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The focus of Steps2Walk is surgeon education through didactic lectures and hands-on clinical and surgical training. Current and upcoming locations include China, Thailand, India, Chile, Argentina, Uruguay, Mexico, Peru, Brazil, South Africa, Kenya, Namibia, and Egypt.

AAOS Now

Published 7/1/2018
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V. James Sammarco, MD

Steps2Walk Brings Advanced Foot and Ankle Education, Treatment to the Developing World

Physicians enter medicine for many reasons, but most feel a calling to help those in need. In 1999, Mark Myerson, MD, formed the Foot and Ankle Association in response to the ongoing need for education and training of international foot and ankle surgeons who had little access to advanced training in their home countries.

In its first 15 years, the program’s main function was to bring international fellows to Baltimore for six to 12 months for clinical education and surgical training. During that time, the concept for a more structured education and clinical care program took hold, and in 2016, the nonprofit organization Steps2Walk was formed. Currently, 103 orthopaedic surgeons from 17 countries volunteer their time and skills to Steps2Walk programs. Current and upcoming locations include China, Thailand, India, Chile, Argentina, Uruguay, Mexico, Peru, Brazil, South Africa, Kenya, Namibia, and Egypt.

Recently, I spoke with Dr. Myerson about Steps2Walk.

Dr. Sammarco: What was your inspiration for starting Steps2Walk?

Dr. Myerson: I always knew that I wanted to participate in humanitarian efforts on a larger scale. I was particularly inspired by a South African friend who runs a very successful organization there called mothers2mothers (M2M). The scope and success of their organization, fueled by his insight and passion, helped solidify my decision.

Dr. Sammarco: What is the mission of Steps2Walk?

Dr. Myerson: The mission is to engage in humanitarian programs by providing surgical care of foot and ankle deformities in underserved regions of the world, and, at the same time, teaching local surgeons, which will ultimately translate into helping thousands of people worldwide who are suffering from crippling foot and ankle deformities.

Dr. Sammarco: How are program attendees selected?

Dr. Myerson: There are two senior and two junior surgeons on each team. We are treating complex deformities, and the surgeons must have a level of comfort and familiarity with managing these deformities. Because an emphasis of our work is on education, all surgeons also need to give numerous lectures.



Courtesy of Mark myerson, md

Dr. Sammarco: How can interested surgeons learn about volunteer opportunities with Steps2Walk?

Dr. Myerson: We ask that they register on our website, www.steps2walk.com, and outline their background and orthopaedic experience. We then match them with available vacancies. We encourage both residents and fellows to apply, although their level of participation may be different. In some countries, a knowledge of the local language is very useful. For example, in Latin America we encourage volunteers who are fluent in Spanish.

Dr. Sammarco: How do you select your sites?

Dr. Myerson: The process must be well organized and requires support from the surgeons, hospital, and local government. There must also be regional surgeon interest and patients with deformities who require treatment. We select local and regional surgeons to participate in these programs as part of the educational component of our work.

Dr. Sammarco: How often do you go to these countries?

Dr. Myerson: Teaching local and regional surgeons how to treat foot and ankle deformities is of paramount importance. Although our goal is to treat those in need, we cannot do it all on our own, so teaching others is essential. Education is vital to maintaining sustainability; therefore, we offer intense, repeated programs two to three times a year at each location. Our work starts and continues by training one new surgeon at a time who will, in turn, provide relief for thousands of people with debilitating deformities.

Dr. Sammarco: How does orthopaedic surgery at the host hospitals compare to practices in the United States?

Dr. Myerson: There is no fair comparison between a U.S. hospital and one in the developing world. The resources available are completely different, and the surgeons do the best they can with the systems in which they work. The most striking difference is the inability of patients to access care because the volume of patients outstrips the resources of the hospital. The lack of subspecialty training is something we try to address with our programs. Orthopaedic surgeons everywhere care about their patients; however, they often do not have the opportunity to develop the same type of relationships with their patients that U.S. surgeons enjoy. High patient volume and distances traveled by patients to obtain care place a strain on the doctor-patient relationship.

The focus of Steps2Walk is surgeon education through didactic lectures and hands-on clinical and surgical training. Current and upcoming locations include China, Thailand, India, Chile, Argentina, Uruguay, Mexico, Peru, Brazil, South Africa, Kenya, Namibia, and Egypt.
According to Dr. Mark Myerson (pictured), there is no fair comparison between a U.S. hospital and one in the developing world. The resources available are completely different, and the surgeons do the best they can with the systems in which they work.

