Roundtable Discussion: Mission Trips and Longitudinal Program Development in Global Orthopaedics
Rameez A. Qudsi, MD, Arvind von Keudell, MD, George S. M. Dyer, MD, Collin May, MD, R. Malcolm Smith, MD, Brian D. Snyder, MD, PhD, Thomas S. Thornhill, MD
©2017 by The Orthopaedic Journal at Harvard Medical School
As described in the ongoing Global Burden of Disease Project, musculoskeletal disease accounts for the second most common cause of disability worldwide, with a large proportion of low back pain, neck pain, osteoarthritis, gout, rheumatoid arthritis, low bone mineral density, and other musculoskeletal disorders.1 Injuries and trauma continue to represent an ongoing cause of major disability, disproportionately so in low and middle income countries, with more deaths from trauma worldwide than HIV/AIDS (human immunodeficiency virus/acquired immune deficiency syndrome), malaria, and tuberculosis combined.2-4
Given the increasing awareness of the high burden of orthopaedic disease in low-resource nations, and explicit calls for global access to “essential” surgical care by the World Health Assembly / World Health Organization,5,6 a critical examination is warranted of the international orthopaedic service many surgeons in high income countries are involved in today. The need remains high for global orthopaedic development, with a call to identify sustainable, effective, data-driven programs to lead the way.7
We present a discussion amongst a group of experienced orthopaedic surgeons with varied backgrounds in global orthopaedics, focusing on the evolution of care from episodic missions to long-term development abroad.
I’d like to begin by welcoming you all to our 2nd Annual Roundtable Discussion for the Orthopaedic Journal at Harvard Medical School. We will be focused today on Global Orthopaedic Surgery, and more specifically, the interplay between traditional clinical mission trips and longitudinal efforts at capacity building and program development. We have with us a hand-picked group of experts in this field.
We will begin with some introductions.
Dr. Thomas Thornhill is the John B. and Buckminster Brown Professor of Orthopaedic Surgery and recent Chairman of the Dept of Orthopaedic Surgery here at the Brigham & Women’s Hospital. He is a former resident of our Harvard Combined Program and has too many accolades to list today, so we will just highlight one of his long-standing accomplishments in organizing and maintaining the Operation Walk Boston mission to the Dominican Republic each year for total joint arthroplasty in a very needy population.
Dr. George Dyer is an Adult Upper Extremity Specialist and Program Director of the Harvard Combined Orthopaedic Residency Program. He is constantly engaged in educating orthopaedic trainees, both here in our Program and also abroad. He has been teaching resident, fellows, and attendings in Haiti multiple times per year since the earthquake and has organized the only recurring annual CME conference for orthopaedic care providers in Haiti.
Dr. Collin May is an Instructor in Orthopaedic Surgery and Attending Surgeon at Boston Children’s Hospital. He is a graduate of our residency program as well as pediatric orthopaedic fellowship at Boston Children’s, and is now an attending surgeon focused on deformity, trauma, and lower extremity disorders. He has led Operation Walk previously as a resident, and is now involved with an annual mission trip to Colombia and pediatric program development in Haiti.
Dr. Malcolm Smith is the Chief of the Orthopaedic Trauma Center at the Massachusetts General Hospital. He was a consultant surgeon in the UK for almost a decade before coming to the Harvard program in 2001. He is an international expert in orthopaedic trauma and has been supporting numerous teaching and clinical programs abroad, including a renewed institutional effort in Uganda.
Dr. Brian Snyder is an Associate Professor of Orthopaedic Surgery and senior surgeon at Boston Children’s Hospital. He is also a graduate of our Harvard residency program and Boston Children’s fellowship in pediatric orthopaedics. He is the founder of an annual mission to Neiva, Colombia as the orthopaedic arm of a larger Healing the Children team, and has recently collaborated on advancing the use of mobile technology in work abroad.
To start with a very open ended question, what do you think is the ultimate role and purpose of an orthopaedic mission trip and doing work abroad, whether a semi-annual trip or something other than that?
Dr. Thornhill: I can tell you about Operation Walk, and in fact I think the way it’s morphed has been far better than I envisioned it at the beginning. For example, we originally thought we would have no residents. We now have 4 residents who play an incredibly important role - Collin was amongst them, and it’s a vital part of our program. I think it really depends on who you’re trying to help. Clearly you’re helping patients. Clearly you’re helping the institution. What we’re trying to do is to develop metrics by which we can measure our success and our sustainability. That’s the reason we go to the same place each year with Jeff Katz. I just reviewed a paper in which we looked at our 10-year history with 552 joints replaced in 350 people, so you’re helping people, you’re helping the locals, you’re helping sterilization at the local hospital, and I think you’re helping the residents to get down there in a learning environment to perhaps continue to do that the rest of their career.
