Dr. Sobral offers a personal reflection about his experience:
Flights into the developing world can arrive at the most curious of times. We landed in Hyderabad sometime around 3:30 AM. Within a matter of minutes we were outside and surrounded by an immense crowd of sound and color. Dr. Are ushered me to the home of the former chairman of surgery. The drive was beautiful and amazing as the sun came up and the daily routine unfolded in this capital city of the south Indian state of Andhra Pradesh. A cheerful man awaited with coffee and a delicious, savory and extremely spicy breakfast as customary. Every step was met with incredible Indian style hospitality, national pride and an incredible desire to make a guest feel comfortable, included and welcomed beyond any inkling of doubt, “worshiped as deity” according to Indian culture. Often times, after clinical duties, I would join some of the attending surgeons or fellow trainees for a well earned meal, samosa, masala tea, or biryani. I will never be able to repay their level of kindness. I can only hope to behave as graciously when my turn comes to be a host.
The majority of time was spent at Indo-American Hospital in a relatively affluent area called Banjara Hills. This is a newer institution that focusses mainly on cancer patients. The project was made possible by a Bollywood celebrity and his desire to help fight the ailment that affected his wife. My accommodations were directly adjacent and there was a large park in front of the hospital. I could easily walk to and from the hospital and enjoy the park as well. I was somewhat surprised to see that the hospital had access to so many of the tools that are available in the United States. Things like the Harmonic and Ligasure were readily available, as well as monopolar and bipolar cautery. The anesthesia tower and cart were very modern as well. This facility had access to virtually all the resources available at a major teaching institution back home. The main difference being that powered instruments like the harmonic and the ligasure were recycled, cleansed, autoclaved and reused. Operating room garments like gowns were also reusable. The size of the hospital, the location, the amount of available resources, made this a great place to transition from a major teaching institution in the United States.
The patient volume was impressive. There was a good mix of cases including buccal mucosa cancers, thyroid, esophagus, breast, GIST, colon and cervical cancers. Most intra-abdominal and pelvic malignancies were treated laparoscopically. There were several patients with advanced stages of cancer, the majority of which I had only read about but had never seen. This created an environment where extensive surgical procedures were more often required. There was ample opportunity to be involved in approximately 4 to 6 cases per day, Monday through Saturday. The surgeons were organized in 3 teams. Each had a chief surgeon that distributed cases throughout the members of the surgical team and supervised, oftentimes partaking during key portions of the operation. The majority of the time not spent operating was used to see new patients and follow up visits in rooms that were adjacent to the operating theatre. The surgeons and staff were very busy but routinely went out of their way to make sure we were learning and having a positive, worthwhile experience.
The culture of an attending assisting the resident through a case did not exist like it does in the US. In one scenario, the attending trusted the resident to perform an operation and the case would be left in the capable hands of that resident while the attending was available next door. In the other scenario, the resident would participate as the assistant until the attending became confident that the resident had gained sufficient knowledge and skill to proceed independently. This structure seemed to be common even during everyday practice after surgical training programs were completed. One of my most salient experiences came quite unexpectedly at the beginning of the rotation from a cervical lymph node biopsy. Even a minor case performed independently in a foreign country can afford trainees with a level of professional maturity that is difficult to match during training in the US. The scrub tech, circulator and nurse anesthetist spoke broken English and I spoke even less of the local Telegu language. That lymph node biopsy suddenly became the summation of my first 3 years of residency. I drew on every bit of knowledge and skill that I had accrued to that point. In retrospect, that scenario was not unlike the first few times operating at a new hospital, as a new attending, immediately after completing surgical residency. Later during my time abroad, I also had the opportunity to take more junior residents through a modified radical mastectomy. After that experience, I realized that I would never again forget the steps of the procedure. When I rounded on that patient in the ward over the ensuing days, I felt the meaning of patient ownership.
My time abroad also afforded the opportunity to participate in several local, regional and national meetings as well as travel with some of my teachers and peers. I was able to get involved in clinical research as well as setting up video conferences to discuss, compare and contrast specific patient cases and their management in India and the US. I had the opportunity to present my research at a national surgical meeting at home also. The international experience during general surgery residency was invaluable and unforgettable and I feel very fortunate to have had the opportunity to partake.
Filipe Sobral, MD
House Officer IV