To build the picture, the investigators combined a systematic search of PubMed and Embase—updating a previously validated global strategy to cover the period from January 2001 to November 2025—with structured narrative reviews led by expert authors in each of 13 representative countries: China, Hong Kong SAR, Japan, and the Republic of Korea in East Asia; Indonesia, Malaysia, the Philippines, Singapore, and Thailand in Southeast Asia; and Australia, Fiji, New Zealand, and the Solomon Islands in Oceania. Incidence studies were eligible only if they reported population-representative rates of diabetes-related lower-extremity amputations or foot disease hospitalizations using international diagnostic definitions, distinguishing major amputations proximal to the ankle from minor amputations through or distal to it. The team calculated trends using compound annual growth rates and supplemented incidence data with validated national prevalence estimates covering 31 countries and territories. System capacity—the actual state of guidelines, models of care, barriers, innovations, research, and policy—was independently scored on a four-point scale across six domains aligned with the WHO Global Diabetes Compact, with inter-rater agreement rated as substantial.

The burden findings expose a region of stark internal contradictions. At the regional level, median amputation incidence—2.2 per 1,000 person-years with diabetes for all amputations—was actually slightly lower than the global median of 2.5, with major amputations falling faster in the Western Pacific (−6.1% per year) than globally (−3.7%). But hospitalizations tell a grimmer story: median regional hospitalization rates exceeded global figures for every foot disease category measured, including infection (6.8 versus 5.1 per 1,000 person-years), ulcer (5.2 versus 4.3), peripheral artery disease (3.9 versus just 0.7), and all foot disease hospitalizations combined (16.6 versus 12.2). Prevalence followed a similar pattern. While regional diabetes prevalence of 11.3% closely mirrored the global 11.1%, foot disease prevalence of 2.9% was substantially above the global 1.9%, driven largely by neuropathy without ulceration or amputation (2.5% versus 1.5% worldwide). In multivariate regression analyses, national diabetes prevalence was positively and strongly associated with overall foot disease prevalence, neuropathy, and ulceration, but only the Oceania sub-region was independently associated with amputation prevalence.

That geographic fingerprint is the review’s most striking finding. Oceania recorded the highest rates of nearly everything: median major amputation incidence of 1.1 per 1,000 person-years, minor amputations at 2.9, all amputations at 3.9, and all foot disease hospitalizations at 24.8—more than double East Asia’s 10.5. Oceanian countries also showed the greatest between-country variation, with overall foot disease prevalence differing by up to 9.7-fold and ulcer prevalence by 15-fold across the sub-region. Trend directions were equally polarized: in East Asia, amputation and hospitalization rates were falling across the board, with major amputations declining 7.2% annually and peripheral artery disease hospitalizations dropping 9.0%; in Oceania, nearly every rate was climbing, with ulcer, infection, and peripheral artery disease hospitalizations rising 2.7%, 3.5%, and 4.1% per year respectively. The Pacific Island nations of Fiji and the Solomon Islands fared worst of all, facing limited podiatry and vascular surgery workforces, scarce basic supplies such as dressings, footwear, and prostheses, poor public awareness, and profound geographic isolation.

The system-capacity assessment helps explain these disparities—and offers clues to solutions. On guidelines, the regional median score of 2 reflected that most countries had at least partially adapted international recommendations, led by China and the Republic of Korea, which adapted International Working Group on the Diabetic Foot guidelines with endorsement from major professional bodies, and Australia, which systematically adapted the guidelines and built implementation tools including pathways and screening instruments. Models of care varied widely: Singapore emerged as the region’s benchmark, with specialist multidisciplinary foot teams integrated across primary, secondary, and tertiary levels of care that have demonstrably reduced major amputations, while Hong Kong, Japan, Indonesia, and the Philippines relied mainly on hospital-based services, and Pacific Island nations offered little beyond general surgical care. Barriers remained the weakest domain regionally, scored at just 1 out of 3, reflecting a chronic shortage of skilled foot disease clinicians, fragmented referral pathways, limited training options, and low public awareness—even in well-resourced Australia and New Zealand, where rural communities and Indigenous Peoples experience documented inequities in access and outcomes.

