Brazil

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                                                   S.T.A.R. Scholars Program

                                                                        Stanford Travel Abroad for Residents

                                                                      Arjun Desai, M.D and Pedro Tanaka, M.D.
                                                                                  STAR Pilot Project Report
                                                                                              12/15/2010

Mission Statement:

The Stanford Training Abroad for Residents (STAR) Scholar program is a full cultural and clinical immersion. Often traditional medical mission trips provide wonderful clinical experiences but only allow you exposure to a country’s airport and a few hotels. With STAR, we have created a two-week rotation that allows residents to understand the cultural threads behind clinical education, the practice of medicine, and national health systems. The STAR scholar will learn to appreciate local flavors, cultural events, and most importantly the people that makeup a country.

Location:

The National University of Parana in Curitiba, Brazil generously hosted the inaugural trip. The two weeks were divided between five clinical facilities. The majority of time was spent at the main teaching hospital, Hospital Clinicas, which is analogous to Stanford Hospital. Additionally, clinical duties were shared between one of the leading pediatric hospitals in Brazil, Pequeno Principe, a state run maternity hospital, and two private hospitals, Santa Cruz and Vitas.

Clinical Experiences:

The STAR experience is unique in that over two weeks you are able to sharpen your clinical skills in a variety of settings that include different classes and generations of medications, machines, and tools. Likewise, the STAR scholar is able to appreciate system similarities and differences in everything from resident education to anesthetic management. The daily work includes a variety of cases ranging from cardiac surgery, neurosurgery, obstetrics (including natural birthing in a bathtub), general surgery, urologic surgery, orthopaedic surgery, pediatric neurosurgery, pediatric general surgery, and pediatric cardiac surgery. The STAR scholar is at liberty to do as much or as little as they would like. It is a wonderful way to learn techniques with different (usually less expensive and older) medicines, non-ultrasound guided central line placement, as well as new methods and techniques for epidurals, spinals, caudals, etc...

Clinical Differences and Learning Points:

  • Real time view of the operational differences between national and privatized healthcare
  • Different medications (Halothane, Dipirona - non-FDA approved analgesic similar to Toradol, etc..)
  • Different methods (non-fiberoptic guided double lumen ETT, different positioning for spinals/epidurals/caudals, non ultrasound guided CVC, high throughput/short stay PACU, Mapleson D circuit, home-birthing techniques, etc…)
  • Nerve stimulator guided peripheral nerve blocks at Trauma Hospital
  • Rescue airway “suitcase” with glottic lifters on laryngoscope and one LMA unique for appropriate situations
  • Infrastructural differences in proximity of ICU and other care units to the operating room and Anesthesia services area in the hospital.
  • Environmentally friendly materials (reusable scrubs, gowns, and scrub caps, reusable surgical drapes, anesthesia circuit filters, all reusable rescue airway devices, etc…)

Educational Endeavors:

A large part of our goal for creating STAR was to provide an international forum for the exchange of ideas of how to best educate the coming generations of anesthesiologists. Like most industries, medicine operates on a global platform with revolutionary therapies and procedures being developed every day. To best understand our role we need to
understand our environment and learn how our colleagues have established their respective niches.  All of us have seen the visiting Brazilian residents in the operating rooms
and at the breakfast nook. When speaking to them a common theme thread throughout all of our conversations.  They were categorically thankful for the amazing perspectives that had been gained during their time at Stanford. I wanted to reciprocate that same feeling with our residents so they could take those perspectives and shape their future careers. To truly integrate into the Brazilian residency we created a lecture series, conducted in English, which is well understood amongst a majority of medical professionals. For our first lecture, I provided an overview of “How we learn at Stanford.” The talk was given at the weekly lecture that is designed for all classes to participate. Additionally, I
gave the same lecture at the pediatric hospital and one of the private institutions (where it mainly focused on our regional and web2.0 aspects).  I received a lot of great feedback and comments from the faculty and residents after each lecture. They were very interested in integrating aspects of our educational culture into their system and were taking steps necessary to do so.

Learning points from Educational interactions:

  • With the hard work and dedication of Dr. Pedro Tanaka, the former program director at the University of Parana, many novel and progressive initiatives are being integrated into the residency program at Hospital Clinicas.
  • Workbooks similar to our CA1 lecture series, written in large part by the chairman Dr. Sergio Tenorio, are distributed to medical students and new residents.
  • The Parana society for Anesthesiology (similar to our CSA), is currently working to incorporate city wide combined lectures amongst the four residency programs to boost cooperative learning efforts and better utilize resources.
  • The same society hosts several workshops (including our very own Stanford difficult airway team and regional team) and national meetings to encourage research efforts and evidence based practices.
  • After our visit, many residents were learning more about web 2.0 and the tools available to learn regional blocks with nerve stimulation.
  • Several Brazilian residents were enticed to look further into exchanges to Stanford and other universities when they had not previously considered such options.

I consulted on quality improvement projects including how to effectively launch a “time out” in the operating room. Using my experience as a Quality board member for SUH, I spoke with administrators and surgical staff to gain insight into the difficulties they were experiencing. After our discussions, I suggested to designate the charge nurse to be the responsible party for initiating the time out – similar to Stanford. The suggestion was well received and successfully implemented.

Cultural and Community Perspectives:

It is no secret that Brazil is a country and people full of a lust for life. As you step outside of the airport this fact is immediately self evident in the food, music, nightly atmosphere, and most strongly in the generosity and goodwill of the people. From my host, the chairman of the department of anesthesia, to the fellows, residents, and even locals – I was graciously hosted and exposed to Brazilian culture on a daily and nightly basis. My first afternoon I was taken to the local fruit market where I could dig my teeth into new textures and colors. They were all delicious.  Food is an art form, an emotion, and a way of life in Brazil. My hosts and the friends I met ensured I was able to sample all of the culinary delights that Brazil has to offer.  The evenings were mixed with local dining, dancing, and cultural events including art shows, theater, and local festivals surrounding the winter (summer in Brazil) holidays. Travel within Curitiba and the surrounding southern region of Brazil is a special part of STAR. One of our important objectives in creating STAR was to allow residents to feel as if they truly integrated into their new cultural surroundings. My time in Curitiba allowed for weekend trips to Florianopolis and Rio de Janiero. With help from the residents and other physicians I met in Curitiba, I was able to arrange a “locals” itinerary that made for a truly unique perspective of Brazil.
Overall, being able to understand a new culture through its medicine, people, food, and travel was an unforgettable experience. The clinical strategies and perceptions I was exposed to in Brazil will forever shape my personal style and practice as an Anesthesiologist. Additionally, the friendships and experiences gained will last a lifetime.

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