Building a Career in Global Surgery - Purpose, Mentorship, and Impact

Welcome, Behind the Knife listeners. My name is Mike Molla. I'm your host for this third global surgery series episode on Behind the Knife. I'm a trauma surgeon and acute care surgeon here in Charleston, South Carolina, and I also do a lot of humanitarian and global surgery work with the program that I run. If this is your first time listening to the global surgery series, please check out the Behind the Knife website or app and find the first episode, Practical Approach to Understanding Global Surgery, which is a great primer for this space. Today, I'm really excited to talk about career pathways in global surgery, and for that discussion I have two amazing guests. First, I would like to introduce you to Dr. Barnabas Alinde. He is a general surgeon, surgical educator, and global surgery leader who serves as chair of the Center for Equity and Global Surgery

at the University of Global Health Equity in Rwanda. ~His work focuses on strengthening surgical systems across Sub-Saharan Africa with training that spans surgery, public health, business, and global surgery, including completing a surgery fellowship at Harvard's program in global surgery and social change.~ Dr. Alinde is widely recognized for his work in trauma care, surgical education, health equity, and developing context-specific solutions for underserved populations. Welcome, Dr. Alinde. So glad to have you with us. Thank you so much. Such a pleasure. Next, I would like to introduce Dr. Lacey LeGrone. She is an acute care surgeon, surgical intensivist, and global surgery leader whose work focuses on strengthening surgical systems with specific regards to clinical knowledge access and sharing. She is an associate clinical faculty at the University of Colorado. Additionally, with an initial investment from the Boston Consulting Group and the Gates Foundation, she co-founded a public benefit corporation focused on ensuring patients receive evidence-informed care. Welcome, Dr. LeGrone. Thank you so much.

You've both fascinated me for a while.* Could you tell us a little bit about your current role and your path to global surgery?* Dr. Alayande, you're originally Rwandan, is that correct? I'm originally Nigerian, interestingly Nigerian? Oh, I'm sorry. Yeah. I just had such a close association with you and Rwanda. Where did you grow up? Oh, so I grew up i- in a mix of places, but primarily in Nigeria. Born in Nigeria and spent some time in the UK, came back to Nigeria, and then because my mom was pretty itinerant, she was working with the federal government, moved in the north, the south, the east, all, all around ~a lot of~ Africa's most populous ~n-~ nation. That's ~mult- ~multiple countries in one. And then from there, we settled in North Central Nigeria, and ~it's interesting because~ my interest in medical care, surgical care really started from there. My mom was looking for, literally looking for money for healthcare. Someone- one of us, as children, had malaria, and she

was looking all over, opening drawers, looking out. We didn't grow up with a lot of privilege and resources, looking for money. And my younger sister looks at her and says, "Mommy, where do they make money?" And she says, "The ~printing and~ minting company." She said, "When I grow up, I want to work there." Right? And today she's a finance person. She's been for the past several years. That's amazing. But I was asking myself a different question, "Where do people who don't have access to healthcare or the resources to be able to access healthcare, where can they go for care?" And that stayed with me. W- while my mom was saying, "Go study computers," I said to her, "I think I need to study medicine." Right? ~So I was supposed to be a computer engineer, given the direction that my parents were giving me, but I filled my forms out myself. I insisted. I even spent a couple extra years at home because I was not given admission to study medicine, but I decided that this is the direction I wanted to go. So I make it through medical school and I draw...~ I, I remember this very clearly. ~Still have the book.~ I drew a map of Africa, in which I wrote under it, "General surgery, public health," or, like community medicine, public health, global health, that concept with what am I going to reach Africa. My thought was that they were two divergent things. ~You can't meet, can't...~ ~And that's the way we were trained, right? But I finished with prizes in public health, in community medicine, in the global health space. ~I decided I wanted to go do residency in a place where I would- I was paid half the, the amount that would be

paid for other, the people who are doing residencies other places, although I was offered that job, because I felt I would learn surgical skills first on call. Really challenging environment. But eventually I was posted to a place where I was the only doctor covering 19 local government health centers, right? And the greatest deficit I saw was a deficit in surgical _healthcare. Some people even died close to the facility_. ~ I did what I could, but I understood that I needed to go back and strengthen my capacity for surgical care.~ So here I was having completed surgical education, but not being exposed to this con- step of global surgery. Some random person sent me this global surgery program, and as soon as I looked at it, I knew that this was exactly what I was looking for when I drew that map of Africa and wrote global surgery public health. But interestingly, in, in the words of Prof Roy and a number of our friends who wrote a paper about rural surgery as global surgery, it was really something I was already doing.

