MJM MedTalks
Global Surgery in our “Backyard”; A Discussion with Dr. Evan Wong

Vanessa Ross (VR) [00:02]: Hello everyone, and thank you for joining us on another episode of The MJM Podcast. McGill Journal of Medicine, or MJM MedTalks, is a podcast series where members of the Faculty of Medicine and Health Sciences at different universities are interviewed on topics related to career, research, advocacy, and more. The aim of MedTalks is to open a space where faculty members can share information and advice for trainees in healthcare and medical sciences. My name is Vanessa Ross, I’m a McGill medical student. In this episode, as a member of the MJM's podcast team, I will be interviewing Dr. Evan Wong. Dr. Wong completed his medical degree and general surgery residency at McGill University. During residency, he earned a Master of Public Health at the Johns Hopkins Bloomberg School of Public Health in Baltimore Maryland, where he specialized in epidemiology and biostatistics and published extensively on access to trauma and surgical care in low-resource settings. After completion of his residency program, he pursued subspecialty training in critical care medicine at McGill prior to returning to Johns Hopkins University to complete a trauma and acute care surgery fellowship. Dr. Wong is active in undergraduate and postgraduate education in both general surgery and critical care medicine. He is the current lead for injury prevention at the MUHC. He has been appointed the lead for trauma and general surgery services in Nunavik and focuses on building patient-centred care pathways, quality improvement initiatives, and health care professional education programs in conjunction with the local communities. His research interests focus on these goals, notably disparities in access to care, trauma systems, and patient-centred outcomes. Our conversation today will involve Dr. Wong’s experience working for communities in Northern Quebec, as well as the role of research, collaboration, and community involvement. And finally, we will end with a discussion about future directions and advice for trainees. Hello Dr. Wong, thank you for joining us today.
Dr. Evan Wong (EW) [02:11]: Thanks for having me.
VR [02:12]: So I wanted to just get started sort of by talking about your experience: how you got involved working up North—so how you became actually the lead of trauma and general surgery services in Nunavik?
EW [02:25]: So, it's actually a bit of a convoluted and serendipitous type of story. But throughout my training as a med student, as a resident, I was always very particularly interested in care to underserved populations and under-resourced settings, mostly internationally during my training and that’s– that was mostly the focus of my master’s degree as well and in my master’s of public health. So, when I came back on staff, I had the motivation to continue that line of work, but I was approached by various members of the surgical leadership in terms of whether or not I had an interest in applying some of those themes locally. So by locally, obviously that's a broad term but it's for our populations within the same province that unfortunately still are underserved and under-resourced. So, they asked if I was interested in doing that and I jumped at the opportunity. On a personal level, when I came back on staff, my wife who is an OBGYN was actually also in charge of OBGYN services in Nunavik for which she did for a number of years. So I already had, I guess, an introduction to how things worked and what we could work on from a general surgery and trauma perspective. So putting that all together, you know, I had a particular interest in this and then just flew with it.
VR [04:06]: OK nice yeah, that makes– the stars kind of all aligned at the– at the same time. And sort of, in your time being there, what kind of health care disparities have you noticed specifically for the Nunavik population?
EW [04:19]: I mean, where to start with that. I think that would require a much longer podcast to go over that in detail. I fear I may not answer this with or do it justice. I think what's important is that, especially, you know, I guess for the audience of this podcast, is– you do see a lot of the consequences of these health care disparities providing care in Montreal. So even before actually going on site and working in Nunavik, throughout my training as a surgical resident, for example, we would receive patients from the region that were victims of trauma or even requiring any emergency surgical services like an appendectomy, for example. And I think you can see a lot of the disparities that stem from many historically driven social determinants of health, in terms of disparities from that point of view. And then in terms of access to healthcare services. So again, with the example that I provided, if you need an emergency appendectomy without access to emergency surgical services in Nunavik, you have to be transported down over, you know, 1400–1600 kilometres away from your family and your community, down to Montreal in a foreign community to get your surgery. And that in itself is a huge healthcare disparity. And so, again, I think for the trainees listening in, just interacting with patients from Nunavik on a day-to-day basis within the tertiary care setting you can already see those disparities. Now, once I start to go more and more on site in Nunavik, a lot of these disparities were more solidified in terms of, again, access to resources. But I think the important thing here is that, you know, the disparities are not focused purely on hospital-based access to care. I think it's really important to think about health care disparities as a continuum both from a preventative aspect and again the social determinants of health, and even post hospital. So for example, you know, someone gets care down in Montreal and needs rehabilitation, standard rehabilitation after hospitalization, and those rehabilitation services are not available necessarily in Nunavik. They have to stay in Montreal, again away from their families and their communities. So that even exponentiates the disparities. So I think it's important, again, just to remember it as a– as a continuum. And every step of the way there are disparities.
