Global health Opportunities in Anesthesia

Jo Davies, MBBS, FRCA,

Professor of Anesthesiology and Pain Medicine,  University of Washington,

Director of the Society for Education in Anesthesia (SEA) and Health Volunteers Overseas (HVO) Traveling Fellowship with the Committee for Global Outreach

https://www.seahq.org/sea-hvo-traveling-fellowship 

Elizabeth T. Drum, M.D., F.A.A.P., F.C.P.P., F.A.S.A., Professor of Clinical Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania

Chair ASA Committee on Global Health, U.S. Program Director for the Resident International Anesthesia Scholarship Program

https://www.asahq.org/charity/programs/scholarship

Bryan Mahoney, M.D., F.A.S.A.

Vice Chair of Education

Director, Residency Training Program

Associate Professor, Department of Anesthesiology, Perioperative and Pain Medicine

Mount Sinai West and Mount Sinai Morningside Hospitals, Icahn School of Medicine at Mount Sinai

Check out the podcast, PD's at SEA (Society for Education in Anesthesia) at: https://www.buzzsprout.com/2554558/episodes

Transcript

SPEAKER_00 0:13

Welcome everyone to a new episode of PDs at Sea. We have a great cast of characters to discuss something I'm very passionate about, and I know that our trainees really love. Today's conversation is going to be about global health opportunities, not just for trainees, but also as part of your career. We have two real experts in this field, starting with Dr. Joe Davies, who's a professor of anesthesiology and pain medicine at the University of Washington. She's the director for the Society for Education in Anesthesia's Health Volunteers Overseas Traveling Fellowship, which is run out of the Committee for Global Outreach. Dr. Davies, thank you for joining us.

SPEAKER_03 0:55

Glad to be here. Thank you.

SPEAKER_00 0:56

And we're very lucky to also have Dr. Elizabeth Drumm, who's a professor of clinical anesthesiology and critical care at the Pearlman School of Medicine at the University of Pennsylvania down the street from me. She's the chair of the ASA Committee on Global Health and the U.S. Program Director for the Resident International Anesthesia Scholarship Program. Thank you, Dr. Drum, for joining us.

SPEAKER_01 1:18

Thanks for having me.

SPEAKER_00 1:20

So we're going to dive right in here. First, we want to give people a big overview and also learn a little bit about your career. So, Dr. Davies, how did you come to have an emphasis on global health in your career in anesthesiology?

SPEAKER_03 1:33

Well, it evolved in a natural way that was partly intentional and partly based on opportunity and being in the right place at the right time. I've always loved traveling and my interest in global health really kicked off when I was a medical student, when I had the opportunity to spend a month at a rural hospital in Malawi. As for so many, this was a profound and eye-opening experience for me. A long anesthesia residency limited my ability to pursue this interest for several years, but when I first came to Seattle as an attending, my passion was reignited when I had the chance to participate in various service trips to developing countries doing clef lip and palate surgeries. Around the same time, I joined the Society for Education and Anesthesia, which we all love, and joined the Global Outreach Committee chaired by Dr. Lena Dolman, who has been a fabulous mentor for me. This was followed by a request for me to re-establish a site in Malawi for Health Volunteers Overseas as part of the SEA HVO Fellowship. And in more than 20 years since then, I've had the pleasure of being the chair of the SEA Global Outreach Committee and have been running the SEA HVO Fellowships for the last 13 years. So it's amazing what can happen when you start small and all of a sudden you're sitting on a podcast having these conversations as someone who has had a lot of experience.

SPEAKER_00 2:58

Well, we appreciate the work that you've done. Multiple of my residents have had the privilege of taking advantage of that fellowship opportunity. We also, Dr. Drum, you do something somewhat similar with the ASA, but could you also give us some background on how you came to global health as a major part of your career in anesthesia?

SPEAKER_01 3:17

Well, I always had an interest in volunteering throughout my life and growing up, but never really had much opportunity to figure out how to connect that with my medical career. In 2009, I found myself at a sort of transition point in my career where the children's hospital where I had worked had recently closed, and I was in a position where I had a little time on my hand, and a surgeon colleague was asked to go to Ethiopia to investigate some clinical needs there and asked if I would go with him. And that really sort of opened our eyes to some of the great needs in Ethiopia for ENT and anesthesia education in particular, but in medical care in general. And then soon thereafter was a large earthquake in Haiti in 2010. And because of my work situation, I found myself in a place that I could actually go and volunteer there. So those two experiences together, I think, really opened my eyes to the great needs, not only for clinical care, but for education and training and allowed me to explore those since then.

