Proceedings of the First Joint Haitian American...
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1 PROCEEDINGS OF THE FIRST JOINT HAITIAN AMERICAN UROLOGY CONFERENCE NOVEMBER 14-15, 2013 HOTEL OASIS INTERNATIONAL, PETIONVILLE, HAITI History of Urology in Haiti (Pierre Boncy, MD) Urology in Haiti came to be recognized as a specialty in Haiti some 50 years ago. As everywhere else, it was originally performed by general surgeons who eventually limited their practice to the uro-genital tract. Christian Valme, MD who practiced in the 1960s is considered the true pioneer in Urology at the State University Hospital of Haiti. We also have to recognize the late Dr. Constant Pierre-Louis who organized the Service of Urology at the same hospital. Around the same period, Dr. Constant Andre practiced urology in the city of Cap-Haitien after a short training period with Dr. Constant Pierre-Louis in Port-au-Prince. He performed circumcisions, hydrocelectomies, cystostomies and penile amputations. He became the medical director at Hopital Justinien in 1957 and retired in 1969. The 1970-1980 decade is considered the golden era of Haitian urology as a group of young urologists, most of them trained in the USA at the Homer J. Phillips Medical center in Saint-Louis, MO returned home to practice their skills. They included Decatrel Mirville, MD, Roger Valme, Pierre Nazon, MD, Anthony Camille MD, Raymond Remy, MD and Dr. Benjamin. Most of them have since died or retired. The baton was passed to the third generation of young urologists in the 1980s, amidst serious socio-political upheaval and serious difficulties including an obsolete and inadequate equipment. Between 1980 and 2000, this group was made of Pierre Boncy, MD, Dr. Barthelemy, Bernard Brutus, MD, Pierre-Alix Nazon, MD and Jacques Gracia Medilien, MD. This brings us to contemporary times and the current staff at the State University Hospital that includes in addition to the previously mentioned group, Georges-Eric Brisson, MD, Claude Paultre, MD, Roger Valme, MD, Miletot Clervil and G. Alexis, MD. Every single member of the team has completed a residency training in Urology at the State University Hospital and is thus certified by the Ministry of Health. In addition, they have acquired additional training either in the USA, in France or in the French Antilles. Most of these urologists practice in the “Republic of Port-au-Prince” either in the public setting at the State University hospital or in the private sector, between the Hopital du Canape- Vert, l’Asile Français, the Hopital Saint-Francois de Sales, the Clinique Roger-Emmanuel and the Baptist Mission of Fermathe. The evolution of Haitian Urology is mirrored by the evolution of prostatectomy that went through the stages of - Trans-Vesical Adenomectomy with supra-pubic Pezzer Catheter - Trans-Vesical Adenomectomy with control of bleeding - Trans-Vesical Adenomectomy with Foley catheter - Trans-Vesical Adenomectomy with blood transfusion in less than 50 % of the cases - Finally, Trans-Urethral Resection of Prostate Progress in the field of Urology in Haiti will require not only an equipment upgrade, but also strong leadership and the unification of all involved in the practice of urology and in the training of the next generation in order to standardize the residency requirements and improve the skills of the urologists An Inventory of Human Resources in Urology in Haiti (Claude Paultre, MD) The first Medical School in Haiti was established in 1820. Since then, it has become incorporated in the State University of Haiti as the Faculte de Medecine et de Pharmacie. The medical degree is obtained
Transcript of Proceedings of the First Joint Haitian American...
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PROCEEDINGSOFTHEFIRSTJOINTHAITIANAMERICANUROLOGYCONFERENCE
NOVEMBER14-15,2013HOTELOASISINTERNATIONAL,PETIONVILLE,HAITI
HistoryofUrologyinHaiti(PierreBoncy,MD)UrologyinHaiticametoberecognizedasaspecialtyinHaitisome50yearsago.Aseverywhereelse,itwasoriginallyperformedbygeneralsurgeonswhoeventuallylimitedtheirpracticetotheuro-genitaltract.ChristianValme,MDwhopracticedinthe1960sisconsideredthetruepioneerinUrologyattheStateUniversityHospitalofHaiti.WealsohavetorecognizethelateDr.ConstantPierre-LouiswhoorganizedtheServiceofUrologyatthesamehospital.Aroundthesameperiod,Dr.ConstantAndrepracticedurologyinthecityofCap-HaitienafterashorttrainingperiodwithDr.ConstantPierre-LouisinPort-au-Prince.Heperformedcircumcisions,hydrocelectomies,cystostomiesandpenileamputations.HebecamethemedicaldirectoratHopitalJustinienin1957andretiredin1969.The1970-1980decadeisconsideredthegoldeneraofHaitianurologyasagroupofyoungurologists,mostofthemtrainedintheUSAattheHomerJ.PhillipsMedicalcenterinSaint-Louis,MOreturnedhometopracticetheirskills.TheyincludedDecatrelMirville,MD,RogerValme,PierreNazon,MD,AnthonyCamilleMD,RaymondRemy,MDandDr.Benjamin.Mostofthemhavesincediedorretired.Thebatonwaspassedtothethirdgenerationofyoungurologistsinthe1980s,amidstserioussocio-politicalupheavalandseriousdifficultiesincludinganobsoleteandinadequateequipment.Between1980and2000,thisgroupwasmadeofPierreBoncy,MD,Dr.Barthelemy,BernardBrutus,MD,Pierre-AlixNazon,MDandJacquesGraciaMedilien,MD.ThisbringsustocontemporarytimesandthecurrentstaffattheStateUniversityHospitalthatincludesinadditiontothepreviouslymentionedgroup,Georges-EricBrisson,MD,ClaudePaultre,MD,RogerValme,MD,MiletotClervilandG.Alexis,MD.EverysinglememberoftheteamhascompletedaresidencytraininginUrologyattheStateUniversityHospitalandisthuscertifiedbytheMinistryofHealth.Inaddition,theyhaveacquiredadditionaltrainingeitherintheUSA,inFranceorintheFrenchAntilles.Mostoftheseurologistspracticeinthe“RepublicofPort-au-Prince”eitherinthepublicsettingattheStateUniversityhospitalorintheprivatesector,betweentheHopitalduCanape-Vert,l’AsileFrançais,theHopitalSaint-FrancoisdeSales,theCliniqueRoger-EmmanuelandtheBaptistMissionofFermathe.TheevolutionofHaitianUrologyismirroredbytheevolutionofprostatectomythatwentthroughthestagesof
- Trans-VesicalAdenomectomywithsupra-pubicPezzerCatheter- Trans-VesicalAdenomectomywithcontrolofbleeding- Trans-VesicalAdenomectomywithFoleycatheter- Trans-VesicalAdenomectomywithbloodtransfusioninlessthan50%ofthecases- Finally,Trans-UrethralResectionofProstate
ProgressinthefieldofUrologyinHaitiwillrequirenotonlyanequipmentupgrade,butalsostrongleadershipandtheunificationofallinvolvedinthepracticeofurologyandinthetrainingofthenextgenerationinordertostandardizetheresidencyrequirementsandimprovetheskillsoftheurologistsAnInventoryofHumanResourcesinUrologyinHaiti(ClaudePaultre,MD)ThefirstMedicalSchoolinHaitiwasestablishedin1820.Sincethen,ithasbecomeincorporatedintheStateUniversityofHaitiastheFacultedeMedecineetdePharmacie.Themedicaldegreeisobtained
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afterasix-yearcyclethatfollowsthesatisfactorycompletionofthesecondaryschoolcurriculum.Thatsix-yearcycleincludestwoyearsofBasicSciences,threeyearsofClinicalSciencesandoneyearofrotatinginternship.