Dr. May: I think the mission trip has traditionally been characterized as typically a week spent in a country, with international surgeons coming and performing some clinical role. I think the goal of a surgical mission really is to meet a need that would otherwise go unmet. If there are people who have conditions who at present are not being treated, the role of missions traditionally has been to meet that clinical need that otherwise would not have been managed. I think that people have very strong feelings, positive and negative, about the idea of a “mission trip”, but I think on the positive side it’s main benefit is to provide care that otherwise would not have been provided. Though I’m sure today we are going to talk a lot about ways such mission trips are evolving over time in a positive way to go beyond just clinical need but also to provide education, local capacity, and outreach. But at its core, I think medical missions are meant to treat people who really don’t have access to care at present.
And how do you all think we can understand what the most effective way is to provide care for those who would have that unmet need? Any thoughts on how to analyze, measure, and objectively assess if the work being done is the most effective approach to achieving that goal?
Dr. Dyer: One of the tensions in that is there are both short-term and long-term objectives to that goal. If you’re objective is to crank out cases during your time, the best way to do that is to turn up with everything packaged, and interact as little as possible with the people in the hospital and facility, because you’ll always be faster and produce more clinical throughput than if you’re working with other than your team, but when you leave after the week, you leave nothing but that footprint, nothing else is left. If instead you engage as Dr. Thornhill is describing with Op Walk, with the local staff and nurses and sterilizers, etc. But it takes longer to do that, though you now leave behind more skills, and I’m sure your data shows that the hospital processes and people left behind are more effective for your having been there than not having been there over the past 10 years. And so there is a tension between short and long-term effectiveness, and there are some hospital missions that are all about getting whatever they can done in say 10 days, and generally sacrifice the long term goals for the short term clinical care. Though if you look at the long term at 1 year, well, I clearly have an opinion about what’s a better way to do this.
Dr. May:But do you think those two have to be mutually exclusive, because I think as you mention you are more efficient in the context of bringing the whole team and doing it yourself, but you can as a part of that get into education, capacity building, and have it reach as many people as you can. I am certainly in your camp as far as wanting to develop capacity and the resources to have it be self sustaining once your gone, but in the meantime, I do think there’s a need to take care of the people at hand.
Dr. Dyer: I think you’re right, but it has taken a huge effort, like Dr. Thornhill’s version of Op Walk, which really operates differently from many of the other Op Walks, which may parachute in and perhaps not return even to the same site. In contrast, your group suffers some cost in the short term but great benefit in the long term.
Dr. Thornhill:If I look at what we’ve accomplished, I would say one of the most important things we have left in the imprint at Hospital de Salud where we work, is that the hospital has completely revamped its sterilization process. But I think one of the big things about these mission trips, as Collin was saying, is that there’s benefit in all of them, but it depends on what you do. George went down after the earthquake, taking care of people, but you couldn’t do then what we need to do with joint replacements. In the Dominican Republic (DR), they were first doing only 75 joint replacements per year at this hospital, and now there are over 200 joint replacements per year by the local surgeons even when we are not there. You have to know the culture of the people, and the healthcare system. For instance there is insurance in the DR, but it doesn’t pay for implants. All of our people are means tested, and some of the stuff we’ve talked about on data collection, some of the best things Jeff Katz has done for us is to look at the metrics and see what’s good, what’s bad, and what elements of Op Walk Boston are mandatory to keep going to look at patients on a longitudinal basis.
That raises a good point about research, not just clinical record keeping or even just Quality Improvement (QI), but genuine clinical research being done on these trips in a low-resource setting. Do you think that’s important, or that all trips should include this component?
Dr. Thornhill:I’m not sure it’s possible to have everyone to do it, and I don’t think everything has to fit in the same box. I wouldn’t criticize a program that doesn’t do it. For us, to know whether we’ve been effective it’s a very important way to look at evidence-based studies, and many of them are done by our Harvard medical students or other students, and this paper I was referring to has all the work we’ve been doing.
Yes, that is referring to work done by Jennifer Bido and the research team with Dr. Jeffrey Katz, an example of integrating in parallel research and QI work along with clinical work abroad.
There is a lot of technology available now for work overseas – what do you think are some ways technology can be leveraged for more efficient and effective work, and why do you think there has been such slow uptake of newer tools in global orthopaedics?
