Spotlight: Dr. Ana Crawford

By Mohammed Al Kadhim

October 9, 2023

Dr. Ana Crawford

Dr. Ana Crawford is a Clinical Associate Professor in the Department of Anesthesology. She has been leading the Global Health Equity program at Stanford’s Department of Anesthesiology for more than a decade.

Q: Welcome Dr. Ana Crawford, please tell us about how your passion for Global Health started, and how you interpreted that into actions throughout your remarkable journey? 

A: I’m an anesthesiologist and an ICU physician at Stanford. I’ve been at Stanford since 2008.

Once I finished my ICU training, I already knew that I want to do Global Health, so I went back and got a Master’s degree in Global Health Sciences at UCSF with intentions of starting Global Health programs within the Department of Anesthesiology. That was my goal. I was so fortunate to be supported by my chairman, Dr. Ron Pearl, who saw my vision.

I founded the Division of Global Health Equity in the Department of Anesthesiology in 2011.  That division now includes a residents’ pathway where Stanford Anesthesia residents can apply and access a core Global Health Equity curriculum and other elective activities. We also started the first Global Health fellowship for Anesthesiologists. Our first fellow started in 2013, and we have had three fellows participate the program.

Another part of our Division, of which I’m most proud, is the Visiting Observer program. We bring colleagues from abroad to rotate and observe within the department. We also send them to our national meeting, the American Society for Anesthesiologists annual meeting.

Our program continues to evolve, and we now have six people on our Global Health Equity Leadership Council, who run the division. I have actually turned over the division directorship to two women who I mentored; Dr. Cynthia Khoo and Dr. Sara Strowd. They are now the co-directors of the division, while I moved to a more external networking and strategy role called the Director of Global Engagement Strategy. My friend  and colleague, Michelle Arteaga, has also been an incredible force in our Global Health Division and has been by my side building these programs since 2012. She is now our full time program manager.

You mentioned that you have global residency pathways; where do you have clinical sites?

We have four elective rotations that are approved by the ACGME as well as Stanford’s GME office: The University of Zimbabwe, The University of Rwanda, FAME private hospital in Tanzania, and Hue in Vietnam. Dr. Cynthia Khoo runs the FAME rotation. Sara Strowd runs the Vietnam rotation and I run the Rwandan and Zimbabwean sites.

You just returned from a trip to Rwanda. What were the objectives of that trip?

I have an honorary appointment at the University of Rwanda as an associate professor. The University of Rwanda is our longest partnership, and this was my 15th or 16th trip to Rwanda. I go every year for a month to teach anesthesia in the ORs, maternity wards, pediatric operating theaters as well as in the intensive care units.

This relationship started in 2006 as a partnership between the University of Rwanda and the Canadian Anesthesiologists’ Society. Shortly thereafter the American Society of Anesthesiologists hopped on board and supported the partnership as well. It is a long-running partnership, and I am proud to say that I had a role in the training of almost every anesthesiologist you’d meet in Rwanda. To date we have graduated somewhere between 30 to 40 physician anesthesia providers. However, we have lost about a third to “brain drain” where they seek opportunities outside of their home country.

On every one of my trips to Rwanda, I take Stanford trainees (and also from other institutions) with me and I supervise their experience. This year I am excited to take a Stanford ICU fellow with me for the first time, Dr. Andrea Comisky.

Tell us about the elective rotations in Rwanda.

This is one of our annual rotations, and one I developed and participated in for the last 14 years. Every year we go to Rwanda for one month as “volunteer teachers,” but the reality is that it is an educational exchange from which both sides benefit. I feel that Stanford residents learn as much as they teach. Same goes for me, I feel that I learn more every time I go there.

Mondays are academic days, and they are largely run by Rwandan anesthesia faculty. The program is no longer completely dependent on volunteer teachers from other countries.

In the morning there is usually some didactic lectures, case-based discussions, and pre-reading assignments with discussion. The afternoons are spent doing simulations, oral board exams, practice with ultrasound, learning how to do airway management, learning how to do central line placements, and other skills training.

We largely facilitate the afternoon sessions while our Rwandan colleagues facilitate the morning sessions.

The rest of the weekdays are spent at the bedside, whether in the operating theaters or in the intensive care units, where we work side-by-side with our colleagues in an educational exchange where we discuss resource utilization, best techniques, patient safety, and all things perioperative care.

