Hi there, my name is Isabel Germano, I'm delighted to be here with you today to present this great educational activity offered by the American Association of Neurological Surgeons entitled Neurosurgery Around the World, Education and Other Opportunities. These are my disclosures, there is no conflict with the current CME activity. I've divided this course into two sessions, during the first one we will review the current structures, limitations, trends and future directions of neurosurgery training in each continent through the lens of the organisation in each continent that is overseeing such neurosurgical education and namely the Society of Neurological Surgeons, the Continental Association of African Neurosurgeons, the Asian Australasian Society of Neurological Surgeons, the Pan-Arab Association of Neurological Surgeons, the European Association of Neurological Surgeons, Japan and the Asian Congress of Neurological Surgeons. During the second sessions, we are going to explore the opportunities to educate for individuals who have dedicated their academic life to educate in different parts of the world, will show us how did they do it and what are the opportunities for those peoples that would like to get engaged in neurosurgical education around the world. And before going any farther, I need to spend a minute to thank each of the faculty members that agreed to be part of this educational activity. It is a privilege to have each and every single one of them with us and has been a privilege for me over the years to have the opportunity to collaborate, to cross fertilise, to be able to discuss plans and visions and most importantly to know that we're all in it together because what we want is to make a stronger neurosurgical world. Thank you so much for your dedication, not just for today's educational activity, but for your dedication over a lifetime. It means a lot. The current pandemic more than ever has shown us that we're all connected. Because we're all connected, it is very important to understand what are our needs and what are the needs of our neighbours and what are the needs of our neighbours' neighbours. Only by so doing, I think that we can really establish a better knowledge and a way to move forward. The title of this very brief talk is Neurosurgery Education Met and Unmet Needs with the goal to define what education is and what the needs are and most importantly, what is met and what is unmet. Let's start with the first word, met. What does that mean? A met need, the need to understand what has been accomplished and it's important to understand what has been accomplished within your own geographical area, but also around the world. Unmet, that is the need to understand if what has been accomplished is sufficient, if it can be improved and if it must be changed because there are evolving circumstances. All those three situations would represent a need that is no longer met. The most important concept about an unmet need is that every single unmet need is actually a great opportunity, an opportunity that is there for us to pursue. Neurosurgical education has been a passion of mine for many years. Over the past three years, I've been appointed by Professor Servaday as the chair of the Neurosurgeon and Training Committee for the World Federation of Neurosurgical Societies. This organization was founded in 1955. It is a professional, scientific, non-governmental organization. It does have 130 society members, five continental associations, 119 national neurosurgical societies and six affiliated societies. It's representing approximately 30,000 or more neurosurgeons worldwide. The mission is that of promoting global involvement in neurosurgical care by working together with the member societies to improve worldwide neurosurgical care, training and research to benefit our patients. In alignment with the WFNS mission, the mission of the WFNS Education and Training Committee is that to facilitate neurosurgery education and training throughout the world with particular attention to low and middle income countries, LMICs, by providing educational courses on site, online, website materials and publications. In the map, the blue dots represent the 17 completed courses over the past couple of years. As you can imagine, this is not a one-woman show. This really takes the energy, the enthusiasm, the generosity of an entire committee. The members of the rosters for the 2017-2019 are listed on the right-hand side. And as you can see, each continent is represented. And this year, Dr. Satoshi Kuroda joined as the co-chair of the committee. The red dots are the courses that we were planning to do on site. But because of the pandemic, there has been a delay and some of those will be transformed into web-based material. In the previous slide, I mentioned the word LMIC. What is an LMIC? An LMIC is a country with a gross national income, GNI, per capita, ranging between $1 and $3,995. This is approximated or quantified by the World Bank Organization that classifies the world economies into four income groups, high, upper middle, lower middle and low. And this is updated every July 1st based on calculations done by the WB. Now, it's clear that this system is not an ideal and or a perfect system in the sense that it does not completely summarize a country levels of development or measure welfare. However, it has been proven to be useful and easily available as an indicator to closely correlate with other indicators in the country, such as non-monetary measures, quality of life, life expectancies, and so on and so forth. Below you can see four geographical areas and you can see the distribution of the LMIC in the red box in those four geographical areas. It is important to notice that the WHO recognizes that all countries with less than one neurosurgeon per million inhabitants resides in LMIC. I told you about my passion for education and in the next few slides, I want to focus on the word education. What is its definition? How education is constantly changing, just like the landscape is changing. And why is it changing? Because there are factors that influence education, such as the stages, demographics, rules and regulations, and finally, the desire to harmonize it, harmonize the process and make it more homogeneously. Finally, scalability and technology are very important for education, just like they are for many other businesses. And ultimately, we want for this education to be global, but what does global really mean? Stay tuned. I mentioned that education is a great passion of mine, but what does it really mean? Education comes from the Latin word ex duco, I bring out, I develop from within. It is the process of facilitating learning by acquisition of new knowledge, by development of new skills, so important for a neurosurgeon, by establishment of new values. And how do we do that? Well, we do that by training. And I believe that many of us that have been athletes know that you cannot succeed unless you train. And this is so true for neurosurgeons as well. By way of discussion, and clearly, the more we discuss, the more we understand what the limitations are, what the opportunities are. And finally, by storytelling, the humankind has been always gathering around the fire, around a room, around a table, to do what? To tell each other what our experiences are. And those experiences are very important in the process of