International Electives

Dr. Manjunath formed close relationships with their own residents and staff in and out of the operating room, and learned a great deal about medical and urologic training in South Africa. He was able to appreciate unique aspects of urologic care abroad, such as how all metastatic prostate cancer patients get surgical castration or how conduits are performed with the Wallace technique. It total, he was involved in large open oncologic and pediatric cases as well as endoscopic surgeries. An AUA/GURS conference took place during his rotation, and he was fortunate to observe and refine his technique for prosthetics, male slings, and complex urethroplasties.

In addition, Dr. Manjunath learned about South Africa’s two-tiered healthcare system, in which the public sector takes care of 80% of South Africa’s population but with only 20% of the physician workforce. This can contribute to extremely long wait times, which were evident in the urologic cases he took part in. For example, he saw patients with staghorn calculi whose kidneys atrophied and lost function while they waited a year or longer for their PCNL surgery. Despite these obstacles, the urology team’s dedication was inspiring, as they were fierce advocates for their patients.

Lastly, he was able to appreciate South Africa’s history and learn about the liberation struggle against apartheid. He enjoyed traveling with his wife around beautiful Cape Town and they took part in an amazing safari experience.

Dr. Patel spent his rotation at St. Vincent’s University Hospital, one of the major health systems in Dublin. During his time there, he spent the majority of his time with Dr. Barry McGuire, who trained as our Northwestern Endourology fellow under Dr. Robert Nadler and Dr. Kent Perry from 2013 – 2015. He also spent time with the other urologists in the practice and traveled to affiliated sites such as St. Vincent’s Private Hospital and St. Michael’s Hospital. Throughout this experience, he was able to participate in daily rounds, conferences, clinics, and cases in the operating room.

Ireland is a small country of roughly 5 million people with a unique healthcare and medical training system. During his rotation, Dr. Patel was really able to appreciate these differences. After medical school, Irish surgical residents must complete 9 years of training including an intern year, two years of rotations through various surgical specialties, and 6 dedicated years of urology. Also in contrast to the US, residents have the benefit of rotating through various hospital systems around the country providing them with a very diverse experience. Dr. Patel’s elective also gave him the opportunity to experience a healthcare system vastly different from the US. Irish citizens are provided with universal healthcare but also have the ability to purchase private health insurance. Having rotated through St. Vincent’s Private and University Hospitals, he was able to gain a unique appreciation of the limitations and benefits of each approach to healthcare.

Since 1992, the American Austrian Foundation has sponsored over 150 residents through the residency exchange, allowing American and Austrian residents to supplement their education and broaden their experience through exposure to a foreign healthcare system. Dr. Oberlin spent four weeks interacting directly with the urology faculty and housestaff at the largest hospital in Austria, Vienna General Hospital, a 1,500-bed hospital and outpatient clinic with over 1,600 physicians. During his rotation in Vienna, Dr. Oberlin worked closely with chairman Dr. Shahrokh Shariat and urology faculty in the clinic, operating room and research facilities.

Dr. Oberlin learned not only about the field of urology but in particular the nuances of European urologists, which differ from American urologists. During his time in Vienna, he was able to fully integrate himself into the department of urology with significant interactions with the urology staff, housestaff, nursing and research department. In particular, Dr. Oberlin enjoyed discussing salient topics in urology such as PSA screening and neoadjuvant chemotherapy with the urology staff. Through these discussions, he was able to learn new perspectives and management techniques. In particular, he appreciated the differences in the way medical care is provided in a different health system. He also enjoyed learning different perspectives on clinical management and how medical management differs in the Unites States when compared to Austria. For example, healthcare in the United States is burdened by ever-increasing costs, especially with regard to prolonged hospitalization and the cost of hospitalization. To counter these rising costs, there is a significant importance placed on shortening hospital stays in order to maximize efficiency and cost to taxpayers. While in Austria, there is less emphasis on decreasing hospital stays. In many ways, this was refreshing, and many patients are given a couple extra days in the hospital to recuperate and recover.

This non-profit, volunteer-based medical mission educates local urologists and provides surgery and care for women with genitourinary fistulas, a condition that occurs as a result of prolonged and obstructed labor. Fistulization between the bladder, urethra, vagina and rectum occur from extended pressure from the baby’s head. Consequently, the woman constantly leaks urine, and if the rectal wall is also affected, she may be incontinent of feces. Many of the women seen during this biannual, month-long program were ostracized from society and their families as a result of their condition.

The fistula project served a population of women with a great medical need in a specialized surgical field that was largely unavailable in Rwanda. The patients seen in the fistula clinic were often unable to obtain employment due to their urinary and/or fecal incontinence and were relegated to living in small groups of women with fistulas. These patients did not have access to consistent urologic care, nor were they able to afford to pay for the necessary medical care. Advertisements for the biannual fistula program are broadcasted nationally over the radio, with hundreds of women traveling from throughout Rwanda and surrounding countries to be seen. While urinary fistulas are infrequently seen and treated at Northwestern Memorial Hospital, fistulas of the bladder, vagina and rectum are significantly more common in underdeveloped nations, where prolonged and obstructed labor are widespread. As a result, the frequency, severity and breadth of complex female urogenital reconstruction in Kigali far exceeds that of the United States.

