|| Maîttrise Education
M.O. : Can we start off with the ritual opening gambit: would you please introduce yourself.
F.C. : That’s not easy because it involves philosophical notions of identity. I can simply say that my surname is Chaise, my first name is Francis and I work exclusively as a hand surgeon at the Jeanne d’Arc Clinic in Nantes.
M.O. : How do you operate ?
F.C. : I’m part of a group of nine surgeons. We work exclusively, or almost exclusively, on surgery of the hand. The Jeanne d’Arc Clinic where we work is a private clinic, located in the centre of the city of Nantes, which has a catchment population of approximately 600 000 inhabitants. Hand surgery had not been developed in a structured fashion here previously.
M.O. : Nine hand surgeons, isn’t that a lot for a place like Nantes ?
F.C. : In my opinion, that’s scarcely enough for the regional requirements in hand surgery because there are two aspects to our job. There is the “programmed activity” part of the job that the surgeon can carry out in almost any hospital, but there is above all the “emergency activity” part of the job which is considerable because we do 6 to 7000 emergency operations per annum. And this emergency activity takes up a lot in terms of time. A substantial team therefore has to be available if quality management and proper follow-up is going to be available on public holidays, at night and every day of the week. That’s why the formatting of our group of nine specialist surgeons is not excessive and perhaps is even understated.
M.O. :Does that mean that you’re the only ones in the region ?
F.C. : Today, I can safely say that we are the only ones because we have set up institution to institution conventions with the teaching hospital in Nantes, which is a large teaching hospital, and with a number of regional hospitals which send us their patients for treatment at the Jeanne d’Arc Clinic.
M.O. : Why don’t the hospitals manage this type of emergency themselves ?
F.C. : Without going into detail and provoking arguments, you need to understand that competition for activity has been stiff over the past fifteen years. Our team, which clearly defined its development objectives at the outset, has had to grow considerably, both in volume and in skill to reach them. The teaching hospital sat on its laurels with a single specialist surgeon who ended up tossing in the towel. In return, the agreements with the CHU, which we had been asking for and which had always been refused, were finally signed at the request of the hospital, given the incontrovertible fact that something needed to be done to organise the management of injured hands at the regional level.
M.O. : What is your "economic" analysis of this situation ?
F.C. : Well, I’m no economist, but I have long been interested in cost per disorder and operational costs of various services. It is clear that the operating costs of private sector clinics are much lower that those in public sector institutions simply because of the cost of personnel. This has got nothing to do with medical activity, but a lot to do with the status of personnel who are paid considerably less in private institutions. In addition, hand surgery can be carried out in institutions which don’t need to have weighty intensive care, or complex structures, which are very staff intensive, and therefore expensive, such as can be found in public hospitals. So private clinics, as long as they get themselves organised for it, i.e. they set up permanent operating theatres and care units, can perfectly carry out the job of providing a service to the public with regard to hand surgery. Which is exactly what we did, and in the last two years we have become an official "emergency centre” specialized in surgery of the hand.
M.O. : It might be surprising that emergencies are not dealt with at a hospital, but it’s also a good example of collaboration between private and public sectors in the case of A & E management …
F.C. : Some years ago, and in order to avoid sterile competition, we asked the CHU if it wouldn’t be a good idea to built up a hand surgery department, managed partly by the private sector and partly by the public sector. The governing bodies decided not to proceed with the project and even turned us down rather curtly. However, we continued on with our development and, as time went by, those who had rejected us, or their successors, finally came to see that, in the interest of patients in the region, collaboration would undoubtedly be more effective than pure competition.
M.O. : Why did the public-sector structures reject your project for collaboration ?
F.C. : There are probably a number of reasons, but the main one is that hospitals are the victim of extremely complex administrative regulations and that “public-private” entities are very difficult to build up, so finally it didn’t happen. I don’t think it’s a question of ill will, but it’s a statement of fact which unfortunately I don’t think is yet on the way to being sorted. I think that hospitals hunker down a maximum because of the political constraints they’re under. They don’t openly opt to work with the private sector, particularly as far as training goes. It seems to me to be evident that the experience we have gained in hand surgery should enable residents to be able to train in our organisations, to learn techniques which are not taught at the CHU because the skills are not there.