learning. The bottom line is that education is what is helping us to strike out onto new paths and by so doing, to achieve greater success. When thinking about education, we have to keep in mind that there are very different learning stages. The first is the first time that we hear something, like in medical school, like an infant. And then we can learn it to learn how to do it ourselves, like a kid. And finally, we learn it to become a specialist during our fellowship. And then the first year of practice, and unfortunately, the first possible successes are coming around. And finally, when we become professors, and our student thinks that by that time we know how to do it, well, that is the time where we understand that it's time to change it all. All these different stages are important to keep in mind, because our education needs to be tailored to those stages. The second factor that can play changes in education patterns is changes in demographics. And for instance, in the United States, since 2005, 50% of the US medical students are women. What about neurosurgery? Well, in neurosurgery, the number of women has been increasing. That is true. However, really still a big gap between the two genders. And this is in and by itself a very important observation, because it could open doors to opportunity. And remember what I said before, an unmet need is actually an opportunity. And so here's the question, are we attracting the best and the brightest to our field? Are we retaining the best of the brightest to our field? And if the answer is no, well, that is a great opportunity. And I would encourage you to take a look at this book that you can find free of charge online that was written by four girls to empower girls around the world to know that neurosurgery is a profession. And I love the wording in the red box, I can do it. Just to let the girls know that if they want to, if they're passionate about it, they can do it too. So, of course, the rules and regulations by all means do affect education. Since 2003 in the United States have been very strict rules about the working week and in some of the other continents and countries as well. And we think that because we trained under different rules, maybe the experience can be stopped and or changed. However, this is also opening the door to new opportunities. And what are the opportunities here? Well, the opportunities are simulation, virtual and augmented reality, computer and phone generated apps. And you will hear some of this opportunity being exploited in the different countries when the presentations will occur later in the course. And finally, a couple of words about harmonization and homogeneity. When we are educating, it is important to understand if there are differences in training within a similar geographical area. And if the answer is yes, it is important to analyze what are the possible causes for such difference, because ultimately we want people that are trained in similar geographical areas to all have the same kind of training. This is a topic of great interest, and you will hear a lot about harmonization and homogeneity in training. I want to just give you one example, and that is about the African continent. Here you can see a map depicting the size of Africa and showing how many states, countries can actually fill within Africa. Africa is pretty large. It comprehends 54 countries, 1.216 billion people, compared, for instance, with the United States that only has 323 million people. Well, the literacy rate in Africa when the independence was gained in the middle of the 20th century was 90 percent. And as Professor Abdesalam El-Kamlichi describes in his book, neurosurgery in Africa was really not able to start until very recently, illiteracy being one of the main causes. Professor El-Kamlichi and other African neurosurgeon pioneers immediately recognized that within Africa, there were differences between geographical areas. For instance, when we look at the Sub-Saharan Africa, SSA, a huge part of the world, 17 percent of the world land, 14 percent of the world populations, but only one percent of the GDP. They immediately recognized that the neurosurgeons that were actually providing the training were not going to be present in that geographical area, were very few and apart, one neurosurgeon per six million inhabitants. They took that unmet need and transformed it into an opportunity, the opportunity to train African neurosurgeons and to train them on site. They understood that unless the young neurosurgeons were trained in the same continent where they were, it was really not practical for them to stay and to receive the training that was important for the territorial needs. And this paper that was just published by Claire Kerensky and collaborators show that increased significantly, whereby in her paper, in some of the Sub-Saharan countries now, the ratio is one neurosurgeon for 1.26 million inhabitants, significantly improved from the previous 10 or 20 years. Additionally, 100 percent of the trainees were retained in Africa and 90 percent are working into low-income countries within the SSA. What a great success and what an inspiration for the rest of the world. Why do we talk about scalability? Scalability is a very important concept in anything we do. And it is tied to the fact that resources are limited, just like water. There is no place on Earth where water is abundant. Maybe there is for just this limited time, but then it becomes an issue. Economics focuses on the study of scarcity and how best to use resources that are limited. And in this picture here, you see scalability surrounded by the six tenets that are incredibly important. And basically, this diagram can be summarized in a sentence saying that unless the model that you're constructing, and in this particular case, we're talking about an educational model, cannot be fully exported and made through in different circumstances, is probably not a model that is there to stay. And so, when we look at scalability, each of our countries is thinking, are we really there? Did we really develop a model, educational model that is scalable and that we can export to other parts of the globe? And if the answer is no, then the other question that we should pose is, are we really exploiting everything that we have in the way of virtual connection, telemedicine, computer power? One question is, all this training that we can provide at home that might be incredibly expensive and therefore is not scalable. Can that be transformed into virtual boot camps, into virtual learning? The prices of apps and outcome repository, mining of big data is decreasing on a daily basis as we speak. And we should be able to grab those opportunities to make them part of our global training. I'm afraid I used the word global too many times, and I told you that you had to stay tuned to hear the definition. Well, here we are. What does global mean? Transcending natural borders. And I think until when we do not comfortably see the map the way in which I have it now on the screen, we cannot say that we reached a global status. And with that in mind, I hope that you will enjoy the rest of the course and that you will be able at the end of this to be global in everything you do, especially in education. Thank you very much for your attention.

neurosurgery

education

opportunities

training

global involvement

scalability