In 1998, Dr. Oheneba Boachie-Adjei, an orthopaedic surgeon at the Hospital for Special Surgery in New York, established the Foundation of Orthopedics and Complex Spine (FOCOS) and started medical mission trips to Ghana to provide spinal deformity care. Since then, >500 volunteers have accompanied Dr. Boachie to Ghana, including surgeons, nurses, physical therapists, technicians, and medical students. I (K.V.) was one of the lucky medical students to make the trip in 2009, which was also the year that Dr. Boachie was president of the Scoliosis Research Society (SRS). I visited Ghana a second time as an orthopaedic resident in 2013, and I returned in 2016 after finishing a fellowship and starting my clinical practice. My first visit to FOCOS had cemented my decision to pursue a career in spinal deformity, and I was excited to return as an attending physician. The 2016 trip was a reunion with Dr. Boachie, whom I credit with igniting my lifelong interest in research and volunteerism. I felt like a student again. I still had so much to learn. Learning never ends, especially in Ghana, where Dr. Boachie has taken medical mission trips above and beyond. He is building an academic institution in Africa that rivals anything that I have seen in North America, and he is collecting outcome data diligently. Dr. Boachie was exactly as I remembered him—quiet, gracious, and enthusiastic. With his laptop open, he showed me how he backs up his clinical files and how he organizes that important information.
This was an important lesson in being meticulous about clinical data, not just about surgical technique. The morning conference started with a review of the inpatients, followed by a discussion of upcoming cases. This transitioned smoothly into an educational topic that Dr. Boachie asked me to choose, noting my eagerness to share the knowledge that I had accumulated over my years of training. Conferences also covered the various research projects that each local surgeon was required to take on. Over the years, this diligence and collaboration in research have improved patient care and every aspect of the outreach effort at FOCOS. During afternoon clinics, physicians saw patients in a formalized manner, with Dr. Boachie overseeing everything and giving his experienced opinion when asked. The knowledge and expertise that he has acquired by bearing witness to the changes in scoliosis practice still astonish me.
Surprise Clinics FOCOS recently started using electronic medical records, which help the clinic to run more smoothly. At times, the pace can become extremely quick with “surprise clinics.” One day during my 2016 visit, a group of 20 or so children from Ethiopia with severe scoliosis showed up all at once. When that happened, our *This article reflects the direct experience of Kushagra Verma; Casey Aaron Slattery and Oheneba Boachie-Adjei also contributed substantially to the writing of this paper. Disclosure: The authors indicated that no external funding was received for any aspect of this work. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors. checked “yes” to indicate that the author had a relevant financial relationship in the biomedical arena outside the submitted work and “yes” to indicate that the author had a patent and/or copyright, planned, pending, or issued, broadly relevant to this workmain task became triage.(http://links.lww.com/JBJS/F269). 854
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We spent a few minutes with each patient to identify those who needed workup or treatment most urgently. Despite the sometimes-overwhelming number of unanticipated patients, surprise clinics were fun. Spinal deformities did nothing to dampen the mood of these kids, who were ecstatic from all of the attention. On our way to the operating rooms (ORs) on surgery days, we saw happy children playing everywhere since the patient beds, ORs, and cafeteria were close to one another. Many of these children had traveled great distances and had been separated from their families for months in order to have operative management. Yet not one of them complained, despite apprehension about their upcoming surgery or the challenges of their recovery. Seeing the positive attitudes and resilience of these kids continuously reminded me of the incredible value of outreach work for any physician. Prayers in the OR A common misconception is that clinical outcomes in a “medical-mission” setting are worse than those in developed countries.
But at the FOCOS hospital in Ghana, optimizing clinical outcomes is a top priority. Almost every spinal curve that we saw had a Cobb angle of ‡120. After several weeks of traction, most of those curves had improved by approximately 30%. The OR was the Ghanaian replica of a United States OR, and, to my surprise, very efficient. The nursing staff had everything prepared, the anesthesiologist was prompt and timely, and the research coordinator was constantly documenting. The only difference to the workflow was the addition of a prayer to the time-out regimen. For me, prayer in the OR was unexpected at first, but regardless of your religious beliefs, it seemed appropriate for the environment, and my experience was that everyone felt comfortable with that time-out custom. In addition to the satisfaction from helping kids who usually have minimal access to health care, I continue outreach work for other reasons. In outreach settings, volunteers and employees come to work smiling and warmly welcome other “outsiders.”
Everyone who works with FOCOS and similar organizations has a deep sense of satisfaction from taking care of children. As a scoliosis surgeon, I thrive in this type of collaborative environment. For a young attending physician, spinal deformity surgery can be stressful. There is constant worry about a strained spinal cord, management of blood loss, and the delicate balance among neuromonitoring, anesthesia, and blood pressure. During many cases, we must choose between finishing the surgery or aborting the case and continuing another day if there are intraoperative issues with neurological status or blood loss. Balancing all of these factors and staying focused can be stressful, and sometimes even the satisfaction of a successful surgery with satisfied patients and families is not enough to counterbalance the stress. Outreach work with Dr. Boachie and FOCOS added an extra dose of purpose to my career, increasing my happiness with what I do and relieving some of that stress.
Clinical Excellence
Many Americans have the impression that international surgery is resource-limited, less academic, and less focused on achieving clinical excellence. While resources in many places are shockingly scarce, my experience in Ghana has been that clinical excellence remains the top priority. Teaching and education also are paramount there; local doctors, nurses, and technicians learn the same protocols that are practiced in the United States. Perhaps because of the severity of the spinal deformities that are seen in Africa, the quality of spinal care at FOCOS may be even better than that provided in most of the rest of the world. The FOCOS hospital in Ghana has established standards for long-term preoperative traction and risk-scoring methods, and FOCOS spine researchers have published cardinal work in major spine deformity journals.
Ultimately, for me, Ghana has always been about mentorship—learning from the senior surgeons and mentoring those who are junior to me. Over the last 3 years, I have expanded my outreach efforts to another organization—Global Spine Out-
reach (GSO)—which funds outreach missions in Latin America. This closer geographic location allows for more frequent weeklong outreach trips and closer relationships with surgeons in the host country. I recently brought Casey Slattery, a medical student from the University of Washington, with me on a GSO mission trip, just as Dr. Boachie had brought me to FOCOS. This early exposure has influenced Casey to pursue both volunteerism and orthopaedics. I am honored to have had some small impact on his career.
Kushagra Verma, MD, MS1
Casey Aaron Slattery, BS2
Oheneba Boachie-Adjei, MD3
