It is easy to take for granted the advances that have taken place in vascular surgery over the past decade. There is little doubt that new endovascular techniques and technologies have improved patient outcomes over the past ten years. However, it is the skill of the surgeon that remains the essential tool in treating vascular disease and this is no more evident if a surgeon does not have access to the most ‘basic’ of resources.
It is perhaps unique that a vascular surgeon would have at their disposal the latest technologies to treat vascular disease and then six months later have to use a fishing line to close a wound. However, these are the exact challenges that faced Dr Bart E Muhs, Assistant Professor of Surgery at New York University (NYU) Medical Center, the current recipient of the Marco Polo Award and a Fulbright Scholar.
Vascular News talked to Muhs about his experiences in Europe, as a result of the Marco Polo Program, and the challenges he faced in the West African country of Cameroon, as a recipient of a Fulbright Scholar’s Grant, and how they have left him with lifelong friends and unforgettable experiences.
“The Marco Polo Award was suggested by two of my mentors at NYU where I did my training, Tom Riles and Paul Gagne, who thought it might be suited to me because I have always had an interest in distant places, interesting cultures, alternate ways of doing things,” said Muhs. “I spent many years doing my training in the US and I was looking to experience something different rather than go directly into practice. That is also why I applied for the Fulbright award later on.”
The Marco Polo Program was established by US and European Societies for Vascular Surgery in recognition of the importance of international exchange. Now in its third year, the Program sponsors a limited number of young American and European vascular surgeons to pursue additional training at international centers of excellence lasting six to 12 months. The J William Fulbright Commission was established by the US Congress to promote international educational and cultural interchange through the exchange of students, scholars and teachers.
“I had already completed my application for the Marco Polo when I came across the Fulbright while surfing the internet one weekend. The Fulbright program was particularly interesting to me because it combined vascular surgery and teaching with the opportunity to live in an amazing part of the world. I picked Cameroon because my wife and I had previously taken a trip up the Niger river in West Africa and we wanted to also go to Cameroon but we didn’t have time. West Central Africa is stunning, the people and the culture are amazing. I sent both the Marco Polo and Fulbright applications at the same time and heard back that I had being successful in both. So I had to contact the Society for Vascular Surgery and Fulbright commission and asked if I could delay one – thankfully they agreed.”
Marco Polo Program
Before heading off to Africa, first Muhs headed to Europe, The Netherlands to be exact. Some 30 years previously, connections between the Netherlands and New York had been established when Professor Bert Eikelboom, came to NYU and to worked with Tom Riles under the sponsorship of the Fulbright program. This same link allowed Muhs to go to The Netherlands and train under Professor Frans Moll.
“The time I spent in the Netherlands was extremenly productive and after publishing some 17 papers, was privileged to be offered enrollment in the PhD program at Utrecht University. I was extremely fortunate to work with Frans, as well as Hence [Dr Hence Verhagen] and Eric [Dr Eric Verhoeven, at Groningen University Medical Center],” he added.
“On the very same day that I arrived in Europe, Frans signed a letter to say that he was a qualified person to supervise, I was introduced to all the staff and I was scrubbed in the operating room doing an operation with Hence Verhagen. In comparison, for someone to come to the US and perform an operation on the same day, the paper wok alone would be insurmountable! I was amazed!”
It was not just the speed at which he was allowed to operate that surprised him, but the working environment also made an interesting comparison to the US. “There is a much more consensus driven environment in The Netherlands compared to here, I am not sure whether that has to do with the financing system. Whereas, in the US people more or less earn what they bill for, my impression is that in Europe, at least at the hospitals I was at in The Netherlands, they get a salary, plus some extra. But there are not some surgeons earning a million euros a year and some surgeons earning 150,000 euros a year. At least in the academic centers it does not matter whether you do 100 cases or 80 cases you still get the same amount of money. I think that fosters a co-operative environment rather than a competitive environment.”Other differences between the Netherlands and the US are in access to advanced devices and training. “Although the techniques used were similar in the US and Europe, the actual devices themselves were more advanced. Europe is probably five years ahead of the US in terms of endovascular devices. Primarily that is due to the restrictions placed on us by the FDA. In Europe, I focused entirely on endovascular procedures not widely available in the US, such as fenestrated and branched grafts. People such as Tim Chuter and Roy Greenberg have access and implant them regularly, but certainly no one in the New York area. When I was in The Netherlands with Eric we were implanting perhaps two maybe three a week, and that has given me significance experience, which I can now use. There are probably 20 to 30 people in the US with that experience of this technology. The training is slightly different. When I trained in the US, we spent a lot more time working as residents and fellows, in the order of well over 120 hours a week, although this has since changed in the US since they passed some laws. But in The Netherlands there is a little bit less time spent in hospitals.
