The Deep, Enduring Satisfaction of Medical Volunteering Overseas
The need is great, and resources are few…but the few persist. Ted Belanger, M.D. is one of them. Dr. Belanger, an orthopedic spine surgeon with the Texas Back Institute, has traveled to Ethiopia four times in the past five years in order to perform spine surgery and teach Ethiopian physicians. He tells OTW, “I work through a group known as Conscious International. In Ethiopia, a country where the average per person per year expenditure on healthcare is $20, there is little done for those suffering with complex spine deformities. There is no access to specialized care so by the time these patients see a surgeon they are way beyond the level of complexity we would ever see in the U.S. When I see surgical scoliotic patients in Texas, 90% of them have a curvature between 50 and 90 degrees; in Ethiopia, 90 degree is on the mild end of things. There, we often see 120-150 degree curvatures.”
“In 2014 we did 15 surgeries, most of which were on scoliosis patients some of which were on those with spine tumors. An example of something particularly complex was a pedicle subtraction osteotomy for a chronic fracture that had collapsed into kyphosis. Our team has also safely performed several vertebral column resections (circumferential removal of an entire vertebra) for the most complex spine deformities.”
“Rick Hodes, M.D. an internal medicine doctor who has been living in Ethiopia for 28 years, works the patients up preoperatively with ultrasounds, chest X-rays, MRIs of the spine, and spine X-rays. Dr. Hodes has identified 1, 500 spinal deformity patients in Ethiopia who are in need of care. Many of them end up at the hospital in Ghana run by Oheneba Boachie-Adjei, M.D., but traveling there is expensive. And if the patient is, for example, a 13 year old, then he or she must go without his or her parents…a huge, international trip where a child must undergo major surgery without the care of their parents. Part of the advantage of us going to Ethiopia is that Dr. Hodes can direct some those patients to us and the family can be present.”
“Dr. Hodes also looks after patients postoperatively; they even stay in his home if they have no family of their own. And if after I leave, someone has a complication like a wound infection, then they can handle that. It is problematic, however, if someone needs a revision of their hardware.”
“We have an ICU and medical and nursing staff; we are working on getting anesthesia situated so that we can do spinal cord monitoring. The biggest obstacle to this monitoring is anesthesia because it must be done with a particular technique. On the trip I just returned from we brought an anesthesiologist from Colorado who was able to figure out how to do the anesthesia properly. The hospital we work at in Addis Ababa does have anesthesia staff; going forward we will help train them in these procedures.”
“The Ethiopian orthopedic residents do spend time with us in the clinic and OR. In fact, the hospital where we work has just built a medical school and celebrated the end of its first year.
While we have not yet been able to teach them to do scoliosis surgery as performed in the U.S., we have mentored the Ethiopian surgeons in simple fusions and trauma cases.”
Dr. Belanger is pleased to see that the Ethiopian project is growing. “Each year we have more physicians; this year was the first time that we brought along a scrub tech and an anesthesiologist. We have just commenced with fundraising, which is a new undertaking. Five years from now I hope that we will have another team of surgeons, neuromonitoring technicians and anesthetists to travel to Ethiopia on a regular basis.”
NYU’s Innovative Residency Boot Camp Raises the Bar
Orthopedic surgeons in training at the Hospital for Joint Diseases (HJD), NYU Langone Medical Center have a leg up these days due to an innovative program that takes place at the school each July. Kenneth Egol, M.D., is vice chair for education in orthopedic surgery at the NYU Langone Medical Center. In discussing what is the largest residency program in the U.S., Dr. Egol tells OTW, “Under the direction of Donna Phillips, M.D., we have a new training approach that quickly and effectively prepares our incoming interns with skills they will need to be effective as residents. This four week program takes into account the requirement from the Accreditation Council for Graduate Medical Education (ACGME) that programs teach professionalism, communications, and surgical skills, gives incoming residents in-depth information on anatomy, simulated surgical exposure, and the safe use of surgical instruments. The faculty uses trained actors to teach how to collect the patient’s history and conduct physical examinations and then assesses residents’ competence in these skills. Conferences are provided on orthopaedic conditions, and interpretation of radiographic studies. The incoming residents participate in a communications skills workshop that was developed by the American Academy of Orthopaedic Surgeons. While other residencies provide skills training, what distinguishes us is that we teach and then thoroughly assess all trainees with checklists and videotape them on the skills they are acquiring (we subsequently review the videos with them).”
