Lecture to American College of Surgeons – Humanitarian of the Year Award – 2013

A 3,500 Word Synopsis of the Theory and Practice of International Humanitarian Surgery

Thank you to the great field of surgery – a beautiful, wonderful and happy field to which to devote one’s life. International Humanitarian surgery has the ability to save the world and to make our career happy. This is a big, bold statement, but I will back it up and tell you why. I use the idiom of comparing our international work to ships at sea: ships are safe in the harbor; but they were not built to be in the harbor they were built to be out at sea. And homologously, highly trained surgeons are safe in their living rooms or at the University, but they were trained to be doing work with patients.

At graduation from medical school, we all took the oath of Hippocrates stating that the patient is our primary and our number one concern. The oath of Hippocrates is more than one page. Uncle Hippocrates goes on to emphasize in several ways that we are professional. A professional surgeon is one whose primary interest is not the self, but the benefit of the other person. The surgeon’s own benefit, only should happen when the other person is happy by our acts. I have had enough experience in international work, benefited from mistakes and formed principles and core values. I feel that I must present my international credentials at this point.

Independent Interplast Corporations:

Germany               Dr. Lemperle

Australia               President Miller & Keith Walter

Turkey                  Dean Prof. Dr. Col. Namik Baran

Italy                      Prof. Dr. Paolo Morselli

U.S: Florida, West Virginia          President Richard Ott & President David Folgarty

Interplast Projects:

Lesotho, Africa                        Dr. Terry Knapp

American Samoa                    Dr. Lars Vistnes

Antigua, Guatemala                Dr. Ernest Kaplan & Dr. Lars Vistnes

Temuco, Chile                         Dr. Paul Daines

Navajoa, Sonora, Mexico        Dr. David Fogarty

Santos, Brazil                          Dr. Jorge Palacios of Ecuador

Bilwaskarma, Nicaragua

Cuenca, Portoviejo, Esmeraldas, Guayaquil, Ecuador

Arequipa, Tacna, Iquitos, Peru

Montego Bay, Jamaica

I apologize for that because it sounds like EGO, but it is not. Rather it may be helpful. Regarding the issue of saving the world, I have discussed this with most every international colleague at every chance, during each of the 159 international trips I have personally taken. 159 personal trips, many as Chief. I have been in jam sessions, debates at our national professional meetings, and at many bars and breakfast over and over. This is my kingdom, it is a heavenly relationship, you can’t imagine how good it feels to be a part of this work. Along with Dr. Glenn Geelhoed, I claim primacy with him, as the first ones, in 1968, to take multidisciplinary teams from university or foundation, to developing countries for short-term surgery trips focused on only one or two diagnoses. Repeated and regularly scheduled trips, beginning with one highly organized needs assessment, the so called “parachute” trip.

Both of us started with transformational, or peak, experience, alone, not working with a group, in 1965. Glenn experienced his alone in the Dominican Republic, after the 82nd Airborne’s had evacuated all other U.S. Passport holders, and Laub had his, same year, and started plans for Interplast trips there, to Mexicali, with training, research, and patient care, which lasted 32 years. It started with this patient with the bag on the head – more later.

Long term professional relationships are formed. The LTPR is the sine qua non for sustainability. 58 organizations have since adopted this model for international surgery; not propter hoc but post hoc, which says not philosophically because what we did, but rather, chronologically after our work.

There are two kinds of compensation: Tangible income, money, and non-tangible income, psychic income – the rich and full feeling we have when the patient appreciates the situation and is grateful. This is not quid pro quo, which is that you do surgery to make other people happy so that you become happy. Rather, the professional surgeon does it for the other person’s happiness entirely. We are all surgeons who are professional. But not all of us are happy.

A recent study from 2012 has shown that half of physicians in developed countries are dissatisfied. They also showed that in one recent year, 2012, the percentage of doctors who would choose medicine again as a career dropped from 69% to 54%.  [1]

There are five reasons for this dissatisfaction:

  1. Our fees have been reduced.
  2. Physicians are very highly trained and are smarter than most. Their best use is treating difficult cases and they are not trained to do what other tell them to do, what to prescribe, what operation to do, and how to do it. The malpractice insurance carrier closely designates the parameters of our practice, as do the hospital committees, the County medical society and professional associations.
  3. There has been a transference of wealth from the medical and surgical field into the trial lawyers.
  4. Paperwork is not a source of enjoyable diversion, not true happiness, and there’s a lot of it.
  5. The lack of ability to use the type of reasoning for which we were trained, deductive reasoning, is another restriction on our happiness. We were trained to “know it all or else be able to find the answer, to any chief complaint or medical problem.” We are the only field that uses this reasoning. All the other medical technical fields: radiology technician, surgery technician, etc… uses reasoning similar to an algorithm, which is inductive reasoning. Medicine stands alone in using deductive reasoning and this is being curtailed now. We feel responsible for coming up with a new diagnosis if it is necessary, by reasoning it out and knowing where to look, using our broad background.

