See one, teach yourself one, do one: Barriers and opportunities in self-administered training and assessment for global surgical education.

Objective: We aimed to determine the most important perceived barriers to the implementation of self-administered training and assessment in surgical education according to subject matter experts. With these findings, design thinking was used to explore possible interventions and develop a theory of change for overcoming identified barriers. Specifically, implementation was focused on expanding the surgical skills of associate clinicians (ACs) in low-to-middle-income countries (LMICs). Methods: A qualitative study with 10 field experts representing surgeons, educators, and engineers from the US, South America, and East and West Africa was conducted. Interviewees were selected through purposeful snowball sampling until thematic saturation. Semi-structured interviews were conducted over video conference or in-person. Open-ended responses were synthesized, coded, and used to identify key barriers for scaling simulation-based learning and self-administered training and assessment in low-resource settings. Results: We identified four major barriers to widespread implementation of self-administered training and assessment: demonstration of the safety and quality of surgical care provided after self-administered training; validation of the principle of self-administered training and assessment; translation of simulation skills to surgical knowledge; and integration into existing task shifting and task sharing legal landscapes. Discussion: Increasing surgical capacity in LMICs is an urgent need that could be expanded with carefully developed self-administered training and assessment for ACs. The implementation process will be variable depending on local culture and regulations but is dependent on an international community of local champions to first produce a common body of evidence supporting the technology's utility and then to generate local excitement for its integration into existing systems.