Stanford Plastic Surgery is enhancing the training of reconstructive surgeons throughout the world
By Mohammed Al Kadhim
March 15, 2023
The numbers were astonishing to Dr. James Chang, Chief of the Division of Plastic and Reconstructive Surgery at Stanford and the Consulting Medical Officer at ReSurge International.
He read from the Lancet Commission that 5 billion people in the world do not have access to safe, timely and affordable surgical care, 17 million people die every year from surgically preventable diseases, and every 2 seconds someone dies from a neglected surgical disease. That death toll is 5 times greater than HIV/AIDS, TB and malaria combined.
From a reconstructive surgery perspective, Dr. Chang envisioned training a generation of reconstructive surgeons in lower and middle income (LMIC) countries by teaching them the principles of reconstructive plastic surgery. These pioneering surgeons would, in turn, train many others, thus building a country’s capacity in reconstructive surgery.
Q: Dr. Chang, tell us about the beginning of your journey before becoming a surgeon. Tell us about your childhood, school, community, and the moment you realized that the path you took was the path you wanted to pursue?
All of us have those seminal moments when we make choices that impact the rest of our lives. When I was an undergraduate student at Stanford, I decided to take a year off before medical school to teach English in Beijing, China. That experience opened the world up to me. I fell in love with travelling and learning about other cultures and histories.
When I was a medical student at Yale, I became interested in hand surgery and learned that the specialty of plastic surgery incorporated hand surgery with microsurgery. I also realized that plastic surgery would be very amenable to global surgery because, although the principles and techniques are complicated, the equipment needed is fairly simple. With a scalpel and a few dissecting instruments, many reconstructive procedures could be performed. There would be little need for complex and expensive equipment to care for these patients suffering from burns, cancer, trauma, and congenital problems.
At Yale, I read a journal’s letter to the editor from a plastic surgeon in Pakistan who was treating Afghan soldiers during the Soviet invasion in Afghanistan. Towards the end of medical school, I was able to work with this plastic surgeon in Peshawar, Pakistan for several weeks. This experience solidified my interest in global reconstructive surgery.
Q: You trained at Stanford. Why did you choose Stanford?
The main reason I chose Stanford Plastic Surgery for residency was because of its long history of involvement with global surgery. Dr. Donald R. Laub, my predecessor as Chief of Plastic Surgery, started Interplast, which has now become ReSurge International. I wanted a program that was truly dedicated to a global outlook. This still differentiates Stanford from other plastic surgery programs.
Becoming the Consulting Medical Officer of ReSurge International
Q: How and when did you first get involved with ReSurge? And how does your position as the Consulting Medical Officer inform the activities mentioned above?
I came to Stanford to train with the world experts in plastic surgery and hand surgery. At that time, residents were able to travel with Interplast to participate in surgical trips for cleft lip and palate surgeries as well as general reconstructive surgeries. Later on, when I was an attending surgeon, the opportunity came up to serve as ReSurge’s CMO (Consulting Medical Officer). It allowed me to combine my Stanford academic career and clinical practice with one of my early loves: global surgery.
I have several responsibilities as CMO. The first is to ensure the safety and appropriateness of surgical trips and operations being performed by the organization. The second is to develop teaching programs for long term sustainability and scalability, and the third is to act as an ambassador - connecting the best plastic surgery faculty from Stanford and around the world with the programs that need help the most. Our mantra at ReSurge is that the best plastic surgery faculty should be the ones training the world.
Q: Can you tell us about the transition of ReSurge from a mission-based organization to one that focuses on education and capacity building?
The evolution of Interplast (now Resurge International) is fascinating. The organization began by bringing one patient from Mexico with a cleft lip to Stanford to have an operation, then it evolved to sending teams of medical specialists to go to a hospital in another country to operate for a period of two weeks. We began to realize that we needed to scale even further. We started training local surgeons, and after a local surgeon was trained, Resurge would fund that surgeon to stay in his or her community to care for patients. More recently, my goal has been to train many of these surgeons around the world to continue training others. Hence, we have gone from “teaching one person to fish” to “building fishing academies” where many plastic and reconstructive surgeons could be trained.
In order to do this, our educational model completely changed. We began to focus on incredible trainees around the world, and the goal was to send smaller teams of professionals to travel to the host sites several times a year to continually train these surgeons and to develop entire training programs where we enhance not only the surgeons, but also the anesthesiologists, nurses, therapists and pediatricians. Our new model has moved away from the large team trips of 20 people carrying all their supplies to a hospital to operate for 2 weeks and then leave; instead we are now trying to have a sustained presence with both virtual and in-person training at select sites.
