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Volunteerism in Orthopedics: Good Feelings in Action
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By Elizabeth Hofheinz, MEd, MPH
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April 24, 2007
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Alcohol, cigarettes, volunteerism? Says Dr. Richard Coughlin, founder of the Institute for Global Orthopedics and Traumatology, “While volunteering is about improving the lives of others, one cannot deny that it leaves the giver with a good feeling. Volunteering can be a self-fulfilling act such that at some point you’re also doing it because it feels good—and that’s where you get hooked. That’s the drug—a drug that actually helps other people. I watch our residents and after a month of working in Africa, it’s in their eyes. They have rediscovered the passion of serving others.”
Dr. Coughlin, a recipient of the American Academy of Orthopaedic Surgeons (AAOS) Humanitarian of the Year Award, was hooked. “I knew there was more I could do to bring services to those in need worldwide. In 2006 I launched the Institute for Global Orthopedics and Traumatology, now part of the San Francisco General Hospital and the department of orthopedics at the University of California, San Francisco [UCSF]. The main focus is on developing connections and partnerships between academic orthopedists and entities in areas of the world that are in need. We are now partnered with Makerere University in Uganda and the Nelson Mandela Medical School in Transkei in South Africa. In 1999 I established a formal overseas rotation for orthopedic surgery residents in the Transkei. We at UCSF also assist these schools with training programs and research. Regarding the latter, we review research proposals put forth by the residents at Makerere and then help fund them. Each resident receives $500, which goes a long way towards helping the student, as well as his or her community. It’s a great multiplier effect.”
In order to connect with that part of oneself that recognizes this moral duty, says Dr. Coughlin, it is imperative to step back from one’s daily life and reflect on giving. “Not everyone can or should take off weeks at a time and head off around the globe. Small acts of selflessness can lead to enormous change in the recipient’s life, as well as provide the giver with a greater feeling of value and self worth. Life shouldn’t be about the extra $50K you could make doing more surgeries.” Examining the subtle, internal processes that doctors go through, Dr. Coughlin states, “The ‘aha’ phenomenon of volunteerism converts is incredible. They end up thinking, ‘Oh, that’s why I trained all these years.’ If you feel obligated to volunteer, then it is a job. But, however, if you give willingly, that defines you as someone of a higher calling. We probably all started out that way, but then economic and social issues got in the way.”
Dr. Boachie, who would one day receive the Humanitarian of the Year Award from the American Academy of Orthopedic Surgeons, kept that promise—to himself and to his country. Dr. Boachie: “In 1988 I established a foundation called FOCOS [The Foundation of Orthopaedics and Complex Spine] to bring free and/or affordable care to the underserved in Ghana. There are 200 orthopedic surgeons for the 250 million people of West Africa. As you can imagine, there is an incredible backlog of cases, as well as limited infrastructure. And while dealing with things such as clubfeet and tendon transfers are manageable under these circumstances, major joint reconstructions are much harder to do.” Fortunately for the many in need, Dr. Boachie was not daunted by the scope of work to be undertaken. Buoyed by a sense of purpose, he asked for a little help from his many friends. “Friends, associations, companies, and patients—all opened their hearts and wallets to help get this project off the ground. DePuy Spine helped with equipment, as did Zimmer and Biomet. Osteotech provided bone grafting material and Ethicon contributed suture material. The materials management folks at the Hospital for Special Surgery loaned us other necessary equipment. Volunteers raised funds while I wrote letters to patients and asked them to match contributions. Additionally, I set it up that any royalties I receive from my work with DePuy go to FOCOS.”
Nearly 20 years later, FOCOS is established in its excellence. And word has gotten around the medical community. Says Dr. Boachie, “Every trip I have at least 20 volunteers, including nurses, medical students, orthopedic residents, fellows, and their research coordinators. Many are from other countries, such as Japan, Spain, and India. They provide invaluable help with not only medical care, but data entry, registry, and videotaping, among other things. Seeing these people work is a great example of how every contribution matters.” And what does a typical day at the clinic look like? “By the time the team arrives, the local staff of 11 people has worked up all the patients, including X-rays and bloodwork. There is usually a long waiting line, and people are screened and prioritized according to medical need. While we do not perform emergency surgery, occasionally people come in with a traumatic injury. Perhaps, for example, they are experiencing sudden paralysis from tuberculosis. They are attended to also, of course.” Due to Boachie’s planning, when the team departs for New York, the giving and learning continues. “Each trip we host an instructional course on a topic relevant to the region. In general, we are trying to stimulate more interest in orthopedics in West Africa. At present, there are only two colleges in West Africa—and no orthopedic residency programs in Ghana. In talking with several Ghanaian medical students, however, they have expressed an interest in switching from general surgery to orthopedics because of the work we do at FOCOS. AAOS is set to hold a program in West Africa next year, so hopefully that will incite more interest in the field.” And then some of the disparity will melt away. Dr. Boachie: “On each trip I see the healthcare disparity in the faces of children. They have been experiencing clubfoot and painful spine deformities—and see people dying slow deaths. They are frightened. And then all of a sudden it is like something good dropped from the sky. They are so helpless and innocent and look at us as if to say, ‘I’m yours, help me.’ When they are better, and give me a big smile, I am six inches taller.” Dr. Dorr, founder of the Dorr Arthritis Institute at Centinela Hospital Medical Center in Inglewood, California, is pleased with this spin-off effect. “It seems to be working. Each team raises its own funds and takes one trip per year. We take veteran people to show the new folks how to do things and eventually they become self sufficient. The fundamental theme is that we want to help the poor and educate the local doctors on the latest in orthopedic care. This can be particularly challenging given the lack of equipment and/or devices. While we are deeply grateful for the donations we have received from J&J, Zimmer, and Biomet, we still have to be creative sometimes. In Nepal, for example, the doctors lack implants, so we have taught them how to improvise. They have no power instruments, so we did a total knee with osteotomes. In the Philippines we once had to do a total knee with a flashlight. But the creative thinking is good for everyone involved.”
