global distribution of wealth and things like that. I thought I knew! But then I get into the hospital and soap is restricted to the scrub sinks in the operating room...because the government couldn\u0026rsquo;t afford to provide soap outside of the operating room...I had no idea that it was like that, and that was my experience with the culture shock.\u0026rdquo; (PGY4, Malawi)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAs trainees spent more time engaging with STEGHs, particularly at the same site, they were able to develop deeper insight into global surgery and its complexities, often recognizing the need to learn more.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think the second and third time I went back, in terms of personal goals, maybe not formally. I was a little bit more interested in figuring out what kind of preparation goes into making those weeks successful, how [SOfA co-founder] networks with donors beforehand to make sure we have all of the equipment and supplies we need.\u0026rdquo; (SOfA STEGH)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAs trainees were exposed to different health systems, they also gained new perspectives on the strengths and weaknesses of their home systems. Trainees often reflected on differences in the distribution, perception and utilization of resources in the US compared to international settings. They also appreciated the flexibility and intentionality of care in settings with limited resources, viewing these as beneficial traits which could be applied to their own future practice.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I started to see [US hospital] better for what it was. The ways in which it\u0026rsquo;s strong, the ways in which it\u0026rsquo;s limited\u0026hellip;our brand [in the US] is based on projecting to people that we have essentially unlimited resources and skills, and it\u0026rsquo;s not true\u0026hellip;seeing that through the lens of having worked at [Malawi hospital] was helpful to me\u0026rdquo; (PGY4, Malawi)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eThemes Related to Individual Aspirations and Needs\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThrough the STEGHs, trainees developed a deeper understanding of their needs when considering engagement in future global surgery opportunities. Some of these needs were personal preferences like connection with the hosting community, feeling empowered to make positive change, or having competent language skills.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The cultural impact of being in a space where you look like the people that you go to work with every single day\u0026hellip;for many [minority] trainees, it might be the only opportunity they have to be respected every single day and to not have to prove that they deserve to be respected or even treated as an equal\u0026hellip;that was a profound impact for me. I didn\u0026rsquo;t walk into an OR and I was [name], the Black girl. I was [name]. And it felt good.\u0026rdquo; (PGY3, Malawi)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003eOther needs were related to factors external to the trainees\u0026rsquo; control, including the presence of accessible opportunities or mentors, geopolitical circumstances, or family or career responsibilities.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003e\u0026ldquo;It\u0026rsquo;s hard enough being a surgery resident and buckling up and doing your 80-hours\u0026hellip;but then you\u0026rsquo;re fully going away for a few months\u0026hellip;if you do have a family...it\u0026rsquo;s just another burden on them when it\u0026rsquo;s already tough.\u0026rdquo; (SOfA STEGH)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003eTrainees\u0026rsquo; perceptions on whether they would anticipate participating in future global surgery opportunities depended on alignment with these identified needs. Some trainees appreciated how having the option to participate in an existing STEGH lowered the threshold for participation which they may not have otherwise been able to overcome. Without existing opportunities, trainees felt they would be likely to disengage or pursue selective engagement in the future.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;You have [STEGH faculty] who is out there full time, but you also have attendings who were there for a month, taking one of their trainees and also teaching the medical students and clinical officers at [Malawi Hospital] as part of their career\u0026hellip;there are many ways to incorporate global surgery into your career\u0026hellip;what do I want my career to look like?\u0026rdquo; (PGY5, Malawi)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003eAdditional feedback from trainees included a desire for more frequent opportunities to debrief and about their experiences. Some participants expressed frustrations related to re-integration and their inability to apply new leadership skills and lessons learned to their home system. Many also requested additional opportunities for international engagement.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;There are so many ways to be involved in global surgery\u0026hellip; And after being in Malawi\u0026hellip;it made it easier for me to have better conversations about global surgery\u0026hellip;it opened up my understanding \u0026ndash; it didn\u0026rsquo;t complete it at all.\u0026rdquo; (PGY4, Malawi)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eThemes Related to Institutional Responsibilities and Sustainability\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eHowever, trainees acknowledged that beyond the limited scope of their individual impact, institutional investment in sustainable methods of global surgery engagement, even beyond direct engagement, can have significant positive impact on a hosting community.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The thing that [US institution] contributes to that I think is really important is supporting this as a horizontal rather than vertical global health intervention\u0026hellip;providing financial support for [STEGH faculty]\u0026rsquo;s presence\u0026hellip;is making a difference. He is a pillar of the community in that hospital.\u0026rdquo; (PGY4, Malawi)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e Trainees\u0026rsquo; views of responsible institutional engagement are reminiscent of the standards which they apply to themselves regarding the pursuit of health equity and service.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think our responsibility lies in recruiting people with really diverse interests and promoting people who may be a little more unconventional. And that takes a lot of guts from a leadership position\u0026hellip;I don\u0026rsquo;t know if global surgery makes money for an institution\u0026hellip;but is it important? Absolutely\u0026rdquo; (PGY5, Malawi)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003eTrainees also emphasized the need for institutional involvement in domestic, underserved communities as an essential component of global surgical practice.