Twinning of Neurosurgical Educational Programs to Address Resident Future Needs in Global Neurosurgery

Twinning of Neurosurgical Educational Programs to Address Resident Future Needs in Global Neurosurgery

Robert J. Dempsey, MD

Chairman and Manucher J. Javid Professor of Neurological Surgery
Department of Neurological Surgery, University of Wisconsin SMPH
Chairman, Foundation for International Education in Neurological Surgery

Serious discrepancies exist in the distribution of all healthcare throughout the world, especially between that of high-income countries (HIC) and those of low- and middle-income countries (LMIC). There are many ways to address these needs and, historically, many successful and unsuccessful attempts have taken place. The purpose of this article is to develop an understanding of twinning of programs, or dyads between those HIC and LMIC for common educational goals, as well as lasting benefits to patients in need. Historically, the exchange between these programs were decidedly one-sided. In the past, discrepancies in all healthcare have been recognized, but responses were primarily dominated by the need to address infectious disease, nutrition and medical therapies in areas of need. Nevertheless, disparities in surgical care – especially that of specialized surgical care such as neurosurgery – are far more extreme.1,2

The WHO recognizes 33 countries without a neurosurgeon and all countries with less than one neurosurgeon per one million population reside in low- and middle-income countries.3,4 The impacts of such a shortcoming are profound. In the absence of a neurosurgeon systems are unable to completely deliver trauma care or provide appropriate care for benign tumors, pain, spinal deformity, cancer and stroke. The landmark 2015 Lancet Commission on Global Surgery and the World Bank reports reason that access to essential surgical care which could be lifesaving and return productive citizens to society, is lacking for five million people worldwide.5,6 The costs of such a shortfall are measured in millions of lives and trillions of dollars; therefore, unique solutions were necessary.

Historically, attempts to solve such shortcomings of care have had limited impact. The first is to bring the brightest people to HICs for complete training. Unfortunately, because of the complexity, infrastructure and instrument needs of neurosurgery, these trainees seldomly return to their country of origin, choosing rather to practice where their talents could be utilized. In turn, humanitarian neurosurgeons traveled to provide care in the LMIC regions, but their impact was minimal because of the episodic and non-self-sustaining nature of such care.4,7,8 Indeed, without an ongoing presence there was a profound lack of understanding of the geo-political forces which would affect developing a self-sustaining system of care.9

While early efforts to provide service within the countries of need did not provide lasting impact, they then provide insight into important lessons of care. Chief of these with a need to empower physicians of the area of need to be in charge of a program and to attempt to make it self sustaining. Organizations such as the Foundation of International Education of Neurological Surgeons (FIENS) developed a concept of “service through education” in their attempt to travel to areas of need to gradually over years develop training programs led by local champions and training local doctors.10 During these periods it became clear that one must establish infrastructure, repeated presence, equipment and its repair, local certification and funding of residencies.11,12

It was readily apparent during that period that the most effective programs were those that made a commitment of a group of doctors from HICs to commit to an area of need and that those doctors return repeatedly to the LMIC they were working with. Initially supplying service and operations, they gradually learned the training of physicians on site would provide ongoing sustaining models of care. In that process it was learned which equipment was needed and could be procured. Remarkable progress was made, such as through the Duke program to build capacity, often with repurposed equipment and biomedical trainers to continue repair in the countries of need.13

In the early part of the 21st century, such programs began to be formalized as dyads or twinning programs, numerous examples began to take place, including that of the Spanish society NED with East Africa and individual US academic institutions throughout central and south America, sub-Saharan Africa and eventually southeast Asia. In each case, individual lessons were learned from the twinning process. The key to lasting programmatic care beyond the scope of the HICs input would be to develop a training program which would be under the leadership of the LMIC program training physicians from their own countries to be distributed to areas of need throughout their country.14,15,16 Such steps require cooperation over large areas and often the involvement of major neurosurgical societies of the world, including the World Federation of Neurological Societies (WFNS), the American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS). FIENS was also able to involve the Society of Neurological Surgeons (SNS) for two important steps: the development of a curriculum which could be modified to areas of concern based, with their permission, on the US curriculum and the modification of post graduate education such as boot camps and extended courses based on the model they had started in North America.17 Additionally, certification needs to be local and working with COSECSA in east sub-Saharan Africa, a traditionally general surgery organization was able to develop neurosurgery specific standards which would be locally recognized.

At this point, the impact of dyad twinning programs of HIC and LMIC regions became profound. By repeatedly returning to the areas of the educational program, modern electronic techniques would link the programs and the residents from each program for case discussions and mutual education efforts.

Because of the twinning of the programs and repeated presence, individual faculty would be able to confer regarding the exact equipment needs of an individual site and work to attempt to achieve those needs. In addition, because of repeated episodes of contact it became clear that the needs were beyond that of simply neurosurgery and needed to simultaneously address critical care, anesthesia, biomedical, radiology, neuroradiology and neuropathology needs.

A profound example of this was the focused training of one single neuropathologist with the help of the Wisconsin Neuropathology Program to address the question of identifying the types of tumors removed by the growing cadre of neurosurgeons in eastern sub-Saharan Africa. Without that, it is very difficult to have a tumor program. With a neuropathology program impact of such a small change was clear. Now adjuvant therapy programs and appropriate follow up is possible. That same example led to an understanding of the value of relatively short periods – three months in length – of specialized refined training for the trainees of the LMICs in the HICs. These training episodes could be as focused as neuropathology, neuroradiology or specific neurosurgical techniques. Often, they involve working with simulations, observing in OR clinical settings and working in cadaver and surgical techniques laboratories. In addition, these people being trained in the LMICs are being asked to take on the academic responsibility of maintaining the training program in their own country. Therefore, short periods of additional training could be given for the nuts and bolts of running an academic program, residency administration, publishing, etc. Such collaborations led to mutual publications and self-sustaining residencies in LMICs.11,18

At every step along the way funding has been an issue. Twinning of dyad programs has assisted this through access to philanthropy and equipment. HIC universities often have global health programs which sponsor faculty development in such efforts. In addition, programs such as WFNS Africa 100 and FIENS have developed scholarship and fellowship programs to assist, including that of the FIENS Bassett and Clack Fellows for assistance in funding education for short periods of the educational process.

