Are medical missions a time to learn techiques?

Over this next month, we will be exploring how surgeons learn surgical procedures and how suitable medical mission settings are for this sort of learning. Many aspects of how surgeons learn in general is being addressed in an upcoming issue of Cataract and Refractive Surgery Today. In addition, we will holding a webinar on June 3rd featuring this question. Please join us as we discuss some of these questions with Dr. Baxter McLendon during that webinar.

 

In exploring the concepts of how surgeons learn surgical procedures and whether mission settings are good settings to do so, we have engaged surgeons involved in international humanitarian efforts on a regular basis to find out how they might answer some of the following questions.

1. Are medical missions a good time for surgeons to learn or relearn techniques? If so, why?
2. What are the parameters and variables involved on how one should learn techniques?
3. What are the questions a surgeon should ask themselves when setting up a learning experience?
4. What are bad situations for learning new techniques?
5. What are good situations for learning new techniques?

 

See below how these surgeons addressed some of these questions.


Anderson Steven 1Steve Anderson: Depends on what one is referring to. If a surgeon is wanting to learn MSICS, a medical mission can be an excellent place to learn if the surgeon is prepared and well supervised by a more experienced MSICS surgeon who can step in to help if needed. MSICS in particular lends itself to learning in a medical mission setting because it is an appropriate technique for the setting (i.e. mature cataracts in low resource areas). Also, for most US surgeons it is difficult to get a sufficient volume of MSICS cases in the US to feel comfortable with the technique, whereas in a mission setting there are often large numbers of patients with mature cataracts that are appropriate for MSICS.

The above comments really pertain to MSICS specifically. In contrast, a mission setting may not be the best place to learn phaco. The reasons being that the cataracts tend to be much more mature and the facility used may have older generation phaco equipment, lower quality viscoelastic, poor quality scopes, etc. all of which add challenges to a surgeon wishing to learn phaco. The risk of a dropped nuclear fragment is also higher with phaco compared to MSICS.

Mission settings are generally situations where there is less back up in terms of vitreo-retinal surgeons, availability of specialized equipment, etc., so an important goal is to make sure the patient is provided a high level of care regardless of whether or not someone is in a training mode. High quality outcomes should be the expectation of the team even if some of the surgeons are learning a technique. This can be accomplished in a teaching environment if adequate supervision with an experienced surgeon mentor is available.

 

mspencerMarty Spencer
This is a very interesting question. I think that to make a difference in tackling blindness in developing countries we should be teaching the locals rather than using those less fortunate than us to hone our skills. Having said that, I almost always find that I learn more than I teach when I go abroad, but the intent is to teach, and I always do that. There are times when an extra pair of hands is needed and one can contribute by just doing surgery, but that’s after one has already acquired the skills appropriate to the setting. In order to make a difference one should learn the appropriate technique before embarking on doing surgery in unfamiliar settings. Taking the most common example, which is manual sutureless cataract surgery (or the older ‘standard’ ECCE), one can learn such techniques at wet labs, such as at courses at AAO or ASCRS, or, more thoroughly in courses taught at centers where the technique is commonly used, such as Aravind Eye Hospital, LV Prasad, etc.

I feel very strongly that we shouldn’t be using the concept of ‘mission’ surgery as a way of learning a new technique. One should learn the technique first, then do missions when it’s possible to make a difference.
It is more difficult these days for recently trained surgeons to do MSCS. When PMMA lenses were being used it was easier to make the transition, but now the scleral tunnel isn’t widely taught. But I’ve found through years of experience that a well motivated surgeon can learn MSCS in a week, beginning with wet lab and proceeding to surgery with close oversight. Of course I’m speaking here of surgeons who have been doing standard ECCE, but a phaco surgeon would likely not be different.

I’ll be interested to hear the comments of others.

 

mayargaEduardo Mayorga: Any surgical procedure, done at any place can be a learning opportunity if it is supervised by a well trained surgeon following good practice teaching strategies, processes, and procedures.

Medical missions should not be used to train surgeons that would learn from their own unsupervised mistakes.
Under proper supervision medical missions would be a great opportunity for learning, specially if after reaching competence the trained surgeon keeps committing some of his/her time to future medical missions.

 

Glenn Strauss: A medical missions setting tends to force creative learning and heightens ones awareness of the value of every life. For the physician with a strong humanitarian drive, this can be an excellent setting to learn a new technique that will be valued not for its financial potential, but for its potential to do good.

Though there is a risk that learning in a medical missions setting can become a dangerous lab experiment, my experience is that with proper oversight and motivation patients as well as surgeons benefit.

 

matt oliva mdMatt Oliva: I think that this is a complicated question. If there are large number of patients with complex ocular problems and no “center of excellence” nearby to take care of complications then the answer is no. If one is learning techniques in a non time pressured environment with adequate supervision and in a “do no harm” manner, than outreach events can be good teaching environments.

What are the parameters and variables involved on how one should learn techniques?

An observer scope is an absolute and a skilled “master” surgeon nearby is also a must for those learning new techniques. While a trainee can be left unsupervised, there must be an understanding that at the slightest hint of trouble the supervising surgeon is consulted. Also there needs to be backup ophthalmic services that the patient can be referred to in case of dropped nuclei, etc. This is the model of “no disasters” left behind. The surest way to undermine demand for cataract surgery is poor outcomes.

