Informal teaching with surgeons, OR and ward nurses, and physiotherapists
How things are discussed is as important as what is discussed. Open discussions in which all questions are considered while going through decision-making steps out loud can leave lasting impressions and are productive ways of teaching. Showing respect for the patients and members of the team, as well as their opinions, opens the discussion further. Manners count.
Many volunteers think teaching means trying to pass on a vast amount of detailed knowledge, and the more facts given, the bigger and better the impact. Our greatest impacts often come from simple gestures and the seemingly inconsequential. Anyone who has worked with young surgeons, even in a nonteaching position, knows they watch and judge everything a volunteer does. A few days after showing and explaining some small maneuver to facilitate a fracture reduction, it is probable this young surgeon will put your methods into action and explain it to another colleague, using your same words and reasoning. This sort of teaching may well improve patient care better than any lecture detailing a classification system that cannot be put to use in the present setting or is immediately forgotten.
Teaching organizational skills seems far removed from a typical orthopedic volunteer agenda, but such skills are sorely lacking to some degree and at various levels in most hospitals or orthopedic departments in developing countries. In some cultures people do not think they have any control over events and never devise risk management systems to prevent untoward consequences. Hospitals may lack the infrastructure that demands organization, or the existing processes are ineffective. We can help organize OR instruments, set up surgical safety plans, and offer protocols that suit their needs. Those would truly be lasting contributions.
When volunteers are tasked with formal teaching, they should find out the level of instruction expected and what information or skills are expected. Some organizations have training programs directed at specific providers, with syllabi and approved teaching materials. Discussion with previous volunteers or the administrators of the volunteer organization will help determine what would be useful. Canned PowerPoint presentations copied from the Internet are usually irrelevant and show a lack of imagination and effort. Instructive, entertaining, and pertinent lectures—PowerPoint or scrawled on a white board—given with humor and experiential knowledge are another story.
Most volunteers from high-resource countries have been exposed to different ways of teaching by numerous, enthusiastic teachers. Among the limited resources in many developing countries are good teachers and productive, uncorrupt systems of teaching. In some countries and cultures, teaching is fraught with ambivalence: if too much information is given to the student, he will surpass the teacher and steal the patients. Knowledge is power in such a zero-sum world and is best if not shared too widely.
In such places there is little opportunity to learn how to teach. Surgeons are taught by watching, often becoming technically skillful operators, but when in a position to train may be unable to put the ideas of why, how, and when, not to mention judgment within reach of a resident or trainee. Volunteers can help teach the teachers by framing each patient encounter into a teaching and learning situation.
Good teachers listen. Good teachers ask for advice, are humble, and secure enough to say they do not know what to do or are not comfortable doing a certain procedure. By such examples of professionalism, they will teach more than just orthopedics.
The ultimate in teaching is an exchange of ideas, not simply a one-way dissemination of information. Even in programs that are strictly service-oriented, skills and ideas will be left behind, and the volunteer will have learned aspects of orthopedics he or she had not expected. Just as important are the personal, professional relationships one establishes. They become a conduit for further exchange that can last a lifetime.
Educational Resources
Donated books are welcome teaching aids, but bring the right ones and make sure they go to the right person. In many settings textbooks are limited and are prime targets for theft. As a consequence libraries may be locked with limited access. At some universities—where books are not readily available and the professor is the authority whose views become standard practice for the institution—the culture of referring to books or journals or looking things up is weak or nonexistent.
In settings where books or journals are limited, the culture of how to read scientific literature, evaluate its validity, and put it to use may have never been taught. A volunteer can bring classic or review articles or download them from the Internet and distribute copies for discussion or bring e-libraries on flash drives to distribute.
In settings in which e-books are abundant, usually pirated, local surgeons may be more interested in practical knowledge: how to approach a problem, thinking through the pathology in a systematic and logical way, suggesting solutions with pros and cons, and having backup plans. A surgeon revisiting a hospital or training program will have the advantage of learning what is needed and be prepared with appropriate materials on later visits.