VR [07:16]: So a lot of the times, and you've mentioned this, but they do have different cultural backgrounds, they're often more familiar speaking Inuktitut and not really English or French. So sort of on a day-to-day level, when you spend time up North, how can you provide what we say is culturally safe care and maybe you might want to define what we mean by culturally safe care as well? Yeah so how do you go about that in your interactions with these populations and when you're providing care and advice?
EW [07:49]: So, I mean, I think once again for the audience and for the purposes of this type of podcast, I'm not necessarily the person that should be the authority to discuss any of this. I think in terms of providing culturally safe and sensitive care, obviously I’ve– I'm not from Nunavik, I didn't grow up there. In terms of culture, I'm really a newbie to all of this and learning as I go, but I think my approach to all of this is being very open and asking questions and being interested. And it's through my interactions with patients and healthcare personnel that actually come from the region, that's how I get a sense of how to keep patients more comfortable. I think it's all about– it’s really more of an approach and an attitude here, obviously not coming with biases and presumptions about what is important to these local communities. I think, again, asking questions and being very open to adapting and improving, you know, the care that we provide, I think that's the most important thing. And obviously collaborating.
So, you know, the question is, how do I connect? First of all, I think, any interaction, you have to remember the history behind interactions with healthcare personnel and historically where things have gone wrong, repeatedly. I think you have to work very hard to establish that sense of trust and I would even use the term “to re-establish” that sense of trust, because you’re– sometimes as soon as the patient walks into the clinic room, and I'm sitting there in a chair wearing a scrub top for example, there’s already that sense of “oh well, is he a figure of authority and is he going to tell me what I need to do”. I think that the number one thing is to really re-establish that sense of trust and collaboration but sometimes it's hard especially if you only have a few minutes to chat. I think what's really helped me over time is seeing the same patients over and over, and going up North repeatedly. I've been told by a number of patients and a number of community members that, again, if you keep showing up then there is that sense of trust that's building because they’re used to some health care professionals coming once and never coming back again, for example. So building that long term relationship and just genuinely showing that you're there and you care, and you want to provide the same quality of care that you would provide to any other patient in your practice, you know, whether they're from Nunavik or from Montreal, they should have the same quality of care. I think that really helps. I think what really helps as well is, at least in the care I provide in Puvirnituq, you know, having the interpreters present to really provide explanations in Inuktitut I think is particularly helpful. My Inuktitut is very very subpar and I'm working on that, but I think that helps a lot to connect and even a word here and there really goes a long way. < VR [11:35]: Ok nice, I'm sure your Inuktitut is probably better than a lot of others so… he's shaking his head. Ok so, we’ve talked a little bit about the health care disparities, again with this question on culturally sensitive care, and I think we'll probably talk about this kind of throughout the interview. But could you just start by introducing how, in your role as the lead of trauma and general surgery services in Nunavik, how you've approached mending the gap between these health care disparities between people down South and up North. EW [12:12]: Yeah so, first of all, I'm a single individual, part of a massive healthcare system with a lot of moving parts. And I do work, thankfully, with a tremendous team: both on site in Nunavik and down South in Montreal. I think the first thing to recognize is the support from, really, all stages of the health care system. And what I mean by that is, you know, our surgical leadership at McGill is 100% supportive of these endeavors and truly prioritizes them. So I think that's particularly helpful. And I think the leadership in Nunavik clearly recognizes that trauma and surgical problems are very very important within the communities, and therefore prioritizes, again, any endeavors that can help improve care.