But this kind of gave me a framework, nomenclature, clarity about it. So from there, as part of my work there, that's when I came into Rwanda to help write up the curriculum, set up the teaching training, and then eventually we started the Center for Equity and Global Surgery. ~From there,~ we've built residency programs, built master's programs in global surgery, and eventually are building global surgery education programs. That was my path. All that together has formed my ethos and my understanding of what global surgical care is and the clinical perspective and fellowship perspective. So that's been my space, and it's a, it's really a pleasure to be able to take some of those learnings and pass it on to the next generation. Quite a tremendous journey. Similar to that question, Dr. Lavrone, could you tell us about your current role now, and what was your path to global surgery as well? Yes. So

honored to be on this call. My current role, I'm an associate director of research at Medical Center of the Rockies, a level one trauma center, like an hour north of Denver. So like as narrow as you could imagine compared to what we just heard described. And my focus in that space is my job is to help us get verification and to publish work that most importantly improves lives. ~And so when we talk about global health, we're talking about health in rural Kansas. I think Dr. Alindade just quoted a paper, and I constantly quote him because he has this slide that I am enamored with that shows that Rwanda has better access to blood, blood products than Canada. So day job is the research.~ Second real focus is around this like how do we re-envision how we develop and disseminate clinical guidance, which then leads to the third focus, which is ~the,~ as you mentioned, a co-founder of Together Made, which is a public benefit corporation. ~And the, the role for-- my role in that and the role for that in, in the things that I care about is that we really recognize that if we're gonna solve the problems that are so tenacious...~ ~I remember being at a conference and hearing somebody ask Tarpley, Dr. Tarpley. It was Barclay Stuart- Legend... asked-- Yes, Barclay Stewart, also a legend, asked Dr. Tarpley, "Hey, are we ever gonna move the needle on this stuff? Is this a Sisyphean task?" And I think fundamentally, I definitely believe that we will, right?~ ~There's a really great book by Hans Rosling, Factfulness, that's like all of these social science fact, right? People always as- If you just query strangers, and you say, "Is infant mortality better or worse than it was two years ago?" We all have a negativity bias, and we think it's worse, but all these numbers are actually improving.~ ~We can move the needle on these things. And so but recognizing if we're really gonna sustainably move the needle when it comes to knowledge generation, knowledge sharing, digital solutions are central to actually executing that. And like where the common thread in all of this is like my advanced training, I got an MD, and then I did a couple of master's degrees and a Fogarty fellowship in Peru, and all of that was centered around dissemination and implementation science.~ ~So ~early I realized my passion is not in defining the gold standard. It is figuring out how do we get the gold standard actually into practice in a sustainable and scalable way. And so Together Made is this beautiful opportunity where the world's leaders from the private sector who know all about where is there money in the system, what are the existing incentives in the system, and how do you build something that is

sustainable, then coming hand in hand with people like Nobeej Roy and Andres Rubiano and other people who are leading the bedside relevance and global policy perspective to say, "Where are the, the needs of the patient and the provider aligned with where there are resources in the system?" 'Cause if we can capture that, we can really build and scale something. And so that's what I'm really excited about at this point in my life. ~You both mentioned Dr. Roy, and he's someone who I've been trying to get to interview on this podcast, but he's a hard man to catch. Be ~ ~careful what you ask for. ~ ~Yeah.~ ~I had the privilege of meeting him a few years ago at COSECSA. Anyways, both of you touched on intersectionality. You mentioned the access to blood products in Rwanda versus Canada. I've had a similar conversation with leadership in my institution about poor access to surgery in my state. It's the same conversation around global surgery.~ I want to get just a little bit personal, Dr. Lagrone. What is it about your background that made you interested in pursuing this career f- field, this topic, this discussion? ~What was it about your background that made you pursue this? ~ ~Thank you for asking. One, I'll say so the Canadians aren't mad at us-~ ~that slide is for Rwanda and Kansas. I don't... Canada might have great access as well. Oh, I ~ ~thought you said Canada. I'm sorry. ~ ~They... No. They probably don't 'cause they're a really big country. I'm sure they have some of the same rural issues we do, but it was- but it's Kansas.~ But I would say the most crystallized version would be, like, I grew up in a home with parents who were phenomenal examples of knowing why you're doing what you're doing and being intentional about it. I really had a strong foundation in that, and then I remember from just a very practical standpoint, I remember being 11 years old and everybody always asks you, "What do you want to do when you grow up?" And I

