The Path to Global Neurosurgery with Sandi Lam, MD, MBA

• Lam reflects on her upbringing as a "third culture kid," a Canadian who grew up in Hong Kong and is now a neurosurgeon in the United States. These experiences helped to shape her global perspective and challenged her to be more thoughtful about how she could contribute to society. 
• She received both her undergraduate and medical degrees  from Northwestern University but medicine was not her first career. After studying political science, Lam took a job in tech transfer consulting for a Japanese startup. She says this experience was not only fun, but taught her about business, sales, what makes people “tick” and how to improve people’s daily lives.  These skills still come in handy in her work as a neurosurgeon today. 
• The move to medicine was motivated by her desire to help people. She started her training in orthopedic surgery, but after her first two years in surgical training, was drawn to the acuity of neurosurgery and switched specialties. After her training was complete she pursued an MBA, something she was glad she pursued after having some time in the workforce. “I feel like I got a lot more out of business school than I would've as a professional student earlier on in my educational career.”
• During the past decade, Lam has become a world renowned specialist in the area of epilepsy surgery and neurovascular surgery. At the same time she has built a career in global health. 
• Her interest in global health took shape while celebrating the end of her fellowship training with a trip to Kenya to climb Mount Kilimanjaro. There she connected with a fellow neurosurgeon, Dr. Leland Albright, who was living in Kenya developing training for neurosurgeons in Africa in pediatric neurosurgery.
• While in Kenya she donated her time and services in pediatric neurosurgery alongside Albright and found herself being “part of something that was much bigger than everything I had worked towards in that point in my life.” She has returned to Africa nearly every year for the past 12 years and has formed collaborations with surgeons and staff in Uganda to build pediatric neurosurgeons capacity there. 
• There is a great need for pediatric neurosurgeons in low and middle income countries, especially those who focus on care for children with epilepsy. Through support from a grant from the Havey Institute, Lam is working with CURE Children's Hospital of Uganda to develop capacity for a sustainable program to elevate pediatric epilepsy care in Uganda. 
• Her goal is to teach the team in Uganda how to make a diagnosis and treat people with epilepsy and how to choose which children would benefit from epilepsy surgery and be cured from their seizures. 
• She says the relationship she has with the Uganda team is truly collaborative and she has learned innovative ideas from surgeons there that she has brought back to the U.S. and her colleagues at Luire Children’s.
• During COVID-19, Lam was able to continue this work through virtual learning techniques. She is excited to continue using virtual learning to Zoom and virtual learning to scale epilepsy teaching and epilepsy care worldwide.
• Her advice to students who are interested in a career in global health is to be curious and have an open mind and remember that life does not have to take a linear path.

[00:00:00] Rob Murphy:Welcome to the Explore Global Health podcast. I’m Dr. Rob Murphy, Executive Director of the Havey Institute for Global Health here at Northwestern University Feinberg School of Medicine. A quick look at the bio on Dr. Sandi Lam's Twitter account paints a compelling snapshot of who she is. The text actually says, MD MBA, professor of neurosurgery at Feinberg School of Medicine, chief of pediatric neurosurgery at Lurie Children's Hospital, health services, research, innovation, and third culture kid. We're gonna dive into all of these facets of Dr. Lam's life and career today, as well as her work here at the Havey Institute for Global Health in developing capacity for a sustainable program for elevating pediatric epilepsy care in Uganda and sub-Saharan Africa. Welcome to the show, Dr. Lam.

[00:00:59] Sandi Lam: Thank you so much Dr. Murphy.

[00:01:01] Rob Murphy: Well, let's start at the beginning. You refer to yourself on Twitter as “third culture kid.” Can you explain that to me and what your upbringing was like?

