International Education Scholarship Provides Residents a Unique Surgical Experience and Supports Legacy of Care

The team in Ecuador, from left to right: Zach Quanbeck, MD, PGY-1, Sara Van Nortwick, MD, Deb Koop, Lauren Casnovsky, MD, PGY-4, Steve Koop, MD, Alejandro de la Maza, MD, Walter Truong, MD, Mikhail Klimstra, MD, PGY-4, Leo Abrahao, MD

WHEN THINKING OF ORTHOPEDIC RESIDENCY, you might imagine long hours in the operating room, limited time off, and endless studying; but not necessarily providing orthopedic care outside the U.S. But this isn’t the case for the University of Minnesota Department of Orthopedic Surgery Residency Program. Our program is one of a handful in the nation that offers residents a scholarship to perform orthopedic work in underserved areas. Because faculty have been involved in long-term programs in Peru, Ecuador, Honduras, and elsewhere, residents are offered an opportunity to participate in international orthopedics and encouraged to pursue this learning experience.

The scholarship is sustained through ongoing philanthropy. The International Service Fund was initially funded by Gordon Aamoth, MD, and his wife, to support travel and orthopedic surgery, education, and training. In conjunction with this, the generous Dr. Paul C. and Jodi McRae Matson Endowment was established in 2016 to create an international training program within the department. Since its inception, the program has supported 30 residents providing orthopedic care in eight countries.

While volunteering time, resources, and expertise improves the lives of those that wouldn’t normally have access to quality orthopedic care, it’s also a unique learning opportunity and a chance for residents to operate in a different surgical environment. The impact of the scholarship is evident and life-changing, with some recipients continuing trips throughout their careers. “In order to continue to offer this program to increasing numbers of interested residents, ongoing donations are needed,” says Professor and Residency Program Director Ann Van Heest, MD. “We have more residents interested each year, and continue to solicit donations to support the program. After reading the powerful impact of this program, I would encourage anyone reading this article to donate now.”

Scholarship to Peru Impacts Alumnus’ Practice
Scholarship recipient Jason Caron, MD, graduated from the residency program in 2008 and went on the first-ever trip to Peru with Professor Peter Cole, MD, during his fourth year of residency. Now, as a general orthopedist in Bemidji, MN, Caron goes back to Peru once or twice a year and sits on the board of directors of Scalpel At The Cross, the nonprofit that Cole founded in Pucallpa, Peru.

“The scholarship made it easier to go the first time and to do it as a resident, when you don’t have a lot of extra money,” Caron says. “Minneapolis is an expensive city, and while the residency salary is adequate, having the opportunity to access the scholarship fund makes it easier and encourages it.” Caron says that the city of Pucallpa has changed dramatically since he first traveled there in 2007. Dirt roads have now been paved and the main hospital has been remodeled. Still, the technology and resources available are not as sophisticated as those in the U.S.

“In Peru, we don’t have intraoperative x-rays, which makes a big difference in how we operate,” Caron explained. “So much trauma work involves using live x-ray, so you really have to plan before surgery.” Caron’s operative experiences in Peru have helped to keep surgical skills outside of his subspecialty area sharp, which improves care for patients in Minnesota upon his return. “There are many things that I do in Peru that I don’t routinely do in Bemidji because you are the only option that they have,” Caron explained. “I think providing care there builds greater confidence in general. Even though you’re out of your comfort zone, you see these successfully completed operations that you wouldn’t normally have performed.”

Since Scalpel At The Cross’ campus is permanent, the team is able to follow patients closely through recovery. “One of the things that I love about Scalpel At The Cross is the fact that we have exceptional long-term follow up, so you get to see the end result,” Caron says. For Caron, the scholarship was a catalyst that inspired him to routinely provide orthopedic care in Peru, and he encourages residents to apply and get involved. “I don’t believe that I’ve met anyone who has not felt, in the end, like they gained more than they gave,” he says. “I think it’s awesome that the University of Minnesota encourages residents to take advantage of the scholarship opportunity, and I’m pretty confident that they were unique starting the program over a decade ago. There may be more residencies that do it now, but the University of Minnesota orthopedics program has always been very forward-thinking in encouraging diverse training experiences.”

Work Abroad Spurs Resident to Choose Orthopedics
For Cody Sessions, MD, PGY-3, his first volunteer experience in a foreign country was building a home for a family in Mexico in ninth grade. “I walked away from that knowing that in some way, shape, or form, I wanted to continue to experience that feeling that I felt in ninth grade,” he says. “It took me a little while to realize that it was going to be in medicine.”

Sessions asked himself, “What gift would I be most appreciative to receive?” Athleticism is a huge part of his life – in fact, he rode his bike across the country and competed on television’s American Ninja Warrior. So naturally, the gift he would be most appreciative of was mobility. Helping people become more mobile led him to orthopedic surgery. But Sessions had never considered medical school, and nobody in his family had ever been a doctor. Even though he had already completed his undergraduate studies, he decided to go back for a postbaccalaureate to fulfill his medical school prerequisites.