These five reasons for lack of happiness stand in contrast to the happiness which I find in a very high percentage of participants, almost 100%, when on international humanitarian surgery trips.

Dr. Marcelo Velez, #1 Plastic Surgeon in Equador, and Terry Knapp, CEO of large American Company are united by a common purpose and become instant friends
Dr. Marcelo Velez, #1 Plastic Surgeon in Equador, and Terry Knapp, CEO of large American Company are united by a common purpose and become instant friends These images show happiness on international humanitarian trips. I have 92 more showing happiness in the files.

On the left, our Engineer – Pilot. This anesthesiologist liked surgery and became a physician at the advanced age of 37.

On the right, founder of Collagen, my resident, Terry Knapp. Pure joy in knowing another surgeon in another country. To his right is the top surgeon in Ecuador, Marcelo Velez

American nurse. Not uptight at all, as at home. Married a surgeon from Honduras. Has started several foundations

And the reason why I can say that happiness is over there, not over here as much is that I taught a course at Stanford – Principles & Practice of International Humanitarian Surgery – 20 lecturers, speaking to undergraduate students. Each has academic rank of professor, 10,000 operations under their belt, and is a founder or part of a 501.c(3) foundation. Each lecture shows 40 slides, and there’s approximately 100 smiling professionals pictured in each lecture. These 100 from slides at each lecture show happiness at close to that 100% – everyone’s smiling. And you multiply it out, there’s about 2,000 people, surgeons, enjoying practicing international medicine.

And as you know, students are considered liabilities in many cases by foundations and universities. Students at the course not only learn the theory of humanitarianism, but also learn psychomotor skills so that they can be contributory to the success of any trip.

The student was had learned medical photography, and later choose that as his career. That is Ray, my son.

These diplomates are actually able to learn simple suturing –  I call it how to suture like a plastic surgeon, medical photography, research – shown here on the left with Dr. Tom Weiser, good patient intake, keep professional records, make reports. Just about everything except doing the surgery.

Now, let me tell you the Interplast Story, the first of three stories today. The Interplast story is interesting because the foundation began, paradoxically, for the wrong reason, not for humanitarian. Stanford Medical School was founded by “5 wise men” of Nobel calibre, not as a general hospital, but rather, to satisfy research needs. When a freshly minted, Midwest surgeon named Laub landed at Stanford. Expecting a plethora of sick patients, or good patients or challenging or difficult cases, he found a scarcity.

Two roads diverged in a yellow wood – one road was research scientist, about 8 years of hard work. A slip-up in Stanford’s value system occurred just at that crux in the road, and it pointed to the clinical, with Antonio Victoria. This grotesque congenital anomaly precluded any social or educational advancement beyond primary school. Professor Chase, with Laub assisting, in 2 operations, transformed him from social pariah to complete human personality. From dependent person to productive citizen in a short time. A fantastic thing! Faced with 8 years of research to become world-class, or 2 years of surgery residency in order to be able to do international work and derive psychic income from work with the patient, the choice was for the immediate gratification.

In psychic income, you become rich with personal satisfaction obtained when you help somebody else. It accrues when we practice medicine, curing pathology of a medical nature in a single person – one by one. The interaction with a single person’s life, experiencing the cross-section of their life, knowing them, is a large part of what our lives are about. Helping their problems is significant and meaningful and opens many doors. Your life leaps ahead with learning, joy, and an addiction to do it again and again the rest of your life.

This very first patient that Chase and I saw in clinic looking for more cases had a bag on his head, because of a relatively straightforward burn on his face, pulling down of the eyelid, ectropion. This small physical deformity had caused a huge social disability in that particular culture, which had, at that time, less money and less technology and a greater value on the physical appearance. But I realized suddenly he could be cured by the skills that I possessed at that early stage of a young surgeon’s training. All it would take is a skin graft and release of the ectropion, and perhaps a little cartilage implant. That would change the patient’s life – he’d throw the bag away!

