The LMIC surgical context: high burden, limited visibility

Low-and middle-income countries account for nearly 70% of the global surgical disease burden, yet contribute a disproportionately small share of surgical research output. ^{Reference Meara, Leather and Hagander4} Surgeons in these regions routinely manage advanced pathology, delayed presentations, and limited perioperative support. Despite this, they often operate in environments with minimal protected research time, scarce funding, and limited access to academic mentorship.

Global analyses have consistently demonstrated that surgical research output is dominated by high-income countries, even though procedural volume is substantially higher in low-and middle-income countries. ^{Reference Alkire, Raykar and Shrime5} This imbalance reflects structural inequities rather than differences in clinical expertise. As a result, surgeons delivering the highest volume of essential care often remain underrepresented in academic discourse.

The consequence is a widening gap between clinical contribution and academic recognition, a gap that increasingly shapes career progression and institutional prestige.

Barriers to publication in low-and middle-income countries

Despite managing a large clinical volume and complex surgical pathology, surgeons in low-and middle-income countries often publish fewer scientific papers than their counterparts in high-income countries. This disparity is not necessarily due to a lack of clinical expertise, but rather due to structural and systemic barriers that limit research productivity. ^{Reference Meara, Leather and Hagander4,Reference Alkire, Raykar and Shrime5}

One of the most important barriers is a heavy clinical workload. In many low-and middle-income country centres, surgeons perform a large number of procedures and are also involved in perioperative care, intensive care management, outpatient services, and administrative responsibilities. This leaves limited protected time for research activities such as data analysis, manuscript preparation, and submission. ^{Reference Horton6}

Limited research infrastructure is another major constraint. Many centres do not have dedicated research coordinators, statisticians, or data management systems. Clinical data are often recorded primarily for patient care rather than for research purposes, making retrospective data collection time-consuming and difficult. In contrast, many high-income country institutions have structured databases, research staff, and funding support that facilitate publication. ^{Reference Bickler and Spiegel7}

Lack of formal training in research methodology and scientific writing also contributes to lower publication output. Many surgeons in low-and middle-income countries receive extensive clinical training but limited exposure to research methodology, biostatistics, and academic writing. In addition, lack of mentorship and collaborative research networks further limit opportunities for publication. ^{Reference Sullivan, Alatise and Anderson8,Reference Chu, Jayaraman, Kyamanywa and Ntakiyiruta9}

Financial barriers also play a role. Publication fees, conference travel, and research funding are often limited in low-and middle-income country institutions. These constraints may discourage submission to indexed international journals. ^{Reference Sullivan, Alatise and Anderson8}

Language barriers and lack of editorial support may also affect publication rates, particularly for authors whose primary language is not English. ^{Reference Chu, Jayaraman, Kyamanywa and Ntakiyiruta9}

Addressing these barriers through institutional support, collaborative research networks, and structured data collection systems is essential to improve research output from high-volume centres in low-and middle-income countries.

Practical strategies to improve research output in LMICs

Improving research output from high-volume surgical centres in low-and middle-income countries requires structural and institutional support rather than individual effort alone. Several practical strategies can help bridge the gap between clinical experience and academic publication.

One of the most important steps is the development of institutional clinical databases. Systematic data collection allows outcomes, complications, and long-term follow-up to be analysed and published. Even simple prospective databases can significantly improve research productivity and quality of publications. ^{Reference Bickler and Spiegel7}

Collaborative research networks and multi-centre registries are particularly important in low-and middle-income country settings. Pooling data across institutions allows the generation of large datasets, improves statistical power, and enables the publication of clinically relevant research reflecting real-world disease patterns. Global and regional registries have already demonstrated the value of collaborative data sharing in improving surgical outcomes and research output. ^{Reference Meara, Leather and Hagander4,Reference Alkire, Raykar and Shrime5}

Mentorship and research training programmes are also essential. Structured training in research methodology, biostatistics, and scientific writing should be incorporated into surgical training programmes. Senior surgeons and academic institutions should actively mentor younger surgeons in converting clinical experience into scientific publications. ^{Reference Chu, Jayaraman, Kyamanywa and Ntakiyiruta9}

Shared research resources such as institutional statisticians, data managers, and research coordinators can significantly improve publication output. Many high-income institutions have structured research support systems, and developing similar support systems in low-and middle-income country academic centres would help improve research productivity. ^{Reference Sullivan, Alatise and Anderson8}

The use of digital tools and artificial intelligence-assisted literature review, data analysis, and language editing may help reduce some barriers to publication, particularly for authors with limited time and limited editorial support. However, these tools should be used ethically and under appropriate academic supervision. ^{Reference Hyder, Bloom, Leach, Syed and Peters10–Reference Topol12}

Finally, academic institutions and professional societies should encourage and recognise collaborative publications, registry participation, teaching contributions, and outcome reporting as part of academic evaluation systems. Such measures would allow surgeons working in high-volume clinical environments to contribute meaningfully to academic literature while continuing to deliver essential surgical care.

