While many closed their doors during the pandemic, Stanford Surgery was providing open education with global partners to save lives.

Meet Dr. Anna Luan, a 5th year plastic surgery resident at Stanford who worked with ReSurge International during her professional development year between 3rd and 4th years of residency. Anna Luan had very recently won the 2022 AAHS (American Association of Hand Surgery) Annual Research Grant for her project entitled “Application of Machine Learning to Osteoporosis Screening Using Hand Radiographs."

How it all started: Dr. Anna was interested in global surgery even in medical school but never found the opportunities that she was looking for, as she was interested in more than being an observer. During her early years as a plastic surgery trainee, she identified opportunities in education due to its potential for long-term impact. Dr. Anna learned about the Laub Fellowship with ReSurge International as a way to engaged in the educational work she was so passionate about during her research year. Dr. Chang, the Chair of Plastic Surgery at Stanford, is the Consulting Medical Officer of ReSurge and has been heavily involved in global surgery for many years. Dr. Anna was inspired by the work, and also knew of the experience of Dr. Peter Deptula, one of her fellow residents who was part of the same fellowship one year prior. The Donald Laub International Fellowship is named in honor of Dr. Donald Laub, the founder of Resurge International.

The Visiting Educator Program: Dr. Anna spent a year as part of the Visitor Education Program. Resurge International engaged in some traditional “mission” style surgical trips, but its main focus is on education and sustainable knowledge transfer. Visiting educator trips involve an educator team traveling to specific partner sites for a week. It usually includes a surgeon together with hand therapist or a speech therapist, anesthesiologist, or a pediatrician (or any member of the team who would be beneficial to the local medical team) to provide specific training and education. Dr. Anna worked on setting up and participating in these educator trips. Unfortunately, in the middle of her work COVID interrupted her plans, so she helped transform the efforts to virtual education. While Dr. Anna and her team were worried that this system wouldn’t be as effective as in-person visits, they soon realized that if it was done properly it could be a scalable, sustainable method to provide continuing remote education. Even after resuming personal trips, this system has been a valuable resource: trips where surgeons get hands-on training are supported and supplemented by virtual sessions with some of the most

respected experts in the field who could be available for questions, and where participants could follow up on cases and learn new topics. She was proud to be part of the team that established this virtual education module.

We asked Dr. Anna if the virtual education sessions were maintained at the centers visited. She answered: “We had big seminars where we invited partners of ReSurge from all over the world. These were large webinars normally attended by 40-50 participants, but we also had smaller education sessions which were focused on certain groups of people such as a series of seminars we hosted with about 5-7 surgeons from COSECSA [College of Surgeons of Eastern, Central, and Southern Africa] in Africa. These were once a month on average.”

We asked Dr. Anna about the frequency of these seminars, and how they dealt with the different sites time-zones. “The time zones were hard, and we had to find the right time that worked reasonably for the whole group. Typically, it would be either early mornings or late at night [California time]. In terms of frequency, the large seminars were quarterly while the smaller seminars with Africa surgeons were once a month.

“We focused a lot on pediatrics including congenital hand surgeries like polydactyly, syndactyly. Also, congenital craniofacial syndrome cases like cleft lip, cleft pallet. The other big category is burns. In many countries, the initial treatment of burn injuries is not as good as it is in the US. A lot of patients don’t get initial treatment, or they don’t have good care afterwards so a lot of them end up developing contractures. So we treat a lot of secondary burn scars with surgeries.”

Remarkable trips and different priorities: During her year Dr. Anna went to Havana, Cuba on a Micro-Surgery trip; there is no Micro-Surgeon in the whole country at all, meaning that any patient needing microsurgery reconstruction had to do without it. She also went to India, Nepal, Ecuador, and Vietnam as part of her fellowship.

We asked her what the main differences are between the training and practicing in the US and developing countries? “We get used to certain things here that are not available in many other countries. In some countries the patients are responsible for bringing any medication or supplies that they need during and after the surgery, and many cannot afford that. Coming from a place where healthcare spending is astronomical, you have to think what is necessary or crucial for the surgery and

what I can safely do without. It’s a different way of thinking than here [at Stanford] where I can demand even the smallest things just to be sure it will be available. So we have to prioritize what’s critical to have, I thinking more flexibly during a surgery depending on principles rather than a specific instrument I am used to using, or find an alternative for a certain implant that I might normally prefer. You have to be creative.”

“It's an eye-opening experience, especially for a trainee to go to a completely different environment and learn how to adapt. Otherwise as a trainee I memorize the steps and think that it is the only way to perform that kind of surgery, while after such experiences I am more open to thinking of what is possible at the moment and situation.”

We asked Dr. Anna about the level of eagerness and will of surgeons in those sites to learn and attend such sessions. “It’s true that not all surgeons are at the same level of engagement, but ReSurge was able to identify the truly motivated ones who are dedicated. The challenge here is that these surgeries might not be affordable to a lot of people and accordingly they were not considered as money making to certain hospitals, so we are lucky that we get to work with a selection of dedicated partners.”

“Nepal, India and Vietnam are where surgeons whom we’ve been working with for years are extremely dedicated and our relationships are permanent and extended. Due to these partnerships, many of them became the only surgeons in their regions who are capable of performing these higher level operations. It is both meaningful for them personally and at the same time a privilege for their hospitals. It allows them to attract more and more patients gradually, and gain the recognition and special reputation on a national level. It is a win-win and that’s how it’s supposed to be.”

“For Cuba, it’s a great benefit to surgeons who were learning microsurgery and being the only surgeons in the country who can do this, they were very motivated. It is a great reward to me, the team I worked with, and to Stanford Surgery to teach techniques and help these surgeons change lives of numerous patients who had no hope of living a better life.”

The impact: “Although we don’t have reliable metrics about patients follow up, we were able to quantify the impact of the Visiting Educator Program. We looked at

our three partner hospitals in Vietnam and the topics of training we implemented there, and we found more than 2000 operations corresponding to these topics performed by the local surgeons over the five years corresponding to 12 visiting educator trips. Yes, some of the local surgeons were already doing some of the surgeries, but we and other organizations taught them special techniques.

“As cumulative effort, 2000 operations in five years is phenomenal. We are talking surgeons in their 30s or 40s who have many more years to practice over their career and teach these techniques to their residents. It is a lot when we’re looking in the next few decades, and especially when we are looking at the multiplier effect.”

Unforgettable memories: “It’s remarkable to know that we helped patients who had lived with certain conditions for so many years. For example, in Cuba there was a patient with a history of a congenital esophageal problem, he was living with what we call a spit-fistula which means that his esophagus was not connected with his stomach but instead it was going out of his chest, leaking drainage and fluids constantly, while he was feeding himself through a feeding tube to his stomach. He lived with that for decades and you can imagine the effect of that socially and functionally. We were able to do a reconstructive surgery for him to restore continuity of his esophagus to the stomach and he didn’t have the fistula and drainage anymore. It was very inspiring both to us and to the patient.

“Even smaller surgeries made a big difference, such as one in Nepal where a teenager had a burn in his hand and wrist as a child and developed a bad contracture where his wrist was stuck in a fixed position. He had limited use of that hand all the time, he wasn’t able to work, he didn’t have friends, and felt miserable all the time. We were able to release the scar with a skin graft. It’s a relatively small surgery but it was very meaningful to the patient and his parents. These and many other cases are things I think about. I feel grateful for the opportunity I had to help. I am happy with my decision to pursue my dream in global surgery and I wouldn’t trade it for anything.”