Alan Chu, MSc MD FRCPC

Sustainability, capacity-building, and buy-in.  Integration with the public health system.  Education, interprofessional collaboration, and government support for anesthesia infrastructure.  Although I was disappointed to learn that CASIEF’s legacy-worthy Rwanda project was winding down, its latest pickup in Guyana has great promise!

I have participated in many overseas missions, always small standalone projects, predominantly focused on care provision.  Care provision in Bolivia, Kenya, Haiti post-2010 quake; high-needs settings with minimal infrastructure and, in the case of Haiti, almost complete lack of government capacity.  With training in global health delivery focused on upstream and systemic solutions, I could not help feeling frustrated by organizations with great ideas but impatience with follow-through.

CASIEF’s current project in Guyana is a partnership with the University of Guyana in its capital city of Georgetown, at the country’s lone tertiary care hospital and sole academic centre for postgraduate training.  This is a vibrant community of physicians with training from all parts of the world and where many of the consultant educators are from Canada’s own McMaster University.  Indeed, McMaster has been instrumental in the development of nearly all residency training programs in Guyana, including general surgery, orthopedic surgery, pediatrics, psychiatry, and of course anesthesia.

Are you a senior anesthetist who has developed some wisdom in professional relationship-building and have a few good teaching scripts?  This is the project for you.  Most physicians doing this type of work fit this demographic: practicing physician, married with no children at home, late-career, with a good income.[1]

That being said, a refreshing aspect of the medical community at the Georgetown Public is that it is a youthful group.  The overseas volunteers were mostly early- and mid-career physicians, all with lots of energy.  The thoracic surgeon was a young fellow who hoped to develop a local thoracics training program using his recent residency and fellowship experience in North America and the UK.

These people are fascinating and inspiring.  I met not one but two ex-pat Guyanese who grew up in my own hometown of Toronto, and have returned to contribute to their country.  One precocious young office manager speaks only in inspirational sayings; his bumper sticker reads “Your attitude determines your altitude!”.  There are also several Canadian and U.S. physicians who maintain adjunct positions with the University of Guyana, some of whom leave the comfort of their homes to return frequently or stay for long stretches.

The anesthesia staff are an eclectic group, mostly mid-career, and clearly engaged in the ongoing development of this residency program.  They also contribute to the training of medical students and nurse anesthetists.  Dr. Alex Harvey is both Program Director for the anesthesia program and Head of the Institute of Health Sciences Education (akin to our PGME department).  She is a Jamaican-trained anesthesiologist and the only staff who provides cardiac anesthesia care for the open-heart team that visits every few months.  The sound of Spanish flows throughout the ORs as four were trained in Cuba, similar to a good portion of their surgical colleagues.  Some are not particularly academically inclined, having thrived in their environments because of their pragmatism, but they all are both engaged and engaging.  Hearing their varied and worldly stories is humbling and inspiring, a balance of acceptance of the realities of life and the empowerment that comes from taking it by the horns.

Accompaniment

“Safe Anesthesia & Surgery Saves Lives” is CASIEF’s motto[2] and while this may seem a daunting political task, there is much that individuals can contribute!  The single greatest task for Canadian anesthesiologists is to build relationships with Guyanese physicians and staff.  It is this accompaniment that is the backbone support for the development of contemporary anesthesia professionalism, with its focus on patient safety and the relief of pain and suffering.

“There's an element of mystery, of openness, in accompaniment: I'll go with you and support you on your journey wherever it leads. I'll keep you company and share your fate for a while. And by ‘a while,’ I don't mean a little while.” – Paul Farmer, 2011 Harvard commencement address

The role of bilateral partnership became evident one day quite early in my stay.  It was an important national holiday and I had plans to attend the Diwali parade with some friends.  What unfolded however was far from a celebration, it was catastrophic.  We found our Guyanese friend’s father unresponsive at the bottom of his stairs and, after learning there was no ambulance available, proceeded to perform forty-five minutes of basic life support in the back of his vehicle as he raced to the hospital, dodging countless potholes, struggling to understand what was happening on this most holy of days.  Back at the visitors’ residence an hour later, far away from my usual debrief supports and quite shaken, I was surprised when Dr. Harvey appeared at my doorstep.  We sat and chatted for a good while and I felt more at home than I have on any other mission.  What a display of accompaniment, and of partnership.  I can no longer assume that the privileged are accompanying the poor for when I needed support it was quite the opposite.  Despite the heavy workload and trying circumstances of Georgetown, here was yet another case in which Dr. Harvey did not hesitate to simply do what was required given the situation before her, much as each of us do in our daily work.  In many ways, we are the same, and we walk this journey together while building the relationships that are the foundation of all global health work.