Future-facing capacity showed similar gaps. Innovation activity, scored at a median of 1, ranged from Australia’s suite of national programs—a foot disease registry, multidisciplinary team accreditation, a national wound dressing program, and region-wide telehealth—to pilot telehealth services in Indonesia and Thailand with inconsistent uptake. Research activity was even more uneven, with Southeast Asia scoring highest thanks to multi-centre epidemiological and health services work in Malaysia, Singapore, and Thailand, while China rapidly became a world leader in publication output and the Republic of Korea ran industry-funded trials of cell-based therapies and smart technologies. Policy development lagged furthest: most countries held aspirational statements rather than implemented mandates, though Thailand’s Ministry of Health has legislated foot screening requirements and care reimbursement, and New Zealand has mandated quality standards for diabetes care while building equity-focused registries. The authors’ ecological analysis hinted at a critical association—countries and sub-regions with stronger care systems appeared to carry lower disease burdens.

From these findings, the team distilled eight consensus recommendations aimed squarely at the WHO Global Diabetes Compact’s call for countries to monitor multidisciplinary care access and amputation rates as national quality indicators. Each country, they argue, should establish a dedicated national foot disease organization; develop culturally responsive national strategies, guidelines, and multidisciplinary care standards; build systems to monitor amputation and hospitalization rates; and create national registries tracking who gets screened and who reaches multidisciplinary teams. They further call on countries to share successful innovations across borders and consider forming a Western Pacific or sub-regional alliance of national organizations—citing existing networks such as D-Foot International’s Western Pacific arm and the Asia Pacific Association for Diabetes Limb Problems as potential vehicles. Proven models worth exporting, the authors suggest, include Australia’s accreditation system, the Republic of Korea’s nationwide registry, Singapore’s integrated services, and Thailand’s government-mandated screening and reimbursement.

The recommendations carry substantial economic as well as humanitarian weight. Large cost-effectiveness analyses cited in the review indicate that many severe foot disease outcomes are preventable, with earlier, higher-quality community care improving quality of life while generating considerable savings for health systems. The authors emphasize that surveillance must extend beyond hospital walls, proposing that registries routinely capture outpatient outcomes such as time to multidisciplinary team presentation, ulcer healing rates, recurrence, mortality, quality of life, and patient-reported measures, alongside intervention details like offloading treatments and antibiotic regimens. They also caution against over-reading traditional metrics: while rising minor amputation rates have sometimes been interpreted as evidence of better care—reflecting earlier intervention that spares limbs—global evidence shows that well-implemented systems achieve simultaneous declines in both minor and major amputations, hospitalizations, and costs.

The review is candid about its limitations. Most incidence studies came from high-income countries, some carried risk of bias, nearly all hospitalization and amputation data predate 2020, and the system-capacity scores rest on expert narrative assessment of 13 representative rather than all countries. Aggregated national data cannot capture within-country differences in remoteness, ethnicity, or culture—and the authors specifically flag that Indigenous Peoples’ knowledge and community structures, fundamental to health in the region, remain under-recognized in national data and strategies. They also raise an emerging threat: climate change. Many Western Pacific nations sit in equatorial zones where heat and humidity damage the skin of the foot, promoting maceration, ulceration, and infection; rising temperatures, sustained humidity, and more frequent extreme weather events may worsen these risks while simultaneously disrupting wound care supply chains, specialist access, and transport.

For a region that already shoulders the world’s largest diabetes and foot disease burden, the message is unambiguous. The Western Pacific’s comparatively low amputation rates—largely a credit to East Asian health systems—should not obscure disproportionately high rates of ulcers, infections, and hospitalizations, or the fact that in Oceania nearly every indicator is worsening. The tools to reverse the tide exist, are already working in pockets of the region, and, the authors argue, can be adapted and scaled if nations commit to the organizational infrastructure, registries, workforce strategies, and cross-border collaboration their eight recommendations demand.

Amputation remains a profound life-altering procedure for many patients, and it is essential that medical professionals feel equipped to handle the complexities that arise from such interventions. Many healthcare systems are placing greater emphasis on rehabilitation and patient-centered approaches to care after limb loss. The findings from this survey reflect a stark reality: while medical students may graduate with extensive knowledge of anatomy and surgical protocols, their practical exposure and confidence in managing amputee care are insufficient in preparing them for real-world challenges.