Dr. Snyder: The advent of cell phone and smart phone technology available to many of the patients in the third world during these trips has revolutionized our ability to continue communication and interaction with these patients and compensates for the lack of available infrastructure and structured health care available to these individuals. We can leverage this technology by creating an electronic medical record based on a smart phone app that allows an identifying picture of the patient and finger print, relevant demographic information, a listing of the diagnoses, relevant physical findings (template based on diagnosis to facilitate consistency in record keeping) picture of pre-op x-ray, a brief operative note, intraoperative x-rays and final radiographs at the completion of surgery, and an outline of the post operative plan. The app would also then include regularly scheduled questions posed to the patient from a clinical coordinator from the team with regard to pain, function, and complications. Sequential pictures of the wound to assess healing and use of the gyroscope/accelerometer embedded into most smart phones to evaluate improved mobility and perhaps when combined with a Fitbit device (funded by donations to the mission) would allow assessment of improved ambulation. This would allow us to follow our global health patients with the same consistency as the patients' we follow at our own hospital. These data should then be entered into a Redcap Registry so that we can track the outcomes of the medical and surgical services provided by these global health missions and compare among mission trips as well as compare the effectiveness of Global Health Care services to those services provided our own patients. A version of this App is being developed for our trip to Columbia and is an adaptation of the electronic record currently used by Smile Train.
Now shifting gears a little, regarding the balance between clinical work and education, do you think it is feasible to link education over multiple trips into an integrated curriculum over time?
Dr. Dyer: Well, I definitely do have a strong opinion about this, and perhaps the best way is to start by explaining how I became involved in all this. Malcolm and I after the Earthquake in Haiti, were 2 of the surgeons who went, and it was really the fulfillment of much of the reason I went into medicine itself, because I was interested in trauma and disaster relief, though it took 18 years from the time I was a military officer thinking I wanted to become a doctor until I was in Haiti with Malcolm responding to a disaster, and a lot of things evolved in my understanding. But during those 2 weeks in Haiti, I think we both realized that aside from the trauma of the disaster, the system of Haiti was not equipped even for the routine daily trauma, road accidents, fall from height, and even though we could do a lot treating the immediate trauma, the best path would be to dedicate a lot of time to help train and support Haitian orthopaedic surgeons to care for their own patients there over time. So even though it was a great honor to help then after the Earthquake during that short-lived time of the first visit, really I think I’ve done far more by a sustained engagement over the 7 years now I’ve been there since then trying to build capacity in Haiti, and that is really all about education and that’s the thing we do reflexively, those of us in teaching institutions, and something we can do for free except our time. So just by going, by befriending, and building a long term teaching relationship with people who have become colleagues in Haiti, I think I’ve benefitted them and the people there even when I’m not there. So although you can do surgery for a week and get a bunch of operations done, if you can teach somebody to do all that surgery all year when you’re not there, that’s a real gift.
Do you think the week trips can be utilized as a part of a long term curriculum?
Dr. Dyer: Well that’s exactly how I do it. It’s setup where during the week that I’m there, they will bring operations that there is no local capacity to do yet, some technical injury that they are unable to do. I do no surgery on my own there, but rather guide my colleagues through operations which after that they know how to do.
What should teams then be doing between trips abroad to help achieve long-term goals?
Dr. Snyder: We believe that identifying appropriate caregivers and allied medical professionals at the local hospitals and clinics that we attend on mission trips is most important to continue the evolution of medical and surgical care provided to our global health patients. Therefore we are organizing an exchange program where the physicians, nurses and allied health medical professionals that we work with on the ground during the mission trips can come to Boston to spend a few weeks training and observing their contemporaries at Boston Children's Hospital. Boston Children's has made available grants for such exchange fellowships and observership programs. This type of global health training could be expanded Harvard wide. Additionally, surgical training videos and computer simulations and animations such as those being developed by TOUCH SURGERY could be used to teach surgeons and medical professionals how to perform the procedures performed during the mission trips. Email and video conferencing on a regular basis for local caregivers to discuss difficult patient problems and develop appropriate treatment plan should become an ongoing process to extend the impact of the mission beyond episodic surgery. Rick Schwend. a former HCORP resident and incoming president of POSNA has also developed use of webinars and the use of real time iPad imaging in the operating room to assist local surgeons remotely from afar when performing complex surgeries.
Dr. Thornhill: Well you know the elephant in the room is funding - everybody who goes with us, it’s all vacation time and volunteer. There are certain rules and regulations both federal and local that preclude some of it, and there are some departments like Anesthesia that have embedded within their program some time, and some have endowments but endowments are getting harder and harder to even obtain.
