Physicians have always crossed borders in search of teachers — and to teach others. The celebrated Greek physician Claudius Galen (c. AD 129 – c. 200) traveled widely, absorbing many medical philosophies before settling in Rome where he compiled the significant medical thought of his day — along with his own theories — which dominated European medicine for more than 1,500 years.
While centuries separate us from Galen, the international exchange of medical knowledge and skills still fuels many of the most important advances in medicine. Memorial Sloan Kettering’s clinicians and nurses continue the tradition of global exchange, sharing their expertise with colleagues around the world.
What follows are profiles of just a few of the Memorial Sloan Kettering clinicians and programs that reach far beyond the walls of the institution.
A Global Extended Family
(From left) Larry Norton, Hedvig Hricak, David Dershaw, and Elizabeth Morris are supporters of and participants in the Department of Radiology’s global training efforts.
“Having physicians who are nationally and internationally prominent, who love to teach and contribute to the global community, raises awareness of Memorial Sloan Kettering and benefits our institution tremendously,” says Hedvig Hricak, Chair of the Department of Radiology. “Our international reputation attracts not only patients in need of specialized care, but also the most-talented physicians, scientists, and trainees from around the world.”
The faculty in Memorial Sloan Kettering’s Department of Radiology lead several international outreach programs that provide training and resources in oncologic imaging, the most ambitious of which is a series of initiatives focused on breast cancer. These include a training program in breast imaging sponsored by the Breast Cancer Research Foundation (BCRF); a visiting scholars program run in collaboration with the European School of Radiology (ESOR); and a training program funded by the National Cancer Institute that supports the development of ultrasound services in Southeast Europe.
The BCRF-sponsored breast program — of which Larry Norton, Memorial Sloan Kettering Deputy Physician-in-Chief for Breast Cancer Programs, has been an ardent supporter since its establishment in 2004 — provides visiting radiologists with intensive instruction in breast imaging interpretation and clinical research methodology. “Science is a necessity, not a luxury, and clinical research is essential to the advancement of care,” says Dr. Hricak. “So in addition to clinical skills, we provide trainees with an opportunity to become engaged in research. We are training future leaders in their respective countries.”
Visits by faculty to other countries are also integral to the program. “When traveling to a country from which we have had trainees, we meet with them,” says Dr. Hricak. “It’s important to provide the initial training, and it’s equally important to have follow-up.” In Croatia and Serbia, where Dr. Hricak and her colleagues have organized conferences, they routinely include former trainees on the program, giving them the opportunity to present their work. “In this way,” she explains, “we continue to foster their careers.”
Continuing involvement can take many forms. Training through the BCRF program was instrumental in starting the breast cancer screening program in Croatia. “And we were also instrumental in helping to obtain a grant from the Stavros Niarchos Foundation to purchase a mobile mammography unit, which, combined with the BCRF-sponsored training, helped start a breast screening program in Serbia,” says Dr. Hricak.
In China, Elizabeth Morris, Chief of the Breast Imaging Service, and radiologist D. David Dershaw worked with a former BCRF fellow to obtain a grant from the Radiological Society of North America to establish a program for educating radiologists throughout China.
Surgeon Peter Kingham with a patient on whom he operated in Malawi.
Over the past eight years, the BCRF program has trained 38 radiologists, four radiation technologists, and a medical physicist from Southeast Europe, as well as Russia, China, Australia, Italy, Spain, the Netherlands, and England.
“Working with the ESOR, we also provide highly competitive three-month scholarships to radiology residents who wish to receive mentored training at Memorial Sloan Kettering in a subspecialty area of oncologic imaging,” Dr. Hricak says. Directed by Memorial Sloan Kettering radiologist David M. Panicek and Dr. Hricak, the program has so far trained seven radiology residents from Spain, Italy, Turkey, England, and the Netherlands.
“It’s enormously gratifying to contribute to a better tomorrow by training the next generation,” observes Dr. Hricak. “And over these years, through these programs, we have benefited as well — we’ve developed a global family.”
A Mideast Partnership
Another international initiative partners the American University of Beirut (AUB) in Lebanon with Memorial Sloan Kettering. For medical oncologist Ghassan K. Abou-Alfa, this relationship is of special significance: He grew up in Lebanon and earned his undergraduate and medical degrees at AUB. Now he plays an integral role helping Memorial Sloan Kettering enhance oncologic training at that institution and in the surrounding region.
Surgeon Peter Kingham with medical students in Sierra Leone.
“I’m proud we’ve established this collaboration with my alma mater,” Dr. Abou-Alfa says. “We are helping fulfill MSKCC’s educational mission, and our physicians also benefit greatly from the interactions.”