• Subsequently,threeadditionalprivatemedicalschoolswereadded:UniversityofQuisqueyain1988,UniversityLumierein1993andUniversityofNotre-Damein1995,whichisaseven-yearprogram.Thus,therearecurrentlyfourrecognizedmedicalschools.Moreschoolsareintheprocessofseekingrecognition.Withinthosemedicalschools,UrologycoursesareprovidedtotheFifth-Yearstudentsbyfiveprofessors:Dr.R.ValméandDr.M.ClervilattheStateUniversity,Dr.R.ValméandDr.J.M.AubourgatNotre-Dame,Dr.P.BoncyatQuisqueyaandDr.C.PaultreatLumière.ThemedicalstudentsreceivetheirfirstclinicalexposuretoUrologyintheirfifthyearofeducationunderthedirectionoffourClinicalInstructors:DrP-A.NazonandDrG.AlexisattheStateUniversity,Dr.J.M.AubourgatNotre-DameandDr.J.GanthieratLumière.ThesecondclinicalexperienceinUrlogyisprovidedasaone-monthrotationinUrologyduringthefinalyearofrotatingInternship,whichtakesplaceattheStateUniversityHospital(HoppitalGeneralinPort-au-Prince)fortheStateUniversityStudents,attheHôpitalUniversitaireJustinieninCap-HaitienforthestudentsfromNotreDameandQuisqueyaandatHôpitalImmaculéeConceptioninLesCayesforthestudentsfromLumière.AtthePost-Graduatelevel,theresidentsreceivetheirspecialtytraininginUrologyattheStateUniversityHospitalinPort-au-PrinceandatHopitalUniversitaireJustinieninCap-Haitien.InPort-au-prince,theFacultyincludes:Dr.P.Boncy,HeadofDepartment,Dr.G.E.Brisson,AssistantHead,Dr.C.Paultre,ProgramDirectorandastaffofseven:Dr.B.Brutus,Dr.D.Barthelemy,Dr.J.G.Médilien,Dr.G.Alexis,Dr.P-A.Nazon,Dr.M.ClervilandDr.R.Valmé.In2013,thefour-yearprogramcounts12residents:3atthethirdyearlevel,sixatthesecondyearleveland3atthefirstyearlevel.Therearecurrentlynofourthyearresidentssincetherewasnograduationin2010,becauseoftheJanuary12,2010Earthquake.TheServiceofUrologyattheHôpitaluniversitaireJustinienofCap-HaïtienisdirectedbyDr.JeanGetoDubé,whoisalsothechiefAdministratoroftheInstitution,aidedbyhislonestaffmemberDr.JoryDésir.Fiveresidentsarenowintraining,twoatthesecondyearlevelandthreefirstyearresidents.ThroughvarioustrainingopportunitiesofferedinEuropeandinNorthAmerica,someofthestaffmembershaveacquiredaspecialexpertiseinspecificareas.InEndourology,Dr.Pierre-AlixNazonisthemostversedinUrethrocystoscopy,InternalUrethrotomy,TURPs,TURBTs,Resectionofposteriorurethralvalves,ureteroscopyandshockwavelithotripsy,whileDr.ClervilhasspecialskillsinfemaleurologyandurologiconcologyasheisthemostfacilewithColporrhaphyandcolpopexy,aswellasRadicalProstatectomiesandCystectomies.Finally,Dr.JacquesJeudyhasbeenpioneeringarenaltransplantprogram,whichisstillinitsinfancy.BesidesthetwotrainingcentersinPort-au-PrinceandCap-Haitien,UrologicproceduresarealsoperformedinLesCayes,Petit-Goave,St-MarcandJacmel.Inconclusion,overthepast20years,24physicianshavebeentrainedinUrology.Currently,thereareatotalof26urologistsinHaiti:20inPort-au-Princeand6fortherestofthecountry,whichrepresentsaratioof1:>300,000population.Thisnumberislikelytogrowsoonthankstothetwoaccreditedsitesofresidency.UROLOGICSURGERYINAPRIVATESETTINGINPORT-AU-PRINCE–Pierre-AlixNazon,MD
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MyassignmentwastopresentalistofthemostcommonurologicpathologiesencounteredinHaiti.Suchdatahasnotbeencompiledatthenationallevel.Inlieuofnationalstatistics,Ithoughtthatasurveyoftheproceduresperformedoveratwo-yearperiodatasingleinstitutionwouldgiveanidea,albeitabiasedone,oftheurologicconditionsseeninHaiti.ThispresentationisbasedonareviewofthesurgicalinterventionscarriedoutfromJanuary2010toJanuary2013attheCliniqueRogerEmmanuel,whichisasmallprivateambulatorycenterlocatedonAvenueJohnBrowninPort-au-PrinceanddedicatedtoUrologicProcedures.ItconsistsofoneOperatingroom,threepatientroomsandonelithotripsysuite.ThreehundredthirtyUrologicprocedureswererecordedoverthisperiodandcanbeenumeratedbyorderoffrequency.TURP 133Ureteroscopy 36Circumcision 32Varicocelectomy 31InternalOpticUrethrotomy 24Hydrocelectomy 22SurgeryforKidneyStones10
Bilateralorchiectomy 10SurgeryforBladderstones9Cryptorchidycorrection8Prostatectomy7PosteriorUrethralvalveablation4Vasectomy 2 RadicalProstatectomy1
Theycanalsobelistedbyanatomicsiteasfollows:150Prostateoperations(or45.45%),63scrotalprocedures(19.09%),55interventionsforstonedisease(16.66%),32circumcisions(9.69%),24urethraloperations(7.27%)andtwootherprocedures(0.60%).Breakingeachcategorydown,wefindthat113prostaticproceduresweredoneforbenignprostatichypertrophy(106-TURPand7opentrans-vesical)and37foradenocarcinoma(27TURP+Orchiectomy,10orchiectomiesand1radicalprostatectomy).Sixty-threecases(19.09%)wereclassifiedasScrotalproceduresandincluded31varicocelectomies,22hydrocelectomies,eightundescendedtestesandtwovasectomies.Fifty-fiveinterventions(16.66%)werecarriedoutforstonediseases:36forureteralstonesextractedbysemi-rigidureteroscopywithorwithoutintra-corporealpneumaticlithotripsy,10openpyeloornephro-lithotomiesandnineforopenorendoscopicremovalofbladderstones.Undertheheadingofforeskinprocedures(9.69%),welisted32circumcisions–6ofthemforchildrenlessthanfouryearsofage.InthegroupingofUrethralProcedures,wecounted24internalopticurehrotomyandfourposteriorurethralvalvefulgurations,foratotalof28proceduresor7.7%.Finally,twoadditionalurologicprocedureswereclassifiedasothers,includingoneunsuccessfulrepairofavesico-vaginalfistulaandacaverno-spongialshuntforpriapisminapatientdiagnosedwithsicklecellanemia.
Conclusions:BenignProstaticHypertrophyandProstaticcarcinomaremainthemostcommoncasesseeninourpractice.Bladderoutletobstructionrepresentsanenormousburdenforthemalepopulationsincetheyspendoftenmonths,evenyearswithindwellingbladdercatheters.MostpatientsinourseriesweretreatedwithTransUrethralResections,whichisnotwidelypracticedinHaiti.WorkshopsandadditionaltraininginthisareawouldbebeneficialformostofHaitianUrologists.Astotheprostaticcarcinomas,theyweremostoftendiagnosedinadvancedstages,onlyonepatientqualifyingforaradicalprostatectomy.Theonlyoptionforthemajorityofthe
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caseswashormonaltherapy,whichconsistedinasurgicalcastration.Fortunately,itwouldappearthatthehighgradeprostaticadenocarcinomareportedintherelativelyyoungmalesintheAfricanAmericanpopulationandotherCaribbeancountriesisnotseenasfrequentlyinHaiti.Itiscuriousthatinacountryknownforitsoverpopulation,wetreatedmoremenforinfertilitywith24varicocelectomiesagainstonly2vasectomies.ThisshouldbefoodforthoughtfortheMinistryofHealthandPopulation.Asfarasdealingwithstonedisease,wehavebecomequitefacilewiththesemi-rigiduteroscopebutwehavenoexperiencewiththeflexibledevice.ThehighcostoftheLaserequipmentanditsfragilityrepresentmajorobstaclestotheuseofthattechnologyinHaiti,butwehopesoontobeabletoperformpercutaneousnephrolithotomies,sincewealreadyhavetheC-armfluoroscopycapability.OurcasesofUrethralStenosisweretreatedbyOpticalUrethrotomyandourresultsweresimilartothosereportedintheliterature.However,recentworkshopsinReconstructiveurologicsurgeryhavechangeddramaticallytheoutcomeforourpatients.UrethroplastywithorwithoutgraftasthebestapproachfordifficultstricturesconstitutesamajorimprovementinurologicpracticeinHaiti.InthefieldofPediatricurology,circumcisionsandtesticulardescent+fixationareregularlydoneWedonothaveapediatriccystoscopyset,soweusetheureteroscopeforposteriorurethralvalvefulgurations(4patients)Finally,asfarasfemaleUrology,mostofthepatientspresentedwithrenalorureteralstones.WealsohadonecaseoffailedVesico-VaginalFistularepair,whichhassubsequentlysuccessfullyrepairedsincethenbyDr.AngeloGousseduringoneofhisrecentvisitstoourinstitution.Thissurveyhascertainlymanylimitations,butourpurposewastopresentthestatusofHaitianUrologyinordertohelpourgrouptoimplementprojects,findstrategiesandmeanstoreachwhatshouldbethegoalofthiscollaborationbetweenHaitianandAmericanUrologists,whichisto:“AchieveanappreciablestandardofcarefortheHaitianUrologicpatients.”HaitianResidencytraininginUrology–ObstaclesandLimitationsbyJoryDesir,MDandYouryDreux.Fiftyyearsago,aresidencyprograminUrologywasinitiatedattheGeneralHospitalinPort-au-PrincewhichsincehasbecometheStateUniversityofHaitiHospital(HUEH).TheUrologyResidencyprogramstartedinCap-HaitienattheJustinienUniversityHospital(HUJ)in2006.ThesetwoinstitutionsconstitutetheonlytwotrainingvenuesinUrologyinHaitiandtodate,theyhavegraduated26urologistsoverthepast20years:24inPort-au-Princeand2inCap-Haitien.ThefacilityattheHUEHincludes
• 2consultationsroomsforoutpatientvisits∗ 9inpatientbeds:4foremergencycasesand5forelectiveones∗ 1roomforarchives∗ 1roomforminorsurgery∗ 1treatmentroomforFoleycatheterinsertionsandreplacements
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∗ 1conferenceroom∗ ThreeofficesfortheChefofUrology,theHeadNurseandtheSecretary.