[00:01:11] Sandi Lam: I am Canadian and I grew up in Hong Kong, but now I'm a pediatric neurosurgeon working in the United States, so I'm based out of Chicago. And I think for anybody who has grown up in a certain culture and moved somewhere else and lives in a different language or a different culture than what you were used to as a child, that's what I understand to be a third culture kid of sorts. And that gives interesting perspectives, right? So that causes a lot of soul searching for where do I belong in the world? Where do I fit in? What are my contributions to society going to be? And that can be difficult, but that can be very freeing and very challenging. So being a child and not looking like everybody else can be difficult. But I had both experiences when I grew up in Hong Kong, it was generally homogeneous. Everybody had black hair and dark eyes and looked like me. And when I moved to the United States, I became somebody who was visibly in the minority. And that has evolved a lot over the past few decades with really celebration of diversity and recognition that diversity and inclusion actually makes everything stronger in the world, in business, in corporations, in thinking. 

[00:02:40] Rob Murphy: Let's talk about your undergraduate, years you received your undergraduate and your medical degree from Northwestern University. A true wildcat, but you didn't go right from undergraduate to medical school. You were a political science major in undergrad and worked in tech transfer consulting and the startup field. Tell me about that part of your life before you switched to medicine.

[00:03:04] Sandi Lam: That was the most fun I've ever had, and that taught me a different perspective. In medicine, we tend to be conservative in training and thinking, and there are frameworks in which we are operating and coming up with diagnoses and treatment algorithms in thinking about business and developing strategies and bringing products to consumers and how that looks a lot of it is very creative. And that was amazing in my twenties in terms of thinking about a local community and in thinking about a global community. So I worked at a startup that sold high-end Japanese consumer tech and our customers were from all over the United States and all over the world. So we would take off the Japanese operating system of a Japanese personal computer, and we would put on the operating system of any other language that you would request, and then we would send it to you by courier and it was an opportunity to meet people all over the world and to really understand what customers needed and wanted and to really provide a service. And I learned a lot about sales and business development, and it sounds strange to have a neurosurgeon talking about sales, but that is a really important people skill for life to really connect with people and understand what it is that makes them tick and what it is that they need and what it is that could make their daily life better. And I feel like I still do that as a surgeon.

[00:04:53] Rob Murphy: Where did your MBA come in? Was that before you went to medical school?

[00:04:57] Sandi Lam: My MBA was after my neurosurgery training and I get a lot of questions from students now in college and medical school and at any point in the educational journey for when do I do an MBA? Should I just do it now and get it over with? And I actually think that there are pros and cons, but to me, having that additional experience in life and different perspectives made me feel like my MBA, later on in life was more valuable, because otherwise, when you're a student, you get really good at going to class and taking tests and you kind of study to the test, right? But, I appreciated school more after working the sales world and business development world and working in medicine. When I got to actually read and think about things that were beyond my daily scope of neurosurgery and I got to interact with my classmates and professors who were from all different walks of life, I really appreciated that time. And I appreciated those connections that I had with really motivated, bright, curious people, and I feel like I got a lot more out of business school than I would've as a professional student earlier on in my educational career.

[00:06:20] Rob Murphy: That's a great perspective. Moving on, your path to becoming a neurosurgeon was also not a straight one. So when did your career in medicine happen and what drew you into neurosurgery in particular?

[00:06:35] Sandi Lam: This was about, I guess, over 20 years ago, in medical school and in early residency. I wanted to help people, and that sounds a little cliche, but I felt like I understood that motivation better after selling things to people for some years. I felt like I knew how to make a living. That I could put food on the table because I could do sales of any sort and I could get a job. So I felt like my choice to go into medicine was something that was going to be a sustainable reason for why I did this every day. And that helped shaped my perspectives in training. I first matched into orthopedic surgery, because I was an athlete in high school and college, and I thought that that made a lot of sense, that I wanted a very practical way to fix things and help people get better. And I realized after my first two years in surgical training that there was something that was very compelling about the acuity of neurosurgery, that there was still a lot of fixing with our hands, but that connection with people during a very difficult time in their lives and being a full service doctor, if you will, for critical care and brain and spine pathologies was something that I felt like if I was gonna spend years in training, that was worth it to me. So I actually switched from orthopedic surgery to neurosurgery after my second year of training. A lot of that in those days was general surgery and really a lot of surgery training and overlap. So I don't feel like I lost time. I don't feel like there was anything wasted in any way. And I get that question a lot. I feel like if life is an adventure and we are sponges and getting experiences, then everything that we see should be something that is of value. And I learned a lot about bones and I learned a lot about people and working in a hospital. And I also met my husband, who is an orthopedic surgeon. So, those were very valuable lessons in terms of my early surgical training, and I'm really glad that I met the neurosurgeons who inspired me and enticed me into this field because it gave me a lot of opportunities to think about the world and think about life, and think about impact that we can have with our fellow human beings.