I was thrilled to possess the ability to change this patient’s life. I underwent peak experience at that moment. The transformational or peak experience is a sudden coalescence of all previous training and experience into one clear career path. My clear, career path was to set up a clinic 500 miles away from Stanford on the US border with Mexico, visiting every three months, with twelve operations per weekend, teaching the skills of plastic surgery four times a year to residents, and watching the residents undergo an attitudinal change, that is, learning the value of helping others with surgery, a way of life directly taken from Hippocrates’ directives to us; we are his progeny.

The peak experience can be summarized as, “this is what I want to do for the rest of my life.” I’ve heard that quote 39 times at the operating table with a trainee on an international trip. I have also heard, “this is what I went into medicine for in the first place.” “Service is actually really fun.” The big vision was that eventually 25% of plastic surgeons would participate in international humanitarian surgery at some time. And this was verified with a study, done by myself as President of the Educational Foundation, in 1980.

I speak in defense of the parachute trip. The parachute trip as the initial introductory trip is necessary. That first trip is in ACTUALITY is the first trip of 30 to 50 following trips. The trips

Go through this sequence, more frequently than not:

Trip Once: Needs Assessment – what they want, not what we offer

Trip Two: Collaborative Model – the formal letter of intention, or LOI, is formed and

written by both countries, not the individual, signed formally (which is important in the other country). This letter is a clear legal document, and is usually crowned at the signing with champagne

Trip Three: Task Analysis, assignment of jobs to persons

Trip Four: Implementation, immediate feedback and revision of plans

It is interesting to note that as experienced business CEO’s began to assist us at the B of D level in Interplast, the business axiom surfaced – “every decision must relate directly to the bottom line.” And now, that theory became opposite to the reason why Interplast was started in the first place. Even though the students and residents would provide for succession 10 years later, the bottom line was 1 year. The students were viewed by the businesspeople as not directly contributing, and after fierce debate, were eliminated by 15-13 vote. As I’ve said before, the precipitating cause for starting the great Interplast was to find patients and teach. And now, they did not fulfill the axiom.

So, I left Interplast sort of as a martyr, and began teaching the course, with its own huge multiplier factor. The multiplier effect had occurred earlier, starting of course with my own genes as they were expressed in my first son, Donald R. Laub II, a product of my beautiful wife and myself. Donnie’s or D2’s genetic inheritance and his epigenetic predisposition to service were expressed at a very early age. He became a microsurgeon before entering medical school. He now exceeds me in every department.

The biggest challenge of my life came in the form of aggressive, malignant, large-cell lymphoma of the central nervous system. It was intravascular, not the brain tissue. The challenge was formidable: 85% morbidity after all chemotherapy and stem cell treatments, with only 200 cases report at that time in Christmas 2000. It was at first erroneously diagnosed as prion (mad-cow disease). I was rescued, however, with auto stem cells, a biopsy, and 6 courses of smart-bomb chemotherapy in the hospital. I didn’t have surgery or x-ray therapy. For me, the question remained: if hundreds of patients have died with the same condition, that is, very advanced cancer, and only a very few have lived, why was I was selected to live? I asked this to four experienced oncologists, all of them giving the same five reasons separately: 1) cutting edge medical treatments, 2) intense family and friend support, 3) prayer, 4) dietary methods and 5) an ornery personality.

The second real point here is that medical education over the entire world utilizes the principle of graduated responsibility, not the principle of having guinea pigs upon which trainees learn. Graduated responsibility is the best method of teaching, universally accepted around the world. It’s a stepwise increase in responsibility, carefully monitored, good quality assurance. Of course abuses may occur, but these do not warrant eliminating students and residents entirely from the medical system abroad.

The second story is the Edgar Rodas story. Edgar also received the Humanitarian Award from the American College of Surgeons in 2009. Rodas is a product of American beneficence and his own determination. Our efforts in our country have multiplied in his country. It started with Project Hope, the ship Hope, visiting Peru and Ecuador.

Rodas, in a then second-world country, was a recipient of the teaching, and the skill and knowledge imparted by the USAID, the Navy and the AMA program. Rodas was hit again with beneficence through Interplast, as part of the team doing 50 cleft lip and burn reconstructions in his country, with him as local organizer and active team member.

His questioned himself: Why can’t my country mount a similar, or even better, program for our people? The result of this thinking was his pioneering introduction of a new paradigm in surgery: the doctor goes to the patient rather than the patient to the doctor and he did Mobile Surgery. He brought sophisticated cholecystectomy via laparoscopic surgery to Amazon jungle, Andean Mountain, and sea shore, with a committed team, operating in a hi tech operating room in truck. His record is only 1 mortality in 7,200 cases. He attributes this to the constancy of the veteran team, always committed and always training new recruits.

