For nearly half a century, young surgeons have traveled to the U.S. from as far as Bangladesh, Sri Lanka, Uruguay, and New Zealand with a common purpose—an international exchange of surgical practice and research information. International Guest Scholarships (IGS) provide surgeons from around the globe the opportunity to visit clinical, teaching, and research facilities in North America with the goal of enhancing the scholars’ patient care practices when they return home. The scholarships, in the amount of $10,000 each, also provide scholars with the opportunity to participate in the American College of Surgeons (ACS) annual Clinical Congress.
Most of these scholarship awards are funded through past and current contributions to the ACS Foundation. Some awards—like the Murray F. Brennan, MD, FACS, International Guest Scholarship—have been established in honor of surgical leaders. Since the IGS program was established in 1968, more than 250 surgeons have been selected to receive the awards.
In this article, three previous International Guest Scholars—Pawanindra Lal, MB, BS, MS, FRCS, FACS, a laparoscopic bariatric and general surgeon from New Delhi, India; Alvaro Sanabria, MD, MSc, PhD, FACS, a head and neck surgeon from Medellin, Colombia; and Rauf Shahbazov, MD, PhD, MRCS, Ed, FEBS, a general and transplant surgeon from Baku, Azerbaijan—describe their experiences at U.S. health care facilities and how this exposure to advanced operative techniques has resulted in improved patient outcomes and safer patient care management in their counties of origin.
Dr. Lal brings safer surgery to India
“There are several different kinds of challenges working in India,” said Dr. Lal, the 2012 recipient of the Elias Hanna Scholarship. “The sheer number of patients, combined with the strenuous, time-consuming process of requesting equipment, can be daunting. There are also limitations regarding time available for operations and, specifically, a lack of available operating rooms for bariatric patients—which is in contrast to what I saw in the U.S.,” he noted.
Dr. Lal visited five facilities in the U.S. in 2012, including Mount Sinai Hospital, New York, NY; University of Southern California (USC) Hospital, Los Angeles; Alta Bates Summit Medical Center, Oakland, CA; Barnes-Jewish Hospital, St. Louis, MO; and the University of Illinois at Chicago (UIC).
“Visiting high-volume centers such as these, I learned how to make procedures more safe and reliable,” explained Dr. Lal. “Since I returned to India from the U.S., we have literally doubled our number of bariatric cases. I learned some new tips and tricks generally related to modifications of standard procedures. For example, depending on surgeon preference, there are differences in the stapling device that can be used or the size of the bougie—some go really tight, some very loose. I kept noting these variances in a small diary as I observed them so that I could apply them when I returned home,” added Dr. Lal, referring to a small spiral notebook he kept in a pocket.
Notably, Dr. Lal, a professor of surgery at Maulana Azad Medical College (MAMC), New Delhi, had not performed a gastric bypass procedure before visiting the U.S. “There can be a kind of inherent fear about doing gastric bypass [procedures]. In India, we perform sleeve gastrectomies 90 percent of the time because they are seen as a more simple procedure compared with a gastric bypass due to the reduced number of joints involved,” said Dr. Lal.
After meeting with Namir Katkhouda, MD, FACS, director, USC metabolic and bariatric surgery program, Dr. Lal said he began to seriously consider the possibility of performing a gastric bypass, primarily due to the fact that Dr. Katkhouda “made it clear that gastric bypass is safer because the risk of leaks is lower than it is with the sleeve procedure.”
Although his interaction with Dr. Katkhouda inspired Dr. Lal to pursue gastric bypass surgery, it was his introduction to Ajay Upadhyay, MD, FACS, FRCS, medical director of the bariatric program at Alta Bates Summit Medical Center, that ultimately led to Dr. Lal’s inaugural gastric bypass.
As part of the site visit at Dr. Upadhyay’s facility, Dr. Lal observed a robot-assisted laparoscopic Roux-en-Y gastric bypass, followed by laparoscopic removal of a gastrointestinal stromal tumor. “Dr. Upadhyay agreed to my offer to visit India in the winter of 2012 as an international faculty member and mentor. After his arrival, he performed a laparoscopic gastric bypass while more than 200 surgeons observed the procedure. He also mentored me, allowing me to perform my first bypass on the fourth of December 2012—a date I cannot forget.”