[00:09:20] Rob Murphy: Well, I think this is a very important point for many of our listeners. The fact that you can take this kind of unconventional path.Thank you for sharing that with us. Let's switch over now to your niche specialty. You become a world renowned specialist in the area of epilepsy surgery and neurovascular surgery. Can you tell me about the patients you treat and some of the leading edge surgeries you perform at Lurie Children's?

[00:09:49] Sandi Lam: They are both very niche type of specialties where pediatric neurosurgery is already a relatively smaller subspecialty within neurosurgery. There are just over 200 board certified pediatric neurosurgeons in the United States, and there are over 3000 neurosurgeons for adult in general and pediatric neurosurgery combined. So we tend to serve a relatively large population per pediatric neurosurgeon. So when we look at the things we do and the type of research that we can do to all learn together and push the field forward, we recognize that what we treat is relatively rare. So that made us think together as a field that we really have a strong spirit of collaboration. First of all, there are not that many of us. We all tend to know each other and we really believe in working together and pooling our experience and really having the power of all. And that is the basis of a lot of my research in outcomes and also in big data research and healthcare economics research in the United States for epilepsy. In epilepsy and neurovascular in pediatric neurosurgery, tend to have a smaller number of patients. All of the surgeries that I do tend to be cranial surgeries, because it is for vascular conditions of the brain. There are some vascular conditions of the spine as well. And then, um, epilepsy surgery is also brain surgery. They're both very team-based approaches for, either neurovascular conditions in children, or, epilepsy or continued seizures in kids. So, for epilepsy, it actually translates to global health very well because epilepsy is the most common neurologic condition in the world. So over 80 million people in the world are affected by epilepsy by epidemiology estimates and that burden of epilepsy is actually disproportionately distributed, where more people affected by epilepsy are actually in low and middle income countries as opposed to high income countries.

[00:12:10] Rob Murphy: As you just mentioned, low and middle income countries they're more impacted than even we are. What point in your career did you start to pursue an interest in global health?

[00:12:21] Sandi Lam: I envy young people these days who kind of see global health as something they wanna pursue, and they know that this is something that they want to incorporate into their careers. I think this is wonderful. When I look back, I had no idea that this was something that I was going to do and I had no idea that this could even be in my path. And as you see a recurring theme, I am very lucky to have had a lot of opportunities and I also had the curiosity to seize on some of these opportunities, and I'm really grateful for the people I've met along the way who have really inspired me. So after my fellowship, I trained in neurosurgery at UCLA and I did my fellowship in Pittsburgh. After my fellowship, my mentor said, there's somebody who I used to work with, who used to be a very prominent pediatric neurosurgeon in Pittsburgh, who has now transitioned to living in Africa with his wife, a pediatric nurse practitioner, and, this was Dr. Leland Albright, and Susan Ferson. And Leland Albright had moved to Kenya in semi-retirement from pediatric neurosurgery to develop the field of pediatric neurosurgery and to develop training for neurosurgeons in Africa in pediatric neurosurgery. And he was working in Kenya. So I went to Africa because I wanted to climb Mount Kilimanjaro after my fellowship. And that was actually why I was there. And I emailed Dr. Albright and said, I want to visit you. I heard we would get along and I would love to volunteer my services in any way, and that was actually how I met Dr. Albright and how I got involved in global neurosurgery. I really didn't know. I thought I was climbing Kilimanjaro. And I visited Dr. Albright at his hospital in Kijabe, Kenya. and I worked with him and his team of Kenyan neurosurgery residents and nurses and staff in the operating room and administrative staff, and I found something that was amazing. I thought that what I got from this visit was way more than anything that I contributed, and I felt like even though I donated my time and services in pediatric neurosurgery, what I learned from these amazing, resilient, smart, motivated, gentle, kind people was something that was much bigger than everything that I had worked towards. And Dr. Albright asked me at the end of my visit if I would commit to coming back every year. And for anybody who's met Dr. Albright, you would understand that he is not somebody you say no to. So I said yes, and we are 12 years in, from that time and I have gone back essentially every year, at least once to that site in Kenya. And then now the people that I worked with and helped train, have actually moved over to Uganda to Cure Uganda Hospital and have become the medical director and the head of clinical research in neurosurgery there and have formed collaborations with them. And that is all because of people and relationships.