There is a long line of residents that have gone with me to Rwanda since 2010, and I’ve taken residents and fellows with me every year since except for 2020. And some years I’ve gone twice.

On my most recent trip this year, I took two of our residents: Drs. Bryan Huebner and Justin Yuan. They participated in a month long elective educational exchange with the residents at the University of Rwanda.

We asked Bryan and Justin about their experience, and here is what they said:

“We spent most of our time with the anesthesia residents at the University Teaching Hospital of Kigali. The residents were brilliant, but the transfer of knowledge to intraoperative practice was a work in progress. Our daily volunteer work involved helping with didactics, running simulation stations, and providing intraoperative teaching. We were intentionally not hands on with patient care, partly because of the challenges of obtaining a Rwandan medical license, but more so because, as we came to understand, our role as teachers—discussing, planning, advising, and giving feedback—was a more effective way of helping maintain sustainability in their anesthesia training. Rather than take over during a difficult intubation, tricky IV, sustained hypotension, or simply “do” the case ourselves, walking a trainee through those challenging moments led to far more learning and therefore more capacity building towards safer anesthesia practices.

Of the many lessons we learned about global health volunteer work during our time here, three stood out to us:

● Don’t assume we know. Things might appear a certain way, and our gut reaction might be quick to form a judgment based on our past experiences or understanding of how things should or could be, but that often ignores the context of how things came to be the way they are, or the hidden limitations that we may not be privy to because of the snapshot nature of entering for only short periods of time.

 ● Avoid the mindset that this is yet another poor African country in need of help. This is what the media had primed us to believe - the savior complex is real, and we want to be cognizant of avoiding contributing to it more than we subconsciously likely already are. Rather, it is far more productive to view things from a perspective of awe and innovation. It’s incredible how the Rwandan healthcare workers are able to do so much with what they have available to them.

● Check in with ourselves whether what we are doing is actually contributing to improved patient outcomes. The answer may not always be clear, and sometimes it can take months to years to discover whether an intervention helped or actually ended up hurting. However, self-reflection on whether our actions benefit patient outcomes even after we leave is not a bad North Star.”

Another activity of Dr Crawford’s global work is to advocate for fundamental, foundational, and essential care for all critically ill patients. She recently represented the Anesthesia Critical Care Division at the 16th World Intensive and Critical Care Congress in Istanbul, Turkey. Dr. Crawford leads the training working group for the Essential Emergency and Critical Care  (EECC) Network and is a partner on the recent WFICC grant: “Essential Emergency and Critical Care: Training for Equity in Critical Care.

What’s the purpose of the Essential Emergency and Critical Care (EECC) training?

I’ve been working for about a year with a group called the Essential Emergency and Critical Care Network. We are essentially trying to bring the critical foundations of care to all critically ill patients in all hospitals across the world. I think that critical care is largely neglected in Global Health, and I think that it is neglected because most people think about intensive care units. When you say the words “Critical Care” most people think “ICU.” But the evidence shows that over 90% of critically ill patients are outside of intensive care units. This is especially true in places that have limited resources because they do not have intensive care units. Not being in ICU does not mean that people do not become critically ill.

So, the whole premise of EECC is to make sure that all hospitals in the world can rapidly identify critical illness and can respond to rescue those patients in that window of reversibility.

It is really providing the essential interventions and fundamental care that we think all patients should receive, such as intravenous fluids, oxygen therapy, giving glucose to someone who is hypoglycemic –fundamental essential emergency and critical care activities.

We had two sessions at the Congress, and because I lead the working group for training in the EECC, my talks were primarily focused on training the global healthcare workforce.

You recently started a Global Health Equity newsletter. Can you tell us about it.

I started the newsletter as part of my new role as the Director of Global Engagement Strategy. It falls in line with my vision of helping people with their professional development from a global standpoint. I wanted to highlight the work and accomplishments we achieve within our department. I also aim to highlight the work that is done across other departments and across campus. I want to share all the opportunities that faculty and trainees could take advantage of across the globe.

One of the most interesting things is featuring faculty and staff from other countries. I have created a monthly Global SPOTLIGHT, because we are always looking for ways to encourage diversity and equity. If we look around us, we see how many people are here in our departments who are from other countries and other cultures, and we can really try to learn from each other.

It was such a joy talking with you, Dr. Crawford, thank you. Do you have any final words to close with?

I am super excited to collaborate with the Department of Surgery Global Engagement program. It is so important for all of us to work together.