When metrics replace mastery

The growing reliance on bibliometric indicators has altered the incentives within surgical training. Publications, authorship order, and citation counts now heavily influence fellowship selection, promotion, and grant allocation. While these metrics provide objective benchmarks, they fail to capture core elements of surgical competence.

Surgical expertise is built through repetition, management of complications, and nuanced intra-operative decision-making. These competencies are inherently experiential and cannot be fully assessed through written output. Several studies have raised concerns that escalating academic pressure may reduce operative exposure, particularly in resource-limited training environments where workforce shortages already exist. ^{Reference Greenberg, Ghousseini, Pavuluri Quamme, Beasley and Wiegmann11}

In such contexts, the unintended consequence may be the production of surgeons who are academically accomplished but insufficiently seasoned in complex operative care—an outcome that carries significant implications for patient safety.

Artificial intelligence and the changing nature of scholarship

The rapid integration of artificial intelligence into academic workflows has further transformed the research landscape. AI-assisted data analysis, literature synthesis, and manuscript preparation have lowered the barriers to publication, increasing both the volume and speed of scholarly output.

While these tools offer undeniable benefits, they also risk widening the gap between academic productivity and clinical engagement. In low-and middle-income country settings, where patient exposure is high, but research infrastructure is limited, AI may facilitate publication without equivalent immersion in surgical practice. This raises important questions regarding authorship, expertise, and the authenticity of academic contribution.

As Topol has emphasised, technology should augment—not replace—human skill, particularly in disciplines where outcomes depend on procedural judgement and technical execution. ^{Reference Topol12} While these tools can improve efficiency and help overcome language and technical barriers, their use should be guided by clear ethical standards, authorship responsibility, and appropriate academic oversight to ensure that technology supports, rather than replaces, genuine clinical research and scientific contribution.

Paediatric cardiac surgery in low-and middle-income countries: a specific example

The imbalance between clinical volume and academic output is particularly evident in paediatric cardiac surgery. Many centres in low-and middle-income countries manage a large number of patients with CHD, often presenting late with advanced pathology such as late transposition of the great arteries, neglected septal defects, and complex CHD. These patients frequently require technically demanding surgery and complex perioperative management.

Several high-volume centres in low-and middle-income countries perform surgical volumes comparable to major international centres. However, the number of indexed publications from many of these centres remains relatively low due to heavy clinical workload, limited research infrastructure, and a lack of structured databases. In contrast, centres in high-income countries often publish more frequently despite lower surgical volumes, largely due to dedicated research infrastructure and protected academic time.

This example highlights that clinical exposure and surgical experience in low-and middle-income countries are substantial, but academic visibility may remain limited due to systemic constraints rather than lack of expertise or academic interest.

Reframing excellence in LMIC surgical training

In low-and middle-income countries, surgical excellence must be defined within context. A more appropriate framework should recognise clinical volume, case complexity, complication management, and ethical decision-making alongside scholarly contribution. Research remains essential, but it must be grounded in clinical reality and aligned with local health priorities.

The surgeon–scientist model remains valuable, but it should not become a prerequisite that eclipses clinical mastery. Instead, academic systems must evolve to acknowledge diverse forms of contribution, including service delivery, teaching, and system strengthening—particularly in environments where human resources are limited, and patient needs are immense. (Figures 1 and 2)

Figure 1.

Reframing surgical excellence in low-and middle-income countries (LMICs). Conceptual illustration highlighting the alignment between traditional academic metrics (publications, citations, impact factors) and core components of surgical excellence in LMIC settings, including clinical volume, operative skill, decision-making, complication management, and patient-centred outcomes.

Figure 1. Long description

The illustration features a balanced scale with ‘Surgical Excellence’ at the top, indicating equilibrium between academic and clinical contributions. On the left side, labeled ‘Academic 50 percent,’ are icons representing publication, impact factor, and citation, each with corresponding symbols: a document for publication, a target with a bullseye for impact factor, and a speech bubble with ‘99’ for citation. On the right side, labeled ‘Clinical 50 percent,’ are icons representing case volume, complex surgeries, and outcome, each with corresponding symbols: a stack of documents for case volume, a medical cross with a plus sign for complex surgeries, and a checklist for outcome. Below each side are additional icons: a graduate cap and various academic symbols for the academic side, and medical personnel and equipment for the clinical side. The balance suggests that surgical excellence is achieved through an equal emphasis on academic metrics and clinical performance.