During his site visit to UIC, Dr. Lal observed another robot-assisted procedure—a renal transplant performed by Enrico Benedetti, MD, FACS, co-director of the UIC transplant center. Dr. Lal called the experience a “high point of his visit to the U.S.,” especially considering the entire procedure was completed robotically, including all three anastomoses.
“You see the organ go from cold slush and placed into the body, and then you see a robotic hand instrument that is used to join the vein of the kidney to the vein of the body, which is when the circulation starts,” explained Dr. Lal. “This is a very critical procedure, and something that is challenging for surgeons to accomplish in open surgery, let alone to accomplish robotically. Having seen this, I could visualize that, with hard work and diligence, it was possible to perform technically demanding robotic-assisted surgery, and that is why I mention this was a high point of my visit to the U.S. It was a grand conclusion [to my site visits], before attending the Clinical Congress.
“The exposure to such a scientific wealth of knowledge was incredible,” added Dr. Lal, regarding his first Clinical Congress in 2012. “Clinical Congress is a great forum for exchanging views and for learning from one another. In addition to learning about advances taking place in the West, it was a very enriching experience to see what is happening all over the world.”
At the Clinical Congress, Dr. Lal established some key contacts, including Subhash Kini, MB, BS, FACS, a general surgeon and associate professor at Mount Sinai Hospital. Dr. Kini offered Dr. Lal advice on a case involving a rare complication—an unexpected esophageal perforation caused by a drainage tube in a 35-year-old female who underwent a laparoscopic sleeve gastrectomy. According to Dr. Lal, this complication was so unusual that it had not been reported anywhere in the literature. “We initially thought it was a leak but it turned out to be a perforation caused by a drainage tube. I had to contact Dr. Kini because it was so rare, and we ended up presenting the case at the International Federation for the Surgery of Obesity and Metabolic Disorders annual meeting in 2012.”
Dr. Lal’s visit to the U.S. also inspired him to conduct original research in the area of bariatric surgery. He presented these findings at the 2014 Society of American Gastrointestinal and Endoscopic Surgeons annual meeting in April, in a presentation titled Early Postoperative Weight Loss after Laparoscopic Sleeve Gastrectomy Correlates with the Volume of the Stomach Excised and Not with That of the Sleeve! Preliminary Data from a Prospective MDCT-Based Study.
Of all the experiences he had during the three-week visit to the U.S., observing the systematic training and mentoring of students seemed to have the greatest impact on Dr. Lal. “At all five centers of excellence—this was consistent at each facility—I saw the intense and focused hands-on training of fellows. In India, we do a lot of hands-on training of residents, but the post-residency fellows in the U.S. really have the opportunity to learn in a very direct manner,” noted Dr. Lal. “Each institution knew I was visiting on that particular day, and yet the chief surgeon still allowed the fellow to operate, standing by only to help him when necessary. Now, if I was receiving a fellow from another country, I would take over and show what we do. I would do the case very quickly, in a short amount of time, and reveal all the tips and tricks to the visiting fellow myself,” explained Dr. Lal.
He noted that the chief surgeons “were not at all perturbed that I was visiting,” and he quickly realized this atmosphere was because of the confidence senior surgeons had in their residents. “The fellow would perform the procedure and the chief would step in only to do certain steps—allowing the fellow to resume the operation. This really changed me,” said Dr. Lal.
“These surgeons can do this because they are confident in the fact that the fellow can replicate the procedure in the same manner as the chief has taught him—in a step-by-step, protocol-based manner,” added Dr. Lal. “This confidence shows me the strength of the system, because it says that this fellow, who I am mentoring, will perform this case as I would myself. It speaks volumes of the strength of the training at these centers.”
Dr. Sanabria brings integration therapy to Colombia
One of the main challenges health care professionals face in Colombia, according to Dr. Sanabria, a 2012 International Guest Scholar, is convincing physicians to adhere to guidelines and standards. “Latin people can be resistant to following strict protocols. It is important to encourage health care providers to be more disciplined,” said Dr. Sanabria, a head and neck surgeon at the Universidad de Antioquia-Hospital Pablo Tobon Uribe, Medellin, Colombia. In fact, Dr. Sanabria is currently developing a protocol to validate an MD Anderson Cancer Center (Houston, TX) symptom inventory for head and neck patients in Colombia.