Dr. Sammarco: How do office hours compare to those in the United States?

Dr. Myerson: Most of the hospitals where we work operate as clinics, and there are no formal office hours. The patients arrive and wait in line to be seen, although limited triage may be performed to manage more acute problems. Often patients will travel long distances with family members and, due to limited resources, may need to wait a few days to be seen. In more developed countries, a private system may exist parallel to the public one, but the indigent have little access to the subspecialty care available.



Courtesy of Mark myerson, md

Dr. Sammarco: How about patient interactions?

Dr. Myerson: In the underserved areas that we visit, the doctor-patient relationship is very different than that of the western world. The doctors work under difficult circumstances, and their understaffed clinics are visited by an overwhelming number of patients. Inevitably, patient visits are shorter and involve less interaction. Despite less personal interaction, these patients genuinely appreciate the care and treatment they receive. They do not have the sense of entitlement or the unreasonable expectations we sometimes see in patients from urban centers in the United States.

Dr. Sammarco: How do the visiting surgeons manage language barriers with the local surgeons and patients?

Dr. Myerson: We carefully plan for language barriers so that they do not interfere with our work. Volunteer surgeons are selected for each of our humanitarian programs based on their language skill sets. A key to the success of our work is to integrate the regional and national surgeon leadership into our humanitarian programs. We also have numerous past fellows who are fully conversant in the language and who have the necessary foot and ankle surgery skills to communicate with patients and surgeons who are attending the program.

Dr. Sammarco: Are there concerns about how the local surgeons will implement what they learned during the program after the visiting surgeons leave?

Dr. Myerson: The surgeons who attend these programs are generally mature, practicing surgeons trying to improve their skills and knowledge of foot and ankle surgery. Our focus is on surgeon education, regardless of where we work, and the techniques we teach are within the skill set of the attendees. Surgeries are performed with local equipment wherever possible; we are not teaching techniques that require equipment or implants to which the surgeons will not have access. At the completion of the program, we hold teaching sessions to reinforce what the surgeons have learned during the program. The attendees can also communicate via email with me and the other surgeon volunteers about clinical patient care problems they may encounter. Our goal is to foster communication and long-term education to facilitate further learning.

Dr. Sammarco: What about concerns related to follow-up with patients and patient compliance in general?

Dr. Myerson: The surgeries are all performed in public hospitals where junior surgeons on the team participate in the surgeries and manage the postoperative care in our absence. Surgeon education includes very specific instructions for postoperative care, and if the patients are from a rural area and have little access to follow-up care, then regional nurses are included in the decision-making. We keep a registry of every patient treated and ensure that continuity of care is sustained.

Dr. Sammarco: How does this work compare with the academic and professional success that you have achieved in your career?

Dr. Myerson: Although my academic and professional accomplishments have been substantial, they pale in comparison to the enormous sense of fulfillment that I get from giving to others in need.

More about Steps2Walk

Steps2Walk’s programs are organized as mini-fellowships, during which 10 to 15 local surgeons receive intense training over the course of six days. Attendees are preselected by the host hospital in each country. Faculty members are selected by Steps2Walk and must have at least five years of subspecialty experience practicing foot and ankle orthopaedics, as well as language skills where appropriate. Local and regional leaders in foot and ankle surgery also participate in each country to maintain continuity and integration of these programs.

Each program begins with lectures given by the visiting surgeons on foot and ankle topics appropriate to the location. Faculty and attendees spend the next day in clinic, evaluating and examining patients. During the following two days, the local surgeons observe and assist senior visiting surgeons in performing surgeries. On the fifth day, the faculty provide additional hands-on teaching in a cadaver lab. A regional/national conference that focuses on case discussion, management of complications, and difficult decision-making takes place on the final day of the program.

Steps2Walk programs are funded through direct donations from the public, corporate and industry support, and donations from colleagues and friends. Each program costs the organization approximately $31,000, depending on location. Initially, organizing corporate support was difficult. “I often had to hand-carry the donated implants on the airplane, because advance shipping of the donated instruments and products was not permitted by any of the countries where we were working,” Dr. Myerson said. The establishment of the formalized program in specific cities has improved this process significantly.

V. James Sammarco, MD, is a fellowship-trained orthopaedic foot and ankle specialist practicing in Cincinnati and north-central Kentucky. He is member of the AAOS Now Editorial Board and is active in subspecialty education in the United States and abroad.