SPEAKER_00 4:26

And how, after those experiences, how did you get involved at the national level with the ASA in a leadership role?

SPEAKER_01 4:34

Well, I uh joined several groups and organizations that were working on global health activities to learn more about what was out there. And then I joined the ASA Committee on Global Health. And through my then developing collaborations with Ethiopia and learning about the amazing work that C and HVO did, we decided to try to create a similar program within the ASA with slightly different focus, but really modeled after the highly successful C program.

SPEAKER_00 5:06

I think it's interesting to hear people's stories and we realize that the things that we're involved in and the individuals who enter anesthesiology bring so much to the field. You guys have shown how your personal experiences have led to providing opportunities for trainees. So staying with you, Dr. Drum, you started to touch upon the opportunity with the ASA. Can you describe what the ASA offers and how residents can become involved?

SPEAKER_01 5:32

Well, the Committee on Global Health does a number of things, one of which is run this resident international anesthesia scholarship program. Similar to RC, we solicit applications for the program, and then we select winners every year and then determine where is the best location for them to spend a month rotation. Really, our goal is to embed them into the educational program and within an anesthesia department somewhere to really learn about the challenges to delivering safe anesthesia, to being a patient and a provider, both uh medical and surgical and maybe nursing in another country, and then really to try to in some way interface with the educational activities that are going on. Then most of them, you know, come back full of energy and and some actually have the the ability to have further visits or it sparks uh other global health interests or activities for them in the future. There are other ways it's residents can be involved. For example, residents can join the ASA Committee on Global Health. And there are some other projects that the committee sponsors that occasionally residents can participate in.

SPEAKER_00 6:50

What are some of the sites uh where the residents involved in your program spend time?

SPEAKER_01 6:57

Well, unlike the C program, our sites sort of change over time because it's really dependent on where we have either collaborations or faculty that are working. Our initial plan was to send all of our residents to Ethiopia, which we did for a year or two, but then there was some political unrest and some reasons why we couldn't send our residents there. Uh there was also a pandemic somewhere a few years ago that you know changed sort of our approach. So now, really, we have some ongoing sites in different places in Africa that we have sent people, Ethiopia, Rwanda, and occasionally Kenya. And then some of the members of our committee also have ongoing work in places like Guatemala. And our committee does work in Rwanda and Guyana. And so we've sometimes sent uh residents to those locations as well.

SPEAKER_00 7:54

Well, Dr. Davies, you said you've been running the S the C Health Volunteers Overseas Program for 13 years. Would you talk a little bit about that program and also talk about how residents get involved in that? Sure.

SPEAKER_03 8:07

So I really would like to give a big shout out to Dr. Lena Dolman. This was her brainchild. She went with HVO in the 80s to do a trip with her husband, who was an orthopedic surgeon, and she got inspired to try and set something up. And so back in the early 2000s, she created the C Gatz Fellowship because it was Dr. Gatz who donated the money to support that. She wanted residents to have the opportunity to do a global health elective focused on education of anesthesia trainees in developing countries. And she recognized that helping build a strong foundation of knowledge would hopefully improve the quality of anesthesia care delivered. She then partnered with health volunteers overseas who have the same educational goals across many different specialties. So successful fellows spend a month teaching at one of the HVO anesthesia sites, very much like ASA. And these sites do vary. I ran a program Malawi for 12 years that sadly has since had to close down. But we currently have programs in Vietnam, Uganda, or Rwanda, with Nepal coming online shortly. And we're always looking to expand and have new sites. We'd love to have another site in South America. We've had sites in Peru before, and so it's a constantly evolving situation, depending on situations in countries. You know, if there's civil unrest, we do not go in. The teaching is primarily classroom-based in the form of didactics, workshops, PBLDs, etc. But I'm sure like ASA, there is time spent in the OR helping guide care. But the emphasis is very much on education, not on clinical duties. You know, having people provide clinical, direct clinical care comes with all sorts of complications and issues. So we really want them teaching the trainees, and we recognize that demonstrating certain techniques can be very beneficial, but that isn't always possible. So people have to get very good at describing how to do things to the trainees. These fellowships are all privately sponsored from inside and outside of C, and we actually have a C fellowship where members can all contribute, as you know, to one fellowship that under the heading of just a C fellowship. What started with one fellowship 25 years ago is now up to 10 fellowships a year, including several program specific fellowships, which programs like because if they have good candidates, they have a slightly better chance of getting one of their candidates on that program. Having said that, we always work with those programs and you know say that if the candidates are not making the grade, then maybe they won't award a fellowship that year. So we want the playing field to be as level as possible. We accept applications starting in October of each year for CA2 residents who'll be in the final year at the time of travel. We ask, I'm sure, very similar to ASA, for a letter of motivation, a CV, and a letter of support from the residency program director. We close our applications in late January, and it takes about three to four weeks for the review process to happen before we announce the successful applicants. And Liz and I have worked together, we've collaborated for many, many years because we both feel that we want as many residents as possible to have an opportunity, and it would be unfair for one resident to win two fellowships. And so what we see every year is a variety in terms in terms of numbers, anywhere from sort of four to eight applicants who will apply to both programs. And we have tried to come up with a fair way after the reviewing process that if they rank someone higher than us, they will take them and vice versa. So Liz and I around this time of year spend a lot of time texting and emailing about the nuances that go into this because it isn't always straightforward. But you know, our aim, as I say, is to give as many residents this opportunity, which, as we know, can really change the trajectory of their career. Our awardees attend the annual C meeting in April to be presented with their awards and then get to attend an orientation session, and we take it from there with a lot of interaction prior to their travels. All the information about these fellowships and how to apply is on the C and HVO websites, and wider marketing is done on social media and through email to residency programs to try and spread the word. And that's about it.