Over the duration of the fistula program, Dr. Liu and her peers had the opportunity to evaluate over 100 patients and performed over 30 surgeries. The majority of these surgeries were for fistula repairs, with approximately half managed from an abdominal approach and the remainder via vaginal approach. Over the past decade of the fistula program in Kigali, there's been a distinct shift in types of fistulas the doctors encounter. Previously, most fistulas resulted from prolonged labor and distal vesicovaginal fistula, which are best treated vaginally. In more recent years, with improved access to medical care and more common cesarean section with failure to progress during delivery at local health centers, many fistulas are now more proximal. Involving the ureters, uterus and cervix, these fistulas are repaired from an abdominal approach.

Amanda Chi, MD, traveled to Vienna, Austria, in April 2014 with the generous support of IVUmed’s Traveling Resident Scholar Program and the Andlinger Residency Exchange Fellowship. The Andlinger Residency Exchange is organized by the American Austrian Foundation and encourages training of American residents in Austria or Austrian residents in the United States to supplement the residents’ education and broaden their experience through exposure to a foreign healthcare system. Since 1992, this fellowship has supported the exchange of more than 130 residents.

Dr. Chi spent her rotation at Vienna General Hospital (Allgemeines Krankenhaus), which is affiliated with the Medical University of Vienna. During her rotation in the urology department, she primarily worked with Dr. Harun Fajkovic and Dr. Shahrokh Shariat, in addition to the other urology residents. She was able to observe and participate in daily conferences, operating room activities, clinics and on the wards. Through her experience, she gained an appreciation of how the cultural mentality can drive patient expectations, from patient-physician interactions to how medical resources are shared. According to Dr. Chi, “our medical education systems differ greatly in that surgical training in the U.S. tends to be distributed more evenly throughout our education while the system I observed focused on surgical training in latter parts of residency and beyond. I also noticed the frequent use of ultrasound by the physicians in clinic and in the operating room, a method we are trying to incorporate into our current practice.”

Ghana is a county with 25 million people and a size comparable to Oregon. The annual income per person is roughly $1,800; however, there is a wide gap between the low-income population living mainly in rural Ghana and a middle class located in the urban areas. Dr. Hofer noted that unlike other African countries, Ghana has both a significant middle class and a health insurance system that is financed either by the insured member or an employer. In 2003, a universal-type healthcare system was introduced to cover all children and pregnant women. Because there is a lack of physicians in rural areas, many of the patients Dr. Hofer observed were people from the countryside seeking treatment, requiring several days of travel. Patients were expected to bring all required medications, fluids (IV as well as irrigation fluids needed in the OR), dressing supplies, gloves and glucose strips to the hospital.

There were five operating rooms in the 37 Military Hospital, all of which were equipped with standard ventilation, lighting, anesthesia machines, endoscopy and sterilization facility access. Dr. Hofer noted that he unfortunately saw several patients with advanced renal or prostate cancer upon retuning to the clinic months after their initial visits. Many patients were from outside of Accra, sometimes several hours away by car, so they did not always return for surgery. Many rural populations also seek care from traditional healers and herbal medications, causing a delay in treatment and resulting in inoperable disease.

When Laurie Bachrach, MD, signed up for her International Volunteers in Urology (IVUMed) trip, she had high hopes for a great experience. This was tempered by her previous international experiences where she felt limited in her ability to have a lasting impact. She was more hopeful for this trip based on the experiences of other IVUMed participants and the strong mission of “teach one, reach many.” This trip exceeded all of her hopes and expectations.

Dr. Bachrach's group arrived to Ulan Bator on a Wednesday night. The next morning, they arrived at the hospital and were immediately ushered into a conference room. With little introduction, they immediately began to see patients who were preselected by their Mongolian colleagues as potential operative candidates. The patients were almost exclusively candidates for urethroplasty or laparoscopy. The IVUmed team evaluated the patients’ brief histories and appropriate imaging. Their first case was performed that first afternoon. For Dr. Bachrach’s own records, she took notes and photos of every patient along with relevant imaging and organized it into an ad hoc medical record. This ended up being used by the rest of the team and enhanced their experience, as it allowed them to think about and discuss their surgical approaches in advance and anticipate challenges in the operating room.

Many patients were waiting in the hospital for IVUmed’s arrival with their families and were assertive about being seen. Patients also seemed surprisingly well-informed about their disease process and the treatment options available. Dr. Bachrach believed this was a testament to the Mongolian doctors. The existing knowledge and skill of the Mongolian doctors, coupled with a highly focused teaching mission, contributed strongly to the success of the trip.

