I went on my first medical mission in the early 90s.

I was a volunteer, donor, and director of Operation Smile.

I had just merged a charity I started in New York City called Operation Smile, with another charity, also named Operation Smile in Virginia.

My charity was focused on helping inner-city children in the United States who were too poor to afford surgery. While the Operation Smile in Virginia was a mission group that sent teams of volunteer surgeons and medical professionals on two-week missions to developing countries.

Operation Smile Virginia’s volunteer medical teams would usually spend one-week screening hundreds and hundreds of children who had shown up hoping to get free surgery. Then the teams would select the lucky few who actually received surgery.

It was heartbreaking to watch 2 to 3 kids get turned away for every kid who received surgery. The mothers would plead, beg, cry and throw themselves on the ground hoping that the team would add one more child to their surgery list.

But they never did.

And after five years of going on more missions and watching and knowing hundreds of children were being turned away at every operation smile mission, I quit the board of Operation Smile and set out to create a surgical charity that would turn no child away.

We called it the Smile Train and it was designed to solve all of the shortcomings of two-week medical missions.

When we started Smile Train, many American surgeons told us local surgeons were not good enough to perform the surgeries. They told us local hospitals would take our money, not perform the surgeries and steal from us.

During one very tense board meeting, the co-founder of Operation Smile actually told the Op Smile Board of Directors that he was the only doctor in the room, and he knew that children “would die” if we continued with our plan to empower local surgeons.

This of course was not true at all.

“Teach a man to fish” became the Smile Train rallying cry, in part because we believed that the naysayers were condescending, dismissive and arrogant. We also believe that the traditional, two-week mission model was extremely outdated and colonial.

We believed that empowering and training surgeons was a more intelligent, productive, sustainable, affordable and respectful way to deliver surgeries in developing countries.

Our approach we believe would help very poor but very proud communities become self-sufficient over time. While the traditional mission model made local communities more dependent on these missions over time, making self-sufficiency impossible.

Of all the countries Operation Smile sent missions to over its first 15 years, the busiest location was and is the very first location they ever went to: the Philippines. Over 15 years, the Operation Smile mission model has bred dependence in the Philippines – not independence. The mothers of children born with clefts in the Philippines have been taught to prefer an American surgeon to a Filipino surgeon. They all want American surgeons to operate on their child.

Not surprisingly, Filipino surgeons don’t want to operate on Filipino children because they knew American surgeons will provide free surgery for them. So why bother?

There are two other reasons why medical missions are not a very good way to provide surgeries in developing countries.

The first one is safety. Two-week medical missions have very high sentinel event rates. A sentinel event is something that happens during surgery that is catastrophic either causing great harm or death to a patient. Operation Smile, had dozens of patient deaths over the years and many seemed ot be avoidable. The New York Times actually did a front-page major expose on this.

Charges-of-Shoddy-Practices-Taint-Gifts-of-Plastic-Surgery-The-New-York-Times

That’s what happens when you put together a mission team of people who have never worked together before, you fly them halfway around the world with 10,000 pounds of equipment and quickly build a operating room for them and there is tremendous pressure for them to operate on as many children as they can as quickly as they can.

This is a perfect storm for things to go wrong.

I immediately resigned from the board of Operation Smile after two young children died during an Op Smile mission to Beijing, China. It seems that these deaths could and should have been avoided. The first child died of esophageal intubation – that’s when the tube providing oxygen is put down the esophagus instead of the trachea.

Whirlwind-of-Facial-Surgery-By-Foreigners-Upsets-China-The-New-York-Times

By the time they figured out the patient wasn’t getting any oxygen it was too late and the little boy died. A monitoring machine called a pulse oximeter would’ve told the surgeon his patient was not getting any oxygen, but it wasn’t used. Inexplicably, it had been shipped all the way to China and was in the operating room, but it was not plugged in because the anesthesiologist said he liked to practice “cowboy medicine.”