TheUrologyServiceatHUJconsistsof∗ 1outpatientconsultationroom∗ 11inpatientbeds:6forelectiveandemergencycases,1forisolationand4forprivate
patients∗ 1roomforminorsurgery,whichisalsousedforendoscopicexploration∗ 1treatmentroomforFoleycatheterinsertionsandreplacementsandnursingcare∗ Twooffices:onefortheUrologyChiefandonefortheheadnurse.–Thereisnobudget
forasecretaryinUrology∗ IroomforMedicalRecords∗ Noformalconferenceroom
AttheHUEH,thestaffandpersonnelaremadeof11urologists(10active),12residents(three3rdyear,six2ndyearandthreeFirstyearresidents,10Nurses,seveninterns,fivenursingstudentsandeighthousekeepers.Incomparison,theServiceofUrologyatHUJcountstwoattendings,threeresidents(twosecond-yearandonefirstyearresidents),eightnurses(1headnurse+7staffnurses),12Interns,5NursingStudentsand3housekeepers.TheresidentsarerecruitedfromallthefourmedicalschoolsbutpredominantlyfromNotreDameandQuisqueya,throughanationalcontest.Theresidencycurriculumstretchesoverafour-yearperiodandconsistsofatheoreticaldidacticcomponent,aclinicalcomponentandanoperativecomponent.However,thespecificrequirements,suchasthegoalsandobjectivesofthatCurriculumremainvagueandoftenignored.Indeed,thestandardsareilldefined.Thereisnosystemofaccreditationoftheresidencyprogramsandthereisnoassessmentoftheleveloftechnicalexpertiseachievedbytheresidentattheendofhisorhertraining.Someresidentscompletetheirtrainingwithlimitedexposuretocertainproceduresornonewhatsoever.Eveniftherewasamandatoryquotaofprocedures,howcanitbeenforced?Additionalobstaclestothepropertrainingofaurologyresidentresultfromthephysicaldeficienciesofthehospitalfacilityandtheinadequatesupervisionoftheseresidents,dueinparttothesalarystructureandintrinsicfailuresintheresidencystructure.Indeed,thesefacilitieslackofproperequipment.Theinstrumentsareoftenobsoleteandwhenbroken,itisimpossibletohavethemservicedorreplaced.Onesensesthatboththeresidentsandtheattendingstaffshowalackofmotivationorworkethics.Thesalarystructureispartlyresponsible,sincetheyaretraditionallylow(<US$200/monthforaresidentand<US$650fortheattendingstaff)andtheyarepaidirregularly.Therefore,tomeettheirdailyexpenses,theattendingstaffmustearnadditionalincomefromprivatepractice,whichpreventsthemfrombeingphysicallypresentatthehospitalstosupervisetheresidentsormoreactivelyparticipateintheirformationbyprovidinglecturesandotherdidacticactivities.Thereisalackofanup-to-datelibrarywithappropriateaudio-visualeducationalmaterial.Althoughthereisanabundanceofurologicpathologyinthepopulation,despitethefactthatmedicalcareissupposedtobefreelyavailable,alargepercentageofthepopulationcannotaffordaconsultation,thetestsnecessaryorthecostsofoperationsandhospitalization.Therefore,thenumberofcasesavailableforthetrainingoftheresidentsislimited.Thenumber
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ofinpatientbedsislimited.Adequateimagingstudiesarelackingmostofthetimes.Theequipmentintheemergencyserviceorintheoperatingroomislimitedanddoesnotincludewhatwouldbeconsideredbasicinamoreadvancedsystem,suchasendoscopy,laparoscopy,lasertechnology.Forexample,theemergencyroomlackoftenthefollowingtoolsandmaterials:catheters(coude,rigid…),anultrasoundmachine,aBladderscan,trocarforsupra-pubiccystostomy,Filiformsandfollowers,Cystoscopeset,sterileGauzeandglovesorevenanadequateUrologicTable.Theoperatingsuiteateitherinstitutiononlyhastwoworkingoperatingroomsforsixsurgicalservices.TheUrologyServicehasaccesstotheoperatingroomsonlytwodaysaweek.Theylackofproperurologictables,workingelectro-cautery,suctionmachines,endoscopictowerswithlightsource,overheadlightsetc…Thereisnopossibilityforfrozensections.Evenregularpathologyisverycostlytothepatientsandthereisalongwaitingperiodforthepathologyresultsevenwhenthepatientcanaffordtohavethetestdone.Althoughseveralattendinghavehadshortperiodsoftrainingabroad,cantheyreallybeconsideredspecialists?Cantheyoffersub-specialtytrainingtothefinishingresidents?Arethereanyprogramsofcontinuingmedicaleducationtokeeptheattendingphysiciansup-to-date?ThereisnoexchangebetweentheHUEHandtheHUJprograms.TherearenopossibilitiesforclinicalorlaboratoryresearchandnourologicpublicationsinHaiti.ShortperiodsoftraininginFranceortheFrenchAntillesarerareandunpredictable.Tostarttoremedytoalltheseproblems,wehumblysubmitthefollowingrecommendations:1- Firstweneedarevisionofthecurriculumwithgoalsandobjectiveswell-definedtakingintoaccounttheevolutionoftraininginurologyintheworldandadaptedtotheHaitianreality2- ContinuingMedicaleducationandopportunitiestoincreasetheirskillsandlevelofexpertiseanddefinestandardsofcareforallstaffinvolvedinthetrainingofurologyresidents.3-ExchangebetweenHUEHandJUHtosynchronizethetrainingofurologyresidents:clinicalrotations,videoconferencing,commonresearchprojects,writtenandoraltestsattheendoftheresidencyforbothsitesinlieuofboardcertification.4-EstablishanacademicenvironmentforpropereducationinUrology–Opportunitiestopublishcasereports,caseseries,reviewarticlesorpresentatlocal,nationalorinternationalurologicconferences5-Encouragethefacultymemberstoobtainsub-specialtytraining6-Offertheresidentstheopportunitiestorotateinthesedifferentsub-specialtiespriortotheirgraduationortoobtainthemselvessub-specialtyqualificationaftergraduation.UrologyisanessentialpartofamedicalschoolCurriculumanditcontributestothemultidisciplinaryculture,byplayinganactiveroleinthecrosstrainingofalltheresidents.UrologyResidencyTraining–TheFutureofUrologiccareinHaiti–AngeloGousse,MDTheLanguageforMinimumProgramRequirementswasApprovedbytheACGME,September28,1999EducationalProgram.Itstatesthattheresidencyprogrammustrequireitsresidentstoobtaincompetenciesinthe6areastothelevelexpectedofanewpractitioner.Towardthisend,programsmustdefinethespecificknowledge,skills,andattitudesrequiredandprovideeducationalexperiencesasneededinorderfortheirresidentstodemonstrate:
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• PatientCarethatiscompassionate,appropriate,andeffectiveforthetreatmentofhealthproblemsandthepromotionofhealth
• MedicalKnowledgeaboutestablishedandevolvingbiomedical,clinical,andcognate(e.g.epidemiologicalandsocial-behavioral)sciencesandtheapplicationofthisknowledgetopatientcare
• Practice-BasedLearningandImprovementthatinvolvesinvestigationandevaluationoftheirownpatientcare,appraisalandassimilationofscientificevidence,andimprovementsinpatientcare
• InterpersonalandCommunicationSkillsthatresultineffectiveinformationexchangeandteamingwithpatients,theirfamilies,andotherhealthprofessionals
• Professionalism,asmanifestedthroughacommitmenttocarryingoutprofessionalresponsibilities,adherencetoethicalprinciples,andsensitivitytoadiversepatientpopulation
• Systems-BasedPractice,asmanifestedbyactionsthatdemonstrateanawarenessofandresponsivenesstothelargercontextandsystemofhealthcareandtheabilitytoeffectivelycallonsystemresourcestoprovidecarethatisofoptimalvalue
Theresidencyprogrammustdemonstratethatithasaneffectiveplanforassessingresidentperformancethroughouttheprogramandforutilizingassessmentresultstoimproveresidentperformance.Thisplanshouldinclude:
• Useofdependablemeasurestoassessresidents'competenceinpatientcare,medicalknowledge,practice-basedlearningandimprovement,interpersonalandcommunicationskills,professionalism,andsystems-basedpractice
• Mechanismsforprovidingregularandtimelyperformancefeedbacktoresidents• Aprocessinvolvinguseofassessmentresultstoachieveprogressiveimprovementsin
residents'competenceandperformance.Theresidencyprogramshoulduseresidentperformanceandoutcomeassessmentresultsintheirevaluationoftheeducationaleffectivenessoftheresidencyprogram.Itshouldhaveinplaceaprocessforusingresidentandperformanceassessmentresultstogetherwithotherprogramevaluationresultstoimprovetheresidencyprogram.Overallgoalsandobjectivesmustbedefinedfortheentireresidencyprogramandforeachpost-graduatelevel.TheoverallgoalsshouldfocusonCompetencybasedevaluations–assessingsurgicalskillandjudgment.Thefirstyearresidentshouldlearn:Endoscopicprocedures,Minoropenurologicprocedures-penile&scrotalsurgeryandsurgicaltechniquesforcomplexmajorcasesthroughobservationintheOR.Thesecondyearresidentwillgainresearchskills,understandandfunctionasthe'consult'resident,attempttomasterthemorecomplexsurgicalprocedures,improveendoscopicandresectionskills(i.e.,TURP,TURBT)andmastertransrectalultrasoundbiopsytechniqueaswellasreadingUrodynamicstudies.TheThird-YearresidentwillfocusonPediatricUrologicprocedures,acquireEnhancedknowledgeofrenalphysiologyandvascularsurgeryskillsandmanagetheconsultservice.Inaddition,hewillactasprimarysurgeononmanyofthemajorcasesandasaTeachingAssistanttojuniorresidentsontheminoropenandendoscopiccases.