MD Anderson is one of three facilities Dr. Sanabria visited as a recipient of the 2012 ACS IGS. The other two institutions were the Georgia Health Sciences University, Augusta, and Memorial Sloan-Kettering Cancer Center, New York.
“The most important thing I saw at MD Anderson—something I have never quite seen before—is an integration of other therapies and alternate medicines that support standard treatment and help get better results,” said Dr. Sanabria. “There aren’t a lot of people trained in alternative therapies in my country,” he added. “Before going to [MD Anderson] I was afraid of using them—but now that I have seen them in practice I have a more open mind to the integration of other therapies that can improve a patient’s quality of life.”
Specifically, Dr. Sanabria now recommends acupuncture for patients suffering from xerostomia (dry mouth)—a debilitating side-effect caused by head and neck cancer radiation treatment. Some studies suggest that acupuncture helps treat xerostomia, which can impact a patient’s ability to eat, speak, and sleep.
At Georgia Health Sciences University, Dr. Sanabria had the opportunity to assist in a robotic thyroidectomy. Although one or two pieces of such equipment are available in his homeland, according to Dr. Sanabria, he found it incredibly useful to observe and learn the advantages and challenges of this evolving technology. “If you ask a hospital administrator to buy this equipment, they always ask you how useful it will be—which is understandable because we have a different kind of patient here than you do in the U.S. Here, patients tend to have very advanced tumors,” he said.
Dr. Sanabria said he learned a great deal about clinical and laboratory testing during his visit to Georgia Health Sciences University—techniques that he has since adopted at his current institution. As a result, today Dr. Sanabria’s facility has the largest cohort of outpatient thyroidectomies in the city.
What impressed Dr. Sanabria the most about his visit to Memorial Sloan-Kettering was the “rational use of technological resources” combined with charismatic physicians who exhibited a strong commitment to quality patient care. “My experience here showed me that good oncological care is possible with interdisciplinary and coordinated work and is not exclusively dependent on technology,” explained Dr. Sanabria. For example, the head and neck surgeons at Memorial Sloan-Kettering do not use neuromonitoring of recurrent laryngeal nerve routinely, according to Dr. Sanabria. “After I came back, I worked on a meta-analysis about this subject, demonstrating that its use does not offer much of an advantage in comparison with the classical method of searching the nerve,” he said. “We used to think that you need a lot of technology to make things better here, but in fact, more than technology or money, discipline and a commitment to the patients are what get results.”
Dr. Sanabria said his experience at the 2012 ACS Clinical Congress was memorable, largely due to the format of many of the sessions. “For me, it was a novelty to attend lectures where people are debating a topic. We usually don’t have these kinds of lectures at our meetings, where people show different points of view. In the end, the session chair was able to offer a more balanced view about the topic at hand.”
Dr. Sanabria’s advice for future IGS awardees is to keep an open mind. “I was really impressed to see very famous people sitting at your side and talking to you as if you were their partner, rather than a student. They speak to you as a friend, and you share ideas. So, my advice is to lose your fear of talking to famous people and do not hesitate to discuss a new approach or idea.”
Dr. Shahbazov applies expanded skills and confidence in Azerbaijan
“Although there have been some significant changes and improvements to the health care system in Azerbaijan over the past 20 years, there are still issues in need of a solution,” said Dr. Shahbazov, a consultant transplant surgeon for the country’s Ministry of Health and a 2011 International Guest Scholar. “Not everyone has access to high-quality surgical care due to the lack of an insurance system.” Additionally, new fields of surgery, such as organ transplantation using deceased donors, do not receive enough funding, he said, and are still waiting for approval from the government.
Before Azerbaijan won independence from the Soviet Union in the 1990s, education and medical and surgical services were centralized in Moscow, Russia, according to Dr. Shahbazov. “Whatever Moscow implemented, we were supposed to follow. Unfortunately, the Soviet Union was isolated from the rest of the world and had a health care system that was defective. We didn’t have the opportunity to travel to the west and to be exposed to new advances in medicine and surgery. There are still so many challenges in this independent country, but today, young surgeons have the opportunity to get advanced surgical training in western countries, bring new innovations to their home institutions, and improve overall surgical care for their patients,” explained Dr. Shahbazov.
