“Teach a Man to Fish…”
International ophthalmology is about so much more than just performing live surgeries
I don’t like the term “medical mission.” I actually recoil when people use it. Over the past 42 years, I have performed live vitreoretinal surgeries in 25 different countries in a variety of venues, but I’m not a missionary – I’m just sharing my surgical experience with my colleagues across the world.
International ophthalmology is never just about doing volume surgery. True international ophthalmology is about a multiplier effect – think of the old adage “teach a man to fish.” If you just perform a load of surgeries, you’re not really helping to improve the status quo, because you’re not leaving much behind. But if you truly partner with your ophthalmology colleagues abroad, you can have a sustainable impact; you can ensure that they can deliver volume care based on your teaching – as well as passing that teaching on to others.
Real sustainability
Promoting surgical efficiency is a key early teaching. On my first trip to Beijing, I found they were performing two or three cases a day and had 20 or 30 employees in the operating room. In my operating room in Tennessee, I do 12 cases a day and have two employees! They had a two-year waiting list and people were going blind; teaching them how to be fast and how best to use their equipment and human resources was vital.
Building relationships and maintaining contact is key – as is sharing resources. If you have any books or papers that you can take over and give them, please do; it will support what you have demonstrated in the operating room. Furthermore, if you can share the resources on screen to describe what you are doing beyond the operating room, it has a huge multiplier effect. Even in 1987, when I was operating on the Orbis DC-8 Flying Eye hospital in Moscow, a black and white TV in the cabin screened what was happening in the operating room. When in Beijing on the Orbis DC-10 in 1994, there were way more doctors than could fit into the aircraft, so a large screen was installed in the hangar to allow more people to watch the surgery. And because the doctors were ‘on site’, they could alternate physically coming on board the plane and asking questions – a much higher level of engagement than just live-streaming the surgery on the web.
Sustainability isn’t just about partnership and education, it’s also about ensuring feasibility; there is no point using fancy equipment in a live surgery, if that particular location will not have access to it when you are gone. You also need to make sure they have sufficient finances to source the consumables needed for the surgeries. ‘Vetting’ hospitals to assess infrastructure, as well as the best and most ethical people to teach and pass on knowledge, means that your efforts are likely to be more sustainable. Collaborating with the right people is also important. When attending international meetings, it is always worth seeing who shows up and gives the most insightful and interesting talks; these are typically the leaders in the field back in their country, and are often the best people to collaborate with to ensure sustainability.
The do’s and don’ts of international ophthalmology
DO
- Take a sustainable approach – train the trainers and teach the teachers. Partner with your new colleagues and share skills. Build relationships and maintain email contact. Even facilitate visits to your operating room. All this ensures an ongoing sustainable approach beyond performing surgeries.
- Be culturally sensitive.
- Make sure you are delivering the highest care possible.
- Use their team and their equipment. If you bring technology that they cannot afford, it isn’t sustainable.
- Emphasize medical ethics and post-operative care. Also teach when to operate and when not to operate.
- Teach and instill the importance of efficiency – 70 percent of surgery costs are labor.
- Watch your ego! International ophthalmology is not a ‘photo-op’ for practice building at home.
DON’T
- Show off. There is no need to show an extreme triple procedure. Perform and show a mainstream procedure; something that will be encountered frequently, but can be a little bit difficult. There is no point demonstrating a really uncommon case that might never be encountered again.
- Use the term ‘third-world country’. If you really must assign a title use the term ‘developing country.’
- Drink too much or party too hard…
- Forget why you are there!
Confession
I remember operating in Beijing, when the temperature hit the highest ever recorded. Unfortunately, the operating room only had one spare electric outlet, so either the air conditioning unit or the laser we needed for the procedure could be plugged in. They cut the back out of my scrubs; and when I wasn’t using the laser they blew cold air onto my bare back so the sweat wouldn’t drip off my head and onto the patient!
I have a lot of experiences where my engineering background came in handy. I remember operating in Havana with Orbis, and the power generator and the air conditioning failed. Because the engineers had left the plane, I went and checked what was wrong with auxiliary power unit. I fixed it and got it re-started, restored electrical power and finished the case. Similarly, another time in Singapore, the microscope failed. I found some tools and a ladder, took apart the power supply, and fixed it so that the case could be finished. Being knowledgeable about how equipment works and how to fix it on the fly has definitely been important to my live surgery experiences. Wherever I go, I always try to instill an understanding of how the equipment works.
I have also had some interesting live surgery experiences outside of the operating room. Once again in Beijing, I was invited to a large reception where I was seated across from the Minister of Health. He handed me the aperitif: cobra bile. It was the vilest smelling substance I had ever encountered – but all eyes were on me. So I knocked it back and slammed it down. One of the Englishmen at the same table asked me how it was, and all I could say was that it was much finer quality than the cobra bile we drink back home! So every now and then strange food objects might appear. It does pay to be culturally sensitive, but I do have rules...
International guidelines
In my opinion, there are too many surgeons who can’t wait to travel to a country with eyecare challenges, perform a handful of cases, spend four weeks climbing a mountain or sightseeing, before returning back home and declaring that they are a philanthropist. I think it is simply wrong to go to another country and spend one day pretending to help people so you can put it on your Facebook page or declare a victory in your local church. When I am performing international surgeries, I try to send the right messages (see ‘The do’s and don’ts of international ophthalmology’). I don’t need to go on a VIP trip to the Taj Mahal or the pyramids; I don’t want a fancy private dinner with the chairman of the department or the President; I don’t want to be given an award or have my picture taken for the wall. I am just a regular surgeon, and I want to spend time with all the doctors that I am there to work with. I’m not saying that all sightseeing is bad – if your international colleagues are proud of their culture and initiate the process it is a wonderful way to build collaborative relationships! I just think that spending the majority of your time vacationing and resting can send the wrong message. I also discourage gifts – I would much rather see money being put into equipment and education.
International ophthalmology is about so much more than going and performing live surgeries, it’s really about delivering sustainability. And it is not about you. Train the trainer and leave behind a legacy of better care.
Steve Charles is a vitreoretinal surgeon and founder and owner of Charles Retina Institute, Memphis, Tennessee, USA.
Steve Charles is the founder and owner of the Charles Retina Institute, Memphis, Tennessee, USA.