One of her concerns early on was that it would be tough to balance her desire to pursue her own training and education without taking away from their treatment. A former resident was very helpful in negotiating this by defining specific roles for each case. In the end, they became so busy that there was room for all of the IVUmed members to work at the same time. That allowed them to take care of more patients, while also permitting everyone to get a richer training opportunity. Dr. Bachrach says she was very impressed with the organization of the trip.

She spent her first week at Christian Medical College, a 557-bed hospital in Ludhiana, Punjab, working with Dr. Kim Mammen. She observed two days of operating (simple nephrectomy, ureteroscopy, groin debridement and multiple ureteroscopies) and two days of clinic. While working in Ludhiana, the department was deciding between investing in a laser or an ESWL machine, and she found the discussion of surgical choices on a limited budget fascinating. Additionally, while on rounds with the clinical team, there were obvious differences between the public ward (50 patients in one room with shared bathroom) and the private ward (private rooms, cable television, air conditioning), highlighting the economic disparities in India. Dr. Casey noted that the urologists treated each patient similarly despite their socioeconomic backgrounds.

Dr. Casey then traveled to Sadbhavna Trust Hospital in Mahuva, Gujarat, with Dr. Sakti Das, her mentor from IVUmed who hails from Alameda County Medical Center. Over six days, she performed 34 operations, ranging from delicate hypospadias work to minimally invasive percutaneous nephrolithotomies to an exstrophy repair. During the last case, Drs. Casey and Das worked with a local gynecologist-turned-urologist to do a primary exstrophy repair, ileal cecal pouch and epispadias repair on a 16-year-old boy who had been living with an open bladder since birth. He had been coming to Sadbhavna Trust Hospital for two years hoping for a surgery to make him dry. During her stay in Mahuva, Dr. Casey met Amithi, who underwent bladder augmentation and Mitrofanoff construction one year earlier for her neurogenic bladder from spina bifida; she came to the clinic to thank Dr. Das for changing her life.

During her time in India, Dr. Casey learned how to operate with minimal technological advances and get difficult cases completed with the basics (scalpel, cautery, suction, hemostats and donated suture). Her travel to India highlighted the international need for urological care, and she hoped to continue to operate internationally in the future.

Dr. Zhao visited the old imperial capital city of Hue in central Vietnam. There, he joined several other visiting American residents from Duke and Virginia Commonwealth University to exchange knowledge and work with the local urologists. Dr. Zhao was taken to work in Hue Central Hospital, which Dr. Zhao described as “an impressive complex with swarms of patients and medical staff." He said it "looked like a small city.” In comparison, the Urology Department was relatively small, comprised of only 10 patient rooms and five physician offices. No room was wasted as each patient room housed up to eight patients and the physician offices doubled as equipment storage rooms.

Dr. Zhao and the other residents had brought medical equipment with them that they presented to the chair of the department. Guide wires and catheters appeared to be hot commodities in Hue. He felt this supply of donated guide wires might be all that the department would use until Americans returned in six months.

The visiting residents fell into a surgical routine of two or three hours in the morning, a break for lunch and surgery for two more hours in the afternoon. Differing from his time at Northwestern, Dr. Zhao noted he could easily scrub into six different cases per day, have time for lunch and still get home by 5 p.m. A similar day back in the United States would keep him in the hospital until 7 or 8 p.m.

What Hue Hospital lacked in modern medical equipment, it made up for in efficiency. “I was impressed with how fast the Vietnamese surgeons were and that nothing was wasted in the hospital. Since all the surgical drapes were cloth, they were washed, re-sterilized and re-used. It truly is amazing how much waste there is in the United States. In Vietnam, pretty much the only things which were thrown away were the gloves,” Dr. Zhao said.

Less than 2 percent of India’s population has access to medical specialists. This is partly why Brian Le, MD, spent five weeks in Delhi, India, on an international medical rotation through our department. Looking for a vastly different medical perspective, Le traveled to the capital city, home to 22 million people, in January 2011.

Dr. Le split his time between two major hospitals. He was based at a private hospital that was part of the Max Healthcare Hospital System and also spent time at the public hospital, where the line for services stretched out the door. Jumping right into the fray, Dr. Le was in the operating room with local Indian urologists every day. While technologically modern, the operating rooms were run cost-efficiently. All equipment was utilized for maximum usage. Nothing was thrown away unless absolutely necessary.

While India itself is an affluent country, many of its people are quite poor. Because of this, costs are kept at a minimum to ensure patients are able to take advantage of the modern technology. Due to this access to modern medicine in an area of the world populated with poverty, India is also a travel destination for those seeking treatment from neighboring countries. Dr. Le repeatedly saw patients seeking treatment in India to only to later return to their home countries after recovery.

Dr. Le kept close ties to those he worked with in India, including Dr. PB Singh, the president of the Urological Society of India, whom Le reunited with at the 2011 AUA conference in Washington, D.C.