M.O. : But it’s the role of the CHU to offer the skills required to ensure that they are taught !
F.C. : Quite true, but this situation isn’t just specific to medicine, or even to surgery. Schools that teach woodwork, teach the students a certain number of procedures and methods but can’t teach them the entire experience of an skilled professional joiner who’s been working at his trade for 30 years. I gained my experience in hand surgery both in France and abroad and it goes well beyond anything I was able to learn during my university studies. It was built up progressively and is extensive. For me to be able to transmit that, people need to come to me. It’s not a case of lectures, but a sort of “buddy” system, like the journeymen of old. There’s always a self-taught part in our field, as in all fields where the craft can only be transmitted from person to person, where people can mix together.
M.O. : But if there are no emergency “hand” departments in the teaching hospitals in your region, how does this surgical skill get transmitted ?
F.C. : Until quite recently it was transmitted to volunteers who came and spent six months with us on a personal basis, and outside any university curriculum. At present, we have one resident from the CHU, paid by the CHU, but it would seem that this can no longer continue for administrative reasons. In addition, we have foreign residents. Demand is particularly strong from French-speaking countries. During these semesters we try to transmit to our residents our clinical techniques, our work procedures and our method of operation and they leave after having done a thesis published by the Society for Hand Surgery. In all, a programme which is a not inconsiderable part of their general training. Finally, at the end of the training period, and for those interested, we use our personal network of contacts to find them a place in another structure which carries out training so they can complete their training in this field which is so very specialised.
M.O. : You’re in favour of mobility ?
F.C. : Knowledge isn’t the privilege of one place, knowledge is everywhere and I believe that everyone, whatever their specialist field, be it philosophy or surgery, needs to go and find out what is happening elsewhere, because there’s always much more happening than you think. You need to be able to move about. Those in charge of training need to understand that there is knowledge in private institutions, in semi-public institutions, and that, depending on the objectives they have fixed for themselves, those in training need to be able to circulate. They need to go elsewhere and see what is happening there, they need to visit. The more they visit, the more they will learn. In my time, during my training period in Paris, there were no structures available to enable us to train sufficiently in hand surgery so as to be able to manage all the problems that might be encountered in this specialty field. I therefore had to “go walkabout.”
M.O. : OK, so you needed to "go walkabout," but why leave Paris ?
F.C. : Because I was actively sought out ! One of my present colleagues came and asked me if I would be interested in setting up a centre for hand surgery with him in a private institution in Nantes. The opportunities on offer in terms of fittings and real estate enabled us to put together a project which was both exciting, in that it was forward-looking, and consistent with proper integration into the medical fabric in Nantes. The future offered by the company that recruited us was dazzling. It seemed to me to be more interesting for me to leave my home town and my family for Nantes than to launch into an isolated activity in a clinic in Paris on economic terms which I didn’t think fitted in with what I wanted as a way of practicing.
M.O. : How were you trained in surgery of the hand ?
F.C. : I first of all learned about surgery of the peripheral nerves with Laurent Sedel. Surgery of the hand I learned a little about in plastic surgery with Prof. Baux at the Hôpital Rothschild but the remainder I went and learned in North America. There I spent time in various departments, in particular in a very large department in eastern Canada, where I spent a year. I was able to attain two of my training objectives: traditional, planned surgery, and surgery for patients with paralysis. There was one surgeon who was quite exceptional in terms of knowledge of nerve disorders, whether central or peripheral, Doctor Roy, and I spent a year with him as resident. I was with him every day, in consultations and in the theatre and he taught me an enormous amount. There, I was able to open up both to this passion for nerve disorders that I still have and I learned the essentials of hand surgery. I had another great experience, in terms of hand surgery and in terms of remedial surgery. I spent two years as assistant to Professor Kassab in Tunis at the Orthopaedic Institute, where I think I no doubt spent the best two years of my life, both on a personal and professional level.
Kassab was a remarkable man, very well organised, and I learned from him work procedures, how to approach patients, how to keep case files, in short how to organize and run a department. I had access to disorders which had disappeared in France, in particular poliomyelitis. Each week we operated 40 to 50 patients with severe lesions due to poliomyelitis and I therefore learned a lot about management of paralytic patients. In all, my programme in nerve surgery was peripheral nerves with Sedel in France, central and medullary nerves with Louis Roy in Canada, and poliomyelitis with Professor Kassab in Tunis where I was his assistant and actively in charge of a department with a very high quality of training and care.