[00:15:45] Rob Murphy: Let's talk a little bit about Uganda. You have a grant from the Havey Institute to help develop capacity for a sustainable program to elevate pediatric epilepsy care in Uganda. Can you talk about this grant and the work about that?

[00:15:59] Sandi Lam: First of all, thank you so much for this grant, and thank you so much for the funding and support because this is really important work in so many ways. The first is because it is for epilepsy, which has a huge global burden, and the World Health Assembly several years ago had passed a resolution calling for coordinated efforts in epilepsy care to really elevate and focus on care for people with epilepsy all over the world. So the Cure Uganda site is actually populated by neurosurgeons that I had worked with in Kenya, who actually are Ugandan by nationality and were able to go back to Uganda and be at this wonderful pediatric hospital that is a subspecialty neurosurgery hospital for children in Mbale, Uganda. So, there is a wonderful story of reverse innovation of pediatric neurosurgery in Sub-Saharan Africa by Dr. Benjamin Warf, who is now at Boston Children's. He had originally been in practice in Kentucky and had become a missionary pediatric neurosurgeon and the site that he was in practice at was Cure Uganda Hospital, which was mainly a pediatric orthopedic hospital. He used the endoscope, the flexible endoscope in a way that really taught us a lot about treating hydrocephalus, and there is a lot of hydrocephalus in that region of the world from perinatal infections and from congenital neural tube defects like spina bifida. So Dr. Warf from Uganda had performed thousands of endoscopic third ventriculostomy and choroid plexus cauterization with the flexible neuro endoscope and showed that the outcomes achieved by using endoscopy were very good and very encouraging, and offered an alternative to treating hydrocephalus that could preclude for many people the placement of hardware. So a lot of these babies actually did not need ventriculoperitoneal shunts that would be permanently implanted into their bodies. So, that taught us a lot about hydrocephalus and where when there's a need, how do you innovate in a way with what you have that could give better outcomes in a condition specific and a location specific type of way. I actually learned flexible neuro endoscopy in Africa.It changed the way that I could do that surgery, and I've brought that back here to the United States, and I've taught it to my trainees and actually to my colleagues and my partners. And now the way that I use that instrument, the flexible neuro endoscope, is very different than the way that I did five years ago or 10 years ago, and I continue to take those approaches and the way that I think about the neuro endoscope now, to apply it to not just hydrocephalus, but to other problems that we see more commonly in high income countries like tumors or other types of pathologies, so that I can actually get to places in the brain in a more minimally invasive way and think about avoiding other types of surgeries or procedures and be able to apply the use of the flexible neuro endoscope in different ways. And we've been able to publish on new techniques and really think about how to push the envelope in minimally invasive pediatric neurosurgery. And I credit all of this to my African neurosurgery colleagues teaching me and having that patience and the perspectives to be able to teach me how to be a better pediatric neurosurgeon. My colleagues now who are there Dr. Emmanuel Wegoye, who Dr. Warf trained, and Dr. Humphrey Oketchi, who Dr. Albright trained. They reached out to me and said, we're pretty good at taking care of babies and taking care of children with spina bifida and meningitis and other congenital and neonatal types of conditions to the point where when we see patients in follow up, they are now school age children and they are not at risk of dying. They are actually living for many years, but we realize that they have conditions that really impact their quality of life like epilepsy and spasticity. And this is a consequence of the conditions they were treated for as a baby. So we recognize that there are actually very good neurosurgical procedures that we can offer that can cure or can really lessen the burden of epilepsy and spasticity. But we were not really trained in a way that gives us the tools to be able to develop an epilepsy surgery program. Can you help us? That was a long answer with a long history, but really kind of puts into context why this place of pediatric neurosurgery is so special. That it is a place of reverse innovation that really taught us a lot about pediatric neurosurgery from the techniques that Dr. Warf applied in hydrocephalus from Uganda and has really changed the way we treat hydrocephalus in high income countries now, and also speaks to the power of these outcomes from the babies being treated with congenital conditions and infections, now living longer and having diseases that have a chronic burden. And for epilepsy, there are medications that can treat epilepsy and give good seizure control. And there are people who fail these medications and continue to have seizures and have a reason or a specific area of the brain why they're having seizures and those types of patients actually may be very good candidates for epilepsy surgery and can have a surgery to remove the lesion that is causing the seizures, and that can actually produce a surgical cure and that is from a surgical sense wonderful and awesome. And that is kind of from my nerdy neurosurgery side, that's a success. Right? But when you think about it from a society and family and community perspective, a child who is having seizures all of the time is something that affects more than the child. It places a burden of care on the family, on the parents, and really takes time and resources and attention away from their siblings and time and resources and attention away from the community. And also there is a large social stigma to having epilepsy Many cultures can think that it is being possessed by the devil, or retribution for the family doing something bad in their lives, and it really can cause a lot of mental health issues, for people with epilepsy, that are comorbidities, but can also be very socially isolating for the families and be a big cause of social stigma. And a lot of families have foregone employment or really have to put a lot of resources into caring for somebody with epilepsy. the, prospect of being able to diagnose somebody with epilepsy and find a surgery that could potentially cure somebody of seizures is life changing for the patient and for the family and for the entire community. And that's why I think epilepsy is beyond a diagnosis and one illness. It's a way to really think about how we can make an impact across a community and working with my colleagues in Uganda to teach them and their entire team how to make that diagnosis and how to treat people with epilepsy and how to choose people who can really benefit from epilepsy surgery and be cured from their seizures is something that I think is very powerful and I hope that we can make sustainable so that we can make an impact on generations to come.