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TheFourth-YearResidentwillmasterorganizationandmanagementofthepatient’ssurgicaltreatment,inpatientandoutpatientcareandorganizationandoperationofanefficientservice.Thedidacticaspectoftheresidencytrainingshouldbeinclusiveofthefollowingactivities:
– CaseDiscussion/IVP(Uro-radiology)– Pathology/TumorBoard– QualityAssurance/MorbidityandMortality– MultidisciplinaryOncologyConference– Didactics/”Campbell’s”Club– Evidence-BasedMedicine–JournalClub– PediatricUrology–Nephrology– Research– Urodynamics– VisitingProfessorships– Tele-MedicineConferences– WebBasedEducation
Thepurposeofthesedidacticactivitiesistosecureacoreknowledgethatwillinclude:. BPH,LTOS• Cancer:Prostate,Bladder,Penile,Renal• UrinaryIncontinence–MaleandFemale• Urolithiasis• PediatricUrologicDisorders• ErectileDysfunction,MaleInfertility• GUInfections• TraumaandUrethralStrictureDisease
Aspartofhisadministrativeduties,theChiefResidentshallorganizetheCallschedules,managetheDutyhours,beresponsibleforDisciplinaryaction,providecounselingwhenneededandparticipateintheappraisaloftheperformanceofJuniorresidentsandfacultymembers.Tomeettheirresearchrequirements,theResidentsareencouragedtobeinvolvedinclinical/chartreviewresearchthroughouttheirresidency.Theyarealsoencouragedtopresenttheirclinicalresearchfindingsatscheduledlocal,nationalandinternationalconferences.ThereisanurgentneedforUrologyCertificationinHaiti.SuchprocessshouldimplicatetheMedicalSchools,theDepartmentofEducation,theRectoroftheUniversityandtheHaitianSocietyofUrology.ThereisalsoaneedforVerificationofthecredentialsandExpertiseofUrologyVolunteersworkinginHaiti.BoththesecertificationswouldbebestservedbyaCentralizedProcessandwithsupportandinputfromAmericanUrologicAssociation,theSociétéInternationaled’Urologie,theIVUmed,IndividualUrologistsandotherInterestedOrganizations.Meanwhile,thereisagreatneedfor- BasicSupplies:Catheters,stents,wires,sutures,GUtrays- EndoscopicInstruments:rigid,flexiblescopes- UltrasoundEquipment- UrodynamicEquipments
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- OperatingRooms:staffandequipments- Computers-ForEducationWebBased,DVDs,Audio-visuals,etc.- TeachingModels–Animals/ManikinsObstaclestothePracticeofUrologyinHaiti–AnAnalysisofNeeds–JeanGetoDube,MD,MscThisfirstJointHaitianAmericanUrologyConferencewastriggeredbyDr.Ziegelbaum’sinitiale-mailfollowedbytheimmediatechainreactionofalltheAmericanurologists,whointhepasthavevolunteeredinHaiti.IamspeakingofDrs.Lanctin,DeVries,AngeloGousse,Dale,Peterson,SamBroaddus,etc…UndertheleadershipofDr.Louis-JosephAugusteandhispartnersoftheAMHE,thediscussioncontinuedandeventuallywaschanneledtoresultinthisfirstjointmeetingoftheseHaitianandAmericanAssociations.Ithankallofyouforyourenthusiasm.IwilldiscusstodaytheobstaclestothepracticeofUrologyinHaiti,whilepresentingananalysisoftheneedsofHaitianUrologists.TheultimategoalistheadvancementofHaitianUrology,throughthisfrankdiscussionbetweenourHaitianandAmericancolleaguesaboutwhatneedstobedone,particularlyintheareaofformation.Wecanapproachthistopicintwoways:eitherbydiscussingtheneedsinCap-HaitienandseparatelytheneedsattheStateUniversityofHaitiHospitalinPort-au-Prince,orbylookingattheproblemmorebroadlyfromanationalstandpoint.Weelectedtopursuethesecondapproach,becauseUrologyisnotpracticedonlyattheHUEHandHUJ,butalsoinprivatepracticesettings,incertainphilanthropiccenterswhereurologyservicesareofferedandfinallyincertaingovernmentalmedicalcenterswhereurologiccareisprovideddailyorsporadicallyeitherbyHaitianUrologistsorvolunteersfromabroad,suchasBonneFinHospital,ImmaculateConceptionHospital,BienfaisanceHospitalofPignon,etc...Aneedisthedifferencebetweenwhatonehasandwhatonewishesforandthereasonswhytheseneedscannotbefulfilledrepresenttheobstacles.Withthisinmind,weaskedourselvesthreequestions:
- Whatisthecurrentsituation?- Whatshouldbethecurrentsituationandwhatwecandotoachieveit?- Whycan’tweachieveityet?
Thesequestionswereintegratedinasurvey,whichwassenttoalltheurologiststrainedateithertheHUEHortheHUJ.Weinsistedthatallquestionsbeanswered.Ahospitaladministratoraswellasthemedicaldirectorofahospitalwasalsoaskedwhytheirhospitalsdonotbuycertainurologicequipment.Certainly,oursurveyhadseverallimitations.First,thenumberofindividualsinterviewedwassmall.Second,giventheshortperiodoftimeallottedforthestudy,wedidnothavethetimetosubmitthecompiledanswerstotheintervieweesinordertoverifyiftheconclusionstrulycorrespondedtotheiropinions.Theselimitationshowevershouldnotinvalidatetheresultsofourstudythatweintendtosubmittothecriticalreviewoftheurologistsinattendancetodayandwhoforsomepracticalreasonsdidnottakepartinthestudy.Fromtoday’sdiscussionwillemergeadditionalinformationwhichwillfurtherourknowledgeoftherealneedsinHaitianUrology.Thismeetingrepresentsthereforean
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importanttoolfordatacollectionandasignificantstepintheassessmentofourneedsandtheobstaclestothepracticeofUrologyinHaiti.RESULTS:OBSTACLES-Asfarasthetypesofsurgicalproceduresperformed,theyconsistpredominantlyofopen,breadandbuttercases,althoughwehaveseenatimidprogressintheformofafewradicalprostatectomies,tworenaltransplants,someurethralinterventionsandsomeendoscopicprocedures,particularlyintheprivatehospitalsettings.Fromatechnicalpointofview,theurologistwhowantstoperformagivenprocedure,hastobringhisownequipment,rangingfromelectrocauterytoendoscopicinstruments.Imagingstudiessuchasasonographyorevenassimpleasanintra-venouspyelographyareeasilyobtainableintheprivateinstitutionsbutextremelydifficulttogetinthepublicinstitutions.ACTscanispossiblebutbeyondthereachoftheclientsofthepublichospitals.Itisdifficulttoobtainbloodtests,suchasfreeorboundPSAanditmaytakemonthstoobtaintheresultsofabiopsy.ThemedicaldirectorthatweinterviewedcouldnotseetheneedtopurchasesophisticatedurologicequipmentbecausetheyareveryexpensiveandtheORcasesarerare.Itisthereforenotclearthatonewillgetadecentreturnontheinvestment.Thegovernmentshouldabsorbthecostoftheseinstrumentstomakethemavailabletothepublic.Mostoftheresponderstothesurveyfeltthattherewasalackofasenseofresponsibilityregardingtheequipmentinthepublicsetting.Themaintenancesysteminthepublicinstitutionsisinadequateordownrightinexistent.Thusthehalf-lifeoftheinstrumentsintheprivatesettingismuchlongerthaninthepubliccenters.Thereisalsoaproblemofindividualism,sincetheurologistswillseldominvesttogethertopurchasetheveryexpensiveitems.Thetrainingoftheresidentsremainsadilemma,sinceitisnotstandardizedandwehavenotfigureouttomeasuretheircompetencybeforegraduation.Someofthemareluckytoreceiveadditionalformationabroad,butthisisinconsistentandsomegraduatefromourtrainingprogramshavedifficultyperformingtransurethralresectionwhileelsewhereintheworld,theyarealreadyintheeraoflaparoscopyandroboticsurgery.Inaddition,theancillaryhelpmaynotbeverydependableandsomeurologistsworryaboutthequalityofpost-operativecarethatthenurseswillprovidetotheirpatientsintheprivatesector.Needs:Itisimperativetokeepthebasicinstrumentsofurologyavailable.However,atthesametime,asenseofresponsibilitytowardtheequipmentmustbeinstilledintheusersandamaintenanceservicemustbeestablished:Teachthephysicianshowtousethemandthepersonnelhowtocareforthem.Opportunitiesshouldbeprovidedforthepracticingurologiststoupdatehisorherknowledgeandtoparticipateincontinuingmedicaleducationprograms.Wemustalsoencouragetheyoungphysicianstoacquiresub-specialtytraining,particularlythoseworkingatauniversitycenter.Whyareweinthatsituation?Thereisanoveralllackofinvestmentsinthearea.Thereisroomforinvolvementbytheprivatesectors,butthegovernmentshouldpurchaseandmakethebasictoolsavailable.Thereisalackofvision–Wedonotknowwherewearegoingorhowtogetthere.Manyurologistshavelostallconfidence–Whyshouldwetry?Wearesofarbehindandwewillnevergetthere.Thereisalsoalackofleadership.TheHaitianSocietyofUrologyismoribund.Wearetooindividualisticanddonotwanttoworktogethertomakethingsbetter.Thereisnoregulatorysystemforthespecialty.Theeconomyisinbadshapeformostofthepopulation.Thepopulationdoesnotunderstandthevalueandtheroleofurology