“By the time the interns are done with the boot camp program in July they are able to hit the ground running and are beginning at a higher level than residents of the past. This program is especially important given the limitation in duty hours and changes in healthcare delivery…it’s much harder these days to ensure that trainees are getting the experience they need. And not only does it help us to attract top quality medical students, but it truly helps the trainees be prepared.”
Asked about the hardest skill to teach, Dr. Egol noted, “Professionalism can be a challenge because it is a nebulous concept and it means different things to different people. Dr. Phillips has been a leader of orthopaedic trainee professionalism training utilizing vignettes that are followed by discussions. Some of these vignettes are about ways to approach difficult conversations, negative interactions with another staff member, how to identify and handle a colleague at risk for psychiatric or substance abuse issues. As orthopaedic surgeons this is an area we struggle with this because, historically, we have not received this training.”
As they move on in residency NYU HJD has other programs to continue to assess what their trainees have learned. “We also have an unannounced standardized patient project whereby actors come into the outpatient clinic and the residents don’t know they are evaluating simulated patients. Through this program we are able to pick up information such as, ‘Were patients greeted correctly? Did the trainee wash his/her hands? Did the intern review the diagnosis with the patient? Was there shared decision making?’”
“We feel this program has been a success, and we obtain constant feedback from trainees to help ensure that success. With the government and private insurers looking closely at individual doctors with eventual plans to tie his or her reimbursement or employment to patient feedback, programs like ours are essential. Our boot camp program helps to ensure that our interns will be well prepared to care for patients compassionately in this shifting, more intense healthcare climate.”
Two-Thirds of Athletes With Shoulder Instability Recur in First Year
What happens to athletes who injure their shoulder in the middle of season? New research shows that despite the fact that those patients treated nonoperatively often return to play in the same season, recurrences are more frequent than previously thought. Jonathan F. Dickens, M.D., winner of the 2014 Aircast Award for Clinical Science from the American Academy of Orthopaedic Surgeons, conducted a study that included 45 patients from West Point, the Air Force Academy and the Naval Academy. Dr. Dickens, assistant professor of surgery at the Uniformed Services University of the Health Sciences, told OTW, “There is little agreement on how to treat athletes who sustain shoulder injuries mid-season. We took these high level athletes and looked at recurrence rates and time lost following in-season instability events. In addition, we used the Simple Shoulder Test, the Single Assessment Numeric Evaluation, the American Shoulder and Elbow Surgeons test, and the Western Ontario Shoulder Instability Index to evaluate patient reported outcome scores at the time of injury. ‘Then we correlate those patient reported outcome scores at the time of injury with their ability to return to sport and the likelihood of predicting shoulder instability.”
Dr. Dickens, a fellow at the West Point John A. Feagin, Jr. Sports Medicine fellowship stated, “We found the recurrence rate to be much higher than we expected. Only 27% of our athletes were able to complete the season without recurrent instability. This is remarkably different from previous research which found that 37% of athletes that returned to sport had a recurrent instability event.” Dr. Dickens points out that there were several differences in the studies. The previous study by Buss et al was retrospective and looked at approximately 30 high school athletes, individuals who were at liberty to seek treatment anywhere. At our academies we have a closed healthcare system and in this prospective evaluation were able to detect a higher recurrence rate.
“In our study, which has been accepted for publication by The American Journal of Sports Medicine, athletes who sustained a subluxation were 5.3 times more likely to return to the season than those with a dislocation, though there was no significant difference in recurrence rates between the groups. Regarding time lost from sport, those who sustained a dislocation lost approximately seven days whereas those who sustained a subluxation lost three days.”
“Interestingly, we were able to construct a predictive model for how many days an athlete might be away from sport based on their score at the time of injury. We used the Simple Shoulder Test—administered immediately after the injury—that included 12 questions. If the athlete got, for example, a score of 100, then he would likely miss two days of play; if the athlete got a score of 20 then he would miss 12-14days.”
“Our subsequent research is continuing on this patient population and will be more impactful. We want to know if these athletes who have surgery will successfully return the following season. Additionally we hope to look at outcomes after surgical stabilization between athletes that only had one instability event and were fixed during the season compared to those with multiple recurrences who underwent a stabilization at the end of the season. Knowing this will help practitioners and team physicians better counsel our athletes.”