M.O. : Where did you do your clinical practice ?
F.C. : My two years in Tunis were endorsed as clinical practice, but I also did six years in clinical practice at the Hôpital Saint-Louis with Professor Witvoët. I had some marginal activity in general orthopaedic surgery and a very largely predominant activity in surgery of the hand and peripheral nerves which I then developed. At the end of my clinical practice, not seeing any future for myself in the university system within a reasonable period of time, I accepted the offer to go to Nantes and set up this centre for hand surgery. I’ve never regretted making that choice.
M.O. : How many of you were there ?
F.C. : There were three of us to start with. That was in 1984-85. Life was difficult because we were on call one day in three. It’s true that the number of emergencies treated annually was not as high as it is today. But holidays were not something that were mentioned a lot, and when we did take some time off, it was always very split up. Progressively, as the department developed we brought in one, then two, then all the others who are here now. Building up our unit, and I say “our” unit because it doesn’t just belong to me, has always been carried out with personal criteria in mind. We have always put personal human qualities above occupational qualifications. The craft can always be learned, but human qualities, unfortunately, I don’t think they can really be changed.
M.O. : You arrive, you set up your unit, what’s turnover like ?
F.C. :It’s good, and fast and works well. We do both emergency and planned surgery.
M.O. : Is there a field you favour in particular ?
F.C. : I’ve always had a predilection for the peripheral nerve. With downstream damage to the peripheral nerves, paralysis of the hands, the odd paralysis of the foot, but in Nantes I don’t do that. Paralysis of the hand is the field that I prepared for and it’s the field in which I’ve spent the most time, thought about the most, and expended the most energy on.
M.O. : How much paralysis of the hand is there in current practice ?
F.C.: Post-traumatic paralysis of the hand has become rare here because, fortunately, our techniques in microsurgery are very effective. Nerves are repaired better and better, because they’re repaired as an emergency and the neighbouring arteries and tendons are also repaired. This philosophy based on working as an emergency means there is less paralysis of the hand than we would have seen, say, 20 years ago. So, to continue to work in the field that I’m so passionate about, I go overseas to operate, to places where this type of disorder still exists to an impressive degree. During my time as a house doctor in Paris I was lucky enough to forge links with the Order of Malta which ran a block entirely given over to management of patients who had had leprosy at the Hôpital Saint-Louis In Paris, I was able to treat dozens of patients who had fallen victim to leprosy and the mutilations caused by the disease. I really became trained in this type of surgery there and at the same time I got into the world of overseas missions, both in Africa and in Asia, to treat the mutilations of this terrible disease which unfortunately has never attracted hand surgeons. And yet they could do a lot for these patients who have been rendered particularly fragile by their disease.
M.O. : Are there still a lot of cases of leprosy ?
F.C. : Yes, the latest WHO statistics, which are most certainly understated for a host of administrative reasons, indicate that there are some 700 000 new cases per annum around the world. 300 000 in India alone and the remainder spread between Brazil, Burma and southeast Asia.
M.O. : In a word, what damage does leprosy cause ?
F.C. : It’s an infectious disease caused by an agent which has been identified, mycobacterium leprae, or Hansen’s bacillus. It’s a disease where the first symptoms are cutaneous, in the form of blotches on the skin with loss of sensation. But the bacillus has a considerable tropism for Schwann cells which it destroys and causes destruction of the nerves by a very complex local immune mechanism. It causes a practically irreversible destruction of the nerve, which means that these patients will develop paralysis of the large nerve trunks with, finally, paralysis of hands and feet. And these sensory motor paralyses will themselves continue to develop despite the medical treatment which kills the mycobacterium. You need to understand that a patient who has had leprosy, even though cured from the bacteriological point of view, will continue to have a Damocles sword over his head in the form of this sensory motor paralysis which can continue to evolve and mutilate if nothing is done to protect him.
M.O. : Why ?