SPEAKER_00 12:52

Well, that's great. You know, I have been very fortunate to have had a lot of experience in global health. Some of the sites that you mentioned, I've actually done anesthesia education in Vietnam and Nepal. I'm thrilled to hear you're going to have a site in Nepal. It's a bunch of really enthusiastic anesthesiologists out there, and that's going to be a lot of fun. However, I never knew about these programs when I was a resident. Dr. Drum, you mentioned that sometimes people get the bug, they get really excited. Have you seen a lot of your participants, or maybe just a couple of anecdotes, uh, go on to have an emphasis on global health in their career after the opportunity you guys provide?

SPEAKER_01 13:30

Yes, definitely. And that is one of the most exciting things of the program to see residents become faculty and attending physicians and then incorporate global health in their career. So, yes, I can think of one early scholarship recipient who is now faculty at UCLA and has started a global health program for that department. She's originally from Ethiopia, and so she did her scholarship month in Ethiopia and has been back there several times. But certainly her collaborations and her upbringing give her advantages that might not have been there without an opportunity to travel there under the auspices of the ASA. One of our other scholarship recipients has also started a division of global health in his institution at Colorado and is now has Global Health Fellows there. And also he started a neuromonitoring training program in Ethiopia. So the first for the country to allow local physicians and other technology-trained nurses to be able to provide neuromonitoring in a in a hospital there. Another one or two former recipients have done global health fellowships and have really started some educational and long-term fellow-up programs in other places. So it's really exciting to see to see that.

SPEAKER_00 14:56

We're definitely planning seeds. We're going to transition. I want to talk a little bit more about global health in general. Going back to you, Dr. Davies, you mentioned how for these fellowship opportunities, there's a lot of emphasis on education. Just stepping back a little bit away from maybe fellowships for trainees just in general. What do you view as the role for U.S. anesthesiologists, or maybe more broadly, anesthesiologists or care providers from higher income nations in global health, particularly in low and middle-income nations? Where do you see us serving the best need?

