June 2001 Bulletin

Fellowship opens new world for orthopaedist

Lack of modern devices challenges surgeon; rarely encountered diseases expand skills

Practicing at Bedford Orthopaedic Hospital in Umata, South Africa offered challenges and satisfaction.

The Orthopaedic Research and Education Foundation (OREF) has funded the Orthopaedics Overseas-OREF Traveling Fellowship since 1999. With this support, Orthopaedics Overseas has been able to identify more than 10 senior orthopaedic residents interested in going overseas and learning more about the challenges of delivering care in developing countries. To date, five residents have completed their assignments and five more are on schedule or have been approved for funding. Eric Lee, MD, recently returned from his assignment in the Transkei region of South Africa. His report follows.

By Eric Lee, MD

The azure sky stretched as far as the eye could see with wispy, cirrus clouds stretched thin like cotton candy in a futile attempt to filter the brilliant sunlight. The earth was the color of burnt amber with interspersed palettes of pale green and almost imperceptible reflective dots that could only be the makeshift squatter houses of the shantytowns.

A single small plane pitched with the shifting wind towards the desolate airstrip, descending over the modest flat-topped peaks, which looked like misaligned molars of some prehistoric monster. As the plane landed with a high-pitched squeak and taxied to the solitary two-story terminal, my heart raced with excitement and apprehension. "So this is where I will spend the next month," I thought to myself. The warm embrace of the welcoming sun surrounded me as I stepped down the stairway into my new existence.

My month in Umtata, South Africa in June, 2000 was unforgettable from both a personal and professional standpoint. It allowed me to experience and admire a culture so different from my own and reinforced all the reasons why I entered medical school nine long years ago.

When I recall my experience in South Africa, the first thought that leaps to mind is the beauty and diversity of the land. The unspoiled richness of the expansive grasslands and noble peaks of the Transkei, the quaint seaside town of Umhlanga just north of Durban’s pristine beaches, and the majesty of the Umngazi river and Cape Town’s Table Mountain encompass a variety of terrain which is almost inconceivable. Yet, almost as indelible is the stark contrast between the perfectly manicured estates in Bantry Bay and the rough squalor of downtown Umtata—contrast that serves as a chronic reminder of the racial divide.

A constant unaffected by race or background, however, was the sense of community among the Bedford staff. During my second week in Umtata, my fellow physicians arranged a braii, or traditional South African barbecue, at my rondavel. Giorgio, an Italian physician, rolled over his wheelbarrow, which functioned as the fire pit. A pile of hand-picked kindling and a bag of charcoal served as the fuel. After the roaring fire was somewhat tamed, several metal grates were placed over the wheelbarrow. Almost all the surgeons came to the celebration, bringing food and wine. A variety of meats were then charred to perfection with a healthy dose of braii salt. We ate straight off the grill with our fingers.

As I watched the moon rise over the proceedings, I can remember reflecting on the wonder of the moment. The pervasive, warm-hearted feelings of friendship among all of us, each of vastly different backgrounds and interests, had been formed over just the past week and a half.

This willingness to embrace "outsiders" was another hallmark of my experience. The hospital staff at Bedford taught me the everyday hospital routine with patience and good humor, and my fellow physicians from South Africa, Italy, India, Bangladesh, Scotland and Cuba took me under their collective wings and always made sure that I had enough to eat and drink. Perhaps more surprising than that was the interest and acceptance by Afrikaners I encountered during my travels, who were intrigued by my own background and mission.

But most of all, what was emblazoned on my mind then and forever, was the cheerful, uncomplaining and trusting faces of the patients who I had the privilege to treat. Mostly Xhosa tribespeople, their backgrounds could not have been more different from mine, but yet we seemed to instantly share a common bond and goal. Attempting to understand this unique "melting pot," which is in its nascent stages, serves as a springboard to comprehend the racial strife present in American society.

No exposition on the personal value of this trip is complete without mentioning the devoted and saintly undertakings of Chris and Jennie McConnachie. The calm wisdom and selfless, unyielding energy they show to their work serve as an inspiration to me. Their dedication is infectious and it is not possible to spend time with the McConnachies without personally promising to "give back" to the community at home or abroad through one’s medical expertise.

Professionally, my experience at Bedford Orthopaedic Hospital could not be more dissimilar with my experience at the tertiary care centers in America. Aside from the differences in hospital policies and protocol, insurance company authorization, and risk management, the orthopaedic "basic requirements" such as electricity, radiology, orthopaedic hardware and compressed air drivers were always an adventure in Bedford. In fact, there were several days of surgery canceled because of failures of these elements.

However, what soon became clear to me was the extraordinary amount of imagination necessary to successfully accomplish the orthopaedic mission without all the modern-day devices of the developed world at your disposal. This "make-do" attitude put a premium on knowledge and creative application of basic orthopaedic principles and it is this flexibility and fluid intelligence that benefits surgeons when things deviate from the regular routine.

Additionally, I learned a great deal by working with physicians who were trained outside of the American system. Several of the surgeons with whom I worked were trained in Cuba, India or elsewhere. Being able to discuss cases and perform surgery with them allowed interplay between my own Western training and their diverse schooling. Their alternative treatment methods and well-grounded wisdom after many years of practicing in South Africa were also invaluable for my education.

Lastly, common disease processes that I encountered in Umtata are rarely, if ever, seen in modern-day San Francisco and my exposure to them allowed me to grow professionally as a diagnostician and physician. Recognizing and treating conditions such as tuberculosis, osteomyelitis of the spine and appendicular skeleton, three-week-old untreated fractures, and severe, contaminated gunshot injuries which, due to lack of equipment, were treated in traction, all helped to broaden my medical horizons and augment my therapeutic armamentarium.

In conclusion, my trip to Umtata provided a refreshing reminder of why I chose to enter the medical profession. My professional development and sense of achievement from this expedition is undeniable. Applying what I have learned during the past nine years of medical school and residency to positively influence the lives of others was obviously extremely gratifying.

However, in my mind, the professional lessons pale in comparison to the associated personal rewards of experiencing a unique culture, land and society. I will not soon forget the thankful, inquisitive faces of the children and adults whom I was lucky enough to treat. Nor will I forget the steadfast and unmistakably kind hearts of the McConnachies, who have embraced the population and beautiful terrain of’ the Transkei, as well as all the volunteers who have come before me and who are yet to come. So many times during my residence, the current litigious and adversarial tenor of American medicine rears its ugly head and it becomes impossible to separate this vinegar from the honeyed-elixir of unpolluted medicine. This experience has purged that sour taste and recommitted me to being a physician, and for that I will be eternally grateful.

Eric Lee, MD is chief resident, department of orthopaedic surgery, University of California, San Francisco.

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