How I approach this, at least on a, you know, from an individual perspective, is I think about the entire continuum of care. So for example, in terms of trauma, you know, I think about yes there’s injury prevention to start off with but then, as you go on, there's prehospital care, there are the interventions that are provided in Nunavik, and then we talk about interhospital transfers, so transfers between Nunavik and down to the level 1 trauma centre at the Montreal General. We think about the care that we provide in hospital and then, once again, the post discharge care. You think about the entire trajectory that the patient has to go through, and by thinking about it that way, then I think about what are the things that we can optimize at each stage. And using that approach, well the first step for each of those steps, well is to measure what's going on. You know, first we obviously do a needs assessment, always in collaboration with the community to ensure, number one, that this is in line with their priorities and to get their input, once again, every step of the way is essential. And we measure what's going on. And I put the emphasis on measure because you can't improve what you can't measure, right? So a lot of the usual quality indicators that we look at in Montreal for our usual trauma and general surgery patients are not readily available for the patients that originate from Nunavik just because of limitations in terms of data collection procedures. So, if you are unable to measure those things, how do you actually target interventions to improve them? So, a lot of the work we've done as a group and what we've prioritized is to try to gather more data, again of every step of the way. And that's been, you know, it's not an easy task and it's something that's required a lot of input from all levels of care. But now we're getting some preliminary numbers and that's going to serve as a baseline for our interventions. VR [15:46]: Ok so I think they’re sort of research-oriented.
EW [15:49]: Yeah, it's research-oriented. I think, obviously, there are a lot of, I would say, connotations related to research particularly in some of these communities and I think it’s important to think of measuring these things as you know, we're really looking to improve the quality of care. And it’s the– I think the most important thing is that this is not purely research and that we look at the numbers and then that's it. It's not really the end of the way to have the numbers, it's you need to use those numbers to create an intervention to improve quality.
VR [16:24]: Right, yeah. OK, so it doesn't just end with the–.
EW [16:28]: It doesn't end with a publication, or it doesn't end with a presentation at a conference. Those are not particularly helpful to any members of the community. I think that we have to use these data and actually bring it back to the communities so that we can, you know, we can actually design interventions.
VR [16:46]: Ok, we're going to continue talking sort of about how you've approached research, but I just wanted to talk a bit about, I think I can call it a success story. So I remember you mentioning, I think it was at like a meet and greet or general surgery research night or something like that, and you talked about one day for the first time when you operated in Puvirnituq. And so, could you talk a little bit about this day? Because I thought it was really inspiring when you talked about it so I would like our audience to hear about it as well.
EW [17:19]: I'll try to recreate the inspiring tone.
VR: Please do!
EW: Uhm no so, I mean, listen, this is something that I am quite proud of and we are quite proud of as a team. So, again, going back to the care continuum for surgical patients, even elective surgery, so for example if a patient comes from Puvirnituq and needs a run-of-the-mill hernia operation, the usual care would require them to come down to Montreal and maybe take a week off work and, again, away from their families, get the hernia fixed, takes about half an hour as an operation, and then uh travel back home once they’re cleared from the surgical perspective. Sometimes they have to stay in Montreal until they get their follow up appointment. Their follow up appointment might take 5 minutes, where we look at the wound and make sure they're feeling ok. And then they fly back, again up to, you know, 1600 kilometres away, and a flight uh a commercial flight between Montreal and Puvirnituq can cost up to $5000. So, knowing this, one of our priorities was to see if we can increase or even start providing certain basic surgical care on site in Nunavik. So we focused on Puvirnituq at first because a lot of the infrastructure was already in place. There was a general surgeon that was providing some limited surgical care up until perhaps about almost a decade ago I would say. So since then, patients have been transferred down to Montreal for– even for basic surgical care. So in collaboration with the local healthcare teams, and again with broad support from the leadership there and in Montreal, we were able to bring the operating room there up to safety standards for general surgery procedures. And again, since the beginning– since I started in this role, I was very very clear that I would never accept to do any surgical procedure if the operating room was not at the same health standards as down in Montreal. And we got the instruments, and the nurses on site were already very well trained in terms of providing surgical assistance. And I saw quite a number of patients and consultations, and offered them surgery either in Puvirnituq or down in Montreal. And the vast vast vast majority of patients truly preferred care in Puvirnituq so they wouldn't have to travel down. So it's been, now, two years ago and we've provided, I would say, close to 40 operations on site ranging from run-of-the-mill inguinal hernias to incisional hernias and laparoscopic cholecystectomies. And thankfully things have gone quite well. No major complications to report and remember it is a bit more nerve wracking to do a surgery when you're very very far from any form of support, so everything has to go perfectly. So yeah, these patients got their surgeries, I followed up with them either remotely by telephone or on site the following time that I was up in Puvirnituq. So, again, all the follow up they didn't have to come down to Montreal. And they, you know, I guess again, the vast vast vast majority were extremely appreciative of the care and the care being provided within their communities. It's something that we're continuing to build and trying to expand now to the other coast in Kuujjuaq, so things are looking really promising from that point of view.