So how do you think for trainees, with even more limited resources (time and money) than faculty, how can they best participate? And for young attendings looking towards an academic career in global orthopaedics, how can they position what they do academically as an asset for the department rather than something that is simply seen as time away from their job and a burden on their colleagues?
Dr. Thornhill: Well we’ve created, and the other groups from the Harvard Combined program, various buckets, and yes, accounts receivable are good things to have, but also so are peer-reviewed publications. And then there is a whole other bucket of education that unfortunately we are not yet where we academically credit people for those things, and that is one thing we can aim to improve on.
Thank you, I think this remains a key challenge for anyone looking to enter this growing academic field.
Changing gears again, for Dr. Smith, do you think global programs need to have an exit strategy, or are there types of programs that should continue indefinitely?
Dr. Smith: I’m going to be a little more skeptical than people have been so far. I think that working overseas is enormously rewarding and certainly was a seminal moment for George and me. But reflecting on it, other than the emergency to help for disaster, it’s extremely difficult to make a real difference. I think that a Western surgeon has real difficulty going to do something, without the equipment and the services to do something close to what he’s used to doing. And the resources I’ve seen overseas do not allow him to do that unless, as I see Tom has been doing, to take everything with them, and I think it’s marvelous what they have been able to accomplish. As far as setting up the resources, to go somewhere, you will see such an enormous need, if you don’t have an exit strategy, you will never leave. It’s just impossible in the human sense to do that, so you have to have a way out, which tends to be family at home, job, money, normal life, that drives you back all the time. The ideal is to have a long term program with long term aims that feeds the visitor out over time and the locals take over. So far in my experience that has been a vision, pie in the sky.
Dr. Thornhill: I think you have to have an exit strategy, because you need to have a de minimus, those sort of things you have to have at home locally and on your mission. Unless those things are fulfilled, you can’t successfully do it, so I think an exit strategy is mandatory.
Dr. Smith: I think orthopaedics is the worst area in regard to what you can and can’t do, because most of our surgeries require implants which require sterility, and it isn’t there. You can’t do it in most places in the world - last time I went somewhere I had to wash my hands with a bit of soap in river water, and I don’t think you can do anything near clean surgery unless you’re dealing with the ultimate emergency with pus pouring out you have to operate. General surgery is different of course, they’re dealing a lot with pus and don’t need the level of sterility as when you are putting implants in. We do it because we can do it, but it’s way above the risk level you experience in this country.
Dr. Thornhill: Yes, somebody asked me, what are the things you are most pleased with. I would say I don’t think we operate on anyone in the DR that we would not operate on here without the same level of preoperative workup and postoperative care, with the exception of staging where in the DR we may do more bilaterals as we can’t stage as much. But I don’t think we skirt around the issue of sterility, and Malcolm is correct, I don’t think we could do what we do many other places that people go.
So if you think there may be infrastructure, population, and system level issues in these places, do you think there should be encouragement for clinicians to obtain further training in public health and systems level training? Is that realistic to have orthopaedic surgeons doing?
Dr. Thornhill: I think orthopaedics really is more difficult than many fields, with implants and procedures that can’t be done in many places. I think the dept. of emergency medicine here have some people who when they work there work in a horizontal period of time, and it’s easier to do that and they do some marvelous work, not necessarily operations but building infrastructure, clean water, etc. The other thing though we do, and I remember George talking about it at a Grand Rounds, is understanding the cultural differences between the patients you treat here and the patients you treat wherever you go, because it is very profound not only in the collection of the data but in the interpretation of the data.
Dr. Dyer: Although I guess I just have to say that orthopaedics may be harder to do than other branches of surgery, but it is certainly no less important, and in fact in some case more important to be done than many other interventions. There are more deaths from road traffic accidents than from tuberculosis, malaria, HIV combined, and has been clearly identified by the Lancet Commission as 1 of 5 essential surgeries needed, i.e. treatment of open fractures. Yes it’s hard, sterility is a challenge, but I don’t think we can just ignore it. Yes it’s hard, but we have got to do it.
Dr. Smith: Well of course I’m not suggesting we ignore it, just that we are realistic about it. The last time I went to a hospital overseas, in Uganda, it was probably a 50 bed ward with about 6 ignored massive sarcomas, and the rest besides a few appendicitis, were all orthopedic trauma patients, all lying there getting bed sores because hips hadn’t been fixed, open pelvises with excrement, people with osteomyelitis, like a child presented with his entire radial shaft sticking out of his arm. The level of disability and personal suffering from simple things that we treat here routinely is enormous. There was a study about 2 yrs ago from Uganda about the likely economic outcome of simply fixing a tibia fracture in a taxi driver, and they illustrated that there were 5 or 6 people who’s whole education and even livelihoods depended on that man getting back to work, and he couldn’t, ending up with his leg twisted and unable to work. The social impact of that is incredible. The size of the problem though is so big, that trying to have broad expectations of any program is difficult. Which is why I advocate just going in and doing just one little bit well. The other environment I’d dedicate everything to is a very very controlled way of doing things, like for example the education approach, but you could do that for a very long time and I doubt you would see much difference.