remember I thought, "I want to do something that if you don't go to work, people notice and it matters." Is there any impact if you didn't do this? If this disappeared, would it- would the world be any worse of a place? And so I think very centrally knew that I wanted to be in a space to prevent human suffering in a way that really mattered. I always tell people in research when the trainees are getting stressed out, I'm like, "If there's no cross-clamp on the aorta, it's not an emergency." We have a great job because we know what the difference is between it really matters right now versus it doesn't.~ And so sticking with that thread of it just really has to count, there's just no greater opportunity and privilege than getting to participate in efforts that are about relieving physical and moral suffering that are anchored in truths that translate across all the settings.~ And so that's what I love about what I'm doing now, is that it's just... it's truly global in all the senses of that we are all in this together. ~So ~I want to move to just talking a little bit about building a career in global surgery. ~And so ~global surgery is, is often described as a field rather than a specialty, ~and I struggle to even explain this sometimes w- to other surgeons.~ ~So ~for both of you, what did building a career in global surgery look like for you in practice? Yeah. I think I will start with this. For me, I framed

it in three distinct bits. The first was the existential, w-which relates to human experience, is essentially search for life's meaning, philosophy that individuals must find their own meaning. ~And when I'm talking to people about this, I start there because the concept of purpose, I love what you said, Lacey, about the why. There's that Simon Sinek's book about starting with why, and Mark Seidenberg's book about solving for why. So there, there is the concept that there are vital questions that we must ask ourselves.~ The Japanese would speak to it as ikigai.~ Some have said that's not the original concept, but ~that reason for being, ~uh,~ and it really does matter that people start from there when you're thinking of building a career in global surgery, because a lot of global surgery is beyond yourself. Like it's the, the, the time, the effort, the work, the things you do are beyond just this is me. ~And it's finding out whether or not within your framework, there's the convenor of the Global Leadership Summit, Rick Warren, talks about shape within your framework, whether you are really made and wired for this. Because if you don't, if you come at global surgery, surgery as a career without this sense of purpose, it becomes difficult.~ And I've seen people try at it, but there is nothing like greater than them that they're looking for, and it really becomes difficult. So that's the existential, it's one end. Then the practical is really understanding the concept of global surgery. Like you, Mike, a lot of us grapple with the definition of global surgery. ~We know what, what malaria is, we know what TB is, we know what-- but when we couple... In fact, we may know what surgery is, but when we add the word global to it, we start to struggle a bit with definitions. And for me, that practical bit of understanding the space is what really matters to be able to build a career in it, because you shouldn't be building a career really in something that you don't understand.~ ~So if you look at those three definitions of global surgery that have been thrown in literature like this is the definition of global surgery. There was some work by Derr et al., there was some work by Murag, John Murag et al. 2015 Lancet, and then Bath et al. 2019. If you do what we would call a something like an, an analysis, right?~ ~You're putting thematic analysis, you're putting things together. One we understand is the range of disciplines. So a surge-- the fact that we are surgeons does not mean that global surgeries are preserved only. It's a range of disciplines, right? Highly multidisciplinary, highly intersectoral. It's beyond the health service sciences.~ ~The second is that there is a level of cooperation, not necessarily only operative surgery, but you're looking at development, you're looking at global co-collaboration, flux between high-income countries, low-middle-income countries. Then... But this is true that there is a focus on the underserved individuals, populations.~ ~There's a focus on the underserved. So we're embracing something at population level, and then we're also embracing something at clinical care level. And then the priority on equity and equitable access to health also comes down. And finally, the reach, like you were saying, the US is on the planet. Same thing, all continents are on the planet.~ ~So you can do global surgery within a country, right? Without traveling or transcending borders. So that-- the understanding of these five things really comes to bear for you to think about what is go--~ And in my mind right now, I'm seeing somebody who I could say is focused on education but is in global

surgery. Another person focused on advocacy in global surgery. Another person focused on policy in global surgery, research global surgery, not-for-profits global surgery, innovation global surgery, even business, right? For-profit business, but is strong in global surgery.~ So that's the second thing. ~And then the third thought is this. ~So the existential, the practical, and then the ~ concept of frameworks, right? That global surgery is a field and not a job title. So I have to have an anchor profession, right? And global surgery gives me some technical expertise or surgical system problem, and I deploy this within a population or a space. So I could be a nurse, right? And within global surgery, I understand quality improvement, perioperative care, and my focus, my setting is a rural hospital. I still would be taking those same principles and doing global surgery. I could be a surgeon, you know, and I'm at a district hospital. Global surgery has given me the concept of implementation science,