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asaspecialty.Otherhealthcareprofessionalsdonotappreciateurologyeither.Thepracticeofurologyislimitedtojustafewcentersacrossthecountry.However,thereseemstobeasilverlininginthecloud.Thankstoindividualeffortandmotivation,weareseeingmoretransurethralprocedures,acoupleofrenaltransplantsandafewradicalprostatectomiesaswellasafewurethralinterventions.Atthesametime,weseemtodiscernabeginningofchangeintheattitudeofthepopulation,sincemenarenowwillingtobeoperatedforvaricoceles.Myrecommendationswouldbetoseizethisopportunitytoadoptastrategicplanforthegrowthofourspecialty.Seizetheopportunitytoreinforceourstructuresandimproveourarmamentarium.Seizethisopportunitytoestablishasystemofcontinuingeducationforthepracticingphysiciansaswellastheresidentsintraining,inpartnershipwithourAmericanColleagues.Wehavetoestablishabettersystemtomanageandmaintaintheequipmentaswellasasenseofpersonalresponsibilityamongtheusersofthisequipment.TheHaitianSocietyofUrologyshouldassumeitsroleasaleadertounifyalltheurologistsaroundcommongoals.GroupsofUrologistsshouldcometogetherandseekthirdpartyfinancingfortheacquisitionofcostlyequipment.Mypersonalwishisthatmeetingssuchasthisonecontinueinthefuturetokeepusfocusedonthegoal,whichistostirtheUrologyspecialtyforwardforthewelfareoftheHaitianpopulationingeneral.KonbitSante–SamuelBroaddus,MD,FACSMynameisSamBroaddus,MD,aStaffurologistattheMaineMedicalcenterofPortlandsince1984andIagreethatthisFirstJointHaitianAmericanUrologyConferencehasahistoricsignificance.YouwillallowmetoexpressmyheartfeltthankstoourHaitianhostsfortheircollegialandcollaborativespirit.Thiseffortisbothaspirationalandinspirationalforme.IhavebeenworkinginHaitiasavolunteersince1994,firstattheAlbertSchweitzerHospitalinDeschapellesandlateroninCap-HaitienattheJustinienUniversityHospital,undertheauspicesofKonbitSante,alsocalledCap-HaitienHealthPartnership.ThislatterorganizationwasfoundedinMainein2000.Fromtheonset,ourGoalandmissionwastodevelopapartnershipwiththeHaitianMinistryofHealthinordertobuildcapacityofthepublichealthcaresysteminNorthernHaitiwithmaximumlocaldirection.WechosetodesignateourorganizationbythesetwoCreolewords:“Konbit”whichistheTraditionalHaitianmethodofworkingtogethertogetthejobdonebetterandquickerand“Sante”,meaningHealth.KonbitSanteisalegallyrecognizedNGO,thatemploys40Haitians,includingphysicians.Italsoincludes120clinicalandpublichealthvolunteersandmorethan20infrastructurevolunteers.ThroughapartnershipbetweenpeoplewithexpertiseandinterestintheUSandourHaitiancolleagues,weseektobuildlong-termcapacity.Ourworkhasbeencenteredattwopublichealthinstitutions-JustinienUniversityHospitalandFortSt.MichelHealthCenter.TheyarebothstaffedandmanagedbytheHaitianMinistryofHealth.Ourroleisthatofasupportingpartner.Weworktogetherwiththeadministrationandstaffattheseinstitutionstoidentifytheprevailingneedsandpriorities,thenseektheresourcesnecessarytojointlyimplementappropriate
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interventions.ThestaffweemployareembeddedwithintheseinstitutionsandseveralareMinistryofHealthemployeesaswellasourown.OureffortshavebeenfocusedoncertainClinicalInitiatives,suchasWomen’shealth,ChildrenHealth,CommunityOutreachandotherformsofcollaboration.In2008,weconductedabaselineassessmentoftheSurgicalServicesatJustinienHospital,intheformofaSWOTGapanalysisthatlookedatissuesofStaffing,thephysicalstructureandcapacityoftheSurgicalwardandtheOperatingRooms.WealsolookedattheClinicalCaseMix,DifferentQualityInitiatives,OpportunitiesforSurgicalEducationandResearch,theprovisionandmaintenanceofSurgicalEquipmentandMaterials,aswellasotherSurgicalSupportServices.Armedwiththesedata,weundertookseveralSupportprogramsfortheinfrastructuresoftheinstitutions,byrebuildingsomeofthehospitaltoiletfacilities,byimprovingtheHospitalelectricgridandbysupplyingsturdyandhighcapacityelectricwashingmachinesinordertoreplacethearchaicsystemofwashingthelaundrybyhand.ThroughacooperationwithUSAID,wearepresentlyengagedinaprojecttoexpandandupgradethePediatricPavilionattheHospital.OursupporttotheHospitalhasalsoincludedtheregularcollectionandshippingofdonatedmaterialsandequipmenttotheinstitutionandsupportasalarylineforamanagertoorganizeandkeepaninventoryofthestocksinthedepotofthehospital.Ourcommitmenttothisprogramisforthelongrunanditembodiestheconceptofaccompaniment.Personallong-termrelationshipsnotonlymatter,buttheymatteralot.Toaccompanysomeoneistogosomewherewithhimorher,tobreakbreadtogether,tobepresentonajourneywithabeginningandanend.Thereisanelementofmystery,ofopenness,inaccompaniment:Iwillgowithyouandsupportyouonyourjourneywhereveritleads.Iwillkeepyoucompanyandshareyourfateforawhile.Andby"awhile,"Idon'tmeanalittlewhile.Accompanimentismuchmoreoftenaboutstickingwithataskuntilitisdeemedcompletedbythepersonorpeoplebeingaccompanied,ratherthanbytheaccompagnateur.ThisfirstJointHaitianAmericanurologyConferenceisagroundbreakingevent.Totheextentthatothersurgeonsindevelopingcountriesfacethesamechallengesandobstaclesthatwehavemetandarestillmeeting,weareencouragedbytheAmericanCollegeofSurgeonstopublicizeourattempttobringHaitianandAmericanurologiststogetherandraisethebarofurologyinHaiti.ProjectHaiti/IVUmedCollaborationinHaiti–HenriLanctin,MD,FACSSinceitsinceptionin1989,ProjectHaitiincollaborationwithIVUmedhasbenefitedfromthegenerouscontributionsofmorethan600volunteers–medicalandothersfromallwalksoflife.Theprojecthascontributed10,000-20,000lbsdonatedsuppliesannually.IthasdesignedandbuiltHopitalBienfaisanceexpansions,completedmissionarydormitoryfacility,constructedtheinternationalairportofPignon,builtandsupportedaprimaryschoolfor300students,helpeddevelopandfundthefirst“Mother’sClubs”,helpedDr.GuyTheodoretoestablishPignonRotaryClub(votedbestinCarribeanandDr.GuyisHaiti’sfirstGovernor).Wealsodevelopedsolar/batteryenergystorageaswellasasewagesystemforthehospital.Wehavebrought
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surgeonprofessorstoteachforthepast17years.WehaveachievedallianceswithindustryanddonatedtwoEndo-suitesandthecapabilitytoperformsatellitebasedtelesurgery.Wewouldlikeheretoacknowledgeallthecorporationsthathaveaidedusinthisjourney:
• StrykerEndoscopyandCommunications
• ThelenHeating• SellHardware• Gary’sPainting• BrainerdGlass• HoffmanElectric• MultipleConceptInteriors• Fastenal• ToolCriboftheNorth• CuyunaRegionalMedicalCenter• LarsonAllen
• BerchtoldCorporation• JordanArchitects• RiverwoodHealthCareCenter• Stor-MorShipping• Nelson,Inc.• ChristianCoalitionforHaiti• USSurgicalCorp• LakeStatesLumber• LundbergPlumbing• Nor-sonConstruction• GeneralElectric• EthiconEndosurgery
OneofthemostremarkablejointendeavorsofIVUmedandProjectHaitiwastheMultidisciplinaryPublic-PrivatePartnershiptoTrainHaitianPelvicSurgeonsinVesicovaginalFistulaRepair.FromNovember2011-2012,3week-onlyworkshopswereconductedattheHopitalBienfaisanceinPignon.Itinvolvedthepublic,private,non-governmentalandeducationalsectors.Thecoursewastaughtby2USfellowshiptrainedurologistsandtheAttendeesincludedHaitiangynecologists&urologists,aswellasHaitian&USresidents.21patientsbenefitedfromthisprogram,whichwassuccessfulin81%ofthecases,atthesametimethattwogynecologistsandaurologistweretrainedinthecorrectionofVesico-VaginalFistulas.FuturedirectionsofthiscooperationwillincludethecontinuationoftheSupportforHopitalBienfaisancedePignon,thecontinuationofVVFandUrethralReconstructionWorkshops,Supportforurologistsinotherareas,assistancewithHaitiappropriateresidentcurriculumandtraining,thedevelopmentofanEMRsystemasproposedbyDr.FranSchneckandtheUroHaiti.orgwebsiteaswellasthesupportforparticipationintheSIU/AUAtrainingcoursesandSupportforthetrainingcourseattendees.UrologyinHaiti:CurrentObservationsandFutureHopes–MichaelZiegelbaum,MDTheGoalofthisFirstJointHaitianAmericanUrologyConferenceistocoordinatetheeffortsofAmericanUrologistsinterestedinprovidingphysicianseducationanddirectpatientcare.ThisinteractionwithourHaitianColleagueswillrequireapartnershipwiththem,aswellastheirguidanceinordertofulfilltheirmandates.Industryinvolvement,governmentalsupportaswellasadditionalpartnershipswillbecrucialtothesuccessofsuchendeavorandweseizethisopportunitytosaluteandexpressourgratitudetoalltheentitieswhohaveallowedthisconferencetobecomeareality:AMHE,AUA,IVUmed,HaitianSocietyofUrology,representativesoftheindustrysuchasKarl-Storz,Stryker,MedShare,Sonosite,Zeissandindividualfriendsandcolleagues.