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003e\u0026ldquo;Part of what makes us such a powerhouse clinically and academically is that we have an abundance of resources\u0026hellip;we should feel a responsibility to care about the less resourced areas, whether in [our city], in the US or globally\u0026hellip;our primary responsibility is in the city in which we work, but the extension of that responsibility is to address inequities worldwide.\u0026rdquo; (SOfA STEGH)\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis rapid qualitative analysis revealed that our trainees gained deeper insights into global surgery practices, cultural awareness and flexibility, and nuanced perspectives of care provision, domestically and abroad, following their STEGH experiences. Beyond these positive gains, we noted that\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003etrainees struggled with concerns related to their position within the local social contract, adapting to different health systems, and the sustainability of engagements. We provide recommendations for institutions engaging in \u0026ldquo;piggyback\u0026rdquo; STEGHs who lack internal global surgery experts to promote both longitudinal engagements for trainees and sustainable partner engagement to better foster alignment of goals and productive progress (18\u0026ndash;21). These recommendations are informed by trainee feedback as well as best practices guidelines from collaborations who have more experience navigating the complex power dynamics and the historically extractive context frequently associated with STEGH experiences (18\u0026ndash;20).\u003c/p\u003e\n\u003cp\u003eOne major motivating factor our trainees expressed for engaging with STEGHs was a commitment to equity and service. Following the STEGH many trainees recognized their limited scope of impact and inability to uphold the \u0026lsquo;social contract\u0026rsquo; with the local community. Trainees worried about their inability to ensure adequacy of long-term outcomes or ensure competency of care when practicing in an unfamiliar system. The Advocacy for Global Health Partnerships (AGHP) coalition identifies this conflict in balancing service and learning as a common phenomenon in many who participate in STEGHs, and recommend shifting the trainee mindset towards learning role (22). This shift in perspective can alleviate unreasonable expectations of personal responsibility to create change as an individual. It can also avoid the unintentional shift of focus away from collaboration with host communities to favoring the presence of visiting volunteers (22). The Brocher Declaration is a series of six foundational principles for guiding STEGHs towards more \u0026ldquo;appropriate, equitable sustainable, and ethical practices\u0026rdquo;, that may also be a helpful guideline for institutions of all backgrounds engaging in STEGHS to appropriately prioritize the needs of the community in which the STEGH occurs (22).\u003c/p\u003e\n\u003cp\u003eWithin a learning context, however, many trainees identified unmet needs related to their understanding of and role within global surgery. Given the nature of piggyback STEGHs, returning trainees may lack the opportunity to debrief or participate in structured global surgery curricula beyond the short-term engagement. Adopting a long-term perspective on a trainee\u0026rsquo;s global surgery journey can reframe a STEGH within the context of more enduring individual development. Examples of such curricula can be found from existing programs and implemented to support trainees participating in STEGHs (24,25). Encouraging trainees to build multidisciplinary mentorship panels who can contribute to their long-term development as global health providers can also help address the lack of immediate experts within home institutions (26).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn both STEGHs, our trainees expressed admiration for the programmatic sustainability stemming from the longitudinal engagements of STEGH leaders within local communities, becoming \u0026lsquo;pillars of the community\u0026rsquo;. In contrast, trainees struggled with their own short-term roles in the program, frequently only developing insight into the larger goals of the STEGH experiences upon completion. This concern for sustainable practices on both programmatic and individual levels is a commonly emphasized need in the global surgery community. Loh and colleagues (2015) proposed a taxonomy of STEGH programs according to the number of involved partners and frequency of visits and noted that programs with fewer partners and continuous presence create less burden on hosting communities (23). Although STEGHs are inherently short-term, continuity can be enhanced by framing short-term visits around longitudinal program goals. Expanding trainee exposure to the inner workings and long-term goals of STEGHs prior to the rotation can help align this transient group into a more cohesive presence prior to engagement with the hosting community. Additionally, the \u0026ldquo;piggyback\u0026rdquo; partnership model may allow for institutions without long-term international collaborations to contribute to the longitudinal mission of existing collaborations to maximize benefits and minimize disruptions in local hosting communities.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eLimitations\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis is a single-center study with a limited sample size. While we were able to identify key emerging themes within our interviews, we recognize the limitations associated with our inability to enroll all prior STEGH participants from our institution. This may limit achievement of true thematic saturation within our full cohort. Despite this, we believe the perspectives we collected across a 15-year period of our institution\u0026rsquo;s involvement in a \u0026ldquo;piggyback\u0026rdquo; model of global surgery partnership may remain a useful case study for other institutions seeking to engage in similar collaborations. As in all qualitative studies, we also recognize the cultural, confirmation, and reflexivity biases within our research team. We attempted to mitigate these biases by engaging team members with varying cultural backgrounds and global health experiences in independent coding and analysis of interviews.\u0026nbsp;\u003c/p\u003e\n"},{"header":"Conclusion","content":"\u003cp\u003eAs surgical trainees are increasingly encouraged by the ACGME to gain experiences in low-resource settings, whether domestically or internationally, all institutions involved in the trainee\u0026rsquo;s experience have a shared responsibility to ensure they are adequately prepared to engage in patient care in an unfamiliar setting. \u0026ldquo;Piggyback\u0026rdquo; STEGHs are particularly complex experiences which require a higher level of attention and intention to ensure mutual benefit for all parties involved. We hope our findings can provide a case study for institutions seeking to engage in this space and lend advice for how to approach STEGH experiences with an emphasis on humility, reciprocity and sustainability. Institutions and trainees must remain accountable to their patients, regardless of setting, and investment in training global surgeons who are effective clinicians and citizens across diverse settings will only continue to grow in importance.