Interest in creating a partnership began in 2006, after Memorial Sloan Kettering physicians attending the Middle Eastern Medical Assembly — an international meeting — “were impressed with AUB’s outstanding faculty and exacting standards,” Dr. Abou-Alfa says. Soon after, philanthropist Mamdouha El-Sayed Bobst, herself an AUB graduate, provided an initial grant to establish a relationship between the two institutions.
The partnership includes an ongoing faculty exchange in which physicians spend a week embedded within a discipline of their choosing at the other institution. In addition, since 2008, a monthly video link session in gastrointestinal (GI) and breast cancers gives fellows the opportunity to present patient cases and allows doctors at both institutions to share their views.
“Being able to see each other facilitates a candid exchange of opinions,” Dr. Abou-Alfa explains. The video sessions proved so successful that Saudi Arabia’s National Guard Hospital now participates as well. The GI cancers sessions are recorded, distributed on DVDs to the participating institutions, and transcribed for publication in the journal Gastrointestinal Cancer Research.
The first Memorial Sloan Kettering delegation to AUB in 2006 posing in front of the Crusader Sea Castle in Sidon, Lebanon. (From left) Founding Director of the International Center Thomas Fahey, surgical oncologist Philip Paty, medical oncologists Ghassan Abou-Alfa and Eileen O’Reilly, thoracic surgeon Raja Flores (formerly at Memorial Sloan Kettering), and medical oncologist David Ilson.
The partnership receives funding from Memorial Sloan Kettering’s Elmer and Mamdouha El-Sayed Bobst International Center and has the support of Memorial Sloan Kettering leadership. It includes a fellowship research program, which has so far supported one fellow who is now training in radiation oncology at Memorial Sloan Kettering. More collaborative projects are on the horizon, including a joint MSKCC-AUB course to be offered next year for oncologists and surgeons from the Mideast who are in their early years of training.
“We want to start thinking of AUB as being the ‘mother ship’ from which we can start disseminating our expertise to satellites in the region,” Dr. Abou-Alfa explains. “Physicians who participate in the program will be its ambassadors. They will practice what they learn and also help find opportunities to establish relationships with Memorial Sloan Kettering, AUB, and other Middle Eastern medical institutions.”
Palliative and End-of-Life Care: An International Initiative
The End-of-Life Nursing Education Consortium (ELNEC) is a national initiative dedicated to training nurses in the delivery of skilled end-of-life palliative care. ELNEC began in 2000 with a major grant from the Robert Wood Johnson Foundation. The initial focus was on training US nurses, and the program is offered regularly at Memorial Sloan Kettering. But in 2006, ELNEC established an international program. Since then, ELNEC trainers have traveled to six of the seven continents and more than 70 countries.
Prominent among them is Memorial Sloan Kettering nurse practitioner Nessa Coyle. Since 2006 her travels have taken her to the Czech Republic, Tanzania, Nigeria, Austria, Mexico, Armenia, Tajikistan, Kyrgyzstan, the Republic of Georgia, and the Philippines.
Nessa Coyle (in black) with Dr. Rachael Rosario, Head Coordinator in the Supportive, Palliative Care and Hospice Unit, Department of Family and Community Medicine at Philippine General Hospital in Manila. They are joined by pediatric cancer patients at Child House. Staffed mainly by volunteers, Child House provides a place for children and their parents to stay locally while children receive treatment.
“ELNEC’s goal is to train, support, and empower nurses to provide excellent, compassionate end-of-life palliative care to patients and families, regardless of where they may live,” says Dr. Coyle, who has a PhD degree in nursing.
ELNEC uses a “train the trainer” approach in which those who are trained take what they have learned and train others. ELNEC estimates that more than 2,250 nurses and other healthcare providers have received ELNEC training internationally, and the curriculum has been translated into German, Japanese, Korean, Russian, and Spanish.
“Every culture approaches death and dying differently,” says Dr. Coyle, “so going to another country involves understanding the culture. What is the status of nursing? What are the cultural and spiritual beliefs about caring for those who are dying? What are the barriers to providing palliative care? It’s essential we get the answers to these and other questions so we can offer culturally sensitive training.”
Dr. Coyle explains that in the first couple of days in a country she will visit hospitals, hospices, and patients’ homes “to learn what nurses and families are contending with and to do bedside teaching.” Then, when the formal ELNEC course begins, Dr. Coyle has a more intimate understanding of the circumstances of those she will be educating.
As an example of how ELNEC can change practice in an entire region, Dr. Coyle tells the story of Romanian nurse Nicoleta Mitrea who attended the first ELNEC International Palliative Care Course in Salzburg, Austria, in 2006. Among other important palliative care initiatives in which she is involved, Ms. Mitrea now heads the education and palliative care team at Casa Sperantei, Romania’s first inpatient hospice. Casa Sperantei, which began life with one nurse treating terminally ill patients, is today regarded as a Centre of Excellence for Southeast Europe.