surgical safety, and I'm working at district hospital, and I still bring that there. Or I could be a policy specialist, and then I understand. I come do a global surgery course or training. Global surgery has given me knowledge to be able to engage national surgical obstetric anesthesia plans. We do that specifically for some of these leaders and in, across, across countries in Africa, bring them to Rwanda, teach them in that way. ~They go back, and it transforms the ministries of health because there's a champion there who now understands that. So I think in speaking about this- We could very easily parse out things, but it's really by definition complex to understand the direction. So clinical global surgery, surgical systems strengthening.~ ~Some people go research academic careers, policy, governance, program implementation, quality improvement, innovation technology, et cetera. So ~that understanding is a framework for people to begin to pursue careers within global surgical care.~ So okay. So for me, I jumped into the understanding, right?~ But when people who are early in their career really understand this, and there's a whole g- generation of people who will understand this, and it will really guide their engagement even better in global surgery. ~Mike? ~ ~I think that... I think you said something so important, and I want to make sure to point it out for listeners who might be new to the field of global surgery. I think all of us here on the call probably understand, but there are entire... There are folks who, one kind of aspect of this that you just mentioned, that is their entire career field.~ ~Their, their, that is, there, there's an example just off top of mind is Rondi Kaufman, who is kind of the tip of the spear in terms of global surgery advocacy, where she is in constant contact with the state department in trying to change some of the laws around making it so that we can more easily interact as surgeons, you know?~ ~Mm-hmm. There are a lot of surgeons who are in other countries who can teach us a lot of things in the United States and in a developed economy about how to take care of surgical patients in a lower resource setting. And so a big part or a big focus of her career, I don't want to speak for her, she's not here to speak for herself, but at least what I know of her, is that that's a big part of what she's doing, and it's just global surgery advocacy in that space.~ ~And there are other folks who are similarly building entire careers in a vertical of global surgery education and global surgery research. And there are all these different aspects that you can go down and really impact the field in that way. So I love that you said that, and I wanted to point that out for the listeners.~ ~And ~Dr. Le- Lerone, do you have any other thoughts on this question? ~Apologies, because I was immersed in enjoying the Dr. Al- Ali Mdians answer. Will you tell me the question again? ~ ~Let's see. For a global surgery, global surgery is often described as a field. Okay. Okay, so what, what did building a career in global surgery look like for you in practice?~ ~And by the way- Mm... I have other questions too. So you, you don't feel like you have to answer this one. If we don't both... We don't... You don't both have to answer- Yeah... every question. ~ ~I'll give a brief answer. The...~ I think the thing that I try to internalize around this and what I coach people who ask me about it is be world-class in something- Where any leader would be privileged to have you at the

table with them, and that might be the president of the American College of Surgeons. ~A-~ and once you're world-class in that thing, then ask for a wider opportunity to participate in global initiatives. Because this isn't a direct answer to your question, but it's something that I always tell young people when they're asking me, "How do you build a career in global surgery, da-da?" I'm like, "Develop some independent expertise and, and value add that every room would be glad to have you in, including the ones that are on other continents." ~Which actually this is, that's a great answer 'cause it, it's~ a perfect segue into kind of the just more mentorship and professional development aspect of what I was hoping to hit on in this conversation,~ is someone who, for~ both of you, you're now mentoring younger colleagues, whether they be early career professionals or residents or medical students. What do you think ~those, those kinds of~ trainees or junior faculty often misunderstand about career development in this regard? ~Don't add this in the recording a lot. ~ ~We'll just- ~ ~Off the record a lot. ~ ~That's definitely going in the final cut. ~ ~I'm just kidding. I'm just kidding. So the, I- I... But it's mentorship, right? The whole concept of mentorship is someone taking thoughts that are not aligned, things that are jumbled up there, and really arranging it and cleaning it out for one.~ ~And so~ I think ~one, ~some people misunderstand Visibility for

impact, ~right? So~ because it, one is out there, you're all on social media, everything's good. But you- we know the people who work in the space, and they may not be the people who are most visible, ~right?~ The, the visibility does come. So don't pursue visibility before excellence. Like Lacey was saying, be world-class in something. The world eventually will pull you out, and people will find you. ~Yeah,~ I'm not saying be shy with your publicity, but don't give an impression that you have what you don't, ~right?~ And that, I think, in this space, in this time, really, that packaging sometimes is bigger than the quality that we find. So that's one thing I think people misunderstand. ~A- another is the reward of resource. When you start out in global surgery, and really in anything, thinking career, if you're... It's people exchange resources for value. Don't jump only... There's sometimes you're gonna give resource. You're going to give value rather without what you consider as commensurate resource.~ ~You are sowing a seed for something in the future. You don't have to bill everybody who comes to you to speak to them. You don't have to... And, and this is even prematurely before you have grown to a space where you can. So really developing that heart to be able to make impact even when it seems as if you're not making material re- returns on it.~ ~The few things that freely you've been given, freely you give. On, at certain points, of course, that value is going to be valued, and people exchange resource for it. But I think that many times, as early, in early career, we're thinking, "Oh, how can I make this out of that which I have?" And sometimes you build a platform without making, right?~ ~You build a platform by giving.~ Another thing that within the, the global surgery space, we sometimes don't think about early in career, and I love young

