Otolaryngology Outreach

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Otolaryngology Outreach

Business of Medicine

Module Learning Objectives

Identify necessary components of preparation and successful practice of otolaryngology/head and neck surgery in low-resource settings.
Anticipate and be prepared to manage challenges presented by practicing otolaryngology-head and neck surgery in low-resource settings.
Explain how medical ethical principles apply to itinerant practice of otolaryngology-head and neck surgery in low-resource settings.

Preparations and Considerations

Is international service work right for you?
- Considerations
  - Time away from work and home
  - Cost
    - Airfare, room and board
    - Transportation in destination
    - Opportunity cost (lost production from time away from practice)
  - Risk
    - Medical
      - Visit your primary care physician
      - Vaccinations: recommendations vary by country
        
        Make sure your tetanus is up to date
      - Prescriptions for common travel problems
        
        Coverage of bacterial gastroenteritis (ciprofloxacin)
        
        Coverage for giardia (metronidazole)
      - Awareness of local or regional health concerns (e.g. malaria, zika, dengue, typhoid, yellow fever, chikungunya, etc).
      - Review Centers for Disease Control travel recommendations for destination country.
    - Political/cultural
      - Research your travel destination
      - Competency or training in the local language is strongly encouraged.
      - Understand availability of interpreters and translators.
      - Understand stability of your destination country.
      - Review political status and health hazards on the website of the United Stated State Department
    - Malpractice
      - Coverage via government memorandum of understanding
      - Separate malpractice coverage
      - If traveling with a group, inquire about local, regional or national governmental agreements
      - Research whether medical license is host country is required
    - Insurance
      - Obtain medical and accident insurance that includes provisions for emergency evacuation to a United States medical facility.
    - Willingness to practice outside of comfort zone
      - Patience with travel needs and transportation.
      - Language barriers can lead to frustration.
      - Expect delays and discomfort.
      - Living arrangements: single room, roommates, dormitory life
        
        Sleep is important: earplugs, appropriate sleep clothing, eye covers.
      - Designate persons both in the foreign country and in the United States who may be contacted in the event of an emergency.
Choosing a program/location
- Types of Humanitarian Outreach
  - Solo provider
  - Group (nonprofit versus self-organized groups)
  - Academic (e.g. teaching workshops)
  - Rural nonacademic setting
- Accessibility of location
  - Difficulty of travel
    - Length of travel, connections, cost
  - Availability of healthcare in case of emergency
- Types of cases
  - Complexity
  - Need for special services, anesthesia, preoperative or postoperative care

The Practice of Otolaryngology/ Head and Neck Surgery in Low Resource Settings

Pre-Trip Preparation
- Communication between team members and with host country contact is critical.
- Before leaving the U.S., research options for cell phone use
  - May need to buy inexpensive cell phones and minutes in host country
- Before the trip, research:
  - Local customs
  - Greetings
  - Attire – in the hospital and outside the hospital
- Types of patients/surgeries - Be specific with hosts with respect to what types of procedures
- Required screening labs, scans, etc - tests you require, add to tests required by hospital
- Outpatient clinics
  - Appropriate number of patients/clinic days for amount of OR time
  - Equipment - Communicate with hosts to know what equipment is on site and
  - let them know what equipment you will be bringing
  - Research local electric voltage system - Be prepared with appropriate plug adapters, transformers
  - Flexible Nasopharyngolaryngoscopes - If you bring your own, may need to educate on proper cleansing/care
  - Microscope
  - Light - expect to bring your own headlight and light source
  - Instruments
    - Otoscopes
    - Nasal speculums
    - Bayonet forceps
    - Laryngeal mirrors
    - Tongue depressors
    - Topical anesthetic/decongestant
    - Defog
    - Hand sanitizer
  - Be aware that clinics may not have reliable electricity or running water
  - Translation services
  - Consent process
    - Ensure patients aware of post op needs e.g. follow up visits, testing, medications
- Surgery
  - Obtaining necessary equipment and supplies
    - Before trip, communicate with hosts about what equipment and supplies are currently on site.
    - Be aware that some supplies may be a lower quality standard
      - Determine whether equipment will be left in host country
        
        Leave with designated responsible individual who will ensure proper care and use
        
        If medications are left, be sure to leave with qualified medical
        
        professional or healthcare organization
    - Triage
      - Likely there will be far more patients than capacity
        
        Limit clinic patients as appropriate
        
        Have a plan in place to for patients that do not get surgery
        
        Plan to come back
        
        Plan for host surgeons to perform the surgery on their own in the future if appropriate
    - Safety
      - Double glove- Not standard in low resource countries; expect to provide your own additional gloves
      - HIV meds- Rate of HIV infection is significantly higher in some developing countries
        