[00:24:39] Rob Murphy: Yes, I think so. It's clear that in these low and middle income countries, particularly Sub-Saharan Africa which I'm most familiar with, but other places too, that there's a definite shortage of surgeons. Can you tell me about the shortage, how bad it is and how you are helping to address the issue?

[00:24:58] Sandi Lam: The estimates for the shortage of neurosurgeons is in the scale of tens of thousands. So, an estimate from a global surgery study from a few years ago is about 22,000 more neurosurgeons are needed in the world to be able to address sustainable development goals from the UN for the world population having access to safe surgery and safe anesthesia. So if you look at the population of children in the world, and you look at where the people under the age of 18 actually live in the world, the largest concentration is actually in sub-Saharan Africa and Africa. It is not actually in high income countries. So if you look at where I practice in Chicago, the proportion of people who are pediatric age range is actually about 30 something percent. If you look at Sub-Saharan Africa, the proportion of people who are in the pediatric age range is over 50%. So the young people in the world who need pediatric neurosurgeons, if they need a neurosurgeon, are actually in low and middle income countries. So I see that as a moral obligation and a professional obligation as a pediatric neurosurgeon to think about how to actually get the care to the people who need it most. And that can be in different ways. I have a specific skill set that I can share, and that is something that I can either go to the places in the world that need pediatric neurosurgeons, or I can collaborate with people who are neurosurgeons or general surgeons and have the ability to get those technical skills and that knowledge and that know-how and that approach and take care of kids where they live. And that is a model that we are using now is how do you work with colleagues around the world to build capacity and to work towards sustainability. And I guess if you think about the teach somebody to fish versus fish for them, this is really kind of working on how do we think about getting a lot of fish together in different ways, with different approaches and different strategies and different skill sets, and really think about how do we do that better altogether? And I've shared stories of reverse innovation and going there and working on the ground together or thinking about developing ways where we can really share knowledge and skills as a team in education and sustained collaboration together.

