Tuesday, June 15, 2010

Bologna, Italy and Ghent, Belgium

By: Nirav Shah

During the last year of my residency, I was fortunate to be able to travel abroad and participate in orthopedic care internationally for two weeks. I recently visited the European cities of Bologna, Italy and Ghent, Belgium to work with sports specialists focusing on cartilage restoration. As many of our surgical procedures are derivatives of European techniques, I welcomed the opportunity to interact with surgeons who are contributing novel ideas to the orthopedic field.

My travels began in Bologna, a city in Northern Italy and home to the oldest university in the Western World, founded in 1088. Its location as a central hub for European travelers throughout history led to its development into a major academic and cultural center. Unfortunately, its location has also led to numerous episodes of near complete destruction throughout history, most recently with Nazi bombings in 1944. Every episode, however, was met with resurgence by its populace, regenerating itself as a commercial, industrial, and communications center. It is a city that prides itself in its history, wine, and food. With 375,000 inhabitants in the city currently, and another 600,000 in the surrounding countryside, it is a city that bustles from dawn until well past sunset.

During my time there, I was able to explore the city both historically and gastronomically. It is a predominantly Catholic city, filled with churches, seemingly at every corner. As I visited during the Easter holidays, I observed many parades, celebrations, and ceremonies. After leaving church, the people like to gather in one of the many piazzas to have a drink or a cup of gelato. Gelato is such an integral part of Bolognese life, a “university” dedicated solely to training chefs on its production has been established in the city. The people also take pride in their unique flare to Italian cooking, a treat of which I was happy to partake.

When I was not exploring the city, I was at the Rizzoli Orthopedic Institute, a hospital specializing in orthopedics and musculoskeletal care founded in 1896 within the confines of the historic monastery of San Michele in Bosco. The hospital consists of nearly 100 faculty members with 60 supporting residents who see 150,000 patients and perform 18,000 surgeries annually. Historical contributions include bone tumor classification and management by Dr. Campanacci, treatment of spondylolisthesis by Dr. Marchetti, and shoulder stabilization techniques by Dr. Putti. Current work at the Rizzoli Orthopedic Institute, as evidenced by its presence as the largest tissue bank in Italy, includes allograft reconstruction following extremity sarcoma. The faculty is also in the midst of developing implantable biocomposite materials to repair articular lesions as well as replace previously resected meniscus.

I was thankfully able to observe several gifted knee surgeons such as Dr. Stefano Zaffagnini and Dr. Maurilio Marcacci and engage in enlightening conversations regarding their ideas and thought processes on ligament and cartilage reconstruction. In addition, their residents were extremely welcoming, escorting me around the hospital as well as the city. Seeing Bologna from a resident’s perspective was certainly a welcome and inebriating experience.
After my week in Bologna, I took a short flight and long train ride to Ghent, Belgium by way of Brussels. Despite having Dutch as the official language, the region of Fleming in the northern half of the country, where Ghent is located, has a preponderance of English-speakers, to my relief.

The city of Ghent was first inhabited as far back as the Stone Age due to its location at the confluence of two large, Northern European rivers. Today, it is home to 250,000 citizens and 600,000 total people in the metropolitan area. It has served as the center of the wool trade in Europe (leading to the good relations between Belgium and both England and Scotland), the seat for the high court of Belgium, and most recently the location for the Treaty of Ghent ending the War of 1812 between Britain and the United States.

The city of Ghent is extremely navigable, either by foot, or by its extensive public transportation system consisting of trams and buses. This was extremely helpful as I wandered the streets of the city center, taking in the preserved medieval architecture. One of the most scenic locations is the Graslei, site of the old harbor, where the old post office is flanked by St. Michael’s bridge, and the towers of several churches can be seen in the background.

But the city is not one large museum devoted to past architecture; the inhabitants reside in those same ancient buildings. They come out in droves in the afternoon, as early as 3 pm, to indulge in their favorite drink: beer. The region is famous for its Trappist ales, beers produced entirely within the confines of a monastery to fund the monks’ works. As a charitable citizen of the world, I was more than happy to contribute my fair share to their good cause. The appreciation for the food of Ghent, however, required pride that could only come from Ghent citizenship. The diet focuses on soups and stews to carry through the long, cold winters. Thankfully, its presence as a major port city as well as home to a large university has brought international flavors and cuisine to its people, including a new Subway fast food restaurant.
During the days, I was able to spend time with Dr. Peter Verdonk, an acclaimed sports surgeon whose research focuses on meniscal transplantation. He is part of the faculty at the Ghent University Hospital, a center that is committed to orthopedic resident education and excellent patient care. That philosophy parallels that of my experiences at Washington University. The resident participation in clinical care was nearly identical to that of Washington University, with morning conferences dedicated to education, autonomy in clinic, and supervised progression in the operating room. Our treatment algorithms were also nearly synonymous, save for the differences inherent in a socialized health system compared to our private insurance system. As the healthcare bill had just recently been passed by Congress at the time of my visit, this opened up a lively debate about the merits of each system. I was happy to see our European counterparts considered their system to be broken and unsustainable and looked to the U.S. system for solutions.