        Have plan in place should an exposure occur
        
        For instance, designate a team member to get meds from pharmacy to carry at all times – (important to have with a team member because may be operating late and pharmacy may be closed)
    - Wellness
      - Adequate resources for hydration, food, rest
    - Role of Residents
      - Expectations about resident involvement should be established before trip, with residents and with host physicians
      - Resident teaching may interfere with training of host physicians
    - Post op care/adjuvant treatment
      - Establish who will be on call for post op patients and how they will be reached
      - Work with host physicians to make sure that care will be available for patients with cases done late in the trip or for patients with complications
      - Familiarize yourself with available resources for adjuvant therapy if needed
- Education
  - Didactics
    - Dedicated time
      - Topics- Communicate with hosts regarding desired topics, solicit ideas
      - Audience
      - Audio/visual resources
  - Courses – it may be desirable to put on a course dedicated to a specific topic/skill
    - Audience
      - Who will attend and how many expected participants
    - Funding
      - Solicit donations for equipment, cadavers, support personnel
    - Cadavers (if needed)
      - How will they be obtained, funded, cared for, disposed of
    - Equipment
      - Will you be using equipment already available or having it brought in?
      - What are the country’s rules for bringing in equipment?
      - Will surgeons in host country have the equipment/resources to do these procedures after you leave?
      - Research local electric voltage system - Be prepared with plug adapters, transformers as needed
  - Operating Room Teaching
    - Assess capabilities of hosts
    - Identify gaps - Communicate with host surgeons to determine skill sets desired
    - Realistic goals
    - Students - Inquire whether there will be students and/or residents from host country, determine expectations regarding their involvement

Data Collection and Program Improvement

Evaluate current state
- Research literature
- Discuss with host
- Identify gaps in knowledge
Collaborate
- Achievable projects to meet goals
- Involvement in research/quality improvement projects may also advance the career goals of host physicians
- Ensure compliance with requirements (e.g. Institutional Review Board approval) in both host country and U.S. institution
Collect data
- Retrospective data collection very difficult due to higher incidence of lost or incomplete records in developing countries
- Ensure integrity of collected data following U.S. and host country standards
- Plan return visits to collect data on previous patients long-term outcomes
Re-evaluate
- Continue data collection to determine if intervention is successful and identify additional gaps

Interacting with Host Physicians

Assess training level
- Training systems are widely variable
- Have frank conversations about training and experience
- Assess training needs, desires
Collaborate to develop training goals
Respect as colleagues
Understand culture, language
Care for patients after mission trip

Ethical Considerations

Basic considerations
- Continual self-reflection on the motives and realistic goals of the effort
- Recall basic medical ethical principles such as respect for autonomy, beneficence, nonmaleficence, and justice, which can often be summarized as ‘First, do harm.”
- One should never practice medicine or surgical procedures for which they are not certified/qualified in their home country
- Understand how cultural and socioeconomic factors may influence patient outcomes
- Respect universally accepted medical practices of informed consent in patients’ native language
- Responsibility of the visiting physician to establish relationships with local physicians and medical personnel before beginning medical care
- Be a welcome guest: guard against paternalistic relationships; understand local physicians may find it difficult to express their opinions
Deadly sins of humanitarian medicine
- Leaving behind complications and poor patient outcomes
- Failure to arrange appropriate patient follow-up
- Failure to match skills and technology to local needs and capabilities
- Failure to incorporate local physicians and medical staff into service effort
- Failure of outreach groups to cooperate with each other
- Allowing ‘training’ or otherwise ‘good’ goals to trump primary duty and respect owed to the patient
Itinerant care
- All else being equal, long-term physician/patient relationships and care are preferable to short-term care
- Extreme caution with complex surgeries in short-term efforts, unless there is adequate local expertise to manage complications (i.e. no care is better than a bad outcome).
- Short-term trips should always include handoff to local physicians and follow-up plan
Training
- Every effort should be made to incorporate training of local physicians and medical personnel to the highest degree possible
- Training of local physicians and trainees should take precedence over training of accompanying visiting students/residents/fellows
- Visiting students/residents/trainees should be supervised according to the same standard that they would in their home training environment, and should not be allowed to take on tasks which are above their level of training
Special Considerations for Photography and Social Media
- There should be informed consent for any medical photography in the patients’ native language
- Informed consent should include the planned use of any photography (e.g. fund-raising, academic scholarship)
- Informed consent for photography should be documented
- Photographs should not be shared on social media unless there is a specific purpose (e.g. fund-raising) and informed consent has been documented

