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Surgical digest

Navigating the maze of PhD training in global surgery – tips and tricks for the international student


Sr Margaret Ajiko, MD, PhD

Soroti Regional Referral hospital, Uganda
Department of Molecular Medicine and Surgery
Karolinska Institute, Sweden

Alphonsus Matovu, MD

Mubende Regional Referral Hospital, Uganda
Department of Molecular Medicine and Surgery
Karolinska Institute, Sweden

Jenny Löfgren, MD, PhD

Department of Molecular Medicine and Surgery
Karolinska Institute
Karolinska University Hospital
Department of reconstructive plastic surgery,
Karolinska University Hospital
Stockholm, Sweden

Many health professionals are interested in PhD training, and global surgery is a topic that has become increasingly popular. The understanding of what it entails is often fragmented. With this paper, we aim to give insights of the formal and informal requirements as well as some tips and tricks on how to complete PhD training successfully.

A need for independent researchers in low resourced settings

Surgical and anaesthesiology disciplines are important components of healthcare. Research training has not kept up with clinical advances and training of surgical health care providers. To strengthen surgical and anaesthesia disciplines, there is a need for independent researchers to improve representation in research in low resource settings. As an example, Uganda with a population approaching 50 million and over 500 surgeons, currently has three surgeons with PhDs and an additional around 10 in PhD training. There are almost 100 anaesthetists, but only one with a PhD and an additional four in training. Some research is directly applicable to patient care and healthcare systems globally, while some is not. One goal of PhD training is for the student to become an independent researcher, ready to take on new challenges and providing training for young professionals in the future.

Authorships and in particular first and last authorships is a hot potato within global health. The PhD student is usually the first author of the manuscripts resulting from their project. The senior researcher, frequently the main supervisor, is the last author. The most predictable way to get the first authorships, and later on last authorships is to obtain a PhD.

Requirements for PhD training can be broadly presented as academic requirements, language and funding

  1. Academic requirements. In some countries, it is possible to enroll as a PhD student during the latter half of medical school, while in other countries the candidate has to complete a masters degree before enrollment. Where specialist training/residency is an academic degree on masters level, it means that it will not be possible to enroll before completion of specialist training.
  2. The language. The language of teaching on an advanced level in many countries is English, but this can vary. If that is the case, you may need to provide proof that your level of English is adequate for PhD training.
  3. Funding. All research requires funding. In some universities, the PhD is a degree paid for by the student. In other places the PhD student is employed and paid by the university through research grants from the supervisors or other external sources such as when research is carried out as part of ordinary clinical work. A requirement for enrolling a PhD student in most cases is evidence of sufficient financial resources to support the PhD student and their projects until completion of the training within the given time frame.

The requirements are specified on the websites of the different universities. Read these well!

Content of PhD training

The content of a PhD programme is largely a mix of theoretical coursework and practical, hands-on research under supervision. The relative contribution of these two main components can vary a lot. For the individual, it will make a large difference in terms of the likelihood of developing scientific independence during the PhD training. For a clinician whose research is based on their clinical practice, it is probably advisable to select a PhD programme with a focus on carrying out research. This decision has a large impact on how much time away from clinical duties will be necessary.

Sandwich programmes exist between certain universities and are sometimes coupled with funding. A pro is that it facilitates collaboration over time and can contribute to ensure that relevant research is being carried out. On the downside could be issues relating to dealing with administration of two universities instead of one.

Set aside time

PhD training is very demanding and time consuming, and usually takes 4-5 years. It is the PhD student who does the bulk of the day-to-day work required. If this effort is not invested, the work will not be done, and there will be no PhD degree, to the disappointment of both student and supervisor.

It very rarely works out to combine a full-time clinical position with private practice and PhD training. For many, it can take a number of years until it is possible to set aside the time that is required. This may be a particularly difficult dilemma in surgical disciplines where the time and dedication required early on in the career in order to advance professionally is a very important factor to consider. One possible solution is to do the PhD before completing specialist training, when that is possible.

Finding a supervisor

The student-supervisor partnership is one that will have to last several years. It is a very large commitment from both parties, and one that is difficult to terminate. We believe that real-life experience of how research and collaboration work with this particular individual is critical. The best way to go about this is to do a research project together beforehand, during, for instance, a masters degree project. This will give insight for the prospective PhD student about what the research entails and what is expected from them. The supervisor will get the opportunity to determine if this person is able to deliver high quality work, in time.

Each supervisor and student have their own set of individual needs, expectations and abilities. If these can be put on the table early on, it certainly helps in the process of finding “the one”.