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Thereasonsformypersonalinvolvementisthisprogramstandfrommylonghistoryofgivingbacktothelessfortunate,mypersonaldesiretoexpandmyhorizonsandseetheWorld,theJudaicprincipleofTIKKUMOLAM(repairingtheWorld)andmypersonalfriendshipwithDr.LouisJAuguste.ThegeneralguidelinesofmyinvolvementinHaitiarethefollowing:
! Tocooperatewiththelocalmedicalworkforceanditsresources! Tosupportlocalhealthcarewithlearningmaterial,medications,suppliesand
equipment! Toprovideourexperienceandworktoelevatethelevelofcare! ToempowertheHaitianhealthcareprofessionaltopracticebettermedicineand
explorewaystoprovidesustainableimprovementsintheirhealthcaredeliveryInotherwords,ourgoalistoteachourHaitiancolleagueshowtofish,ratherthangivingthemtheproverbialfish.Inthisactofaltruism,letusnotforgetthatwewillfindsomethingforusaswell.Thisprogramoffersustheopportunitytogroundoneselfandtohaveabettersenseoftheworld,atthesametimethatitwillallowustoconnectonewithhis/hertrueclinicalabilitiesandjudgment,despitethelackoftechnology.Itwillprovideourresidentswithavaluablehumanexperienceaswellasasenseofaccomplishmentandforallofus,AmericansandHaitians,abondingexperience.
WewillrememberthatHaitiwasoncetherichestFrenchcolonywithaneconomybasedonslaveexploitation.Thisuntenablesituationledtotheslaverevolution,whichwascrowned,withsuccessin1804,attheendofalongstruggle.Sincethatmoment,wehavewitnessed200yearsofhamperedleadership,non-acceptancebytheInternationalcommunityasanequal,economicpredationbywesterngovernmentsandcorporations.Allthesefactors,coupledwithrecurrentandfrequentnaturaldisasters,haveresultedinmakingthatoncesorichislandintothepoorestcountryinthewesternhemisphere.Thelossofthecountry’sagriculturalbasemixedinwithoverpopulation,atrickledowneconomy,diversionoffundsatthehighestlevel,isarecipefordisaster.Theimpactofthissituationisthat80%ofthepopulationlivesbelowthepovertylevel,earninglessthan$200/year.Only50%ofthepopulationhaveaccesstocleanwater;60%ofthepopulationhasnoaccesstoheathcareand20%haveadifficulttimeaccessinghealthcare,sincetheyhavetowalkover5kilometerstoreachahealthcarefacility.Healthcareexpenditureamountstoabout$83percapitaperyear.Thus,itisnotsurprisingthatLifeexpectancyismerely54years.TheHaitianHealthCaresystemfacesstaffingissues,equipmentissues,energyissues,issueswithcleanwater,alongwithissuesofpatient’scomfortandsafety.AnimportantpartofthehealthcaresystemistheJustinienUniversityHospital,a250-bedinstitutionerectedin1890,renovatedin1920duringtheUSOccupationofHaiti.However,sincethen,severalrenovationsunfortunatelyhavenotkeptpacewithmodernstandardsofcare.Thus,itstillhasliterallywide-openwardswitharchaicsanitaryfacilities.JustinienHospitalnolongerprovidesfoodorlaundryservicesandtheinfrastructureisfortheleastobsolete.Atmylastvisit,theOperatingSuitewascomprisedoftwofunctioningOperatingRoomswithinadequatelightingandcooling.Theanesthesiamachinesoftenmissedpartsandthelimitedavailabilityofblood,intravenoussolutionsandoxygenmadeitariskyundertaking,nottosayanadventure,everytimesurgerywasperformed.Theequipmentisscarceandpoorly
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maintained.Thissituationisfurthercomplicatedbyalackof,aswellasmismanagementof,economicresources.Thereisnoaccountabilityandthehierarchyisunderminedbytheoverarchingdominanceofthegovernmentalbureaucracy.Salariesarepaidirregularly,makingitdifficulttomakedemandsoftheemployees.Informationtechnologyisinitsinfancy.BasicmeasuresassimpleasproperidentificationofthepersonnelwithIDbadgesorasecuritysystemforthefacilityarenotimplemented.Yet,thisMedicalCenteristhereceivinghospitalforthe200,000populationofCap-Haitien,aswellasalloftheNorthernDepartment,aswellastheHaitianpopulationofthenorthwesternareasoftheDominicanRepublicandtheIslandsofBahamas,sincetheHaitianlivingillegallyinthesecountriesaredeniedaccesstoanylevelofmedicalcare.JustinienHospitalprovidetrainingforover60residentsinthespecialtiesofSurgery,InternalandFamilyMedicine,Urology,Orthopedics,Pediatrics,ObstetricsandGynecology,OphthalmologyandOto-Laryngology.AsfarastheUrologyspecialtyisconcerned,intheUS,itisrapidlymovingrapidlytowardslaparoscopicandendoscopicapproaches,whileadvancedimagingtechnologiesandscreeningprotocolsallowearlierandearlierdetectionofdiseasesandbettersurveillanceofpatientsaftertreatmentfortheirmalignancies.Bycontrast,inHaiti,thediseasesarediagnosedlateandmostofurologicproceduresarecarriedoutinanopenmanner,withoutthebenefitofpathologyservices.Thisnascenteffortforcooperationbetweenallthesocietiesinvolvedinthisfirstjointconferencecanplayalargeroleinsolvingthisuntenablesituation.Beyondthesupplyofmaterialandothertechnologicalsupport,itwillrequirealocalwillforimprovement,tomakeorganizationalchangesandagreatersenseofhonesty,accountabilityandresponsibilitytowardthepopulation.ItwillrequirethatallforeignassistanceorganizationsoperatinginHaitilookbeyondtheirpersonalagendasorinterests,rejecttheprospectofperpetualdependencyandaccepttheconceptofgreaterconcertationofefforts,solelyfortheadvancementofthecountrytowardself-reliance.Thesolutiontothissituationwillalsorequirethecooperationofmultiplesectorsofhealthcare,suchasnursing,administrationandsocialwork,aswellasthebusinessandtheindustrysectorsthatcanatlastbecomeinterestedintheupgradingandmaintenanceofamoremodernarmamentarium.Then,ourrolewillbetoworkwiththeMinistriesofEducationandHealthtodesignandimplementabettercurriculumforthetrainingofthenewgenerationsofphysiciansandurologistsandoffertothepracticingurologistsopportunitiesforcontinuingmedicaleducationandintegrationofnewtechnologies.Intheinterim,areliablebroadbandinternetsystemwillmakeavailableTele-Pathology,Tele-RadiologyandTele-Conferencing,thatcanbridgethegapcausedbydeficienciesintheseservices.ItisourhopeandexpectationthatthisconcertedeffortwillleadtotheimprovementoftheurologichealthofthegeneralpopulationofHaiti.ItcanalsoprovideanenrichingexperienceforourUSurologyresidents,sincewiththedisappearanceofphysicalborders,theworldhasbecomemoreandmoreaglobalvillage.WorkingsidebysidewiththeirHaitiancolleagues,theycanbroadentheirhorizonsandletthemselvesbechallengedwithdifferentpathologiesandformsofpresentation.Finally,onamoreselfishnote,IhopethatwhenIcomefora
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vacationinPort-Morgan,Moulin-sur-MerorLabadiewithmyfamily,IwouldreceiveinHaitithesameexcellentlevelofcarethatIwouldexpectanywhereelse.DevelopmentofanIntegrated,OpenSourceElectronicHealthRecords–FrancisSchneck,MDOutofthethousandsofNGOoperatinginHaiti,atleast40ofthemhavefocusedondiverseaspectsofhealthcare.Thishasresultedinalackofcoordinationofresources,withlimitedabilityforinformationexchangebetweenprovidersandorganizations,duplication of efforts, limited consistent follow-up, lack of outcome and effectiveness analysis, limited integrated data for reporting requirements and limited transfer of health information from paper to electronic. In an attempt to solve these problems, we have sought primarily to create an integrated health care record encompassing medical, environmental, social, and cultural information and as a secondary goal, we wanted to create a low cost electronic solution for patient records, create a system designed specifically for geographical need that can evolve over time and increase collaboration between volunteer organizations. Presently, the Electronic Medical Record is a compilation of demographic data, vital signs, progress notes, radiologic images, laboratory values and developmental information. EMR is expected to evolve in the near future and to reflect the social, cultural and environmental context of the individual or the population. An integrated comprehensive electronic health record would provide an invaluable tool for all these organizations to coordinate their efforts. The characteristics of this system should be:
- Open source, i-e Lowcost,allowingbroadcontributionbyhealthprovidersandacademicpersonnelandvolunteers.