I believe the other child died because of massive bleeding. They tried to do an emergency blood transfusion with a member of the medical team which is extremely dangerous and it failed. The Chinese shit down Operation Smile’s mission after these deaths.

The parents of these two children who died were given a couple hundred bucks and an apology from the cofounder of operation smile. If this had happened in an American hospital it would’ve been in major investigation in the lawsuit and the people responsible for this would’ve been held accountable.

The other reason why medical missions are not optimal is because of quality. Most of the surgeons who go on these volunteer missions have not performed a cleft surgery since med school. They are not the best cleft surgeons because they never do cleft surgery.

I know this to be a fact because at Smile Train that gave us a quality rating for every surgeon in the world who participated in our program.

When we started Smile Train, we were very confident in our new strategy of empowering local surgeons, but we were also cognizant of “concerns” from various medical experts and experienced surgeons. We felt it was important to have some way to carefully monitor the safety and quality of all the surgeries we were helping to provide. We immediately went to work on building an electronic patient record database.

It took us a couple years, but we did it and we rolled it out around the world and require that every single one of our partners use it. Our database was called Smile Train Express and our partners would upload electronic patient chart for every surgery that we helped fund. These charts contain comprehensive information on the patient, what type of intervention was provided and before and after photos.

Initially, we created this database because he thought it was the best way to combat fraud and to make sure none of our partner hospitals were taking advantage of us. We were working in some of the most corrupt countries in the world and we were nervous about the possibility of having our funds misspent. There were so many ways a partner could game the system. We had hundreds of different partners in more than 50 countries all over the world. Many of them we had never even met in person and had not yet had the opportunity to visit.

How could we really know that our partners were actually doing the surgeries that they told us they did? By creating this database, we made it very hard to cheat.We used special software that could find duplicate patient charts that partners might submit to double bill us. We used special facial recognition software to detect patient charts that used one patient’s photos multiple times – so they could be used multiple times for one surgery.

We even had software that could detect if someone had used photoshop to make it look like they provided surgery when they hadn’t. Believe it or not we actually caught a partner, based in the U. S. that photoshopped more than 100 patient charts. When we confronted them with this, they told us that they thought someone at our offices had gone in and photoshopped all of their photos. Thankfully, we got all of our money back from these crooks when we threatened to bring them to the Atty. Gen. of Texas.

In addition to our electronic patient chart database we also conducted medical audits where we would do surprise visits to partners and have them pull charts and callback patients.

Overall, I’m happy to report that we found very little fraud and dishonesty. I guess this shouldn’t be surprising because all of our partners with dedicated to helping the poor – not getting rich. They had been doing that for many years before we met them and that didn’t change when we started to help them.

So, it turns out the biggest benefit and value of our patient record database wasn’t really in detecting fraud but in monitoring the safety and quality of the surgeries we were helping provide.

An expert cleft surgeon who was a member of our medical advisory board offered to start reviewing patient charts and giving them grades. It wasn’t as simple as it sounds. Because you have to grade not only the result of the surgery you had to grade the severity of the cleft as well.

Some children would have very mild clefts, that were easy to fix. Any surgeon could do these surgeries and get an A+ for the result. At the other end of the spectrum were very severe clefts and sometimes clefts that had been operated on once or twice or three times before. These surgeries were exceptionally difficult and even the best surgeon would have a hard time getting a good result and a good after photo.

But our expert class surgeon was very bright, and he quickly developed a system that could rate than before and after pictures in such a way that we were always comparing apples to apples. He would review the photos blindly, not knowing who the surgeon was the department was even what country the surgery took place in. this made it very fair also gave us great confidence in the results.

At the time no one else in the world was doing this. In fact, no American hospitals ever rated the quality of the surgeries that their surgeons were providing. We scaled up to where we were reviewing between five and 10% of all our surgeries that was a lot. Because our surgeries scaled up to more than 10,000 a month at one point. That meant 500 to 1, 000 charts would have to be reviewed every single month.