Figure 2.

Pyramid of surgical excellence in LMICs. Hierarchical model depicting surgical excellence with foundational clinical competence and patient care at the base, supported by experience, judgement, teaching, and systems strengthening, with scholarly output positioned as an important but non-dominant component at the apex.

Figure 2. Long description

A pyramid diagram representing the hierarchy of surgical excellence in low- and middle-income countries. The base of the pyramid features icons and labels for operative experience, clinical judgement, and scholarly contribution, indicating foundational elements. Operative experience involves case volume and technical skill acquisition. Clinical judgement encompasses decision-making and ethical stewardship. Scholarly contribution includes research and context-relevant publications. Above these foundational elements, the next level highlights scholarly contribution, emphasizing its importance but not dominance. At the apex of the pyramid, system recognition is depicted, associated with promotion criteria and academic visibility.

Research and clinical practice should not be viewed as competing priorities but as complementary components of modern surgical practice. Research improves patient care by identifying risk factors, refining surgical techniques, and improving perioperative management. Surgeons in low-and middle-income countries must therefore be encouraged and supported to publish their clinical experience so that challenges specific to these settings can be addressed through shared knowledge and evidence-based guidelines. The issue is not whether publications or clinical competence are more important, but whether current academic evaluation systems place disproportionate emphasis on publication metrics without adequately recognising clinical workload, surgical experience, and contribution to patient care. A balanced approach that values both research and clinical excellence is essential for the future of academic surgery.

A way forward: rethinking academic evaluation in surgery

If academic systems are to accurately reflect surgical excellence, evaluation frameworks must evolve to include both scholarly output and clinical contribution. In high-volume and resource-constrained settings, alternative metrics may provide a more comprehensive assessment of surgical performance and academic contribution.

Such metrics may include annual surgical case volume, case complexity, risk-adjusted surgical outcomes, complication management, teaching and training contributions, development of new clinical programmes, and participation in institutional or regional clinical registries. Contribution to collaborative research networks and data-sharing initiatives should also be recognised as academic output, particularly in low-and middle-income country settings where multi-centre collaboration is essential for generating meaningful data.

Academic institutions and professional societies may consider incorporating structured case logs, audited surgical outcomes, teaching activity, and registry participation as part of promotion and academic evaluation criteria. These measures would allow recognition of surgeons who contribute significantly to patient care, training, and health system strengthening, while continuing to encourage high-quality research and publication.

The goal is not to reduce the importance of research, but to create a more balanced academic framework in which clinical excellence, teaching, system development, and research are all recognised as essential components of surgical excellence (Figure 3).

Figure 3.

Multi-dimensional balanced model of surgical excellence in LMICs. Multi-dimensional balanced model of surgical excellence in LMICs. Surgical excellence is determined by multiple domains including clinical volume, surgical outcomes, research publications, teaching and training, system development, and participation in data registries and collaborative research. This model highlights that academic productivity is one component of excellence but should be evaluated alongside clinical performance and contribution to healthcare systems.

Figure 3. Long description

The diagram presents a multi-dimensional balanced model of surgical excellence in low- and middle-income countries. It features six interconnected domains: clinical volume, surgical outcomes, research publications, teaching and training, system development, and data registries and collaboration. Each domain is represented by a colored section with an icon and a brief description. Clinical volume highlights high operative caseload and procedural diversity. Surgical outcomes focus on risk-adjusted morbidity and mortality. Research publications emphasize clinically relevant research output. Teaching and training include mentorship and surgical skill transfer. System development involves protocol standardization and quality improvement. Data registries and collaboration encompass clinical registries and multicentre collaboration.

Conclusion

The central question facing modern academic surgery is not whether research is important, but whether current academic metrics accurately reflect what defines a competent and safe surgeon. In low-and middle-income countries, where surgical care carries immense societal responsibility, excellence cannot be measured solely through publication counts or citation indices. Clinical experience, operative judgement, complication management, teaching, and system development are equally important components of surgical excellence.

The solution lies not in choosing between research and clinical practice, but in restoring balance between them. Surgeons in low-and middle-income countries must be supported and encouraged to publish their clinical work, while academic systems should also recognise clinical contribution, teaching, and outcome-based performance. A more balanced and context-sensitive academic evaluation framework will not only improve academic equity but also strengthen surgical training, patient safety, and health systems globally.