The Twinning program between Henry Ford Hospital and
North Okkalappa General Hospital
Jack P Rock, MD*, Sue Myat Mo**, Karam Asmaro, MD*, Professor Kyi Hlaing** and Professor Win Myaing**
Henry Ford Hospital* and North Okkalappa General Hospitals** Departments of Neurosurgery
The program began in 2013 when under the auspices of the Foundation for International Education in Neurological Surgery (FIENS) and I volunteered for two weeks at Yangon General Hospital (YGH). At the time we were located at Yangon General Hospital and during this first visit I became acquainted with the neurosurgery residents and the directors of the neurosurgery service, Drs. Win Myaing and Kyi Hlaing, operated on patients, gave lectures and teaching session to the neurosurgery residents and shared leisure time around Yangon. I returned to YGH the following year in the same capacity but on the third trip to YGH he brought a team of physicians, nurses and biomedical technicians and the Twinning program began. The following year a Memorandum of Understanding was established between YGH and Henry Ford Hospital and with the expanded team nurses, biomedical staff, neurosurgery residents and faculty became involved.
Each year since the team assisted Drs. Myaing and Hlaing by bringing along individuals prepared to teach different surgical procedures, teach nurses and residents. Three years ago we began hosting the Yangon residents at Henry Ford’s Department of Neurosurgery for six – eight week clinical observorships and beginning 2 years ago after the program moved to North Okkalappa General Hospital, I have brought along one - two HFH neurosurgery residents with the team to Yangon. Additionally, two years ago I began meeting by Skype with the NOGH residents every two weeks to discuss important topics in neurosurgery and patient care. Over the last 5 years we have been fortunate to have a number of meetings with the Ministers of Health and their support has been greatly appreciated. In 2017, the first SE Asia Yangon neurosurgery boot camp was initiated with the support of Medtronic, Storz and Integra companies and these boot camp activities have continued in SE Asia in Singapore (2018), Yangon (2019) and Danang (2020). Generally, these boot camps host 40-50 neurosurgery residents and 15-25 faculty both local and international.
Since 2015 and depending on the facility needs of the YGH and more recently NOGH neurosurgery departments, our group has submitted educational grants to medical instrument and equipment companies in support of equipment needs for a number of surgical procedures including cranial nerve monitors (Medtronic), endoscopes (Storz), aneurysm clips (SurgicalOne and Mizuho) and more.
As of January 2020, in conjunction with FIENS and at the request of Drs. Myaing and Hlaing, a written neurosurgical academic curriculum was developed and the faculty and residents at NOGH began meeting weekly to present and discuss important and diverse topics prepared in advance by the faculty and residents. We have also received an award from the Congress of Neurological Surgeons in 2019 for our work on traumatic brain injury in Yangon and that manuscript is in preparation. The neurosurgery residents at NOGH have played a critical role in all of our activities and our academic work and we are looking forward to additional academic and clinical projects.
The following was written by Sue Myat Moe, 4th year neurosurgery resident at NOGH.
’The value of collaboration between NOGH-HFH’
The health care system in Myanmar is faced with a lot of challenges in every sector including neurosurgery. Looking ten back, there were less than 10 neurosurgeons providing care for a national population of over 50 million people with very limited resources at their disposal including outdated microscopes, cranial and spinal drills, few microsurgical instruments and limited imaging facilities. After contacting Dr. Merwyn Bagan, the director of FIENS in 2011, a collaboration with HFH began which at that time could not foresee the impact this would have for resident training for the younger generations of Myanmar neurosurgeons. As a result of continued collaborations the neurosurgery training program and approaches to patient care began to change as a result of Dr. Rock’s volunteers visiting from HFH in 2013. Initially all neurosurgery residents in Myanmar were required to undergo three years of General Surgery before entering Neurosurgery residency but since 2015, neurosurgery residents are required only one year of General Surgery. Advancing in an educational manner, we were fortunate to host and participate in the 1st neurosurgery boot camp in Myanmar and South East Asia in 2017. At this boot camp, we were exposed to basic neurosurgery topics and fundamental neurosurgical skills training with hands-on stations by internationally known neurosurgeons. As a result of the boot camp we were able to more easily understand more of essential neurosurgery topics and surgical techniques after the lectures and case discussions between small groups of faculty and residents. The opportunity to interact with many neurosurgeons sharing their knowledge at the boot camp and attend other international meetings such as the International Society of Pediatric Neurosurgery in Myanmar attended by Dr. Rock’s team has broadened our appreciation and understanding of the neurosurgical specialty. With every visit of his team, the residents are exposed to new concepts and experiences. Our neurosurgical operation concepts and outcomes become better than those in the past and we have grown more and more starting from basic concepts like positioning of the patient to advanced neurosurgical techniques like the endoscopic endonasal transsphenoidal approach for pituitary tumors, awake craniotomy, endoscopic third ventriculostomy, surgery for foramen magnum tumors, microvascular doppler ultrasound for vascular surgery, intraoperative monitoring for CPA tumors, navigation guided tumor operations and so on. Over the last two years our residency program has improved every couple weeks with tele-discussions with Dr. Rock via Skype. These sessions have motivated us to study the various topics for discussion and we after becoming more aware of differential diagnoses.