The Internet is open at a more egalitarian level than guarded libraries or pricy textbooks. Smart phone usage and cell phone coverage have expanded exponentially in many austere environments since the first edition of this book, making the Internet a major venue for surgeons in low- and middle-income countries (LMIC) to access techniques and find treatments. An orthopedic topic or procedure typed into any search engine will bring up a wide offering of videos and downloadable pdfs. VuMedi (https://www.vumedi.com/orthopedics/) is one of many platforms that provide free up-to-date content including webinars, videos, and case studies from universities, individuals, and industry.
AAOS and the orthopedic subspecialty societies and their publications provide educational materials and videos. JBJS Open Access, JAAOS Global Research and Reviews, OTA International (Orthopedic Trauma Association), and The Open Orthopedics Journal are aimed at the global orthopedic audience.
Social media platforms such as WhatsApp, Yammer, and Facebook support topic-specific chat rooms or groups to share cases or specific problems.
Younger surgeons should be able to maneuver around the web with ease, leaving older surgeons and those who are not easily conversant in a major global language, with the sense that it is confusing and the information spurious. A volunteer spending a couple of hours at an Internet café with a technophobe colleague can open his mind to the professional and personal uses of this marvelous tool.
Realizing the Internet’s potential in low-resource countries, the World Health Organization and major book and journal publishers created HINARI, Health InterNetwork Access to Research Initiative (www.who.int/hinari/) in 2002. National universities, research institutes, professional schools, teaching hospitals, government offices, and national medical libraries in most low-income and some middle-income countries can apply for free or low-cost access. HINARI’s goals are to promote intellectual rigor through the wide scope of available material, provide the basic materials for research, improve clinical treatment and in turn patient health, and support the global expansion of knowledge.
Ptolemy (www.ptolemy.ca) is a partnership involving the University of Toronto; the Association of Surgeons of East Africa (ASEA); the College of Surgeons of East, Central and Southern Africa (COSECSA); and the Canadian Institutes of Health Research (CIHR). Through its website the medical library of the University of Toronto is accessible to the participating organizations and their members.
HighWire Free access to Developing Economies from Stanford University (http://highwire.stanford.edu/lists/devcon.dtl) offers a number of orthopedic journals from those accessing the site from developing countries.
Global HELP (GHO) (global-help.org) provides free or low-cost publications and videos as a cost-effective method to improve sustainable health care in LMICs. GHO’s focus on surgery, pediatric orthopedics, and pediatrics is motivated by the large number of children in LMICs and the potential such knowledge has to prevent disability and provide long-term benefits. GHO’s publications are specifically selected for their pertinence to teaching and learning in low-resource environments, making them extremely useful and accessible teaching aids for any volunteer.
Through their foundations, industry has stepped up to support volunteers, nongovernmental organizations, surgeons, and allied professionals working in austere environments. The AO Alliance Foundation (www.ao-alliance.org) is building an extensive program to improve trauma and fracture care in sub-Saharan Africa and Asia through education, fellowships, clinical research, and clinical infrastructure support.
Some of the most far-reaching initiatives addressing orthopedic trauma in LMICs have come through IGOT (Institute for Global Orthopedics and Traumatology) and SIGN (SIGN Fracture Care International). These two organizations working alone and together provide surgical training through conferences, hands-on cadaveric practice, and networking at their bases in the USA and in training sessions in developing countries. IGOT www.igotglobal.org/) focuses on an academic approach, encouraging research on trauma in LMICs. SIGN (https://signfracturecare.org/) provides implants to improve fracture management, supported by a team of engineers and an extensive database. Both organizations have been instrumental in changing the perceptions of orthopedic needs and improving the ability to treat trauma by unleashing the potential of surgeons in austere environments.
Acknowledgment
The authors would like to acknowledge Dr. Kaye Wilkins for a lifetime dedicated to improving the care of children with musculoskeletal injuries and also for his contributions to this chapter in the first edition of this book.
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