“Another reason I was so interested in go to The Netherlands was the dynamic imaging techniques used. It was developed in Utrecht and is basically a manipulation or a trick in the software and we used it on every patient were operated on. It did not change practice but it was a really useful research tool. Another difference was that in the US we routinely get 3D reconstruction, but in Europe we always did it on the workstation. So in both the US and Europe we use 3D reconstruction, but in Europe we just did it ourselves.”
The Marco Polo Award has given Muhs many wonderful memories on both a personnel and professional level. “From a professional standpoint, gaining my PhD was just incredible. On January 25th I went back to The Netherlands and I was award my PhD from Utrecht University through my work as a result of the Marco Polo award. The Dutch ceremony has remained unchanged for hundreds of years and is in part Dutch and in part Latin. The attendees all wear outrageous ceremonial gowns, including Tom Riles who came over from the US. After an hour of questions and answers, they award you your PhD. It was a remarkable experience. Of course there will always be a link between myself and Frans (who was my promoter), and Hence and Eric (who were my co-promoters). I have just taken a position at Yale as Co-director of Endovascular Surgery, and I am sure that is a direct result of my experience gained from my time in The Netherlands, and I will always be grateful to Frans, Hence and Eric.
“On a personnel level, my wife is an oncology fellow and she agreed to take a year off and Frans got us an amazing house surrounded by canals, sheep and cows. With a Heineken in hand, it was the quintessential Dutch view! On the weekends we would drive to France, Belgium, Germany. It was fantastic.”
“I was aware of the conditions in West Africa, as I had visited many countries in the area previously, including Mali, Ghana, Togo, Cote D’Ivore, Benin and Burkina Faso. I had visited a clinic in the past and had done some hernia operations etc, so I had a notion of what it would be like,” stressed Muhs. “Compared to what we are used to, obviously economics is the big difference. The people make on average a dollar a day, after you have paid for your house, kids, food – there is little left for medical needs. The life expectancy is less than 40 and most people die from preventable diseases like malaria or infections.”
Not only was the economic reality striking but also the lack of the most basic resources. “There was no endovascular surgery and although they had a donated C-arm, they had no equipment, no balloons, no wires, nothing. They didn’t even have prosthetic to do a bypass so everything was done with vein.”
Despite such drawbacks, Muhs has nothing but admiration for the staff at the University of Yaounde. “The surgeons there were very skilled and we certainly decreased the amputation rate while I was there. I was pleasantly surprised by the dedication and skill of the surgeons and nurses. The local doctors would see me throw away two inches of suture and they would be horrified. I can’t tie with two inches of suture, but they can.”
However, despite all the skill and determination in the world whether a patient could be treated or not would come down to cost. “A lot of patients have an amputation because they cannot afford the sutures for a bypass – that’s the sad reality – the economics determine who lives and dies. For example, someone comes in who has been hit by a car and has a femur fracture and the femur is sticking out of their thigh and you say, ‘OK, you need an operation, you need this suture, this gauze, this antibiotic, this alcohol and this anaesthetic – go out and buy it and bring it back.’ All that will cost $300 – but they earn $1 dollar a day. So most patients die because of a lack of $300 dollars, that’s the grim economic reality.”
Despite the lack of resources, Muhs got together with a Spanish NGO and after the US embassy provided some funding, he and a group volunteers went out on several impromptu field trips. “We went out at the weekend with some residents, my wife, some nurses, medical students and made up some operating theatres on a dinning table or wherever, and we would see hundreds of patients and give them simple antibiotics, simple operations like a hernia, maybe deliver a baby. The strange thing was I was performing orthopedic surgeries that I had never done before but had seen at medical school – and this was all free because we paid for it, that was very rewarding.
“I also learned to value the supplies and let nothing go to waste. Here in the US, you’d just throw it away. There was one occasion when I was closed somebody’s skin with a fishing line – you learned to make do with whatever you have.”
“I have been able to get some funding from the American College of Surgeons for one of the local surgeons from Cameroon to come to the US and we have sponsored one big trip to the north of Cameroon and they performed 38 surgeries and saw almost a thousand patients. And we probably want to go back in January and do another big trip, and hopefully get some colleagues to come with me. It was a truly wonderful experience and I have gained some lasting connections. If there was ever a way I could have a “western” standard of life in Cameroon, I would emigrate there in a heartbeat!”