VR [21:31]: Ok cool. And this, just to clarify, is all for elective surgery. So if there's a traumatic case, that would need to be sent down South still.
EW [21:41]: Yeah, so this is, you know, all baby steps. You know, because surgery is not uh an isolated specialty right so when I'm there with an anaesthetist, if there is an emergency surgery– so actually, this happened to– there's a pediatric surgeon who goes on site now and while he was there with an anaesthetist, there was an appendicitis that came in and they managed to do the appendectomy on site rather than transferring the patient down. So you know, sometimes the stars align and if there's a surgeon and anaesthetist then those things can be done there. But I think for any type of trauma or major trauma, again trauma is not just a surgeon it's not just the anaesthetist, it's a system and you need a lot more resources that unfortunately, for now, are only available in Montreal, including a CT scan.
VR [22:38]: Yeah ok, I wanted to clarify that too. There are no CT scans in Nunavik.
EW [22:43]: Yes, that is– that is correct. And I hope that by the time this is published I will be wrong but for now, that is factually correct and it's been quite a while now that, you know, even our group had a say in this in terms of documenting the cost effectiveness of having a CT scan in Nunavik. But all the data is there. There is approval in terms of funding from the government, but it has yet to be implemented. There are two major limitations to the CT scanner. Number one is space; having a physical place to put the CT scanner is difficult, building the infrastructure for that is quite costly and difficult to Nunavik. And the second thing is personnel, so obviously we would need access to technicians that can run the CT scan. And personnel is always very limited in the North.
VR [23:45]: So now to sort of switch, well not really switching gears, we've been talking about research a little bit but– and you did talk about the importance of collaboration with community members when it comes to providing quality of care to populations in Nunavik. But I think it's a really important point so I kind of wanted to just hammer on to it and also see if you had anything to elaborate about working with community members and how that experience has been.
EW [24:14]: I mean, I can't over emphasize the importance of this. I think, you know, we talk about community members, it's so essential to have community members involved in every step of the way. And I would say that, most of– we talk about research but you know, most of the questions that we address in our research originate from discussions with community members to actually identify what's wrong and what is a priority to try to fix in terms of, you know, surgical and trauma care. And I think that– that is the– should be the impetus for any project.
VR [25:04]: Right.
EW [25:06]: And subsequently, once we do our, you know, our academic thing and get some numbers and crunch some numbers, interpreting data can be done in so many ways. But I think you can't interpret this data properly as someone who's not involved or who doesn't originate from those communities. So I think it's so important to remember to bring these numbers back, and it could be, and it should be actually, a formalized procedure with community members to go over things. And there are, by the way, various levels of organization for this. So for example, in a week or two actually, I'm presenting a lot of these findings to the health board in Kuujjuaq because I want, first of all, them to have access to the numbers that we're finding so they can use them to change policy. Again I'm just a lowly, you know, surgeon down in Montreal, I want– but I want to give that data to the people who actually have a lot of power in terms of changing policy. In terms of the community members interpreting the data I think that's essential, and I think that it's really really essential to present the findings to the community in general. This is not my data, it's their data and they own it. So I think again, you know, every step of the way, community involvement is essential.
VR [26:38]: In terms of like, the type of data that you're looking for, and the type– because you can measure a lot of things and look at a lot of things and the questions come from the community members but, what in your experience has been sort of the most efficient or I don't think efficient is the right word but the best way to kind of, because at the end of the day you need to sort of advocate to policy, like decision makers, so that they can create the change that we're seeing. So what do you find is the best way to go about that? What kind of research, if that makes sense as a question, do you need to come up with to get the change happening?