- Crowdsourcing:inotherwords,acceptingdesigninputfromusers,fieldexperts,healthprovidersandtechnicalexperts.
- Integrated: i-e able to communicate with other systems used by multiple organizations- Inclusive:i-eaholisticsystemcapableofevaluatingtheinteractionsbetweenmedical,
environmental,socialandculturalfactorsimpactingoutcomes- Evolving:meaningthatitbeabletogrowandchangewithgeographicalandtemporal
needsandthatitbeadaptabletoeachuniquepopulation.Thus, input received from different hospital networks could be stored in each individual server and sent via satellite to the “cloud” as a backup. In turn, the information so accumulated could be released to involved hospitals and medical clinics, departments of health, Volunteer organizations and funding entities with reporting contingencies. A prototype for this device has been created as a small suitcase, almost like a laptop by the VECNA® company and is essentially a Portable Electronic Health Record and Network in a Box. It is ready to be piloted and IVUmed will bring it down on its next training visit to Haiti. All screened patients will be entered into the electronic health record system. The patient processing and system data elements will be evaluated for feasibility. Patients who receive surgery will have a more detailed information input into the health record. Staff/providers will be asked for input on current practices and feedback and they may be asked to join crowd-sourcing site to provide feedback online if interested. The suitcase system will return to IVUmed after the visit. The pilot will include 5-10 sites and will include repeat visits to these sites. Logins will be given to appropriate individuals, such as Visiting Health Workers and Local Health Workers in order to access the Web-based system. The users will be identified by Names, Birthdates and Biometrics (e-g. fingerprints). The system is very user friendly and information can be entered
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by clicking on consecutive menus or by using a touch-sensitive keyboard. It will also suggest options for treatment based on best Evidence-based medicine recommendations. It will also allow compilation of data for studying different pathology entities or population cohorts as well as preparation of appropriate reports. Following the satisfactory completion of the pilot project and the site study, the timeline for the development of the project will move to a regional evaluation before finally a mass deployment. IVUmed will keep all interested individuals abreast of the different phases of this very promising project. OnlineCoordinationofUrologyEffortsinHaiti–JoshWoodTheMissionofIVUis:ToMakequalityurologicalcareavailabletopeopleworldwideandourMottois:TeachOne,ReachMany.Althoughitwasofficiallyfoundedin1995,IVUmedstartedoperatingin1992.ItrepresentstheLeadingindependentNGOdedicatedtourologicalcareandteaching.Throughouttheyears,ithasexperimentedwithdiversesettingsandprogramsandhasservedcommunitiesinAfrica,Asia,CentralAmerica,Caribbean,SouthAmericaandtheUS.TheprogramsofIVUmedhadincluded:
" PediatricUrology:21years(3w/Interplast)
" GeneralUrology:14years" ResidentScholars:14years" FemaleUrology:9years
" ReconstructiveUrologyandLF:9years
" DomesticUSProgram:5years" IVUmedFellowships(2fellows)" IVUmedSeniorFellows(6fellows)
WiththesupportoftheAmericanUrologicalAssociationandtheSocieteInternationaled’Urologie,IVUhasbeeninvolvedinmultipleprogramsthathavetakenplaceinPort-au-Prince,Leogane,Deschapelles,PignonandCap-Haitien,throughpartnershipswiththeUniversitéofNotreDamecommittedtotheeliminationoffilariasisinHaitibytheyear2020andProjectHaitidevotedtoimprovingthequalityoflifeofthepeopleofHaiti,byprovidingmedicaleducationtoHaiti’sownhealthcareproviders.Tocoordinatealltheseefforts,IVUmedhascreatedaWebsiteentitled:www.UroHaiti.org.Inaddition,thiswebsitewillallowtoCommunicateneeds/wantsofurologistsinHaiti,Educatepotentialparticipants,Shareanddiscussbestpractices,PostcurriculumandothermaterialsandFacilitatecommunication.Individualsororganizationsinterestedinsponsoringaworkshoporothereducationalprogramcanpostthedate,thesite,thefocusoftheeventandpossiblyrequesttheparticipationofvolunteersinwhatevercapacity.Moreover,itcanbeavaluablesupporttotheeducationalprograms,byListingneedsoftrainingmaterials,Postingcurriculum,educationalmaterialsandlinkstousefulresourcesonline,CoordinatingawidearrayofresourcesandInformingothersofcurrenttrainingactivities.ThewebsitewillprovideageneralorientationtopotentialparticipantsintheeffortsbyofferinganOverviewofurologyinHaiti,Matchingpotentialvolunteerstoparticipatingorganizations,informingthepotentialvolunteers/visitingprofessorsasto“Whattoexpect”andfinallyallowthemtoJoinacollaborativeeffort.
