Lessons learned from teaching hand surgery in Thai Nguyen
Volunteer efforts made by the University of Michigan's hand program in low-resource countries over the past two decades have yielded insights essential to winning the fight to improve the welfare of rural patients around the globe.
I recently returned from Vietnam with my family and Sarah Sasor, MD, our hand surgery Fellow, where we conducted surgical demonstrations and educational lectures. We served in a large orthopedic hospital in Hanoi that specializes in congenital hand problems and pediatric injuries, and we visited hospitals in Thai Nguyen – including The Orthopedic and Rehabilitation Hospital and The Central General Hospital. Our trip provided the following collection of experiences and lessons regarding service in the developing world.
Limit one's expectations. We all become physicians to accomplish two things: to serve and do good; the fantasy that we can save the world in one short trip is simply a mirage. Although we want to create sustainable, impactful change in this unique region of the world, our contribution is rather limited.
Nevertheless, I recall a fable in which a young boy was walking down the beach and saw starfish as they were being washed ashore, basking under the hot sunlight. The small child tossed each starfish, one by one, back into the ocean to save them. He was interrupted when a nearby elderly man asked, "Do you not realize that there are miles and miles of beach and there are starfish all along every mile? You can't possibly make a difference!" The boy knelt down, picked up another starfish, and gently tossed it into the ocean. "It made a difference for that one," he replied. This concept resonated for each member of the team. We knew each encounter represented a defining moment in that patient's life.
For example, we treated two different cases of unrecognized radial nerve palsy – one in a 10-year-old girl after a poorly treated humerus fracture that led to impingement of the radial nerve around the spiral groove, the other in a young man after a traumatic laceration of his radial nerve. Both patients were unable to extend their wrist and fingers, which caused marked functional impairment. These two patients were valuable models for an educational demonstration of tendon-transfer procedures – we helped deepen the understanding of nerve anatomy, hand conditions and transfer strategy in a country where trauma is prevalent.
Educate interactively; surgeons are not technicians. On every trip, our goal is to teach principles rather than techniques. "Did you understand?" is a useless question to assess comprehension if all it garners are blank nods of confirmation.
Instead, I asked local surgeons to relay the concept or technique – in their native language – to demonstrate understanding. This approach can glean the level of expertise and comprehension of new concepts being shared. This kind of interactive education model is unique in cultures where passive learning is the norm (e.g., a senior surgeon barks out orders and junior surgeons comply) and can also be seen throughout rooms full of students completely zoned-out from repetitive lectures.
During this trip, I communicated explicitly to the senior surgeons that we are not technicians who follow a precise protocol. I repeatedly stressed that the essence of surgical care is not only knowing how to operate, but also when to operate – and even more importantly, when not to operate.
For example, I evaluated a young child with an unappealing appearance at the elbow due to congenital radial head dislocation. I asked the local surgeons if anyone would operate and which operation would they do. Nearly all of the surgeons indicated they would operate, but no one had an answer for which operation. Further evaluation demonstrated complete range of motion in the wrist, elbow and fingers with slight elbow contracture. I recommended no treatment; making the patient's X-rays look nicer was not an indication for surgery. The child's mother was instantly relieved. She has the same deformity and has functioned well without surgery. We need to carefully and holistically evaluate the patient and recommend treatments with purpose. These skills help us anticipate complications and optimize outcomes in every treatment rendered.
Respect the local culture and adapt. I had to remind myself and fellow team members that we were guests of the country where we served. It is essential to respect the local norms, which are often shaped by the region's economic constraints. Along with limited resources, such as suitable sutures or availability of fluoroscopy, this trip was further complicated by the language barrier and sweltering summer heat. In this rudimentary environment, we had to be flexible and adaptable.
Having a senior, highly experienced surgeon travel alongside a junior surgeon is important to help adapt to the various challenges posed by a foreign environment. A senior surgeon can use his or her surgical experience to adapt and navigate the complexity of the operations often seen. For example, we use large, industrial size drills that were traditionally designed for adults and applied to young children.
Another important concept that I emphasized to my students was to avoid teaching operations that were too complex for the local surgeons to manage. When our group leaves, a disruption in the continuity of care occurs – and local surgeons are left with the daunting task of managing all follow-up care and potential complications. During this trip, I performed a necessary pollicization in a young child to enhance her function. I stressed the importance of maintaining function to the transferred index finger by preserving both radial and ulna digital vessels and an abundance of venous channels for drainage, as well as preventing tension on the flaps to ensure a predictable outcome. Although these difficult operations are life-changing for the patient, post-op care can be challenging when the support network is unavailable. These mission trips should focus only on operations that can be learned in a short time span.
Do not let them see you sweat. When serving in a low-resource country, maintaining calmness and a gentle demeanor and exuding confidence is necessary. An entire audience of nurses and surgeons is paying attention to your every gesture and word.
In American culture, losing one's temper is a sign of losing control, though a few occasional outbursts are generally accepted. However, it's absolutely frowned upon in other cultures – particularly in Vietnam. During a case I performed in Thai Nguyen, the power went out. I calmly paused so the audience in the room could take out their cellphones to shed light onto the surgical field. I then finished my tendon reconstruction as expertly and expediently as possible.
On another occasion, I watched my hand Fellow meticulously demonstrate a radial nerve-transfer procedure for an entire audience of senior surgeons. I was unaware she felt any stress until I saw her surgical gown, which was soaked in sweat. During our trip, we mixed education with gentle humor to lift the spirits of those assisting in or watching the operation. I also made it a special point to thank every person involved – custodians, nurses and surgeons – for their contribution because many of them, if not all, are pulling away from the daily routine to contribute to these missions.
Integrate family and professional life. As physicians, we each have our own mountain of work, academic responsibilities and administrative duties. As a dean of faculty affairs, I met an outstanding rheumatologist for her annual review. She explained how she was able to balance her family life with two young children, a husband who runs their large farm and a busy practice. Her secret was to involve her husband and two children in everything, from the family farm to professional conferences. This was a wonderful revelation for me, as my family never accompanied me on any outreach trips.
I made it a special point to include my wife and son on this trip, which proved to be a wonderful family experience. My son, William, himself a college student, presented a burn lecture and conducted an outstanding series of interviews with the hospital staff to understand their educational model and learning styles, thereby creating an outreach curriculum that best caters to their specific needs. My wife observed our team in the O.R. and gained greater appreciation of our conviction and perseverance for the children we cared.
This long overdue family trip was especially rewarding because we contributed to the welfare of patients, underwent personal growth and connected as a family. Most importantly, it reaffirmed the altruism that is engrained in all of us.
The trip was intense and exhausting, but also gratifying. Our team evaluated more than 80 patients at three different institutions throughout North Vietnam. Although we were physically drained, our minds were and remain refreshed – knowing that we had accomplished an enormous, meaningful task. Without meaning, life is monotonous and mechanical. Finding meaning is the single-most important antidote to the prevailing burnout syndrome that affects numerous physicians in the United States. I wish to acknowledge all of my plastic and hand surgery colleagues who are serving tirelessly for the underprivileged in our country and in the developing world.