\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict of Interest Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOn behalf of all authors, the corresponding author states that there is no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDue to the sensitive and potentially identifiable nature of our qualitative interviews, particularly within our limited cohort, we are unable to make our full transcripts publicly available in order to protect participant privacy and confidentiality. However, all relevant quotes have been directly de-identified in text and additional samples of representative quotes are available in Supplementary Tables. Further de-identified textual data can be made available upon reasonable request to the corresponding author.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKnudson MM, Tarpley MJ, Numann PJ. Global surgery opportunities for U.S. surgical residents: an interim report. J Surg Educ. 2015;72(4):e60-65. \u003c/li\u003e\n\u003cli\u003eAmerican Board of Surgery [Internet]. [cited 2025 Jun 17]. International Rotations Policy. Available from: https://www.absurgery.org/resources/abs-policies/policy-international-rotations/\u003c/li\u003e\n\u003cli\u003eACGME Program Requirements for Graduate Medical Education in General Surgery [Internet]. 2024. 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Am J Trop Med Hyg. 2018 Nov;99(5):1283\u0026ndash;90. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"global-surgical-education-journal-of-the-association-for-surgical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"GSED","sideBox":"Learn more about [Global Surgical Education - Journal of the Association for Surgical Education](https://link.springer.com/journal/44186)","snPcode":"44186","submissionUrl":"https://www.editorialmanager.com/gsed/default1.aspx","title":"Global Surgical Education - Journal of the Association for Surgical Education","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6970087/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6970087/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003ePurpose: Supportive policy changes from graduate medical education bodies have prompted growing development of short-term experiences in global health (STEGHs), particularly in resource-limited settings. Due to a lack of internal global surgery experts, our general surgery residency program “piggybacks” on two structurally distinct surgical STEGHs hosted by other US programs: 1-week mission trips to Central America with a non-profit organization and an 8-week Residency Review Committee-approved surgical rotation in Eastern Africa. We performed a rapid qualitative assessment exploring our residents’ changing perspectives on global surgery through participation in these diverse external STEGHs. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMethods: Current and former trainees who participated in at least one STEGH during residency were purposively sampled for participation in semi-structured interviews or focus group discussions (FGD). Recordings were summarized independently by at least two research team members using an iteratively refined template of domains mirroring the facilitation guide. Reconciled summaries were aggregated into a matrix, and rapid qualitative analysis was used to triangulate salient themes. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eResults: Twenty-six trainees participated in surgical STEGHs from 2009-2024, of which 13 (50%) participated in seven IDIs and three FGDs about their experiences. Rapid analysis revealed significant maturation of trainee perspectives on global surgery practice models, cultural humility, and healthcare delivery following STEGHs. However, trainees also faced many challenges during this period of growth, including dilemmas involving fulfilment of the social contract with the local hosting community and adapting to different health systems. Structural differences between two STEGHs – including scope of practice, trainee role, and duration – influenced the type and extent of impact on trainee growth. Trainees expressed a desire for more sustainable engagement and noted the importance of their home institution’s engagement across all phases of the STEGH. Longitudinal investment in global surgery leaders was viewed as a responsible and powerful method of engagement in global surgery efforts, both domestically and internationally. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConclusions: General surgery residency programs that seek to “piggyback” off of existing global surgery partnerships can maximize trainee and host community benefits by shifting trainee mindset from service to education and emphasizing programmatic and individual sustainability to help support effective, ethical and sustainable collaborations.\u003c/p\u003e","manuscriptTitle":"‘Piggy-Back’ Short-Term Engagements in Global Health for Surgical Residents: A Rapid Qualitative Analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-15 15:26:17","doi":"10.21203/rs.3.rs-6970087/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"","date":"2025-07-18T07:14:11+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-13T13:52:35+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"Global Surgical Education - Journal of the Association for Surgical Education","date":"2025-07-12T18:06:05+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-08T03:40:19+00:00","index":"","fulltext":""},{"type":"submitted","content":"Global Surgical Education - Journal of the Association for Surgical Education","date":"2025-06-30T17:34:01+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"global-surgical-education-journal-of-the-association-for-surgical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"GSED","sideBox":"Learn more about [Global Surgical Education - Journal of the Association for Surgical Education](https://link.springer.com/journal/44186)","snPcode":"44186","submissionUrl":"https://www.editorialmanager.com/gsed/default1.aspx","title":"Global Surgical Education - Journal of the Association for Surgical Education","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"b27f6345-cf93-420f-9516-40967e0e74a3","owner":[],"postedDate":"July 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-11-19T16:13:15+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-15 15:26:17","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6970087","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6970087","identity":"rs-6970087","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}