Dr. Shahbazov visited three medical institutions during his 2011 sojourn in the U.S., including the David Geffen School of Medicine at the University of California-Los Angeles (UCLA); the Annette C. and Harold C. Simmons Transplantation Institute at Baylor University Medical Center, Dallas, TX; and the Cleveland Clinic, OH.
During his visit to UCLA, he observed a few abdominal organ procurement operations. “I learned many things from UCLA in terms of surgical procedure and policy,” noted Dr. Shahbazov. “I learned from Hasan Yersiz, MD, a liver transplant surgeon, how to split the liver in situ in an emergency situation like organ procurement.”
While at UCLA, Dr. Shahbazov also became acquainted with policies for declaring an individual “brain dead.” “Many countries define brain death differently—each country has its own specifications,” he explained. “I realized that, as a country, we should define brain-dead criteria, rather than base it on local customs and culture.”
After returning to Baku, the capital of Azerbaijan, Dr. Shahbazov organized a special symposium with a focus on brain death and organ transplantation. “We gathered more support for this issue by involving Ministry of Health officials, members of parliament, and key figures in the health sector,” he said.
Visiting the transplant institute at Baylor University Medical Center gave Dr. Shahbazov the opportunity to learn about pancreatic islet transplantation. “We have so many pancreatitis patients in Baku who suffer from pain. I met with Marlon Levy, MD, FACS [surgical director, transplantation, Baylor All Saints Medical Center, Fort Worth, TX], and Bashoo Naziruddin, PhD [director, cGMP Islet Cell Laboratory, Annette C. and Harold C. Simmons Transplant Institute], and I learned that this growing field of transplantation can change the pancreatitis patient’s quality of life significantly.”
His interest in islet transplantation prompted Dr. Shahbazov’s return to Baylor University Medical Center in June 2012, to learn the procedure in depth. “Currently, I am a postdoctoral fellow in the islet cell transplantation program. I am learning the procedure as well as actively conducting research in this field of surgery.” Dr. Shahbazov anticipates finishing the program in June and soon after returning to Baku.
The hepato-pancreato-biliary and transplant department at the Cleveland Clinic was the last surgical facility Dr. Shahbazov visited during his time as an International Guest Scholar. “I had the opportunity to meet John Fung, MD, PhD [chair, Digestive Disease Institute], during a previous Congress of International Liver Transplantation Society in Valencia, Spain. However, visiting the Cleveland Clinic environment gave me the opportunity to experience surgical excellence up close. Beside liver transplantation procedures, I observed a trisegmentectomy conducted by Dr. Fung,” said Dr. Shahbazov. (A trisegmentectomy is the removal of the true right lobe of the liver in continuity with most or all of the medial segment of the left lobe.)
As a result of his visit to the Cleveland Clinic, Dr. Shahbazov learned how to resect large liver tumors effectively. After returning to Baku (before entering the post-residency program at Baylor), Dr. Shahbazov performed several procedures requiring specialized skill sets including live-donor liver transplantations, dissection of difficult hilar tumors of the liver, and major liver and pancreatic resections. “My experience in the U.S. has changed my way of thinking and gave me more confidence in doing surgical procedures in my daily practice,” he said, referring to his combined experiences at all three U.S. medical centers.
While attending the 2011 Clinical Congress in San Francisco, CA, he participated in a Panel Session titled The College’s International Travelers, 2011. Dr. Shahbazov’s presentation, Organ Transplantation Perspectives in Azerbaijan, was his first experience speaking before U.S. surgeons. He also attended several didactic and skills-oriented courses at the Clinical Congress, including hepatobiliary-pancreatic disasters for the gastrointestinaI surgeon, management of liver trauma, and management of hepato-pancreatobiliary malignancies. “Senior surgeons were available for every fellow for discussion and idea-sharing,” observed Dr. Shahbazov. “Personally, I was impressed by their modesty, and later I was honored to discover that many of these surgeons have authored chapters in surgical texts.”