Global Orthopaedics Education: Doing More with Less

Global health is at a tipping point. As the U.S. withdrew from the World Health Organization (WHO) and decimated other critical public health aid in early 2025, WHO Director-General Tedros Adhanom Ghebreyesus plainly noted the reality. On May 1, 2024, he stated, “We are living through the greatest disruption to global health financing in memory.” 1 Just a decade earlier, awareness of global health was expanding. Acknowledging that surgical and anesthesia care had been largely omitted from the global health conversation, The Lancet Commission on Global Surgery reported that an estimated 5 billion people, nearly 70% of the world’s population, “lacked access to safe, affordable surgical and anesthesia care when needed.”2 The Commission’s report, “Global Surgery 2030: Evidence and Solutions for Achieving Health, Welfare, and Economic Development,” proposed a multitiered approach to reducing delays and increasing the trained workforce, particularly in low- and middle-income countries (LMICs), where the issue was most prevalent. There is no global health without surgical health. As intended, “Global Surgery 2030” was a catalyst. After its publication, leading orthopaedic institutions intensified their focus on collaborative education and knowledge sharing, reflecting a move toward sustainable partnerships and measurable outcomes3–5. Currently, the need for global orthopaedics education is perhaps more critical than ever, as LMICs disproportionately bear the burden of musculoskeletal disease worldwide6. A decline in available funds may well jeopardize international relationships—both the well-established and the more recent. Hence, the question: How to do more with less? We propose that the current climate could create an opening for more concerted efforts in making use of digital education tools to strengthen the knowledge base of the orthopaedics workforce. Strategic alliances offering continuing education can improve competencies and outcomes, as demonstrated by the educational partnership between our institutions in Colombia and the United States. Digital education, effectively implemented, may help to sustain some of the momentum that has been gained previously in supporting global surgical health. Knowledge Sharing: From Personal to Virtual Knowledge sharing has long been a driving force for the Hospital for Special Surgery (HSS). As a founding member of the International Society of Orthopaedic Centers, an organization dedicated to knowledge exchange among premier orthopaedic centers, the HSS has established several global educational partnerships. Our goal is to achieve equitable, collaborative, and reciprocal partnerships, as championed in the literature7–10. Such was the case with our alliance with Fundación Santa Fe de Bogotá (FSFB) and its newly developed Hospital Serena del Mar (HSM) in Cartagena, Colombia. In Latin America, FSFB is recognized as a center of top clinical care programs, with 20 clinical care programs accredited by Joint Commission International, 6 of them in the musculoskeletal field. However, Colombia is faced with a lack of providers and disparities in quality of care. In 2020, provider density was 13.7 per 100,000, lower than The Lancet Commission on Global Surgery target of 20 specialist surgical, anesthesia, and obstetric providers per 100,000 population11. A recent study of surgical patients in 17 Latin American countries found that peri- and postoperative complications of surgery, most often infections, accounted for an increased death rate; about a third of those who died did not receive critical care during their hospitalization12. In November 2024, we held a 1-day conference to increase our understanding of perioperative risk factors among Colombian orthopaedists and health-care professionals. Doing so was one step in providing lifelong learning to the global orthopaedic workforce. Such efforts will look different from now on. The good news is that there is a lot of information available about how best to structure and implement digital education, even as the toolkit grows with options such as artificial intelligence (AI). In fact, HSS already has substantial experience with this approach through eAcademy, which launched in 2013 and has since reached >57,000 learners in 168 countries annually. Digital education can be efficient and effective, but it depends on implementation. Today, we benefit from the lessons learned as virtual surgical education flourished during the COVID-19 pandemic—an unexpected “silver lining.”13 In an exploration of best practices for virtual surgical education, Rasic et al. defined virtual education as using “technology to provide teaching in situations where learners are distanced from their instructors by either space or time.” In addition, it may also be used “to offer feedback in lieu of the instructor.”13 They surveyed research in 4 key areas of surgical education: clinical decision-making skills and medical knowledge, bedside procedural skills acquisition and development, operative skills training and assessment, and leadership and professionalism training. Each of the categories benefited from standardized assessments, and learners enjoyed “content and pace tailored to individual needs.”13 But there also were disadvantages in each area. Virtual clinical decision-making skills and medical knowledge programming required substantial demands to maintain an up-to-date curriculum. Bedside procedural skills assessed through virtual supervision or virtual simulations did not allow for the true variability of patient needs. The virtual teaching of operative skills obviously was quite limited, and virtual education on leadership and professionalism faced challenges with learner engagement. In fact, engagement can be an important challenge in virtual education. As the WHO observed, in addition to access and literacy, digital learning requires motivated learners14. It requires users to trust the technology and the information provider. For adoption by a wide audience, it requires cultural receptiveness, technical infrastructure, and funding. And an intervention’s effectiveness depends on interconnected factors, including clear learning objectives, instructional methods, and pedagogies. The limits of technology also are important to keep in mind. Researchers have warned against the notion that “The techno-optimistic discourse surrounding artificial intelligence (AI) in healthcare [that] positions it as a direct solution to the greatest challenges facing global health, particularly in resource-constrained settings.”15 In fact, those authors contend that this is far from the truth. “AI cannot be deployed effectively or ethically in contexts lacking sufficient social and material infrastructure and resources to provide effective healthcare services.” In face of the recent cataclysmic disruption to global health, we believe it is essential to continue to support global surgical health by providing educational programming to increase workforce knowledge and skill in order to improve patient outcomes. Undoubtedly, our work will benefit from lessons learned during the difficult days of the pandemic; indeed, we are sure to learn more during the challenging times ahead.