We decided that the best model would be to set up a series of virtual lectures and a virtual preop conference in the first month. This includes host trainees and surgeons as well as the team that will be travelling. In the second month, the team travels for a period of ten days to the hospital, and they act as advisors. We call this the Surgical Team Training Trip (ST3) and it usually includes a surgeon, an anesthesiologist, a nurse, a therapist and a pediatrician. This team of 5 teaches all aspects of perioperative care and safety, including many of the safety innovations that have been put in place in the United States. After the team returns, in the third month, there is another series of virtual follow-up lectures to clarify issues and a post-operative virtual clinic to review patient outcomes. The entire cycle starts once again in the fourth month with another team. So, every month there is an interaction of some kind between the host hospital and our ReSurge teams. It is only with consistent interactions that we are able to make a significant impact.
When the Covid crisis hit, a few interesting developments occurred.
First, we learned that all of us were able to do well with virtual lectures, and we were able to have new lecture series between ReSurge and Sub-Saharan Africa, and ReSurge and South-East Asia. In addition, we learned that having virtual learning accelerates us identifying the most promising trainees. Before Covid, we would visit a site and meet 2 or 3 surgeons. When we returned the following year, maybe one had left and the other 1 or 2 were still there. In the third year, there might be only one interested and talented surgeon to train, and so we would concentrate our training efforts on that person. That took 3 years. Now, since we have monthly lectures, I am able to see the same engaged faces on the screen every month, asking great questions and interested in learning, so those are the trainees that I am going to invest in. Virtual training has allowed me to get to know the star trainees around the world much faster.
The second development relates to minimizing the carbon footprint of global training. We used to send teams of 20 people across the globe, carrying the anesthesia equipment and disposable supplies. You can imagine the large carbon footprint needed to fly 20 people carrying 15-20 large suitcases of equipment. Now, our surgical team training trips are very small (4-5 people), and we train the hosts on their own equipment because that is what will be used after we leave.
Q: How did the partnership between Stanford, ReSurge International and the College of Surgeons of Eastern, Central, and Southern Africa (COSECSA) develop, and what are you doing now?
In 2014, Dr. Sherry Wren, director of global surgery at the Stanford Center for Innovation in Global Health, connected me with Zimbabwean Professor of Surgery Dr. Godfrey Muguti, who was in the leadership of COSECSA already, and whose dream was to train plastic surgeons in Sub-Saharan Africa. The vision of Dr. Muguti was unique and selfless; he asked me to train plastic surgeons in the entire region of 14 countries and not just in his own home institution.
This partnership of three institutions is great because we have Stanford University that has amazing faculty, residents, and resources for teaching and education; we have COSECSA, which is the leading professional body for organized surgery in the region; and we have ReSurge, a non-profit that raises and distributes funds directly to the African programs to support training and care delivery.
When we first started, there were no fully trained plastic surgeons in Zimbabwe, and now we have three. In Zambia, there is only one plastic surgeon, and in Tanzania there are two plastic surgeons. The numbers are very small, but we feel that they will now grow exponentially.
In 1999, ReSurge funded one surgeon to fly from clinic to clinic in Zambia to perform plastic surgery. In 2017 we started sending training trips to a few countries in sub-Saharan Africa. Now in 2023 we have multiple programs, including eight African surgical outreach partners, three formal academic partnerships, three eLearning Centers, three smart glasses collaborations, and 15 African sponsored scholars along with five African participants in the Pioneering Women in Reconstructive Surgery mentorship program. We host monthly virtual lectures in surgery, nursing, and anesthesia and have a complete online COSECSA-ReSurge plastic surgery curriculum. In addition we sponsor care for 700 patient cases annually.
Q: Tell me how you view the need and the reality of plastic surgery in lower resourced countries in the next 20 years?
The clinical disparity is so great. In the United States, if someone burns their hand, for example, they can have an operation the same or next day to get the necessary treatment, while in low and middle income countries, if a child suffers a severe burn, he may not even be able to find a doctor or clinic. That burn will go on to heal with a severe contracture.
What we are trying to do is to offer our expertise so that every child would have a surgeon in that area who is capable of providing treatment. We are not saying that we can fund every hospital, train all the surgeons, or provide the equipment. We need to partner with the ministries of health in order to advocate for reconstructive surgery as a priority. In fact, it is a basic right to have that available for patients.
Q: Any final thoughts?
One of the most rewarding aspects of this work is that many of our residents and medical students are passionately drawn towards it. Having a non-profit like ReSurge nearby to partner with allows our Stanford plastic surgery faculty and trainees to participate, since it leverages infrastructure, organizational capabilities, and long-standing relationships. Based on this synergy and energy, the future of global reconstructive surgery is very promising.