In our HCP model all trainee surgeons have completed an SICS course prior to participating in an outreach event. They all have a good understanding of the procedure already and have practiced before hand and done the steps under the supervision of skilled teachers. Patients at outreach campaigns for training surgeons are selected carefully: typically bilaterally blind patients who have already had their first eye operated on successfully by another surgeon. At the slightest hint of trouble(such as trouble with the wound, trouble getting the nucleus out of the bag, trouble delivering the nucleus, or trouble placing the lens) the attending surgeon is consulted and can either supervise completion of the step or perform the step themselves.
Under no circumstances should the trainee be operating on monocular patients, loose zonule cases, or anything other than a “clean” case. Often times immature cataracts are more difficult for beginning surgeons using MSICS techniques.

What are the questions a surgeon should ask themselves when setting up a learning experience?
“I have this patients vision in my hands and this may be their one chance to see”. If I am at all uncertain about my ability to complete
Am I helping the situation or taking away a microscope from a local surgeon who could be learning?
What are bad situations for learning new techniques?
Time pressured situations, remote situations, poor microscope, no Vitreoretinal support. Challenging PXF cases.
Not working with the local doctors and leaving behind complications.

What are good situations for learning new techniques?
Working in collaboration with local staff. Having a long term relationship with the place you are working.
Working near a center of excellence to deal with complications.
Suitable patients(see above). Having studied hard beforehand.

 

brownHarry Brown:
1. Are medical missions a good time for surgeons to learn or relearn techniques?

No, unless the mission program purpose is to provide an educational experience by qualified teachers for inexperienced surgeons in a short time, Such courses are available.
Most missions are to restore sight to as many disadvantaged blind people in the limited time available. This is not the place for the “See one, do one, teach one” mentality.

2. If so, why?

There are a number of reasons why surgeons should not participate in mission programs to learn new surgical procedures practiced by ophthalmologists in the developing world.

Is not fair to the patients. An organization that allows surgeons to "practice" on the local patients is open to criticism by health authorities and others.

Visiting surgeons should be familiar with surgical conditions that they may encounter and comfortable doing the kind of surgeries that they may face.

Visiting surgeons may find the cases are much more advanced than they have been trained to handle using techniques practice in the Western world.


3. If not, how can a surgeon address learning a new technique effectively and appropriately?

In the case of cataract surgery there are a number of avenues available for surgeons considering participation in clinics abroad.

These include specific courses and wet labs offered at the major medical meetings in the US and abroad.

A number of nonprofit organizations offer courses to familiarize surgeons with techniques to do safe small incision manual cataract extraction surgery.

Video courses are available from a number of organizations to introduce surgeons to techniques of cataract extraction in Third World countries.

What are bad situations for learning new techniques?

Trying to perform ophthalmic surgery by a surgeon who is untrained and unfamiliar with the appropriate surgical procedure.

It is difficult enough, even for experienced surgeons to perform the surgery after long hours of travel with jet lag, operating in the facility in which he is not familiar, relying on local technicians and assistants who do not speak your language and on cases which are so advanced he may be totally unfamiliar with how to safely perform surgery required.


What are good situations for learning new techniques?
Formal courses by recognized organizations that teach new surgical procedures.

What does medical missions have to do with this topic?
It is very important for medical mission organizations to establish guidelines listing qualifications of participating surgeons in order to participate in their programs.

 

Dr. Brown rsDave Brown:  1. Are medical missions a good time for surgeons to learn or relearn techniques?

Yes and no. A short term experience with adequate supervision can be an excellent time to add a small number of focussed techniques. Such as an MSICS incision, or a new capsulotomy technique, or manual nuclear manipulation and removal. It depends on the foundation of surgical skill that the surgeon is bringing to the table. A very experienced surgeon can quickly learn and incorporate and refine these MSICS specific skills in a few days to a few weeks. A newer less experienced surgeon or ophthalmic resident typically does not have the foundation of experience to transition successfully to MSICS in only one week. Some foundations can be laid, but typically a young surgeon will need further exposure, experience, and teaching to gain the skills and experience to do routine, repeatable, successful, and safe MSICS surgery. Managing complication or complex MSICS surgeries requires additional time and experience.

2. If so, why?

See above

3. If not, how can a surgeon address learning a new technique effectively and appropriately?

The key is adequate supervision and appropriate expectations. The teacher has to have the ability to recognize the students limitation and weaknesses, as well as their strengths and successes. The teacher must know when to tell the student to stop, and manage the surgery if necessary for patient safety. This is especially true on a short term mission setting. The reputation of the short term outreach depends on upon successful generally un-complicated outcomes, not on the volume of surgeries done. Overseas missions is not a place to practice and not worry about the quality of the outcomes. Quality outcomes in these settings are paramount, perhaps more important than in a fixed permanent clinic setting.

The student must have reasonable and perhaps even scaled back expectations, on both what his or her ability is to quickly learn and apply new techniques, as well as the speed of their surgical time and related the number of surgeries that can reasonably be done. We surgeons tend to overestimate our surgical times and volume of cases that can be done in unfamiliar settings with unfamiliar staff and unfamiliar instruments with a new technique.

We do what we do so well in today's phaco world, we have made an incredibly complex and highly difficult procedure look very easy to the outside world. Let's not sell ourselves short. Cataract surgery is hard, and takes an incredibly high level of skill. MSICS surgery, especially when not the ophthalmic surgeons go-to technique, is that much harder.

 

feilmeierMike Feilmeier

My answer is absolutely it is a good thing to teach new techniques on medical missions. I think that a few things have to be in place to ensure that we are maintaining a high level of quality.

1. Quality operating microscopes with teaching scopes.
2. Appropriate patient selection for the level of competency and training of the person learning the technique.
3. Most importantly, adequate supervision from someone competent in the procedure being learned.
4. Appropriate informed consent is obtained from the patient.

I do not think it is appropriate to use medical mission trips to experiment or learn or pioneer new techniques at the possible expense of poor or unknown outcomes.

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