“It was a track set a year or two outside of college, off of that vision of giving others a gift that I would value immeasurably,” he says. Sessions’ hard work and vision paid off, and he was accepted into the Department of Orthopedic Surgery Residency Program. He learned about Scalpel At The Cross while working alongside Cole at Regions Hospital in St. Paul, MN. “I was initially really discouraged because the timing didn’t work for me to go with Dr. Cole, but people told me that the trip leader, Dr. Jason Caron, was really cool and an excellent teacher,” he says. “I decided I would go for it.”

On the first of nine days, they held a clinic and saw about 150 patients to determine which ones they could help with the resources available. If they felt like they could significantly improve the patient’s condition, they scheduled a
time for surgery. By the following Friday, Sessions had performed around 30 surgeries. “I actually get a monthly list of the patients that I operated on and their surgical outcomes, along with pictures of them doing range of motion
exercises,” he added. “That part is really fun because I can stay connected with some of the patients.”

The scholarship gives residents a unique chance to work with more autonomy and adjust to operating with limited resources. “I felt like I functioned at a level that was appropriate for my years of training,” Sessions says. “Dr. Caron and Dr. John Wechter are both outstandingly competent surgeons, so when I was operating I felt like they had a high level of confidence in me, but would be right there if I needed help with anything.” Sessions highlighted that while there
is a lot of hands-on experience, there is ample supervision to ensure the best possible surgical outcomes. Patients won’t necessarily have an opportunity to have a revision done, so follow-up is vital.

“I felt like we left with really strong relationships with everyone – the people we had helped and all the people already down there helping,” he says. “Scalpel At The Cross goes down about five times a year, so there’s excitement and high energy amongst the hospital staff for the week.” Sessions admits that when he’s outside running or sitting by the lake, he spends time imagining that someday he will lead efforts and encourage others to participate in orthopedic volunteer work, but, “that would require them experiencing it with me,” he says. “My long-term career goal is to do overseas orthopedics, and I really started wanting to do long-term missions by doing short-term missions.”

Sessions encourages all residents to consider the benefits of volunteering their orthopedic expertise internationally. “If you’re on the fence about going, remember that you will have a lot of vacation time in your life, and you might discover something that really changes your future,” he says. “If I never built that house in Mexico in ninth grade, which didn’t sound like fun at the time, I would have a very different lifestyle and I’m certain I wouldn’t be doing orthopedic surgery. I accidentally stumbled on something that has rerouted the course of my entire life, so I would tell residents that are thinking about it to take a risk.”

Third-Year Resident Gets Unique Hands-On Operative Experience
During her undergraduate studies at Colorado College, Kelsey Wise, MD, PGY-3, played soccer and was part of a program called Soccer Without Borders, which uses soccer as a vehicle for positive change in the lives of young women in underserved areas. Through that program, Wise traveled to Nicaragua and Guatemala and found the experience powerful. “I thought doing something medically now that I’m in orthopedic residency would be exciting,” she says. “Dr. Michael Baer went to Honduras last year and spoke highly of the trip.”

Soccer was the final force that brought her decision to go to Honduras full circle. “The daughter of Dr. Forseth, one of the physicians who regularly takes the trip, just started at Colorado College and plays soccer. I thought that was a unique connection and that he would be a good person to get to know,” Wise explained. Michael Forseth, MD, adjunct assistant professor, has gone to Honduras annually with a group of surgeons from Summit Orthopedics. The surgery center where they operate is located alongside Nuestros Pequeños Hermanos (Our Little Brothers and Sisters, or NPH), a home for orphans, abandoned, or disadvantaged children, about an hour outside of Honduras’ capital, Tegucigalpa. The story behind the surgery center goes back to 2003, when a child named Angela arrived at NPH with a condition called chondroectodermal dysplasia.

The deformity made it extremely difficult for her to walk and she usually needed a wheelchair to get around. The president of NPH called Peter Daly, MD, an orthopedic surgeon at Summit, to evaluate Angela, who at the time was nine years old. When Daly arrived in Honduras, he determined that the surgery trailer they had available was not equipped to handle the complexity of her case. He ended up bringing Angela back to the United States for her operations and recovery, which took a year. During that time, Angela was welcomed into the Daly’s home and became like a member of their family.

Once they realized the condition of surgical facilities in Honduras, Daly and his wife paired with the president of NPH to raise funds to build a surgery center on their property. In 2009, the Holy Family Surgery Center (HFSC) opened, and since then the brigade of surgeons that provide care there has continued to grow. Surgical Care Affiliates and HFSC decided to combine their mission to form a nonprofit called One World Surgery which connects surgeons and patients in need. “At this point there’s a really nice facility that we stay at when we go, and the surgery center is pretty well equipped to function efficiently,” Wise says. “Throughout the year, different specialty groups come and it’s grown to be a pretty big program.”

To date, 2,449 orthopedic surgeries have been completed through the program, in addition to thousands of surgeries in other specialty areas. On her first day there, Wise had a clinic and saw roughly 30 patients. Once they determined who they could help, they performed surgeries from Tuesday through Friday, completing between three to four cases per day. “They were big cases, too; it was definitely a busy week,” she says. “Education is bountiful there. I was the primary surgeon in a lot of cases as a junior resident and I saw conditions that you would never see in Minnesota, so it’s an excellent educational opportunity for residents.”