people thinking about that as they start out, is the integrity of your relationships. Partnerships matter And partnerships really are what will take you further. In the words of Paul Farmer, he said, "The greatest achievements we make on this planet are through one word, partnerships."~ Without them really that field, the, the field, and people know one another, right? It's global surgery, not really so big. So we know each other, and if in partnership we- there's no integrity, if people commit resources into your hand, maybe in, in low-middle income country context, and it's not utilized well, if people expect something of you and it's not done, or you enter into an agreement and th- something goes off or the integrity is not there, then i- word goes round.~ ~You actually are limiting your growth within this field. And this is for both high-income country, low-middle income country individuals. There's a proverb in that, that says, at least Sierra Leonean, that says, "You don't tell a man who's carrying you across a river that he stinks." So you may be bringing resources into this partnership and people are being quiet, but everybody eventually knows that something is go- this is not the best of partnerships, that there are partnership sicknesses within this.~ So I would say these are ~three ~things I think starting out in career one has to pay attention to, integrity in partnerships and doing partnerships well, adding value without necessarily demanding, but really adding that value, and un- understanding that growth is a journey, so putting out one's self prematurely may be a disadvantage. ~Over. ~ ~So ~ I feel so strongly about ~what you just said about~ partnerships ~that it--~ that we dedicated our entire second episode of the series to ethical partnership building. ~ Mm-hmm. So I think also people who are new to the field of global surgery, particularly from the high-income context or developed world, think that we will just go and quote, "Help these people."~ ~And, and, and it's just- and ~we had a extensive conversation with my partner in South Africa ~about how to go about this, 'cause it's, it is difficult and nuanced, and there's a tension on both sides when you have that dynamic of income, dynamic of resources that is, that is different. So I f- I feel very strongly about that.~ ~ Lacey, I want to ask you, part of the reason why, I think I, I may have mentioned it before, but part of the reason why I'm so intrigued to both interview you on this podcast and also get to know you in person is your path. Dottoral groan~ ~ So many folks have just a path that is very set, which is you go to, you get your four-year undergraduate degree, then you go get your medical school degree, and then you get into residency, and then you do...~ ~ Dr. LaGrone~ Moving on, Dr. LaGrone You're an attending physician.

and your path ~through ~and what you are choosing to do with what you have in front of you is very different, which is ~in- ~extremely intriguing. And so I wanted to ask you, ~like ~for trainees, how can they identify mentors when formal global surgery programs or global surgeons might not be easily accessible at their institutions? ~How can they identify mentors? I guess I would... Answer to ~this is gonna be really esoteric ~and hand-wavy of if we zoom all the way out, 'cause you referenced the fact that my pathway is different than some of what we might consider typical in the US academic setting for participation in global surgery.~ ~And I think that I would suggest this, and it a little bit overlaps with my answer before of knowing your why of~ The quote that came to mind~ when Dr. Island Alayande was talking was the folks at the Moral Ambitions School use it, and there's a famous quote by Friedrich Buechner, which I just looked up, or maybe people say it Buechner. And the place...~ The quote is this,~ and you can replace the word God if you're comfort- if you're more comfortable with that.~ ~But, ~"The place God calls you to is the place where your deep gladness and the world's deep hunger meet."~ And so I think... I just always encourage young people because then they say, "Oh, I keep emailing these four people who are often cited on these articles or positions as deans in these global surgery programs, and they don't call me back."~ ~And it's, "Yes, and?" And I would say zoom way out on your life and identify where... Because I thi- I also saw some graphic recently, I don't know if it's data or just propaganda, but the,~ the concept that leaning into your strengths, the return on investment on that is logarithmic versus the addressing your weaknesses is ~le- ~is less. And the one time I got to have any personal interaction with Paul Farmer, which I'll name drop across the planet and so honored to have stood in the room with him. I was in the audience at a big global surgery event, and I walked up afterwards and asked him, because I

was in the position that maybe the people you're talking about would describe of, "But how do I find a mentor?" I was at the University of Colorado. We didn't really have any global surgery or anything, and I'm like so thirsty to be in the room with Paul Farmer and jealous of all the people who are at Harvard. And I asked him, "What specialty should I go into?" Or some equivalent to that. Trying to get him to micro-mentor me in that moment. A- and he said, "Whatever you're passionate about, there's a deficit of everything globally." ~He was like... And so I think that I just would encourage, and I want to learn more about Dr. Alayande's background, including his degre- his formal training in theology.~ Because I think the zoom out approach of your mentor in this might be your grandma, or your mentor in this might be someone in another industry. ~And ~I think that if you broaden your scope and really, as Dr. Alayande referenced also, don't look for visibility, look for impact. ~And then~ if you anchor yourself around what's the definition of success and pursue mentors around that, I think you're gonna find plenty of people who want to mentor you, who will pick up the call and want to walk with you on the journey because it will be joy-filled. If your only goal is to secure an academic position and then get government funding and then be published a bunch, I probably don't. I would say, yep, that's gonna be an uphill battle. But if your