EW [27:22]: Yeah so I– first of all I think that's a really good question. The way I see this is, it's almost like a process-outcome type of dichotomy. So, in terms of process, for me what matters the most is patient-centred outcomes that stems again from conversations with community members. But things that really really matter, let’s– if we take the example of trauma for example, in terms of patient-centred outcomes well, delays in terms of transfer to the South have direct impact on patient outcomes. So looking at how long it takes for the patient to be transferred from a smaller community to Puvirnituq for example, how long does the plane take to arrive after it's been called in for the medevac? How long transport out down to Montreal, how long does that take? You know, I think that’s been a particular focus of our group because that is something that is modifiable and has a direct impact on morbidity and mortality.
Other patient centred outcomes I think are important are, again, through conversations with patients and community members, time away from communities is particularly important. So if there’s any way that we can do to shorten the stays in Montreal and increase the amount of services that are provided in Nunavik, that is a particular target for meaningful interventions. And so again, a concrete example is if we're studying lengths of stay in Montreal and we notice that a good percentage of patients are actually waiting in Montreal for a follow up appointment, well why can't we arrange for those follow up appointments to occur remotely? Allow the patients to fly back home earlier. So, you know, there's the process perspective where we're looking at, again, improving the continuum of care. But then, we're also looking from a practical standpoint, well how do you get the resources to change these things and I'm going to say it blatantly: money talks. One of our focuses is also in terms of cost effectiveness and cost savings. So, you know, a few of the projects we've looked at, for example, just looking at my time in Nunavik, seeing consultations on site rather than having those patients fly down to see me in Montreal. How much do you think we save the government per week? VR [30:04]: You mentioned that a flight down for one patient is $5000. So, that's there and back so for you it would be approximately $10,000. But then if you have like I don't know, I'll be kind of conservative with 10 consults a week, which I bet it's a bunch more than that, I think it’s just exponential at that point.
EW [30:24]: Well, so exactly. So you know we looked at the numbers and the exact numbers will be published shortly but it's anywhere between $200,000 and $400,000 a week that we saved the government if I see consultations on site. So again, that's focusing on the financial, purely financial implications. We're not talking about the cultural and societal implications of allowing patients to stay within their communities with their families and not taking prolonged time off work, just a 5–10-minute visit with a surgeon in Montreal. So that's been one of the focuses of, you know, our research group because bringing those numbers and that information back to policy makers I think is how we can actually secure more resources to target the other side: the processes of care.
VR [31:20]: Right, and even, I’m thinking now about the CT scan like that's probably a huge reason you're flying people down for elective things. I mean, I don't know how expensive CT scans are, but there's probably a cost effectiveness there too.
EW [31:34]: CT scans are expensive but they're much less expensive than flying a huge number of patients a year down purely for imaging
VR [31:44]: Right. Switching gears a little bit, I wanted to know– so we're not the only province, obviously, who has remote communities and these issues with getting people from, for example, Nunavik down South because we don't have the same kind of health care or quality of care that we can always provide in Nunavik, so they have to come down for a CT scan, for surgery etc. In other provinces, I don't know if you know what other people are doing, if you can kind of like bounce off ideas with them, if you've collaborated on projects with them, like what have you seen in that sense? And how can you kind of use, maybe what is being done in other provinces, of course it can’t be mirrored exactly but kind of take some inspiration from other provinces.
EW [32:34]: Yeah so it's an excellent question. I would take that even a step further in that it's not purely a Canadian thing. You know, if you look at providing medical care in general or particularly surgical and trauma care to remote populations, and let's be specific remote Indigenous populations, there is a lot of literature stemming from Australia and New Zealand. And, I would say, they really have taken major steps forward as compared to some of the care we provide here. So, in terms of common themes, there are global common themes and even national common themes in terms of the other provinces across the country. And these themes, like I said, it's not specific in terms of Indigenous populations, it just has to do with providing rural trauma care to remote settings. So again, there are common themes related to that. Where it gets a bit tricky is the geography of Quebec, number one, is peculiar in terms of the landmass compared to other provinces. The resources in place are also peculiar, and again, you can read between the lines but for example we have two functional planes or government funded planes within the province for medivacs, for a vast population. And then the third thing I would say is, if we're talking specifically about Indigenous populations and my relationships have been more with the Inuit populations in Nunavik but some of this can also be applied to the Cree territories, it's a major mistake to assume that Indigenous populations are homogeneous across the board. So as much as I like to, and I do collaborate with people across the country and across the world actually, we have to– you always have to keep in mind the intricacies of providing care in your backyard. Going back to community involvement, it would be a huge mistake to come with solutions that have been successfully implemented in Australia and say “hey I'm going to implement this in Nunavik”. It's extremely important to, yes you don’t want to recreate the wheel, you want to inspire yourself from proven methods, but you absolutely have to vet those with community members and you have to adapt to the local context.