F.C . : Because all these complex sensory motor paralyses occur in people who live in a precarious environment. These are people who, for the most part, live without shoes, eat with their hands, work with their hands and end up by injuring themselves. On a finger with no feeling the slightest cut is not felt, not treated and gets infected. That will cause inflammation, suppuration, osteitis and in the end the finger will finally drop off. I am currently working in a well developed programme which consists of reconstructing hands without fingers. For example, three weeks ago we organized an important symposium in Vietnam on the reconstruction of hands without fingers. You are confronted with terrible problems amongst which you try to work out priorities: disease prevention, early screening, starting up treatment with medication, prevention of disability through early neurolysis, patient education, reintegration into the community. There is an immense amount of work, but the return on investment, so to speak, is wonderful. What could be more important for a hand surgeon than to enable someone mutilated by leprosy to get back a function and be able to feed his family. At the Order of Malta, that’s what we call regaining dignity.
M.O. : What causes the leonine facies of leprosy ?
F.C. : It is the multiplication of the bacillus in and under the skin. That creates nodules which are teeming with germs and which develop if the disease is not treated. These days this is rarely seen except if the patients have not been screened in time. It starts with the mucous membranes, it’s a disease which affects all the organs, but has a major predilection for hands and feet.
M.O. : How is it transmitted ?
F.C. : Through direct contact. The problem is that despite very costly and very targeted screening campaigns the number of new patients detected each year is not being reduced. And, amongst these new patients, according to the WHO classification, there are 20 % who already suffer from mutilations. So, we’re very much behind in this field.
M.O. : But what can a surgeon do in a disease that is related to a precarious environment ?
F.C. : For the Order of Malta, which was founded 9 centuries ago, our aim is not just to use a surgical knife here and there, on mutilated hands or feet. The main aim is to develop a policy of prevention, of screening, of treatment and of rehabilitation at the same time. We try to work at all levels of the problem. We have agreements with NGO’s specialising in rehabilitation so, for instance we work with Handicap International, to close the treatment chain. In Vietnam, where we’ve been active for a very long time, we’ve finally succeeded, after spending a lot of time, energy and, of course, a lot of money, in setting up a treatment chain which has had a remarkable result. Vietnam is now off the list of countries where the leprosy rate was endemic. We can export this experience. A lot of countries now want us to go and work for them, too. So, we’ve started to export our methods to Laos and will be doing so soon in Cambodia where the same procedures are applied so that patients are screened, treated, rehabilitated. Wherever the whole chain of treatment required cannot be set up in full, there is a considerable risk of failure. In terms of medical effectiveness, the result won’t be there and there’s no point in putting in specialist and costly means and equipment. We want clearly stated support from the States where our involvement is sought, and participation from the public authorities through their hospital structures before we can commit ourselves. All the missions have been set up on a State to State basis so that we are partners, not just simply donor and recipient.
M.O. : That presupposes then that the States are sufficiently stable …
F.C. : There needs to be a political will, and political will requires support through economic means. Otherwise political will is not effective. Vietnam is a good example. According to the figures, it seems that India has made a considerable effort. Other countries are markedly behind, in particular in Africa. And this, unfortunately, is not just specific to leprosy.
M.O. : How is the Order of Malta financed ?
F.C. : By donors. It is an NGO but the difference between the Order of Malta and other NGO’s is that it’s been around for 9 centuries and in the beginning it was a State. It is still a State with its headquarters (in Rome), its passports, a State-like organisation, but it’s a State without any territory. The agreements which govern us in the various missions in which we get involved are agreements between States. A mission can only begin once an agreement has been signed at State level. Historically, the primary mission of the Knights of the Order of Malta was to provide assistance to pilgrims on their way to the Holy Land i.e. to Jerusalem. It was medical assistance that they provided for travellers, and it is well known that the first lepers to arrive in France were those returning from the Crusades.
M.O. : What is the place of the surgeon in the treatment chain ?