It was a lot of work but boy was it worth it!

Because it gave us something that no other hospital in America had: a quality rating for every single surgeon that was participating in our program.

We knew who 10 best surgeons in the world are were. And more importantly, who were 10 worse surgeons were. So, we could immediately reach out to them and get them whatever training or help that they needed.

This was such a breakthrough. I’ve spent years attending medical symposiums and training workshops for surgeons and they were always one size fits all. None of the training or education was customized for specific surgeons.

Our Smile Train Express made it easy for us to determine which surgeons needed what kind of help, training or education.

There was another bonus too. after a few years we found some countries that had no medical infrastructure at all. Countries like Haiti, Sudan, Somalia and Liberia. In these places, our teach a man to fish model did not work at all. The only way to provide surgeries for the poor in these countries was to send traditional missions.

This was a little bit of a difficult pill to swallow since smile train was created at the antidote for medical missions! But we cared more about helping as many children as we could, so we quickly got over it.

We identified the top 100 Mission groups in America and started funding them. But we would only fun missions they went to places where there were no surgeons and medical teams that we could empower.

We required these mission groups to upload all of their patient charts to our database. We really didn’t give this a second thought but when we started to look at the quality ratings of the American surgeons that went on these volunteer missions it was a real eye-opener.

Our ratings for hundreds and hundreds of surgeons who had done hundreds of thousands of cleft surgeries showed unequivocally that local surgeons provide much higher quality surgery then visiting, volunteer surgeons from America.

This only makes sense because local surgeons perform 10 times as many cleft surgeries as American surgeons. But it was a little shocking to see this graphic evidence. Especially after all of the criticism we received from the American surgeon community when we started smile train and they want us how unqualified and poorly trained local surgeons were in developing countries.

My favorite part of our Smile Train Medical Advisory Board meetings was when we would review our quality ratings for the more than 1,000 surgeons who are participating in Smile Train programs around the world.

This included all the missions that we funded. We would pass around the latest data including a spreadsheet all of our participating surgeons, ranked from the best to the worst. Members of the advisory board would comment on both the best and the worst surgeons and often they would be surprises when some very prominent and respected American surgeons showed up near the bottom of the list.

The vast majority of our developing world surgeons were scoring extremely high on our ratings scale that measured quality of outcomes; the quality of care they were delivering to patients was uniformly impressive.

Meanwhile, the American mission surgeons scored surprisingly poorly, some well below the median grade. Why was this the case? Surely you would think the American surgeons would have the better scores.

They had gone to some of the finest medical schools and worked in the best hospitals in the country. But our surgeons in the developing world had one advantage that the American surgeons lacked: sheer volume of surgeries. Our partner surgeons were working to clear a vast backlog of clefts. As a result, they might perform more than 500 cleft repairs in a year.

By contrast, a surgeon in the United States might only see 10 to 20 primary cleft cases in a year. In surgery, as with any skill, practice makes perfect, and it turns out volume is a very good indicator of excellence.

I confess, this besting of the American surgeons scores by our partner surgeons felt like validation for our Smile Train model. From the beginning, we had always said that surgeons in the developing world were more than capable of performing surgery if they were just given the support and funding to do so. But it also made us realize how condescending that phrase “teach a man to fish” must have seemed to our local surgeons at the outset.

They were clearly more than qualified to do their work, and nine times of out of ten, they needed our money more than our instruction. Rather than “teach a man to fish,” we should have been saying, “supply the man with a rod and money for bait.”

Over the years, many members of our Smile Train medical advisory board traveled to visit our partner surgeons in the field to observe their work. When they came back, they also expressed that they were not only impressed, they were humbled by what they had seen.

“We have so much to learn from doctors working overseas,” said our MAB member who developed our quality control program, “If we’re just prepared to open our minds and our eyes.”