Dr. May: Well I think this speaks to the clear heterogeneity of people’s experiences, not only of people in this room, but all the places that people work internationally. You take Dr Dyer’s situation, and education is a key component there, and building up the people there to do the work is really important. But you look at the example of Lew Zirkle, founder of the SIGN Nail, starting in Vietnam. It wasn’t the education or people there, they had surgeons available but needed the implants. They had sterile environments, they had the hospital, they just needed the implants, so he come up with that solution, the implant they needed to do the surgery. So you have to be flexible and tailor what you do to what is available or change it to what you can do. There is a wide heterogeneity of experiences and places to work. We’re trying to do our best in all these various environments. One program certainly doesn’t fit all.
Dr. Dyer: This certainly is the spectrum here, from total joints to osteomyelitis and a bone falling out of a child’s body. There was one case that Malcolm and I saw together in Haiti the very first time I was there that really made me realize this, and that was a man who had fallen off his motorcycle right outside the hospital. He had a simple elbow dislocation, and the people in the receiving ward or ED, called me and said what do we do about this? I said we reduce it, and I pulled it back in, and his elbow was stable after reduction, and I said you’re done, don’t lift up anything heavy for about a month. Then I asked the orthopaedist there and said how would you manage it? I got a wide range of dangerously wrong answers from “I have no idea what to do”, to “I would leave it like that” to “I would cast it unreduced for 8 weeks” to “I would take it to the operating room and reduce it then cast it” and every kind of wrong answer. This required no implant, nothing fancy, just a maneuver that we taught in 3 minutes to everyone who was there, and that patient is working and able to continue. I imagine people metaphorically like people riding unicycles across a thin wire over a chasm with all of their family and dependents on their shoulders, and any stumble for him and he falls off taking everyone with him. That patient is now still peddling.
Dr. Smith: You asked about trainees here. You would have massive problems working in places like this because you haven’t been trained to work in those environments, without CT or other advanced testing. Few can put their hands on a patient and tell what’s going on. You need to have an almost Victorian or last-century approach to medicine with physical exam, rather than press a button and get a scan, and that’s not the training now.
Dr. Thornhill: But you know, I do think in a residency program, and it is hard, but if you instill in residents the importance of it and give them an opportunity I think that’s important. One of the common questions of residency applicants now is, “Are there any international or mission-based activities in the program”? If you can take that small group of interested individuals, because you can’t pay them enough to do it, and you can get them interested in doing that and teach the next generation, that’s important. I remember when Colleen Sabatini came to me and talked about doing it, I said well this is not a real resident thing, but it really is a resident thing, and they are a key part of what we do. Missions are missions, but they are very different depending on where you go and what you do.
Dr. Dyer: Well a great example is Rameez, right here. Our host and moderator today, creator of this event, when he was at Harvard medical school, came to me and said Hi, I’m Rameez, and I want to do international orthopaedics, and we were fortunate to match him as a resident. From the day he started as an intern, he said when can I start on this? And it’s been a lot of fits and starts and patience on Rameez’s part to make this work, but he has absolutely made this into a viable part of not only his career as a resident but also a career as an orthopaedic surgeon. He’s figured out how to get the right training, he actually just matched today in pediatric orthopaedics, congratulations to Rameez, and I think that is an ideal specialty in part because it can be at times low-tech. And Rameez, who was already a good surgeon and clinician, I’m certain has gotten better at practicing Civil War era medicine, like putting his hands on people and understanding what’s wrong with them, and I’m sure it has made him a better surgeon. I think it goes both ways. Our trainees benefit the people they work with, and that experience benefits them.
Well thank you for those comments, and highlighting that in our program like many others there certainly is a growing interest in doing this work but also these questions of what is the best way? I think people are no longer just saying that I’d like to go somewhere, but now also saying how can I make the most different in the most objectively effective and meaningful way.
I appreciate all of you taking the time to speak about this issue, as usual possibly raising as many questions as we have tried to answer. I know it’s hard to have everyone get together in one room, and I am so glad we had the opportunity today touching on some of the more big picture characteristics of global orthopaedic work for the next generation to promote sustainable improvement in the access to surgical care worldwide. Thank you again for your time.