[00:27:55] Rob Murphy: Absolutely. Let's switch to talk about what the Covid 19 pandemic did to your projects. We actually had a fairly smooth transition into the pandemic. We didn't obviously travel very much, but we had trained enough people that our projects didn't slow down. Our NIH program officers thought it would be really impacted and actually we didn't see it. But What was your experience with the pandemic?

[00:28:24] Sandi Lam: I agree with you, Dr. Murphy. I think the COVID-19 pandemic taught us a lot and it really opened my eyes to what we can do together and the pandemic made Zoom and other online forums a lot more commonplace and made it more mainstream and in collaborations for teaching epilepsy care and transferring knowledge and skills. It worked really well. When we thought about how to teach epilepsy care, I thought that we would have to travel there and work in person. And when we all had to pivot into virtual forums, the people that I work with in Chicago stepped up and became very creative. Eric Padilla, who runs our epilepsy monitoring unit, actually runs an apprenticeship program for training EEG technicians to do neurodiagnostic services. And he said, you know what? I know how to train people. We have a curriculum and I can teach people how to do EEGs and we can modify this to be online and virtual and we can teach on Zoom and we can do this with video. We can do this with different models and we can really even remote into their servers to be able to configure the montage so that we can see the EEGs in the same way. And the company that had donated the equipment to CURE Uganda actually is the same company that we work with here, and they actually helped facilitate this as well so that we could configure the output of the EEGs in the same way. And our whole team jumped in. Our EEG technicians who were EEG instructors and, the NeuroDiagnostic Society of America donated materials for education and gave online modules and online textbooks and online quizzes, and we were able to meet with the team at CURE Uganda twice a week on the Zoom online forum and actually teach them how to do EEGs throughout the entire pandemic. And we were able to modify our in-person apprenticeship model into a virtual remote learning type of format. And in doing so, we've been able to teach 10 doctors in Uganda how to do EEGs, how to interpret them, and how to put that together with imaging of patients and work up a case so that we can identify who would be a good candidate for epilepsy surgery and we would have never thought to be able to do this all online virtually 10 years ago. And I think the pandemic made it so that we were able to think of Zoom and virtual learning as, more of the norm so that it really changes the way that we think about helping develop capacity and I see this as a very scalable model for medical teaching, for surgical teaching and it really expanded our world in terms of how we can scale epilepsy teaching and epilepsy care.

[00:31:47] Rob Murphy: Now we have our final question. We ask every visitor on our podcast. What would you tell a current medical student who is interested in global pediatric neurosurgery or pediatric surgery even in general?

[00:32:01] Sandi Lam: I would say be curious and have an open mind and life does not have to take a linear path. And the most important thing is to understand that everybody needs to have a why, and you need to have an answer to your why. And if you understand your “why” and why you're here and what you hope to do in your daily life and in your years here, it will really help you understand opportunities and choices and how you wanna spend your time and how you wanna spend your days. It doesn't have to be dictated by what somebody tells you in school or somebody tells you in your current structure. It really is about being true to the type of impact and the type of change that you wanna make in the world.

[00:32:57] Rob Murphy: Great answer. It's been lovely having you here on the podcast and I can't thank you enough for taking the time to be with us today.  you're a great model for our young faculty and students who have an interest in global health. And I thank you very much for sharing all this information today.

[00:33:17] Sandi Lam: Thank you so much Dr. Murphy. 

 [00:33:33] Rob Murphy: Follow us on Apple Podcasts or wherever you listen to podcasts to get the latest episodes and join our community that is dedicated to making a lasting positive impact on Global Health.