“With rare exceptions, all of your most important achievements on this planet will come from working with others—or, in a word, partnership.”  -- Paul Farmer, 2013, To Repair the World.

How is your emotional intelligence?  Are you able to reflect on your role, privilege, and power, and recognize how and why you are reacting to circumstances as they unfold?  It is often the same people who do not get thrown by countertransference from challenging patients who are well-suited to this work, clinicians who can take a step back while still showing up.

The hidden costs of help

The most commonly cited reason for doing overseas work is “to help” or “to do something good”[3], but some missions exhibit a much higher help-to-harm ratio!  Consider that the average physician cost for each short-term mission is $11,000[4].  What could local governments do with the annual spending by visiting physicians alone?  Think of the local costs of visiting missions: garbage, local resource use/waste, even lost employment time in some cases.  Think too of the potential for harm: inappropriate management in the presence of undetected comorbidities; postoperative complication management out of scope or beyond the resources of local personnel; psychological impact of exposure to colonial approaches or views; and Canadian medical trainees providing care beyond their level of training.  It is reasonable to admit that much overseas work suffers from physicians’ “pursuit of self-efficacy”, from various forms of medical tourism, and from other suboptimal motivations that perhaps may not justify its high price tag.[5]^,[6],[7]

It cannot be understated that the risk of harm remains of paramount importance to all overseas work.  A comment like “What?!  You don’t have that here?!  Well, how can you even do this work??  That is not safe!” will certainly make it harder for the subsequent CASIEF volunteer to achieve the goals of this collaborative project.  In fact, much subtler comments have ended relationships.

Thinking about bringing a resident with you?  Do it!  But be smart and cautious, please.

It requires a lot of interpersonal work for you and for them, especially if you believe some of what I have highlighted about the risk of harm and the importance of relationship-building.  Think of all your possible reservations and anxieties about your upcoming work.  Then imagine a sleep-deprived, always multi-tasking, relatively inexperienced resident contemplating these issues!

In my experience, the best way to incorporate a learner into the mission is to begin with pre-departure training that requires them to reflect on what aspects will be the most challenging for them personally and professionally.  Some description of the historical context of overseas work might help them develop a sense of privilege at being involved in this work; at being a guest of colleagues who are allowing themselves to be vulnerable.  There is literature on what should go into such pre-departure training, but in my view working through the ethics is vital[8].  Precepted missions (in which a Canadian anesthesiologist accompanies a Canadian trainee) are most appropriate for inexperienced residents or students, and the Guyana project is perfectly structured for this.  Plan ahead for your post-return debriefing and do not skimp, schedule multiple follow-up meetings.

I tell my residents something akin to: “This is hard work.  I’ve done this a lot and it is still hard for me.  But incredibly rewarding and a ton of fun.  You will be using all of your senses in overdrive, all day every day, and this is exhausting.  Strive to achieve the same principles as you would at home – patient safety, alleviate suffering, optimize patient outcomes.  Assessing your patients for disease severity and stability will require curiosity and thoughtfulness.  When developing anesthetic plans, consider how our context might affect patient outcomes.  Finally, contemplate what kind of global citizen you would like to be, and when you talk to anybody chose each word carefully to reflect that ideal.”

“The doctor, not yet thirty, had been schooled for scarcity and failure, even as I’d been schooled for plenty and success … Working in that clinic had lowered his expectations about what was possible when it came to providing health care to those living in poverty … I’ve since learned that the great majority of global public health experts and others who seek to attack poverty are hostages to similar failures of imagination … How does this story relate to you? First, try to counter failures of imagination … Second point: as you seek to imagine or reimagine solutions to the greatest problems of our time, harness the power of partnership.”  – Paul Farmer, 2013, To Repair the World.