I am extremely grateful to everyone who extended their hospitality in both Bologna and Ghent. Over the two weeks abroad, I came to an appreciation for the differences in healthcare, both clinically and economically, that exists across the Atlantic. I found the entire experience enriching and am very thankful for the opportunity.

Wednesday, June 9, 2010

Lyon, France

By: Julienne Boone

During the last year of our residency training, we are supported by the department to partake in an international elective for 2 weeks. I recently traveled to Lyon, France to work with internationally acclaimed shoulder surgeon, Dr. Gilles Walch. Ironically, while this experience was not in a third world setting, I was the only chief this year to have significant travel problems and spent an extra week in Lyon due to multiple fight cancellations from the ashcloud of the erupting Icelandic Volcano Eyafallajokull.

Lyon is a vibrant city with a unique architectural, cultural and gastronomic heritage. The city proper has about 470,000 inhabitants, but the area of Greater Lyon has a population of about 1,200,000. It is shaped by its two rivers, the Rhone (to the East) and the Saone (to the West). It is located approximately 285 miles Southeast of Paris, 98 miles West of Geneva, and 200 miles North of Marseille and the Cote d'Azur.

During the renaissance, Lyon was one of Europe's largest cities and its first financial place. It's main industry was silk weaving which remained prominent until the end of the 19th century, and it was interesting to explore Vieux Lyon (Old Lyon) to see the traboules (corridors which link two streets through a building) where the pieces of silk were carried amongst the workshops and to the river. These notable architectural features also played a significant role during World War II under the German occupation as they permitted la Resistance to travel undetected and exchange information/weapons since the Germans did not know them very well. As an interesting fact, the head of la Resistance, Jean Moulin, was arrested in Lyon on June 21, 1943 during a meeting with Resistance leaders and notably interrogated in Lyon by the head of the Gestapo, Klaus Barbie (famously known as "the butch of Lyon").

Lyon is a very easy city to navigate on foot and the public transportation system is unparalleled as well. The metro runs city-wide and made it very easy for me to get to the hospital and clinics as well as explore. I was able to see a multitude of cultural landmarks both historical and present day that speak to Lyon's character.

Food is a very important part of the French culture here and Lyon as been called by many the capitol of gastronomy. Everyone here closes their shops and takes a long lunch break (usually from noon to 1:30ish) to eat at a local Bouchon.
I sampled many of the Lyonnais specialties, including quenelles de brochet (a souffle-like dumpling with pike fish), saucisson Beaujolais (local sausage cooked in red wine), and salad lyonnaise (mixed greens with lardons, croutons, a shallot vinaigrette, and topped with a poached egg - delicious!). All meals are typically served with wine and I was able to taste many fantastic wines produced from the nearby regions of Cotes du Rhone, Burgundy and Beaujolais.

France has universal health coverage through the public health insurance system which pays for about 75% of the total health expenditures. Supplemental private insurance and patient costs contribute to the remainder. There are both public hospitals (non-profit) and private hospitals (for-profit). I spent two weeks with Gilles Walch seeing patients in clinic, assisting with operative cases and attending morning conferences. The hospital he predominantly operates out of is Hopital Prive Jean Mermoz, which is a private 260 bed hospital which opened in 2008. He operates on Tuesdays and Wednesdays and usually does 5-6 cases each day.
He is a shoulder specialist, so the majority of the patients we saw had shoulder arthritis, instability or cuff pathology. Interestingly, all of his patients are admitted the night before surgery for their "pre-op" workup, and then they all stay at least one night post-op (even the cuffs!) since it costs the same regardless of length of stay.

During my time in Lyon, I assisted with many arthroscopic cuff repairs, a couple of Laterjet procedures, and a few total shoulder arthroplasties.

Each morning, prior to the OR, Dr. Walch met with his fellow, Allan Young from Australia, and his partner's fellow, Roberto from Brasil, to review the day's indications and provide some informal teaching. (This was also the time for everyone to have their morning espresso!)

On Mondays and Thursdays, I accompanied Dr. Walch during "consultation" (clinic). He belongs to a private group of 11 (soon to be 13) MD's, including 4 shoulder surgeons, knee surgeons, spine surgeons, a rheumatologist, and a few rehabilitation physicians. They own their own building, Centre Orthopedique Santy, and have in-house radiology and physical therapy.

Consultation occurs in Dr. Walch's personal office, where he has an exam table. Patients are called in one at a time and about 20-30 are seen each day. He works very closely with Dr. Jean-Pierre Liotard, a rehabilitation physician who focuses exclusively on the shoulder, and who sees all of his post-op patients. On Fridays, I worked with Dr. Liotard doing injections and post-op visits to assess rehabilitation progress.

My trip to Lyon was a wonderful experience. Dr. Walch is not only a tremendously talented
surgeon, but he is also an amazing teacher. Everyone I met, from his OR staff to his partners, were very welcoming and made me feel as through I was a member of Dr. Walch's team.
Dr. Walch also welcomed me to his house several times. As football (soccer) is huge in Europe and one of his favorite sports, he had the fellows and me over to watch the matches (we watched Lyon beat Bordeaux in the European Champions League quarterfinals)! Overall, I am very grateful for this opportunity to work with Dr. Walch. Both his professional and personal hospitality were quite gracious and this will hopefully be just the beginning of a wonderful collegial relationship.