The proposal

The research plan must be clearly defined before enrolment. It usually consists of 3-4 interlinked studies which together make up the PhD project. For the purpose of research training, it is important to use different research methodologies. That way a topic can be investigated from different angles and the PhD student will develop a wide range of skills, making them well prepared for future research.

One approach to composing the project is through the individual studies to: define and measure a problem, investigate underlying reasons in the community, test a solution to the problem and evaluate the health economic implications. In such an approach the PhD student gains experience and knowledge on epidemiological research, qualitative study design, clinical trials and health economics. This approach is demanding from the supervisor’s perspective and the team of supervisors and core collaborators must together possess expertise in these methodologies. In addition, the relevant clinical expertise needs to be represented.

Challenges and how to deal with them

Corruption. The level of corruption varies between different countries (1). Corruption is a major issue for the development of a country at large as well as a very specific problem for the researcher. The most effective way to limit the negative impact of corruption is to expose it. In particular, the PhD student is vulnerable as they depend on the different research partners for the implementation of their project. PhD students should therefore always refer important decisions about funding to their supervisors.

Be prepared to deal with over budgeting and extortion of money. Keeping track of your budget and reviewing any budget proposal that the research team may need to approve in detail is important. If not, there is a good chance that a one-day meeting to inform the community will cost more than the entire implementation of the project. All important agreements must be in writing and shared with the team. It is advisable to share experiences of corruption with your university and other research teams. Zero tolerance to corruption is a must.

If the PhD student is lucky to obtain a sponsorship for their PhD training, it is equally important to have all agreements in writing. It sometimes happens that promised funding is withdrawn or drastically reduced without prior notice and no realistic explanation other than it ended up elsewhere. While a written agreement reduces the risk, it may be beyond the control of student and supervisor to control that the sponsor adheres to the agreement, and therefore there needs to be a plan B.

Distractions. Distractions are many and these include an entire world of future, exciting research projects. While it is important to consider the next step after the PhD and start planning early, it must not take focus from the research carried out within the PhD training. A PhD is something that is initiated and that must be completed to be of any significant value to the student and the supervisor. Avoid being “all over the place”.

Expect the unexpected. Anything can happen. Potential unexpected events can occur within the private life of student and supervisor, changes in the clinical environment as well as alteration to the conditions of research. The Covid-19 pandemic was a major unexpected event that lasted for years and the impact on clinical research varied between countries depending on the mitigation strategies implemented. Changing a PhD project that is underway is common and is usually not a problem, but it may delay the completion of the training.

Factors for success

Passion and patience. For clinicians, a research topic is frequently derived from daily practice. This could be a problem that if solved would have positive effects to patients, health care providers and society. The larger the cause, the easier it is for the researcher to stay motivated during the course of the project, and the more likely it is that the training will be completed successfully.

There are very many things in research that are uninspiring but that still have to be done. The passion for the research topic and the curiosity to see the results of the project, as well as patience, will help the PhD student overcome the tedious and boring parts of the research.

From a scientific and need-based point of view, it is important that the research topic is relevant in the study setting and that ideally it addresses a real-life problem that has potential to be solved.

Never stop, never give up. Global surgery and anaesthesia research is not the most predictable field of research that there is. If it turns out that your research was not as ground-breaking as expected, do not worry. Manuscripts can be rejected many times before getting published. This happens to everyone, in every research field. The most important factor to success is to just keep going. Research is a continuous process. One study leads to another.

Do it for the right reason. Someone whose main motive to do a PhD is to progress their career, or who thinks there is a lot of money in research, should think again. First, that student is not attractive to a supervisor; second, the risk of failure is imminent; and third, they will be most disappointed when they realize that they were wrong.

Network and collaboration. Among the most exciting and interesting aspects of global surgery and anaesthesia research is the establishment of networks and collaboration. One should take every opportunity that presents to engage in new partnerships. The supervisors must share their networks with the PhD student.

Support from employer, colleagues and family. Support from your workplace, including the possibility of having a study leave, is very useful in ensuring success. Colleagues who take up your duties when you are away, and the family and social communities that support you in your absence for studies, make a very significant contribution towards your success.  

The future

Clinical researchers contribute to daily practice through challenging the status quo. Their role is to strive for evidence-based care and to develop and test new approaches in rigorous ways, and to share the findings with a larger audience. What is done today in terms of training surgeons and anaesthetists to become independent researchers will bear fruit in both the near and distant future on clinical care in their countries.

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