The CASIEF Guyana project is a great place for creative relationship-building.  I made a clinical blunder early on that resulted in a patient requiring a bedside chest tube; as I made the rounds apologizing and discussing the case with various staff, the intensivist roundly congratulated me for inadvertently unmasking the patient’s moderate-sized hemothorax and securing definitive care!  Early in the second week, after treading lightly and getting to know our colleagues and context, we routinely had a large audience of staff and residents in the regional block area looking on and getting involved.  In fact, I might even have imagined that surgeons were thankful that some cases at risk of being canceled could be deemed safe with the use of regional anesthesia or after surface ultrasound assessment.  I learned from my colleagues here that relationships can withstand clinical hiccups and that you never know how things will turn out.

I also had the opportunity to attend M&M rounds, which occurs about once monthly and is attended by all members and residents of the combined Department of Anesthesia and Intensive Care.  The case discussed was a patient who was incompletely optimized and delayed by an anesthesia trainee but subsequently approved by the staff consultant.  This was only after the surgical team had sequentially contacted progressively higher rungs on the ladder until somebody finally acquiesced.  The patient proceeded to arrest on the OR table under the care of the most junior anesthesia care provider on service (a nurse anesthetist) after a code run by the general surgeon.  With some rudimentary understanding of cultural and professional norms, I had some sense of the main issues at play and whispered some thoughts into the ear of the department head, who nodded in agreement.  To my astonishment, he then stood and asked me to address the department – what a heart-racing and humbling invitation that was!  This was what leadership courses call a “crucial conversation”.  The department head nodded supportively throughout, but this was also my last day, so my sincere apologies to subsequent volunteers if they have had to deal with any fallout I may have caused!

One day I was approach by a Guyanese colleague who asked, “So, how do our residents compare to yours?”  Awkward conversation ensued as I had not anticipated this question and I imagined completing an EPA assessment for a resident here.  In retrospect, I wish I had said that our residents are trained for our context and yours must be for yours.  The principles remain the same – safe patient care that also alleviates suffering and optimizes patient outcomes.  Our residents would struggle to accomplish that here.  My hope is that Dr. Harvey and the rest of our colleagues in Guyana, do not receive this message first from reading this newsletter, but rather from a collegial dinner on the balcony overlooking some mango trees, taking in the warm air and faint sounds of bhangra music.  And that those future conversations are replete with imagination.

[1] Caldron PH, Impens A, Pavlova M, Groot W. 2016. BMC Health Serv Res. Dec 7;16(1):682. Demographic profile of physician participants in short-term medical missions.

[2] https://casief.ca

[3] Caldron PH, Impens A, Pavlova M, Groot W. 2017. Int J Health Plann Manage. Jan 12. Why do they care? Narratives of physician volunteers on motivations for participation in short-term medical missions abroad.

[4] Caldron PH, Impens A, Pavlova M, Groot W. 2016. Global Health. Aug 22;12(1):45.Economic assessment of US physician participation in short-term medical missions.

[5] Farmer, Paul. Personal communication, October 4, 2014.

[6] Philpott, J. 2010. Training for a Global State of Mind. Virtual Mentor American Medical Association Journal of Ethics March, Volume 12, Number 3: 231-236.

[7] Arya AN & Evert J. 2018. Global Health Experiential Education: From Theory to Practice. Routledge, New York.

[8] Pinto AD & Upshur REG. 2013. An Introduction to Global Health Ethics. Routledge, New York.

On Saturday September 8th, 2018 the University of Toronto held their 2^nd Annual Department of Anesthesia Sports & BBQ Day. The event works to bring together staff and trainees and their families for some fun, friendly competition. This year we were honoured to be chosen as the selected charity and we were delighted that together the members of the Toronto anesthesia community raised $5,500 for CASIEF to support the development of anesthesia training programs in low resource countries.

A total of 195 staff, fellows, residents, and administrative staff from the Department of Anesthesia and their respective families attended the event. We had fantastic weather and it a true pleasure to see everyone in matching hospital team t-shirts, cheer their teams, compete in fun games, laugh, and enjoy the comeradery.

There was representation from Toronto General, Toronto Western, Mount Sinai, SickKids, Sunnybrook, St. Michael's, Michael Garron, and St. Joseph's. Congratulations to the Toronto General team for winning the sports tournament and fundraising competition - they took home the champion’s trophy (named 'The Laryngoscope') this year.