The concept of twinning of dyads between HIC and LMIC programs is essential for the rapid growth of training programs. Where there were no unique trainees in a region of 400 million sub-Saharan Africa two decades ago, now as many as 100 trainees will attend specialized graduate and post graduate courses sponsored in the region by dyad partners. These courses emphasize not only teaching techniques, but celebrate the great success of the local program which is hosting them.18,19

The concept of twinning of dyads is but one step in a decades long evolution of thoughtful people working together to solve a global shortage of neurosurgical care. It emphasizes education and the development of self-sustaining programs in the areas of need. It utilizes the concepts of collaboration and partnership, which must be present at every level; that of individual surgeons, philanthropists, major worldwide neurosurgical societies, governments and NGOs. This concept marks a major advance in the evolution of our thinking of how to provide care, but it is only one step in a continuum that must always recognize that the goals of such programs are centered completely on the needs of the patients served. On that basis, we will succeed.


  1. Shrime MG, Bickler SW, Alkire BC, Mock C. Global burden of surgical disease: an estimation from the provider perspective. The Lancet Global Health. 2015;3:S8-9.
  2. Lozano R, Naghavi M, Foreman K, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. The lancet. 2012;380(9859):2095-128.
  3. Mukhopadhyay S, Punchak M, Rattani A, et al. The global neurosurgical workforce: a mixed-methods assessment of density and growth. Journal of neurosurgery. 2019;1(aop):1-7.
  4. Orrico, Katie. “Statement of the AANS, CNS, ABNS, and SNS before the Institute of Medicine: Ensuring an Adequate Workforce for the 21st Century.” December 9, 2012.
  5. Meara JG, Leather AJ, Hagander L, Alkire BC, Alonso N, Ameh EA, Bickler SW, Conteh L, Dare AJ, Davies J, Mérisier ED. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. The Lancet. 2015;386(9993):569-624.
  6. Bickler SW, Weiser TG, Kassebaum N, et al. Global burden of surgical conditions. Disease Control Priorities, 3rd ed. Essential Surgery. Washington DC: World Bank. 2015;19-40.
  7. Dewan MC, Rattani A, Fieggen G, et al. Global neurosurgery: the current capacity and deficit in the provision of essential neurosurgical care. Executive Summary of the Global Neurosurgery Initiative at the Program in Global Surgery and Social Change. Journal of neurosurgery. 2018;130(4):1055-64.
  8. Park KB, Johnson WD, Dempsey RJ. Global neurosurgery: the unmet need. World neurosurgery. 2016;88:32-5.
  9. Dempsey KE, Qureshi MM, Ondoma SM, Dempsey RJ. Effect of geopolitical forces on neurosurgical training in Sub-Saharan Africa. World neurosurgery. 2017;101:196-202.
  10. Dempsey RJ. Neurosurgery in the Developing World: Specialty Service and Global Health. World neurosurgery. 2018;112:325.
  11. Leidinger A, Extremera P, Kim EE, Qureshi MM, Young PH, Piquer J. The challenges and opportunities of global neurosurgery in East Africa: the Neurosurgery Education and Development model. Neurosurgical focus. 2018;45(4):E8.
  12. Dempsey RJ, Nakaji P. Foundation for international education in neurological surgery (FIENS) global health and neurosurgical volunteerism. Neurosurgery. 2013;73(6):1070-1.
  13. Fuller A, Tran T, Muhumuza M, Haglund MM. Building neurosurgical capacity in low and middle income countries. eNeurologicalSci. 2016;3:1-6.
  14. Qureshi MM, Oluoch-Olunya D. History of neurosurgery in Kenya, East Africa. World neurosurgery. 2010;73(4):261-3.
  15. Piquer J, Qureshi MM, Young PH, Dempsey RJ. Neurosurgery Education and Development program to treat hydrocephalus and to develop neurosurgery in Africa using mobile neuroendoscopic training. Journal of Neurosurgery: Pediatrics. 2015;15(6):552-9.
  16. Dempsey RJ. Global neurosurgery: the role of the individual neurosurgeon, the Foundation for International Education in Neurological Surgery, and “service through education” to address worldwide need. Neurosurgical focus. 2018;45(4):E19.
  17. Selden NR, Origitano TC, Burchiel KJ, Getch CC, Anderson VC, McCartney S, Abdulrauf SI, Barrow DL, Ehni BL, Grady MS, Hadjipanayis CG. A national fundamentals curriculum for neurosurgery PGY1 residents: the 2010 Society of Neurological Surgeons boot camp courses. Neurosurgery. 2012 Apr 1;70(4):971-81.
  18. Kahamba JF, Assey AB, Dempsey RJ, Qureshi MM, Härtl R. The second African federation of neurological surgeons course in the East, Central, and Southern Africa region held in Dar es Salaam, Tanzania, January 2011. World neurosurgery. 2013;80(3-4):255-9.
  19. Kulkarni AV, Schiff SJ, Mbabazi-Kabachelor E, et al. Endoscopic treatment versus shunting for infant hydrocephalus in Uganda. New England Journal of Medicine. 2017;377(25):2456-64. 10.1056/NEJMoa1707568
August 2022