Wise explained that in the U.S. many complex elbow and upper extremity cases are reserved for the senior residents. Having the opportunity to perform advanced surgeries with Forseth provided a unique experience that she wouldn’t have otherwise had until later in residency. “I typically have the resident see the patients in clinic and then present the case recommendations to me,” Forseth explained. “I think it’s good for them to think through things because they have to consider factors in Honduras that they wouldn’t need to here. In the U.S., we have a ‘the sky’s the limit; let’s do the latest and greatest’ mindset. That’s not always available down there.” In addition to having one-on-one operative time with Forseth, Wise would often take on multiple roles, not only as a surgeon, but as a scrub tech to gather equipment and determine what they would need for the procedure. She was also involved in postoperative care, such as setting up a follow-up plan for the patient.

“You have to do so much more and you realize all the help you get back home as far as personnel, equipment, and resources,” she says. “It gave me an appreciation for all the things we have in the U.S.” Wise feels that taking on additional roles and working with limited resources had a positive impact on her educational experience. “I think it develops problem solving skills because you have very limited resources to solve bigger problems than we would sometimes see here, given how advanced some of the pathology was,” she explained. “I also think access to one-on-one education from senior faculty helped to build my confidence and learning. It was just awesome across the board!” Forseth agrees that the experience has a lasting impact on residents.

“It’s eye-opening for the residents as far as the pathology goes,” he says. “It’s great operative experience and they get to do cases down there that they might not be doing otherwise. From a society standpoint, it instills appreciation for everything that we have here in the United States.” Wise plans to make international orthopedic trips a part of her career, and it’s all thanks to the support of the International Education Scholarship. “I would love to continue this work as a part of my practice,” she says. “I think it’s a great way to give back to the community, and I definitely hope that this becomes something that I do every year long-term.”

Ecuador Experience Demonstrates Impact of Sustainable Programs
Mikhail Klimstra, MD, PGY-4, was first exposed to international medical work during a month-long trip to Uganda that was planned entirely by medical students. Although it was a rewarding experience, he felt that they were limited in providing sustainable care since it was created by students with finite resources. “While I really enjoyed the trip and felt like we made some impact, I wanted to get another experience in a program that’s better established with more continuity in the actual country,” he says.

During a Gillette rotation in his second year, Klimstra learned about the work at Hospital VozAndes in Quito, Ecuador. The program was established by James Gage, MD, in 1996 and has become an integral part of the orthopedic legacy at Gillette. Gage partnered with Eckehart Wolff, MD, a German physician living in Ecuador, to ensure patients had access to quality postoperative care. A regular group of faculty and residents go two to three weeks annually as the program has expanded. It was the kind of continuity that Klimstra had been seeking. After being accepted for the International Education Scholarship, he spent a week in Ecuador in 2018.

During that time, he helped perform about three to four surgeries per day. “It’s a modern facility and a very well-run hospital,” he says. “The operating room had similar equipment to what we have in the U.S., so it wasn’t a drastic transition.” It wasn’t always like this. Because of the program’s duration, Gillette faculty have been gradually bringing equipment and supplies with them and developing resources in conjunction with their partners in Ecuador. Still, there are some notable differences.

“There were no electronic medical records or digitalized x-rays, but rather paper charts and hardcopy images,” says Michael Chau, MD, PGY-4, who also went in 2018. “We had to reuse many things, including gowns, drapes, tourniquets, electrocautery tips, and even implants. We did have all the basic facilities and equipment needed to perform the more complex cases, so apart from those differences I thought the operative experience felt similar.” Chau pursued the experience in Ecuador because he is interested in a career in pediatric orthopedics, which is the primary focus of the Gillette group. He echoed Klimstra’s desire to see how long-term international programs functioned.

“I wanted to learn how pediatric orthopedics can be applied to help children globally in a sustainable manner,” he says. “It showed me the tremendous need for orthopedic care abroad and also the importance of creating a long-term program. It cannot just be about performing surgery and has to include partnership with the local people, hospitals, and institutions in order for the program to be welcomed by a foreign government and make a lasting impact. This experience gave me a great example of how surgical missions can be successfully carried out abroad.”

For both of them, the scholarship played a vital role in their ability to attend when they did. “It made the decision to go much easier for me,” says Klimstra. “I think it’s an excellent opportunity, and I really think if it’s something that residents want to do, they should do it.” Chau agreed that without the scholarship he probably would not have been able to take the trip, but because of it, his educational experience was broadened. “The experience provided another
dimension to my orthopedic training,” he says. “It was eye-opening and gave me inspiration to continue international volunteering in the future.”

“I think it’s awesome that the University of Minnesota encourages residents to take advantage of the scholarship opportunity, and I’m pretty confident that they were unique starting the program over a decade ago. There may be more residencies that do it now, but the University of Minnesota orthopedics program has always been very forward-thinking in encouraging diverse training experiences.” — Jason Caron, MD

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