VR [35:26]: Ok, this is kind of our last section now. So could you talk about– I mean one of the future goals that you talked about, maybe that hopefully is not so far out in the future, is having a CT scan in Nunavik. Could you talk about like maybe some ongoing goals, I mean, you don’t have to go super broad here but just like some ongoing goals and things you're working on to improve surgical care in Nunavik.
EW [35:53]: Where to start…
VR [35:55]: Sorry, I’m asking very broad questions.
EW [35:58]: No I mean listen, the sky's the limit here. I think my overarching goal is, and I'll keep it very very simple, that the quality of care that we provide to any patient in the province– it should be the same regardless of where you originate from or where you physically live and that includes the most remote regions of the province. You should have the same quality of care and if that involves a surgical pathology and that involves getting your surgery closer to home then that's what that's we're going to aspire to. You know there are many ways of going about this. But I think the overarching goal is, if you're a victim of trauma or you have a surgical pathology and you're from Nunavik, the outcome should be no different than if you're involved in a trauma on St Catherine.
VR [36:57]: Right, which is not where we're at. Ok and then, to end the podcast, we like to ask each of our guests about advice for trainees. So you well, in particular, wear a lot of hats which I mentioned in the beginning. So I was wondering about: 1) how do you manage all these different responsibilities? I mean, you don't have to talk about your personal life here but I know that you mentioned your wife at the beginning so I'm sure like, of course you need to spend time with your family, and then also lots of professional responsibilities, so, a question about sort of how you balance all of that. And then any advice, maybe general advice for trainees who would like to get involved in providing health care in Nunavik?
EW [37:45]: Yeah, I mean you mentioned I don't have to talk about the personal life, but I think everything kind of intertwines. And you know I have two kids at home, and I would say that obviously is the most important responsibility but it also, you know, it makes balance difficult. You know how I balance all of that? I would say with difficulty. I think anybody who says that it's easy is lying. You know, I think this sounds a bit cliche but for the trainees is: if you find things that you're particularly interested in and motivated about, it's actually quite easy to keep things going in all aspects of your life. It doesn't feel like it's a drag to move from you know research, to advocacy, to clinical work. That's what I would say in terms of advice, and you know how you balance everything; you just keep going. That's all I have to say, you know. Just trying to make sure that, you know, that everything is moving forward in all aspects of your life.
In terms of, you know, for the trainees who are interested: obviously you can reach out to me, my email is evan.wong@mcgill.ca. We do have, very fairly large, growing research lab that meets every couple of weeks, and a lot of our focus is on again providing surgical and trauma care to underserved populations. But I would say if you're particularly interested in it, ask questions, reach out to anybody who's involved in care in these regions. Gain exposure, I know that electives both in family medicine and other specialties in Nunavik are quite competitive, I believe, to get because there's, I mean, it's a great thing you know everybody's quite interested in going. If you do get the opportunity to go there, immerse yourself as much as possible in the health care system and within the communities. Ask questions and don't just use it as a one off opportunity, you know, if that's something that's particularly interesting to you. Like I said, I can't over emphasize the benefits of kind– of a more longitudinal relationship with the community. So go, get exposed, and then try to go back and try to see the same people and try to, you know, I've worked with some trainees now that are interested in becoming full time family docs there. You know, choose that as your practice setting. Just keep going and that's how you actually are meaningfully involved. VR [40:40]: Ok well that's all the time that we have for today, but thank you so so much for– for your time Dr. Wong. This was very insightful.
EW [40:49]: Thank you for having me.
VR [40:51]: And thank you to our audience for joining us on another episode of the McGill Journal of Medicine, the MedTalk series. Please see the show notes where you will find a full transcript of our conversation as well as links to any relevant papers or projects that we've discussed.