F.C. : In my opinion, the surgeon plays an essential role. As far as hands are concerned, there is a preventive role which is to free up the nerves from inflammatory adhesions. Leprosy is a disease which causes the nerves to swell. As with tunnel syndromes, this causes locoregional hyperpressure. I have measured nerve pressure, and in carpal tunnels there is a hyperpressure of several mm of mercury. With leprosy, hyperpressure is enormous. In a normal nerve it is around 1 to 2 mm of mercury, with leprosy you have measurements of 100-150 mm of mercury in the nerve. This means that paralysis is inexorable from a mechanical point of view, to which is added the problem of vasculitis. It is an immunological mechanism which results in intravascular deposits of complex antibodies-antigens. The destruction of Schwann cells and of myelin by Hansen’s bacillus means that patients will become paralysed but the mechanical component, i.e. swelling of the nerves, is undoubtedly the predominant mechanism in many forms. So, the surgeon intervenes by carrying out early neurolysis. He frees up these nerves from inflammatory adhesions before they become paralysed, in return for which you get a certain number of results in terms of regaining some sensitivity and motricity. This is preventive surgery. And it’s here that we need to fight, this is always the point that we stress, and everywhere we go, we give lectures on the subject. We have training modules in surgery for truncal neuropathies. Here there is a lot to be gained. Once the paralysis has set in and the nerves are dead, you need to concentrate on the aftermath.
M.O. : Which means what ?
F.C. : In the hand, you need to consider the long fingers and the thumb. First of all you re-educate the hands, then you undertake tendon transfers and stabilisation through ligamentoplasty. There are a whole series of techniques which enable you to restore functions to the hands which are fairly close to the standard functions of a hand, aside from the problems of insensitivity which, unfortunately, cannot be reversed. As to feet, we mainly see paralysis of the levator muscles. Early neurolysis of the external popliteal sciatic nerve needs to be carried out. The results are good and when the nerves are condemned, you need to do tendon transfers. The paralysed food is restored and that foot needs to wear shoes, that is absolutely essential. Otherwise, it will be injured, and the injury will turn into a perforating ulcer which will get infected and sooner or later the foot will need to be amputated, or a carcinoma will develop, which is the usual transformation of a perforating ulcer of the foot after it has evolved for about 10 years. Amputation in itself would not be so dramatic if there were limb-fitters on every corner, but unfortunately they are few and far between. We work with the limb-fitters from Handicap International. The patients that we are obliged to amputate are fitted out immediately, re-educated with their prosthesis so that they can walk and regain their independence. In this horrible disease we have a role of primary importance to play which is that of conductor and that leads us to talk to the administrations and to work with the various medical bodies and those concerned with physiotherapy. In Mauritania, as the final stage of rehabilitation, we have even been able to create a protected work scheme for leprosy patients. With Philippe Bellemère with whom we co-founded a charitable organisation called Mains du Monde, we’ve been working for 6 years with a Mauritanian association whose goal is to reintegrate patients mutilated by leprosy into the life of the community. The head of the association is himself a leprosy patient and they came up with the very original idea of a job which is guarding car parks. This association manages the guarding of car parks in the capital, Nouakchott. There are 13 car parks and this provides a living for around a thousand people who otherwise would be out begging in the streets. With Philippe Bellemère our intervention mainly concerned the reconstruction of thumb and finger grasp. For security purposes in their car park, they need a baton and they were not able to hold one. We developed surgical procedures which we call "baton operations" to enable these people to hold a baton and therefore to command respect. The final aim of the missions that we undertake whether in Mauritania, in India where we also work, or in Asia, is to reintegrate patients into the community through rehabilitation and here surgery is only one link in the chain.
M.O. : You’re still able to keep things ticking over at the clinic in Nantes ?
F.C. : Yes, I can assure you that things are running very well in Nantes. We have never had so much work, nor seen so many patients. Our rate of productivity is excellent, our operating costs are no doubt low because our manager has a smile on his face. But for that you need to be organized, and only a team which is united by friendship and which has common goals can combine a quality practice in France with overseas humanitarian aid, and all our colleagues and associates take part in this.
M.O. : How does it function ?
F.C. : We formed a company. We are salaried employees of the company, so in terms of income, we’re all on an equal footing, there are no inequalities in the way the company operates. We all undertake the same tasks: everyone has the same number of consultations, theatre work, holidays. We are all on a par. So far it has worked well for 15 years and, without any great difficulty, we’ve managed to avoid the sterile conflicts that have put paid to many a medical group.
M.O. : And you all have the same staff ?