SPEAKER_03 15:28

You know, this very interesting question, and it's not an easy question to answer. You know, the role of healthcare workers generally from high-income countries to low and low and middle-income countries has always been controversial. And there are whole books written about this subject. With regards to anesthesiologist specifically, I'd love to say that in an ideal world, our role will become smaller as countries strengthen their own educational infrastructure and develop a sustainable workforce. But I think the reality is that's a long way off for many countries who still need support in many different ways. And how we support these countries, I'm sure, will change over time. And I would like to think that in-person will be something that's still possible. But as we know right now, getting to some of these countries, a lot of those flights go through the Middle East. And that's not something that can be sustained right now. So it's not just the willingness to go, it's the logistics of getting there. I know that people will go on financially supporting our programs to make them happen, but we also want to make sure these residents are safe when they go to places. What has been happening is that there is more remote teaching happening. I think a lot of these countries do have better access to technology now. When I first went to Malawi, one person had a laptop. And that meant that it was not possible to do anything like that. What's interesting is that a lot of these countries, everybody has a cell phone. So now you can do with, especially with Zoom, thanks to you know the pandemic, a lot of those technologies are now out there and easily accessible. So it may be that over time, if we can't physically get people there, we're going to be able to do remote teaching, hopefully on bigger screens than a cell phone, but you can certainly run certain formats of teaching through a cell phone. The other thing that we've seen happen is a sort of buddy network where these trainees will text fellows who they have been taught by to ask them questions in real time. And I think, you know, it's a bit like our residents coming to us and saying, hey, I've got this case, what do you think? And that certainly is a real thing and is happening. So I think these relationships develop and last beyond the month that the residents go for. And as I say, I'm hoping we can continue physically being there because I think that is the best way to interact and collaborate with these institutions. But as we've seen, there are other ways to still get education across, which I'm excited about.

SPEAKER_00 18:17

So I know Dr. Ling, who has done quite a bit of work in mainland China, has had to transition all of his interaction to web-based and remote education. He did a lot of work, I think, to provide the most value in addition to on-site teaching. I think he also interacted with government officials to change policy, to divorce more care and money towards uh needs like increasing epidural usage, and also uh contacted local industry and would provide, uh, help industry provide the equipment that a lot of these sites lacked. There's a lot of work that he was able to do. Dr. Drum, I want to hear your opinion on the same issue. You know, in your experience through the ASA and also personally, where do you think we can provide the most service? Um, just building upon what Dr. Davies said, if you can.

SPEAKER_01 19:07

I I have to agree with a lot of uh what Dr. Davies said. Uh, and and I will just add that I think one of the most powerful things for me to be personally involved in and also to witness is the long-term personal relationships and collaborations that can develop between people around the world. I just returned from Ethiopia uh a few days ago. I have been there maybe 23 times, if I'm counting correctly. And it's really amazing for me to see the change and transformation that's occurred there since I was there in 2009. When I went there in 2009, there was one residency program with three residents and probably less than two dozen anesthesiologists. Now, 17 years later, there are dozens of residency programs, probably a hundred or more anesthesiologists. And since the pandemic, there are now seven pediatric anesthesiologists who have fellowship training in other countries. And now Ethiopia is starting their own pediatric anesthesia fellowship program. And I'm not saying that I personally made all those things happen, but the people that have gotten to know over the years and continue to work with, mentor, coach, troubleshoot, listen to, meet at meetings, international meetings and stuff, it's really a joy to be a part of not only their career, but watching them learn to become leaders in their own institutions, their own societies, and their own country. And to me, that's really one of the most powerful ways to impact not only medical care, but um anesthesia care in other countries.

SPEAKER_00 20:47

What I'm hearing is people matter, relationships matter. I hope our leaders are listening because these individuals and the bonds we're forming from your experience seem to make a big difference. Uh, Dr. Davies had mentioned, you know, the current war going on and the issues with transportation. I know I've gone through airports that are closed down right now to a lot of my global trips. Uh, Dr. Drum, how are you seeing the not just the war, but other major global events over the past few years, let's say from the pandemic till now, impacting your initiative specifically through ASA or even your efforts in global health more broadly?

SPEAKER_01 21:25

Well, I will say travel issues, travel bans, uh geopolitical instability in countries is certainly a big factor. More than once we've had to change where our residents were going, sometimes as as soon as you know, a month or two before they were going to travel somewhere. COVID uh also uh certainly changed uh the ability to travel. And so that's certainly a factor in determining where residents might go, where faculty might go, where people's global health efforts can focus. I think. Sort of the flip side is true as well. Through the ASA, we sponsor a program which is called our Global Scholars Program, where we bring young faculty members from around the world to the ASA annual meeting for them to participate in the meeting and have some observerships and really get to develop those relationships in person here in America. And that effort has been really curtailed by visa issues over the last few years, but most dramatically the last year. We're meeting later this week to select global scholars for this fall. And sadly, we had to tell some of the applicants that although they probably were great applicants, we would not even consider awarding them a scholarship with knowing that they would not be able to get a visa. So it really isn't wouldn't be fair to them. And it was no reflection on their candidacy or their likelihood of benefiting from the program, but that we knew we couldn't get them here. So that is as troubling to me as the fact that it's hard for us to go places as well.