Catherine deVries, who also received the ACS humanitarian award and is a fellow refugee from Interplast, formed IVUmed – international volunteers in urology, in 1995, and is now a big, big organization working in Honduras, Vietnam, sub-Saharan Africa, emphasizing teaching, research and patient care. IVUmed originally did 500 free surgeries with Vietnamese surgeons. With subsequent training of local doctors, their surgical output in Vietnam increased 1,000 percent.

Teach one, reach many. If the second world can increase their output by 1000%, then the developed world can have a multiplier effect with their 140 resident scholars and the 20 trainees in each country, the multiplier could be even an additional 1,000%. She has also written a new book New Paradigm in Public Health: International Surgery. Ladies and gentlemen, international surgery has begun as a field.

As you can see, at this point in medical history, the 2nd world has begun to contribute to the have-nots as much as the 1st world, and sometimes more. I give you four other good examples of this: Dr. Shankar Rai of Nepal, with the help of SmileTrain, Interplast, and himself, has done 6,000 cleft lip and palate operations, has a training program, and does multiple trips both in Nepal and in India, has a curriculum for teaching, and does good research. What more could you want? Well…Dr. Sunil Richardson, craniofacial surgeon in the most southern part of India, goes with his foundation on multiple trips, many times a year, with students and residents, and has done 5,000 surgeries.

And just as many have been done by Prof. Dr. Jorge Palacios. And here 30 years ago, he started a burn unit. And here he is recently with his truck. Founder of foundation Rostros Felices (Happy Smiles), mobile surgery, moves his team in small auto-bus to distant hospitals.

Now, the most significant is Prof. Dr. Qadir Fayyaz of Pakistan, who has done it all without any help from the 1st world. I show him here in this slide with the halo. Upon asking him how many cleft lip and palate operations he’s done, he said “only 15,000 operations but my friend here (pictured to his left) has done 18,000.” Wow! I was blown away at this time. The point here is that the former second world is now acting like the first world. They are going to yet other countries with sophisticated humanitarian surgery! The developing world is contributing to the developed world in other ways.

It provides needed pathology and good cases, and now, most importantly, by providing the opportunity to form a new, bi-national team including their own professionals, which then travels to a new country. This is the 4th dimension – the recipient becomes the provider.

This is what has happened.

The peace corp’s directives of direct care, teaching, and leaving the country at the point of medical independence have now changed, morphed, into another paradigm: Direct care, teaching, research, and forming one team with the other country. The two countries form one team that then travels to yet another country, building a beautiful cycle.

The point is that the countries that we have visited have come a long way and are now contributing to the advancement of the entire field, to developing the whole thing. For example, the Rodas story, contributes a whole new paradigm of mobile surgery, surgery in a truck, the idea that the doctor the surgeon can go to the patient rather than the patient to the doctor. This is now being exported by the new team of US and Ecuador to the Central African Republic – there is no pulling out phase. We stay with them forever and advance the field. Developing countries have developed themselves to the point of offering significant international humanitarian surgery, exporting skill and knowledge themselves- without our assistance!

The last point is they teach us. And here we demonstrate. With no money and no technology, we find cultures which tend to solve every problem, including the modern problems: psychology, marriage, and having no time. Here is a song, famous in Ecuador. I began with an idiom, and I end it with another.

It is infinitely gratifying to realize that 58 other organizations have been established following the launch of our original model. Human nature condemns each of us to an emotional struggle to balance two primal impulses: to acquire what we need to survive, and the altruistic care for others. Each was essential and complementary in human evolution. In the 20th century, we witnessed a decline in raw survival needs, affording us much greater emotional and material wherewithal to pursue the care of others.

My lucky destiny has been to experience a revolutionary change in the way we, as surgeons, can use our skills as keeps of our brothers on a global scale. Modern psychology confirms what religions have always taught: that the happiness derived from helping others is the greatest and most enduring. If our work produces the effect we hoped for, it is wonderful for the patient. But it is the action of giving which makes us happy.

The Dalai Lama tells us that living with a conscious attitude of compassion leads to the greatest happiness. All the indicators point to the same conclusion. But all of this is well known, so why are we not all falling down in fits of giggling?

———–

[1] Physician Frustration Grows, Income Falls – But a Ray of Hope. Medscape. Apr 24, 2012. ret: Aug 23, 2013 from http://www.medscape.com/viewarticle/761870

 

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