goal is to do really good work in a way that's creative and the truest expression of who you are, I think you're gonna find that people want to come along that journey with you A central theme to what you both talked about is the why. Why are you doing this kind of work?~ And I... Every global surgery talk or lecture or discussion that I give when I'm the one being interviewed, I start with why, 'cause it is so important because the work is so hard, it's so challenging, and ~it's taxing and poorly compensated, and all of the, ~you know, ~gripes that we all talk about at conferences, right? But so what is gonna push you past that is the realization of why you're there. ~But for the sake of this podcast and for the listeners, I do wanna ask you, going off script a little bit here, ~but ~there is,~ there is a price to be paid. ~And for you all, it...~ I don't want listeners to Behind the Knife to think that we're all just flying around the world high-fiving each other, just it's all glory and ~just ~healing the sick. *I, I want them to understand the challenges of it. And so I will ask you directly, *~*like,*~* what prices have you paid to be engaging in this kind of work? * ~I, I will.~ Let me share a personal story. So I'd started residency, really involved, really engaged, really loving the work and serving

And one day, I got married in residency anyway. Pe- people advised me, "Don't do that." ~Back in the day, we would finish residency, and then you get married. And then so all my consultants were doing that.~ But I decided I wanted to raise my family and then grow my home together. We had an agreement with my wife, but I still told her, "Hey, you probably will not be seeing me as often. ~I'm just doing general surgery when I'm doing pediatric surgery, neurosurgery."~ And one day, I walk back from the hospital, and I find my wife just standing in the doorway with our first child, right? She's holding him like this, and she asked me a question, "What is our role in your life?" That day was just like water poured all over me. And this might be really intense, ~but,~ but from that day, ~I was--~ it was a price. It ~was,~ was something I felt I was paying to be able to move forward. I felt that everybody in my life understood, right? Because I would come back home, and a- as soon as I, I sit down, have a meal, I'm studying again, pushing, we want to save the world. But from that day, I would deliberately

stop.~ When I came home, I would spend time, play with them, et cetera, just be there. And when everybody went to bed, then I would focus on studying, preparing myself for the next day, and that would take me late into the night, shorter sleep time. ~But for me, that represents not all, but that represented a price that I had to pay,~ that I had paid, but had to switch the currency, and then had to pay.~ ~N- no- nobody high-fiving and sipping wine and enjoying ourselves. It, ~it might happen sometimes where we talk about poverty and world problems over a glass of wine sitting in Geneva,~ those kind of things. ~But either sleepless nights are real The pain of seeing systems not working is real.~ The hurt that you have when you see that patients did not get the care that they...~ When you start to care, that in itself is a price that you pay~ when you see that this system is not working, that system is not working. The, the, we don't count hours, and even staying in certain parts of the world is a price that you pay. Some of us are where we are not because we don't have a choice, right?~ ~We are very deliberate in saying the, the push factors are here, the pull factors are there, the stick factors are there, the st- the stay factors. But decide. So ~there are multiple prices that if from both a pragmatic and a moral ~standpoint,~ ethical standpoint, ~and just because there are prices that are paid~ in the space of global surgical care, and there are people who are paying that price every day. ~In district, the doctor,~ the surgeon who's in the district hospital doesn't have a school for his children, ~doesn't have the, um...~ And what he's doing is moving back and forth from family. I know many of these within Rwanda, within this space, in fact, within the institution where- which I serve. The price is paid every day. And it may not be glamorous. Their names may not be