F.C. : Yes, we’re organized like a hospital department, except that everyone, from the youngest to the oldest works full time and is a house surgeon in their own right. We all work as part of a programme or a hierarchy, as would any resident or senior registrar in a public hospital. I find that this is the best way of operating in the private sector. We all have medical activities, which are exciting because it’s a fascinating job, and then there’s the management side where everyone also undertakes a task. For instance, I look after the management of beds, which is not always easy, and others deal with staff, or accounts, and so forth. We all have responsibilities in addition to the surgical side, and every year we also manage to publish quality articles and give papers at international conferences. So, I find that we have good intellectual as well as practical activities. A number of us are involved at the highest levels of the GEM, the FESUM, the College of teaching surgeons …you can when you want to !
M.O. : From what you say, this is the ideal type of structure for a surgeon. Do you believe that all clinics should be structured like this ?
F.C. : I believe that there is a tendency towards setting up this type of company within clinics. Why we’re so successful, is that we chose to associate on the basis of personal human qualities. The human qualities being there, our set up can’t help but function well. Then we divided up the constraints, the holiday periods and the income equally. Whatever the activity, we share the same income right down to the last cent. There is therefore no infighting because our development has been built in and is common to all of us. In addition, this peace of mind means that we can all benefit from professional growth. Yesterday, I had great pleasure in assisting one of my colleagues with an operation that he’d never undertaken before. We all benefit from each others’ experience. I don’t do elbows and Philippe Bellemère is interested in them, so when I see a problem involving an elbow which I don’t have the skills to deal with, I send it over to him. Of course, that only works if everyone plays the game. Which is why we’re so keen to select team members on the basis of personal human qualities. That said, our contracts contain provisions should one of us voluntarily significantly reduce their activities, but we’ve never had to apply these rules.
M.O. : What made you choose surgery ?
F.C. : When I began working in hospitals in Paris, I fell into a department where I had a really great time ! It was in Mr Lance’s Orthopaedics department at Saint-Louis, where Jacques Witvoët was the senior registrar. He was an extraordinary teacher, in a class by himself. The resident was part of the team and at the coal face, in the operating theatre and in consultation… Usually, you did six months as a resident, but I asked to do a repeat and so was able to stay a year. I had already begun to feel that orthopaedics was for me and I was passionately fond of this type of surgery. In addition, I went to do Rheumatology with Mr de Seze at Lariboisière and that was the mother of all intellectual illuminations. De Sèze was a person with the most fantastic medical culture and had assistants who gave me the impression of knowing everything, all the time. You didn’t want to leave the department, you didn’t want to leave because the staff meetings, talks, conferences were all so interesting. Then, thirdly I went to Mr Merklin’s department, he was Professor of parasite diseases and tropical medicine in Paris. He was quite a person… Due to family culture, I was brought up in a spirit of sharing, the model being Albert Schweitzer. And Pr Merklin resembled him with his great white moustache, dressed in cheap clothes, shoes with soles falling apart, holes in his socks, but with a fantastic medical culture and an exceptional humanitarian. I was delegated to his consultations, and he did a lot of them. At each consultation, you saw people who had arrived from Africa and Asia, with diseases we had never seen in Europe. In a few seconds he would say to me “you see, it’s that.” He spoke a heap of exotic languages, African in particular. He would speak to patients in Wolof, in Soninké and I found that fabulous. I used to ask myself how so much talent and culture could be embodied in one person. The question for me was to know how I was going to succeed and blossom in the field of orthopaedics, given that I wanted to combine surgical gesture, medical knowledge and scientific research, all with a window onto the world. In the end, the block for leprosy run by the Order of Malta at the Hôpital Saint-Louis, enabled me to have all that.
M.O. : But what is so attractive about tropical diseases ?
F.C. : Travelling, exotic places… the poverty and destitution in developing countries and the possibility of being able to effectively attenuate the afflictions of people. I have never separated my job as a surgeon from our basic role as doctors, which is to help those in need. And who needs a doctor, or a surgeon, more than the poverty-stricken and the mutilated to help recover their dignity ? As my mother used to remind me every day, one has a duty to the world, and what better way for a surgeon, albeit very specialized, to exercise his profession than to offer his services in this fashion ?
To close, I would like to mention one of Théodore Monod’s sayings: "You should never bring yourself to accept the unacceptable" which I believe the younger generation would do well to meditate before abandoning medicine for more lucrative paths but less involved in the welfare of people.
Maîtrise Orthopédique n° 165 - June 2007
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