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UroHaiti.orgwillallowtosharebestpracticesbyPostingactivities,goals,results,askquestionsthroughaBlogoradiscussionforum,toplanstrategiesandseekpartnerstoaddresschallenges.Viceversa,thewebsitewillallowthelocalentitiestocommunicatetheirneedsinanyspecificareaofEducationandtraining,Equipmentandsupplies,anySite-specificinput,Inputfromnursing,anesthesia,etc.andRecruitsupportfromAUA,industry,etc.Whilewesharecommongoalsandcommitment,wecanharnessouruniquestrengths,shareouruniqueperspectives,ourexpertisebasedonvariousdegreesofexperienceandtakeadvantageofourpersonalpartnershipsandcontacts.FinallythewebsitecanopentodoortomultipleinnovationssuchasTelehealth,Digitaleducationmodules,Increasedopportunityforacquiringskills,ElectronichealthrecordsandOutcomesmeasures.Itcanalsoopenthedoortoregionalpartnershipswithforexample,theCaribbeanUrologicalAssociation(CURA),Pan-AfricanUrologicalSurgeon’sAssociation(PAUSA)andtheSociétéInternationaled’Urologie(SIU),invarioussub-specialtiessuchasGeneralUrology,ReconstructiveUrology,UrologicOncology,FemaleUrology,PediatricUrologyandorEndourology.Inturn,thesepartnershipscanleadtoResearch,Internationalcollaborativeefforts,Publications,ScholarshipsandfurtherrecruitmentofVolunteers.PleasevisittheUroHaiti.orgwebsiteandmakeityourwebsite.EPILOGUEDear Colleagues: If you were not present at this First Joint Haitian American Urology Conference, you missed an opportunity to be part of history or to watch history in the making. This meeting that was sparked by Mike Ziegelbaum's query after his first trip to Cap-Haitien, was eagerly supported by the AUA, the IVUmed, the Haitian Society of Urology, the Haitian Medical Association and the Association of Haitian Physicians Abroad. The latter group played a key role in organizing this conference with the support of the Haitian Society of Urology and Dr. Margarett Osselyn-Abraham. Most of the Urologists who have been involved in Haiti in the past responded to the call. So did 13 of the 26 urologists practicing in Haiti. Altogether, there were 28 participants. The conference went on as scheduled and allowed both the Haitian and the American sides to consider the many aspects of the situation, which have brought it to the level of a crisis and an inventory of the resources available both locally and from the organizations involved in support missions to the different medical centers of the country. The discussion was frank, albeit at times uncomfortable. At the end, we all came out completely convinced that such meeting of the minds was overdue and a sine qua non to proceed forward. If specific solutions were not elaborated, steps to bring about changes at all levels were taken. At the end of the meeting that concluded exactly on time, the following motions were made and approved: 1- The entire group including both the American and the Haitian Urologists would meet again next November in Haiti at a specific date to be determined. There will also be an interim focused gathering of the minds at the Annual AUA conference in Orlando, FL next May 2014. 2- The assembly elected a team of nine individuals to organize the subsequent joint activities. It included: - Angelo Gousse, MD_ representing both the AUA and the AMHE - Samuel Broaddus, MD - Pierre Boncy, MD - Frank Burks, MD - Geto Dube, MD - Henri Lanctin, MD
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- Claude Paultre, MD - Francis Schneck, MD - Michael Ziegelbaum, MD with the administrative support of Josh Wood and Ellen Molino. 3- The group will elaborate a calendar of activities, workshops and other educational opportunities over the coming 3 or 4 years, to allow individuals to arrange their schedules accordingly. Although the website www.urohaiti.org is not completely ready, it is agreed that it will play a major role in the programming of these activities. It is worth noting that the participants were able to acquire up to 6 CME credits for the event. In addition to being a working conference, it was also an enjoyable occasion to have personal interaction with this incredible bunch of "nice people." As for me, it was a lot of fun (and a lot of work) to help make this meeting a reality. Now I am happy to pass the baton to Dr. Gousse. Thank you for having given me the opportunity to serve the people of Haiti.
Louis Joseph Auguste, MD Surgical Oncology/General Surgery Associate Clinical Professor of Surgery Hofstra North Shore/LIJ School of Medicine Clinical Director of Department of Surgery/A-Service – Long Island Jewish Medical Center President of the Long Island Jewish Medical Center Staff Society Assistant Secretary of the Central Executive Committee of the AMHE Coordinator of the AMHE/Justinien University Hospital Project Co-Chair of the First Joint Haitian American Urology Conference
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FirstJointHaitianAmericanUrologyConferenceHotelOasisInternational
November15,2013
RosterofparticipantsandContactInformation
Name Specialty Organization Title Emailaddress/telephone
Badlani,Gopal,MD
Urologist AmericanUrologicalAssociation
Secretary/AUA [email protected]/336-716-4310
Beauvoir,NoelSaint,MD
Urology HôpitalUniversitaireJustinienCap-Haitien,Haiti
Resident
Black,Derrick Vendor Takeda Vendor [email protected],Pierre,MD Urologist StateUniversityHospital Chiefof
[email protected]/509-3401-8534
Brisson,Georges-Eric,MD
Urologist Port-au-Prince,Haiti [email protected]/509-3710-9708
Broaddus,Samuel,MD
Urologist MaineMedicalCenterPortland,Maine
[email protected]/1-207-415-6106
Brutus,Bernard,MD
Urologist Port-au-Prince,Haiti [email protected]/509-3708-6849
Burks,Frank,MD Urologist ComprehensiveUrologyRoyalOak,MI
[email protected]/248-336-0123cell:248-310-7267
Cadet,Jean-Claude,MD
ENT StateUniversitySchoolofMedicine
Dean [email protected]
Clervil,Mitelot,MD
Urologist Port-au-Prince,Haiti [email protected]/509-3455-4880
Codio,Dieusel,MD
Urology HopitalUniversitaireJustinienCap-Haitien,Haiti
Resident
Coles,Maxime,MD
Orthopedist AMHE President [email protected]
Desir,Jory,MD Urologist JustinienUniversityHospitalCap-Haitien,Haiti
A.I.ChiefofService
[email protected]/509-3670-2438
DeVries,Catherine,MD
IVUPresident
Dreux,Youry,MD Urologist StateUniversityHospital [email protected]/509-3758-1116
Dube,Jean-Geto,MD
Urologist JustinienUniversityHospital
ChiefAdministrator
[email protected]/509-3688-9355
Edelstein,Robert,MD
Urologist MerrimackUrologyAssoc.31 Village Square Chelmsford, MA 01824
[email protected](978) 256-9507
Ellison,Lars,MD Urologist PenobscotBayUrology [email protected]/
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Rockport,Maine 207-593-5400Gousse,Angelo,MD
Urologist FloridaInternationalUniversity-AMHE
FellowshipDirector
[email protected]/786-200-3447
Carvajal,Hortensia
KarlStorz [email protected]
Jeudy,Jacques,MD
TransplantSurgeon/Urologist
Lanctin,HenriP.,MD
Urologist PrairieLakesHealthCareSystem
Loubeau,Jean-Michel,MD
GeneralandVascularSurgeon
Larchmont,NewYork [email protected]
Medilien,JacquesGracia,MD
Urologist 97RueOswaldDurandPort-au-Prince,Haiti
Molino,Ellen AmericanUrologicalAssociation
InternationalCoordinator
Myril,Sahmonde,MD
Urologist Cayes,Haiti [email protected]/509-4472-5313
Nazon,Pierre-Alix,MD
Urologist StateUniversityHospital [email protected]/509-3448-0842
Paul-Blanc,Raymond,MD
Urologist 16CreedenStreetMansfield,MA02048-AMHE
[email protected]/508-801-7332
Paultre,Claude,MD
Urologist StateUniversityHospital/SocieteHaitienned’Urologie
President [email protected]/509-3711-1307
Peterson,Curtis,MD
PediatricAnesthesiologist
PrimaryChildren'sHospitalAnesthesiology100NMarioCapecchiDriveSaltLakeCity,UT84113
801-662-3577
Rosenstein,Daniel,MD
ReconstructiveUrologist
StanfordUniversityHospitalSystemPaloAlto,CA
AssociateChiefofUrology
Schneck,Fran,MD
PediatricUrologist
UniversityofPittsburgMedicalCenter
[email protected]/412-692-5260
Surena,Claude,MD
Pediatrician MinistèredelaSantePubliqueetdelaPopulationPort-au-Prince,Haiti
CoordonateurCommissionNationalepourlaRepriseduSecteurSante
[email protected]/509-3702-1578
Theodore,Guy,MD
GeneralSurgeon HopitalBienfaisancedePignon,Haiti
Founder/GeneralDirector
[email protected]/509-4890-7172
Valme,Roger,MD Urologist StateUniversityHospitalPort-au-Prince,Haiti
Wood,Josh IVUmed [email protected],Michael,MD
Urologist IntegratedMedicalProfessionalsLakeSuccess,NY
[email protected]/516-437-4228
KaribeInternationalHotel
JuvenatPetionville,Haiti
www.karibehotel.com509-2812-7000
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HotelOasisInternational
115RuePan-AmericainePetionville,Haiti
509-2248-1105
ProceedingsoftheFirstJointHaitianAmericanUrologyConference
November14–15,2013Petionville,Haiti
TableofContents
HistoryofUrologyinHaiti-PierreBoncy,MD……………………………………………………………………………..1AnInventoryofHumanResourcesinUrologyinHaiti-ClaudePaultre,MD.……………………………….1UrologicSurgeryinaprivatesettinginPort-au-Prince–Pierre-AlixNazon,MD…….……….…………...2HaitianResidencytraininginUrology–ObstaclesandLimitations-JoryDesir,MDandYouryDreux……………………………………………………...………..4UrologyResidencyTraining–TheFutureofUrologiccareinHaiti–AngeloGousse,MD,FACS...6ObstaclestothePracticeofUrologyinHaiti/AnAnalysisofNeeds–JeanGetoDube,MD,Msc.…9KonbitSante–SamuelBroaddus,MD,FACS………………………………………………………………………………11ProjectHaiti/IVUmedCollaborationinHaiti–HenriLanctin,MD,FACS……………………………………..12UrologyinHaiti:CurrentObservationsandFutureHopes–MichaelZiegelbaum,MD………………..13DevelopmentofanIntegrated,OpenSourceElectronicHealthRecords–FrancisSchneck,MD….16OnlineCoordinationofUrologyEffortsinHaiti–JoshWood………………………………………………………17Epilogue–LouisJAuguste,MD,FACS………………………………………………………………………………………….18RosterofParticipantsandContactInformation…………………………………………………………………………..20TableofContents………………………………………………………………………………………………………………………..22