SPEAKER_00 23:02

Well, I've once heard someone say the worst curse you can give someone is to say, may you live in interesting times. And unfortunately, we are living in interesting times. You know, to build a little bit upon what we've spoken about already, I want to ask, as experts, how you foresee the future of global health given changes in politics, in the economy, and also technology. I'm sure some of the themes you've touched upon already will be involved in your answer. But Dr. Davies, maybe starting with you, let's just look down 10, 20 years down the road. Maybe as an American trainee or someone in academic anesthesiology, what does the future of global health look like with your crystal ball?

SPEAKER_03 23:45

You know, it's a hard question. And it's another one that deserves a much longer discussion than the time we have available today. There are people who say that the golden age of global health is over. I really hope that's not the case. But as we've mentioned, we've touched on geopolitical instability. As we know, there has been a lot of decrease in funding, uh, some funding being cut off altogether, which seriously implicates global health endeavors across the world. Whether that's the kind of thing that we do, whether that's um, you know, HIV programs, vaccination programs, I mean, there are so many out there. We understand that for some countries this is a need to for increased spending in defense. And other countries and organizations have promised increased financial support, but it really isn't enough to sustain ongoing projects. And tragically, a lot of the ground that's been gained, I think we're going to lose. We know that just uh USAID being broken up is going to cost something around six million lives from AIDS, which I think is completely tragic. I think another problem is reliance on and issues with supply chains. On a positive note, because of those issues, there is increased manufacturing capabilities in many low and middle-income countries. And some of that's the technology around the production of equipment. And it's so it's good to see, it's not all doom and gloom. I think right now having a crystal ball for 10 years is it's very murky in there. There is no clear path. I think the current political situation uh is so up in the air that I don't think any of us know where we're going to be in 10 years. As I mentioned before, I hope that our fellowships will continue and will weather the storm, much like I'm sure Dr. Drum hopes for ASA, as long as they're needed, and that we can help get more trainees out there to help other trainees. Um, we mentioned technology, the remote learning, that type of thing. My crystal ball is very gloomy, as I say, but I think there are positive um things happening, and we've just got to find ways to evolve and roll with the punches so that hopefully global health endeavors across the world will continue and just change over time.

SPEAKER_00 26:05

Thank you. Before we close out, Dr. Drumm, any prognosticating you would like to add about the future of global health?

SPEAKER_01 26:13

Well, I share Dr. Davies' concerns about all the challenges. I want to try to focus on a few things that might be positive. Number one, I think we need to leverage the collaborations and relationships that we already have. Number two, I think as a specialty and as societies, we need to find ways to leverage our voices and advocate for changes in policies, whether it be visa or travel bans or something else. I think we need to find ways to support organizations, societies, and institutions in other countries in their own endeavors to impact their own ministries of health and education. I think we can support global organizations such as the World Federation of Societies of Anesthesiologists, which is made up of member societies from around the world, and also speaks for anesthesiologists at the World Health Organization. And I think we need to do a better job of educating our colleagues here in the US about the value of these collaborations and relationships and how people understand that it really is important for all of our future and the future of our specialty. And then if we can focus on that while other things are unsteady or unsure, that perhaps we can at least make some inroads in some of those areas.

SPEAKER_00 27:31

Thank you both so much. In addition to just the knowledge, experience, expertise you've shared here today, I want to tell you I've had multiple residents who have taken advantage of these programs. When they talk about their experience and training, that always comes up as a highlight in their career early on. Medical students are always asking about these opportunities. So at least there's a high interest in this with people who are at the start of their career. So if that enthusiasm is any sign, the future is somewhat bright because we have people who are interested in carrying that torch. Thank you for talking about the importance of relationships and the impacts that we can make as individuals with one another. I think that as long as we all keep the faith, the future for our world and global health in particular should be very bright. Thank you guys both for your time. It's been a great conversation. Thanks for having us.

Larry Chu, MD (Producer) 28:22

Thank you for joining us on PDs at SEA. If you found this conversation valuable, we invite you to subscribe and share the podcast with colleagues who are committed to advancing anesthesiology education. You can access additional episodes and resources from the Society for Education in Anesthesia at seahq.org. We welcome your questions and suggestions for future episodes. Please contact us at PDSATSEA at seahq.org. This podcast is produced by the Stanford AIM Lab on behalf of the Society for Education in Anesthesia. Thank you for your dedication to teaching the next generation of anesthesiologists. We'll see you next time on PDs at SEACK.