somewhere. But in, when we think equity, there are people who are paying these prices within the space of global surgical care every day. ~Over. ~ And that, that price is being most paid by folks who are never gonna be interviewed on a podcast or never gonna be speaking at the American College of Surgeons. ~And that's what I struggle with in doing both this podcast and this work, is how do you get visibility and a, a platform for those voices to be heard? Both the question... This question came from both of you referencing Paul Farmer, and I never had the privilege of being in the same room speaking to, hearing Paul Farmer speak.~ ~But so many of my mentors have known him personally and been around him. And then very recently, somebody who I did not know very well actually was telling me that they knew Paul Farmer. And for folks like him who have such a massive impact and are such big names, they Often to be, often become larger than life, larger than themselves even.~ ~And we tend to over-glamorize and glorify them. And they, he should, he should be, and many people should be glorified for the amazing work that they do. But this person told me that there is a hidden price that he paid that most people are not aware of, and that really stuck with me. It's not free, right?~ ~The work is not free.~ And so I'll pitch that question back to you, Lacey, is what, what is the price that you have paid, if you're comfortable sharing? Yeah, ~I think that Dr. Alyande's answer makes me... I think that I agree. I think the only price as far as suffering, ~I'm gonna tell you a funny anecdote, but like as far as actual suffering, it would absolutely just be what Dr. ~Alyande sa-~ Alyande said, which is the like,~ there's the~ Lin-Manuel Miranda quote, something to the effect of, "You can't let all of the world's suffering get into your heart because it would break you, but the suffering that does, you need to do something about." ~Or some-~ that's some of this quote of his. And so I think, like, any suffering that I experienced in this has just been compassion. ~Has been the, like, that if you're actually gonna participate in the work, the suff- the suffering with, and if you have your eyes open you're gonna, it's gonna... If you're not just going to... I, people tell me I, I work, I go to a lot of conferences in a lot of hotels now, right? 'Cause if we go to meetings, like, it's conferences in hotels.~ ~And I'm grateful that I've had lots of periods in my life where that wasn't the case, and lived in Southeast Africa, in Malawi for a year working with pediatric malnutrition, was, like, my first exposure. And so great to, grateful to have a really grounded rooting in. And then as a clinician, every day we see patients who are suffering.~ ~So I'd say the suffering would be compassion. As far as the cost that it's cost me, the anecdote that I'll share is that I remember being in residency, and I was about to go out on my research years and I, and anyone who knows me will be able to infer who this is, but I haven't asked him permission to tell this anecdote, so I won't use his name.~ ~But I'm, I'm sitting with my husband and my daughter, and then I get a phone call and I'm, like, so excited to see this person's name on my phone because they're a global leader in global surgery. They're a celebrity. And then I go outside and I talk to him and he says he'll work with me or mentor me, and I'm, like, freaking out, I'm so excited.~ ~And I come back and my husband goes, "Oh, great. Oh, okay, cool. So you can be, like, the only other surgeon who's poor in the world." He's- I was like, he was like, "He told me I could p- maybe follow in his footsteps and he'd be my mentor." And he was like, "Oh good, okay. You and he can be the only poor surgeons." And because we've been to this person's house and, like, he, he has lived it.~ ~He walked the walk. He lived in other countries, he worked in the WHO, he is the best men- okay, I'm gonna say it. It's Charlie Mock, who's, like, my, the person I respect most. I don't know if... Dr. Mock, I love you and your wife, and you guys have a beautiful home. And so I think, I think I say that not as it actually felt like a cost to me because by the grace of God I was born in a home where my parents, we did not have a lot of money growing up and so I have a really comfortable, like, "Whatever.~ ~We lose it all I'll go move into my in-law's basement. It's fine." I know that I live in America and I have the privilege of this insane safety net, that I am so far from hunger, that my... So I don't actually have any fear around income and finances. But I see, back to the mentoring question, I see how much that limits our partners.~ ~I saw someone speak at the... We had this global meeting and Roy was in the audience. And at the podium a US surgeon is going, "Yeah, if we had all the money in the world we would do that." And then Roy p- presses the button on his mic and he- The rest of the world thinks you do have all the money in the world.~ ~ And so ~I think that US surgeons are often held up of, "Oh, but if I go do a Fogarty, ~I g-~ I delay my earnings by a year, or if I take this position, I make half as much." So I'm not saying it's a real

cost, but I'm saying if you are anchored in the reality of what we're trying to serve, then it doesn't feel like a cost. ~And I went with my daughter when she was one years old to Peru, and she for a year doing a Fogarty fellowship or whatever, and but it's just the nature of who I am, that was in my upbringing that that didn't feel like a cost, but I see that as a barrier to other people who want to participate, and I wish they could go, "You know what?~ Let's get over that." ~This is, is quite personal, but I will share that I have lived on the other side of this, growing up poor. And so that, that trauma of- Yeah... the disparity is real. Part of why I asked the question around poverty and privilege and why we do the work that we do is mostly for the benefit of the listeners.~ ~But it's important that I just have a little disclaimer around the moral clarity of all of us knowing that the price that we pay to do the work is not... It's not about us. It's... There's so- so again, it goes back to there's so many voices and so many surgeons and so many patients who are so far away from the surgical care access that we so often take for granted in the developed context.~ ~And so none of, none of this-- ~I know us three on the call may understand this intuitively, but I, ~I wanna,~ wanna make sure to point it out for the listeners~ that it is... That we are, it, the, the price is not...~ We do pay a price, but ~that pri- ~the majority of that price is paid by folks who are not currently speaking in this conversation, ~and that we need to...~ I wanted to acknowledge that. I'll ask you both one last question,~ and then we'll move into our kind of more rapid-fire section.~* For medical students, residents, fellows, or junior f- junior faculty who are listening today who hope to make a meaningful contribution *~*to the s- field of global surgery,*~* what final advice would you leave them with?* If I were to say one thing, it would be find a mentor. And the mentor is somebody who will stay involved with you. Not necessarily somebody who's a big shot, has a big name, but somebody who the greatest thing you're looking for is staying involved, time, effort, presence, right? ~When I say find a mentor, I'm not saying find only one person.~ ~There are people who are working on the ground, people who are present, people who can stay involved with you and can be that critic evaluator with you, and you may have multiple people who serve that purpose in different parts of your global surgery journey.~ But for me,