As for instruments and equipment, previously we had to do craniotomy with hand held devices like Devilbiss rongeurs and Hudson braces because of limited power drills like Midex Rex and Stryker. Our biomedical capabilities were limited and after Dr. Rock’s team member, biomedical technician Andrew Steiner, arrived to teach and train our local biomedical people our operations have become more smooth and faster with equipment generally in working order. Apart from this Mr. Steiner has shown our group how to repair other machines in the operating rooms. In fact, our nursing staffs and anesthesiologists look forward to his visits to understand better how to maintain and repair many non-functioning machines. Additionally, our nurses have had many experiences and teachings about operative procedures from Ms. Tracy Enos, HFH neurosurgical operating room head nurse and our “nurse Nightingale” . More recently, Marianne Langlois has visited with the team to present to our residents and nurses on ICU care and this has been very educational. Lastly, our clinical rotations to HFH has been unbelievable for us to experience a high-quality neurosurgery residency program. Overall our experience at HFH has been academically fantastic and a wonderful achievement for us. During this rotation we have learned quite a lot including how to extensively examine the neurological system, basic neuroradiology, cadaveric dissection in lab, advanced and latest neurosurgical technologies and techniques.
The best experiences of our twinning program are as follows;
We hope to continue this twinning program as a longterm plan for our neurosurgery program because we can then be able to improve local facilities and experiences for our junior colleagues. We also hope to develop multidisciplinary teams focusing on various specialties including neuroanesthesia, neurocritical care, neuroradiology, neuropathology, neurooncology and physiatry for rehabilitation and physiotherapy that will improve the quality of care for our patients.
The following was written by Karam Asmaro, MD PGY 6 Henry Ford Hospital Department of Neurosurgery who accompanied the HFH team in November 2018.
In developing countries like Myanmar, the general population lacks the resources, access to adequate healthcare and far less access to centers providing advanced neurosurgery. The majority of the population lives in rural, isolated areas where there is a critical lack of sophisticated medical care and this leads to significant morbidity and mortality from otherwise treatable causes. The purpose of the Henry Ford mission to Myanmar is to provide neurosurgical care by utilizing a team approach. This is accomplished by working alongside the local neurosurgery staff and residents to empower and enhance their skills. The goal of recent biannual trips is to enrich the care delivered by the neurosurgeons in Myanmar and boost the quality of training as those are the best ways to ensure lasting change. The proverb of teaching a man to fish rather than giving him one is quintessential to medical missions abroad, as long as there is an attentive and enthusiastic audience. The success of these trips depends largely on developing an excellent rapport established early on by the senior neurosurgeon in Detroit and their counterparts in Yangon. This has led to unique cultural and educational exchanges where attending staff and residents have visited each other’s programs for a two-way learning experience.
Providing neurosurgeons and neurosurgery residents with a stronger understanding of anatomy, neuroradiology, neuropathology, neurophysiology and clinical neurology leads to improved outcomes and this has been the primary focus of the HFH team visits. Technological advancements over the last century have widened the disparity of care delivered in developing countries compared to the rest of the world and because neurosurgery relies heavily on cutting edge technology, the secondary goal of the collaboration has been to help provide critical technologies in hopes that this will lead to improved patient outcomes. This idea has led to the first awake craniotomy for brain tumor, the first endoscopic intracranial surgery and more being done over the last five years.
Although significant strides have been made with the help of many generous donations, a great deal is left to be done. The neurosurgeons of Myanmar are the unsung heroes who do a great deal with very little. Their lack of basic hemostatic agents and diagnostic studies are just two of the many internationally available items that we take for granted on daily basis. Moreover, the lack of ICU equipment such as ventilators and continuous telemetry makes managing critical and post-operative patients difficult, if not impossible. Medical missions in combination with twinning programs will help reduce these opportunity gaps and it is our privilege to continue this work.
The experience in Yangon has brought to light how extremely efficient the residents, nurses, and the health care workers are required to be. They accomplish so much with very limited resources. The residents are in charge of the entire ward which at any time may include many types of patients including pediatric patients, routine adult and pediatric postoperative patients, critically ill patients and polytrauma patients. Despite these challenges, they rise to the challenge and able to manage their goals.
Resident training in Myanmar
Residency training in Myanmar is also unique. Upon completion of their high school diploma, the students join a six-year medical school which grants them the Bachelor of Medicine and Bachelor of Surgery (MBBS) degree. Newly minted physicians practice as assistant surgeons in underserved areas depending on exam scores and vacancies. The mandatory residency in General Surgery prior to neurosurgical training was recently decreased from three to one year. Based on this change, a tremendous growth of interest on the part of your physicians has occurred which is crucial to the success of this nascent specialty. After a year, they can now join a master degree program in neurosurgery where formal specialty training begins for a total of three years. Upon graduation with a Master of Medical Science (MMedSc) in neurosurgery, they must complete a two-year minimum government service project (which can be at the resident’s master degree hospital) prior to initiating the doctorate track which is available based on the slots that open up. The doctorate degree (DrMedSc) of neurosurgery is also a minimum of three years and requires a rigorous research thesis, entrance and exit examinations. The residents in their final year of training are called junior consultants, which is the equivalent of a chief resident in the United States. Upon successful completion of the doctorate program, they are sent across the country based on government need and serve as associate professors until a promotion occurs when a position for professorship opens up.
Figure 1. Dr. Kyi Hlaing (Director of Neurosurgery NOGH), Ms. Tassa Patrick (neuromonitoring technician from Detroit) and neurosurgery residents in NOGH operating room.
Figure 2. Neurosurgery residents Su Myat Mo and Nang Saw from NOGH in the Henry Ford Hospital Anatomy Lab during their 2-month rotation in Detroit.