Challenges

Patients:
- Travel – lower number of otolaryngologists per capita means most patients in rural communities, significant distance (and cost) to gain access to healthcare, particularly specialists
- Cost of care – costs low by U.S. standards may be insurmountable especially for patients who are subsistence farmers, large family to support, breadwinner disabled for period of time
- Cost after surgery – even if surgery is provided free of charge, cost of maintenance medications (e.g. leveothyroxine) or adjuvant therapy (e.g. radiation therapy), may be prohibitive and may affect decision whether to have surgery
- Impact on family – cost of care may affect multiple family members, for instance if cost of care means no school fees for children, selling an animal or land to pay for care
Hospital:
- Lack of equipment/supplies, running out of necessary supplies
  - Basics in the US (e.g. endotracheal tubes, gloves) may be in short supply and may be unavailable at times. Equipment may be lost or broken for yearsAging, and/or outdated equipment
  - Critical equipment (e.g. cautery unit) may be very outdated and unreliable
- Poor quality supplies, equipment
  - Lower quality supplies and equipment are often sent to developing countries (e.g. thinner gloves, suture breaks easily or needles bend easily)
Lack of resources
- Hospital: Mission, Private, Government
- Many hospitals in low resource settings struggle to maintain and acquire equipment and purchase necessary supplies on limited budget
- Bring all necessary resources possible- Avoid relying on availability of any critical piece of equipment or supply items
Busy clinics
- Degree of need greatly exceeds available resources
- Be prepared to manage emotional burden of leaving untreated patients.
Busy Operating Rooms
- Be considerate of burden of mission on hospital resources and staff
- Balance patient and surgeon safety with degree of need
- It is not possible to care for all patients in need
- Try to maintain balance of treating as many patients in need as possible without endangering team members due to fatigue, dehydration, jet lag, infectious diseases, emotional burden
- Create supportive environment for team members to take breaks, experience the culture and community, speak openly about impact of trip physically and emotionally
Short-term nature of trips
- Leaving untreated patients
- Excessive patient load
  - Visiting physician fatigue and wellness issues
- Inability to fully appreciate the local culture
- Inability to completely understand medical and surgical environment and patient care issues outside the operating room
- Lack of long-term follow up
Politics
- Political actions may have profound impact on healthcare and on the safety of the host country for visiting surgeons. Be constantly aware of the political situation in the host country and be prepared to adjust plans if there is an increase in security threat. For example, avoid visits during elections/change in government
Corruption
- Corruption and bribery are common in the developing world and may affect your ability to provide care as well as the safety of the team members
Culture
- Education
  - The general population may be less educated (particulary health Literacy) than surgeons are accustomed to, and this may affect ability of patients to fully comprehend their medical situation, the proposed treatment/surgery, and post op care needs
- Religious/spiritual beliefs
  - Patients and/or family members may have belief systems that affect care. For instance, patient may have sought care from a tribal healer prior to seeking care from western medical practitioners. There may be some suspicion for western medicine.
Language barriers
- In addition to typical language barriers, patients may speak only their tribal language, particularly if they live in a very rural area or are not educated

Sustainability

Long-term partnership with host otolaryngologists
- Establishing and maintaining a relationship with surgeons and healthcare providers in a community allows building on the education of host physicians and also building on the understanding of the local practices/limitations for the visiting team members
Continue contact after trip
- Ongoing communication aids in relationship building with colleagues in host country, better trip planning and expectation setting, feedbackregarding patient outcomes
Building host otolaryngology program/department
- Appreciate that host physicians have career goals and desires for their clinic, hospital, department as well
Outcomes
- Plans to return and build on previous experience also allows for collection of data on long-term outcomes of care from previous trips

References

Jafari A, Campbell D, Campbell B, Ngoitisi H, Sisenda T, Denge M, James B, Cordes S. Thyroid Surgery in a Resource-Limited Setting: Feasibility and Analysis of Short- and Long-Term Outcomes. Otolaryngol Head Neck Surg. 2017;156(3): 464-471.
Sykes K. Short-Term Medical Service Trips: A Systematic Review of the Evidence. Am J Public Health. 2014;104(7):e38-e48.
Fagan JJ, Aswani J, Otiti J, Mushamba V, Liyombo E, Woodson G, Weed D, Zender C, Mannion K, Netterville JL, Wagner R, Zafereo M. Educational workshops with graduates of the University of Cape Town Karl Storz Head and Neck Surgery Fellowship Program: a model for collaboration in outreach to developing countries. Springerplus. 2016 Sep 23;5(1):1652.
Fagan JJ, Zafereo M, Aswani J, Netterville JL, Koch W. Head and neck surgical subspecialty training in Africa: Sustainable models to improve cancer care in developing countries. Head Neck. 2017 Mar;39(3):605-611.
Welling DR, Ryan JM, Burris DG, Rich NM. Seven sins of humanitarian medicine. World J Surg. 2010 Mar;34(3):466-70.
American Academy of Otolaryngology-Head and Neck SurgeryPosition Statement: Humanitarian Photography.

Otolaryngology Outreach

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