it was beautiful mentors like Robert Riviello, Abebe Bekele, John Tarpley. They're the ones that really helped me organize, guide my path forward. Make sure that you get into a circle, mentor circles, individuals who can help you along this journey. Beautifully said. Then I would say something about people are high achieving type A personalities oftentimes in this space. ~Do the next right thing.~ The motto at Harborview is exceptional care without exception, so some version of excellence in everything you do and doing the next right thing, and then the work will speak for itself. 'Cause I see a lot of young people getting super stressed and pressured about who will recognize this, how do I get into the right room? If you keep doing the next right thing excellently, the work will speak for itself. In the worst case scenario, you have a beautiful impact. In the best case scenario, you have a beautiful impact and get that position that you want to get. That's amazing. So rapid fire questions. ~I'll have each of you answer each question, and~ I'll alternate who goes first. So first one,

Barnabas, one book, article, or resource every future global surgeon should read. ~Gaze and Pose in, in Global Health. That paper probably should be important. It's within the global health space, but is important for people in global search ~ ~What was the paper? I'm sorry. ~ Gaze and Pose. ~So ~it's called The Foreign Gaze: Authorship in Academic Global Health. Interesting.. Dr. Loughran? Essentialism by Greg McKown All right, Dr. Lagrone, a leadership lesson that you learned the hard way Leadership lesson that I'm in process of learning, and don't ask anyone who works with me if I've already completed learning it, it would be learning how to bring the best out in people ~i- i- ~instead of identifying who's a good fit and not, and then the people who aren't a good fit moving on. And I am a decade away from mastering that at least. Delegation. Delegation. I learned it the hard way. Still I could sit down, bury myself in work,

do deep work, do it myself, and still was trying to carry that into leadership and leadership positions and it, it failed, right? So I had to learn to slowly let go of those things that were precious to me and allow things to be done at 60%, 70% and not at the 100%. Nice. Next one, Dr. Alayande. One skill outside of surgery that has been surprisingly valuable in your career. Playing the keyboard. Yeah, it helps you with your fingers too, but also with, with cooling down. All that is really helpful in the relaxed space and gives you a life outside of surgical healthcare. Same one. I don't want anyone to fact, fact-check this, but comedy. Yeah. Like you as a comedian? Meaning I'm not a comedian. I don't do stand-up comedy, but that the ability to bring a little levity in has helped me defuse situations that would've gone sideways, ~et cetera.~ And I spend a lot of time developing that skill by exposing myself to people who are funnier

than I am. All right, last rapid-fire question. Lacey, I'll start with you. Biggest misconception about global surgery. ~We were like global, but then~ people still don't realize Italy is on the globe, and the US is on the globe. How do we talk about, ~like,~ resource-relevant care or adaptive care or contextually responsible care? We keep outgrowing the terms because people bake into them truths that aren't there. ~Hmm.~ Biggest misconception was that global surgery meant someone from high-income countries crossing borders into low-income countries and then ~pr-~ providing care. I still face that one almost every day. Unfortunately, I would love to keep this conversation going 'cause it's so interesting, but we've reached time. I ~really ~want to thank you both, Dr. Alayande and Dr. Lagron. I really appreciate you taking the time out of your days to share your experiences. I really want to thank my amazing Global Surgery Program Coordinator - Elizabeth Fine who helped produce this episode. For our

loyal listeners, thank you so much for your time and attention to this topic. If you enjoyed this episode, be sure to keep an eye out for future Behind the Knife Global Surgery Series episodes coming soon. We're exploring additional topics, including surgery in active conflict zones and ethics around global surgery research. If you have an interest or other topics that you would like to hear represented on this podcast, please feel free to reach out to me. My contact information will be found in the show notes. You can also contact Behind the Knife at hello@behindtheknife.org or on X. We really appreciate you listening. Thank you so much, and until next time, dominate the day.