Nessa Coyle and Dr. Rachael Rosario make a home visit to a patient.
“Those who have received ELNEC international training know the importance of advocating for changes that will improve palliative care,” says Dr. Coyle. “Fifty-eight million people die annually worldwide and 45 million die in developing countries, with cancer and AIDS accounting for the greatest number of deaths. Fifty percent of the world’s newly diagnosed cancers are now occurring in developing countries. Unfortunately, approximately 80 percent of patients will have incurable disease at the time of diagnosis, with little attention paid to pain, symptom management, or psychological distress. So, though much has been accomplished in educating nurses throughout developing and marginalized countries, challenges lie ahead. But we’re a global community, committed to improving the care of the seriously ill and dying by transforming systems of care.”
In the Operating Room: We Speak the Same Language
Hepatopancreatobiliary surgeon T. Peter Kingham always wanted a practice that would involve work in developing countries. His conviction grew during medical school and his residency, when he used most of his vacation time to work in African nations. “I saw the difference one person could make collaborating with surgeons in an underdeveloped region,” Dr. Kingham says.
“One reason I chose surgery as my specialty is that it’s a field where you can have a big impact in a short time, especially training someone who will carry on after you leave,” he says. “It’s also a wonderful bonding experience between surgeons to realize that in the operating room we all speak the same language.”
Over the past decade, Dr. Kingham has spent months in Tanzania, Sierra Leone, South Africa, Malawi, Nigeria, and Mexico providing basic healthcare, doing surgery, and training local medical professionals. In 2007, he co-founded Surgeons OverSeas (SOS), a nonprofit organization that helps increase surgical capacity in developing countries through collaborative training, funding, and research initiatives.
“The most urgent need in these countries is for long-term surgical development projects,” Dr. Kingham says. “There’s already a severe shortage of surgeons — there may be just one at a hospital that covers two million people — and no program in place to train the next generation.”
Peter Kingham performs surgery in Malawi.
The results of such training can have lifesaving effects. Nigerian surgeon Isaac Alatishe spent several months observing at Memorial Sloan Kettering as a Soudavar fellow and learned a technique for rectal cancer surgery that eliminated the need for a colostomy — an outcome so stigmatized in his country that patients often forego treatment and die. “This has changed practice in an entire region and is being passed on to all the surgeons he now trains,” Dr. Kingham says. (The Mammadi and Alireza Soudavar Traveling Fellowships enable physicians from across the world to study in cancer centers and bring their knowledge back to their home countries.)
Recently, Dr. Kingham’s overseas activity has involved less actual surgery and more focus on cancer research and developing cancer treatment programs in West Africa. He is also working to help Memorial Sloan Kettering physicians play a more active role in the region. He still spends several weeks a year in Africa and stays involved from New York the rest of the time. No matter how often he visits, Dr. Kingham explains, there always is something new to appreciate. “Every time I think I understand a place, there’s another cultural dimension I haven’t encountered before,” he says. “But what’s most fulfilling is my close relationship with my collaborators, especially in Sierra Leone and Nigeria. They’re not only brilliant surgeons, but wonderful people who have become great friends.”
Memorial Sloan Kettering physicians also make contributions to training others in areas beyond those related to the treatment of cancer. Infectious disease specialist Kent Sepkowitz, who leads Memorial Sloan Kettering’s infection control program, for many years traveled to Romania to help a group of public health officials there develop programs for controlling the spread of tuberculosis.
Specifically, Dr. Sepkowitz and the organization he represented, now called Healthrights International, were concerned with the high rate of tuberculosis among the Roma people. Infection rates among the Roma are believed to be about ten times higher than in the communities surrounding them. “There are lots of reasons for this,” Dr. Sepkowitz explains. “They live close to each other, and tuberculosis is spread by coughing. In their culture, there is also a tendency to avoid doctors and a stigmatization about TB.”
Dr. Sepkowitz helped set up a peer education program in which the Roma people who had been successfully treated for tuberculosis would counsel others to get treatment and continue receiving it. Continuing treatment is important because the course of medication can last up to six months and ending it early can lead to drug-resistant disease.
“Through my experience there, I learned the importance of considering the practical aspects when working with patients to make sure they take their medication,” he says. “And this applies to many diseases, from diabetes and high blood pressure to HIV infection. Many patients with chronic illnesses have been disappointed by healthcare, and the struggle both there and here is to reestablish patients’ confidence in their doctors and the healthcare system.”