To help is joyful. To return, sublime. “We feel it is important to follow up with the patients we have helped. We normally return to the same countries and take care of any complications that may have arisen. It is practical, useful, and provides a terrific sense of continuity for all involved. There is one expansion, however. This year we will go to Africa for the first time. Our team will consist of 40 – 60 people and will bring everything down to a Band-Aid.” Dr. Dorr, also a recipient of the AAOS Humanitarian of the Year Award, notes, “Each individual has to decide if volunteering is right for them. I highly recommend it, however, as using one’s talents and time in the service of others is extraordinary and life-altering. It is very satisfying to see patients grow up and doctors grow in their character. When you operate on patients who would not otherwise get this care, they are incredibly appreciative. It’s not like in the U.S., where if they don’t like the care at one clinic, they can go down the street. In many instances, we’re it.” Echoing the sentiment of Dr. Boachie, Dr. Dorr says, “For the people who thought they would never walk again, when one of our teams appears, it’s like a miracle has dropped from the sky. Their smiles are our reward.” Orthopedics This Week thanks these and other physicians who dedicate themselves to expanding healthcare access – and hope – for those in need. For more information on the organizations profiled above, please see:
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Dr. Coughlin’s foray into orthopedic volunteerism began in the 1980s. “I was in private practice with someone who had lots of experience working in the Philippines and China and my interest was sparked. The more I learned about the great need in these and other countries, the more I found it difficult to sit by and do nothing. Those worlds were in stark contrast to the world in which I operated, which was full of resources and privilege. In the early 1990s my partner and I started the orthopedic component of a group called Operation Rainbow which does mission trips to Central America. As we began to make shorts trips, which usually included residents, several things happened. First of all, I saw that the need kept getting greater, and, while doing these trips was making me feel good, it probably wasn’t having the effect we wanted. Also, I had moved into being more disgruntled about my own practice. Although my partners said I was crazy, I decided to leave private practice and join a county hospital. My salary was halved, but the feeling of contribution was astounding.”
And that is the way to not just create, but sustain change. To obtain further multiplier effects, Richard Coughlin donates his time to another entity seeking to “give a man a fish.” States Dr. Coughlin, “I am the chair of Orthopaedics Overseas, a primary component of Health Volunteers Overseas [HVO]. For 40 years, HVO has been committed to teaching and training people in other countries so as to improve healthcare for local people. The institute focuses on connecting medical center to medical center and training program to training program. The goal is to help not just with teaching, but with enhancing the capacity for research and program development. That way, you create an infrastructure for future generations. Here in the U.S., we are seeing a wave of younger residents and fellows who have a more clear understanding of globalism than most of the people in my generation. The result is an increased activism in our medical students and residents who have spent time in developing world settings and truly appreciate the joys and challenges of service. In fact, we have found that residents who are exposed early to volunteerism are more likely to continue on with this work. They seem to understand the moral duty that we all have.” 
Dr. Oheneba Boachie-Adjei, chief of scoliosis service at the Hospital for Special Surgery, also heard his higher calling ... all the way from Ghana. “My dedication to volunteerism emanates in part from my childhood experience of being ill. I recall being very sick, thinking that there was no hope and that I might die. Then someone came from abroad and helped me—that goodness and giving set me on a path to do the same for others. On that day, I think somewhere inside I made a promise to help.”
Excited, but prudent, Dr. Boachie took the time up front to ensure his project would be sustainable. “We took one year to establish the protocols, and spent a significant amount of time doing site visits and exchanges between American and Ghanaian healthcare professionals. We brought orthopedists, neurosurgeons, and anesthetists to New York to work with us and observe our protocols so they could participate at the same level.”
Spin the globe and you will find another, taller physician. Dr. Lawrence Dorr, founder of Operation Walk, an organization dedicated to improving orthopedic care for underserved communities, knows that there is no experience parallel to that of giving. “In 1994 I took a trip to Russia with several doctors who instructed the Russian physicians and helped patients. Realizing the incredible need for both skills and technology, I began doing medical trips abroad. In 1996 I founded Operation Walk and we left for Cuba that same year. During that trip our team of 28 volunteers trained more than 100 physicians, nurses and physical therapists in joint replacement techniques. Dr. Merrill Ritter accompanied us on that first trip, and was sufficiently enthused and moved to form his own team out of Indianapolis. Others who have gone with me through the years have done the same. There are now seven teams in the U.S. and one in Canada.”
And sometimes that extends to administrative tie-ups. “We have an ‘angel’ in every country. If we have a problem, say, getting our cargo into Mexico, for example, we can turn to that person to get us out of a jam. But things usually run fairly well and we dive right into work. The local hospitals are gracious enough to let us commandeer several OR’s for three or four days. When we depart, we leave extra implants for them to use.”
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