The study, conducted by an expert team led by Mahmood and involving a wide array of respondents from various UK medical schools, found that a significant number of students reported limited hands-on experiences with amputation procedures. The ramifications of such findings are distressing, both for the medical community and future patients. The lack of practical exposure betrays the necessity for institutional reforms within medical education to ensure that students are adequately prepared for the surgical and rehabilitative needs of amputee care.

The survey further explores the attitudes of these students towards their training, revealing an alarming level of uncertainty when it came to personal confidence in managing amputee care. This lack of confidence is perhaps understandable in light of empirical findings; however, it calls for immediate action from educational institutions to integrate more comprehensive amputee care training into their curricula. Students expressed a desire for increased training and exposure, which could positively correlate with greater levels of confidence and competence post-graduation.

Interestingly, the survey not only noted gaps in exposure to surgical techniques but also indicated a concerning lack of familiarity with the psychological and social dynamics that accompany amputations. Understanding the emotional impact of limb loss is critical for providing empathetic care and effective rehabilitation strategies. Consequently, this indicates a pressing need for a multi-disciplinary approach to medical education—one that encompasses not only surgical training but also the emotional and social aspects of patient care.

In addition, the findings stress the importance of mentorship and clinical placements that encourage active participation in surgical procedures related to amputations. Without direct involvement and guidance from experienced surgeons, students may struggle to bridge the gap between theoretical knowledge and practical application. Institutions should consider fostering environments where students can observe and take part in surgical procedures, ensuring they are exposed to various amputation scenarios that they might face in practice.

The survey also calls into question the adequacy of current teaching methodologies utilized in medical schools across the UK. Traditional lectures and textbook learning may no longer suffice for complex subjects that require practical skills and emotional intelligence. Innovative teaching approaches, such as simulation and role-playing, could better prepare medical students for real-world challenges they will face once they enter clinics and hospitals.

Moreover, collaborating with external organizations specializing in limb rehabilitation and psychosocial support could enhance training modules, offering students insights and resources that are integral to comprehensive patient care. Building partnerships with these organizations would reinforce the idea that amputation is not solely a surgical event but a pivotal moment in a patient’s life that requires ongoing support and care.

Educational curriculum reform in this area could also benefit from involving patients themselves, allowing medical students to hear firsthand experiences from amputees. Through storytelling and patient engagement, students can develop a more profound understanding of the lived experiences of individuals with limb loss, which can translate into more compassionate care in their future practices.

Improving educational frameworks is not just beneficial for students; it also holds transformative potential for healthcare systems as a whole. Ultimately, if future healthcare professionals are better trained in amputee care, it may lead to improved patient outcomes, reduced anxiety around surgical procedures, and enhanced rehabilitation experiences for amputees.

In summary, the findings from Mahmood and colleagues’ survey have brought to light a critical need within UK medical education concerning amputations and amputee care. By addressing the gaps in exposure and confidence highlighted in this comprehensive study, medical schools can foster not just skilled surgeons, but compassionate, well-rounded practitioners who are prepared to meet the multifaceted needs of their patients. As such, this investigation represents a crucial step in redefining how we train the next generation of healthcare providers, ensuring they are better equipped to face the challenges of modern medicine.

In conclusion, collaborative efforts and reform in medical education regarding amputations and amputee care are required—for the sake of training capable healthcare providers and, ultimately, for enhancing the quality of life for those who undergo such significant life changes.

Subject of Research: Confidence and exposure of final-year medical students to amputations and amputee care.

Article Title: Undergraduate exposure and confidence to amputations and amputee care: a national survey of final-year UK medical students.

Article References:

Mahmood, A., Macdonald, H., Ali, I. et al. Undergraduate exposure and confidence to amputations and amputee care: a national survey of final-year UK medical students.
BMC Med Educ 25, 1658 (2025). https://doi.org/10.1186/s12909-025-08027-4

Image Credits: AI Generated

DOI: https://doi.org/10.1186/s12909-025-08027-4

Keywords: Amputation, Medical Education, Healthcare Training, Patient Care, Medical Students, Rehabilitation.