In this episode, I am joined by Dr. Berend Mets, a professor and chair of Anesthesiology and Perioperative Medicine at Penn State University College of Medicine. Dr. Mets has a passion for globalizing quality anesthesia care and in particular to increase the quality of surgery and anesthesia in under resourced environments. We discuss specific steps taken to increase access to quality anesthesia and some of the amazing physicians and others with whom he has partnered.
Hello and welcome to episode 41 of the anesthesia success podcast. I’m very pleased to be joined today by dr Berend Mets.
Dr Mets is professor and chair of anesthesiology and perioperative medicine at Penn state university college of medicine here in my home state of PA. He also serves as director on the board of the world Federation societies. Of anesthesiologists as well as being the chair of the global humanitarian outreach committee of the ASA Berend. Thank you very much for joining us today. Those are to be here and I’m really excited to dig into this topic of global access to anesthesia. So I recently read this article, which you penned at Kevin MD. Talking about this statistic that grabbed my eyeballs was 5 billion people globally don’t have safe access to anesthesia. So I’m really looking forward to unpacking your experience in the context of global anesthesia.
Dr. Berend Mets (01:39):
Right. And so, you know, the, the statistics are stocked. So the last launch and commission, which is a commission that’s launched by the Lancet journal, propose the commission to look at the state of anesthesia and surgery around the world in 2010 and their findings were that while there are about 4 million people that die from infectious disease around the world, there are 16 million, I E four times the amount that die from lack of access to surgery and anesthesia. Wow. This is a terribly stocked statistic. And they went on further to say that of the 7 billion people in this world today, 5 billion lack, lack access to a successful surgery and anesthesia, which has a huge, huge problem for of course those, those individuals and in terms of an increased mortality and while there are around 300,000 surgeries performed a year, just 6% of those occur in the low and middle income countries where this access problem is. Wow.
So tell us a little bit about your background, cause I know you’ve trained in Europe and South Africa and I’m sure that has contributed to your global perspective.
Dr. Berend Mets (03:04):
It very much has. I was born in Indonesia of Dutch parents. I’m originally Dutch and my father delivered me of my mother in a Bush hospital in Indonesia. And after six weeks I was on my first plane and since that I’ve traveled to 80 countries. Wow. Traveled and worked literally all over the world. I grew up in Indonesia and Singapore in the West Indies and England and Holland. Then eventually my parents settled in South Africa where I trained in medicine and then also started anesthesia. If I happened upon anesthesia in South Africa, you have to be a medical officer before you can specialize. And I thought, well, let me try this anesthesia stuff. And so in a very large KwaZulu natal hospital, I started anesthesia and it was just so thrilling and so exciting that I thought this is what I would make my career.
Dr. Berend Mets (03:58):
Out of. Got it. Was your father also a physician? He was in fact he was also a general physician and in those days, of course they did surgery and they gave anesthesia as well with ISA. Okay. And so really I started anesthesia in a very rudimentary environment with the finger on the pulse and the blood pressure cuff. And I actually write off many of these histories that I’m about to relate. If asked in my book, I waking up safe and an anesthesiologist record where I use my life as an example of how anesthesia is actually progressed over the years. And so my first anesthetic was given in Aqua Zulu natal. I was scared stiff as a I as I thought, you know, I’m going to kill this patient. I fortunately didn’t and my career took off after that.
Got it. Excellent. So we’re going to link to that in the show notes. So that book waking up safer, if you go to anesthesia, success.com/ 41 you’ll be able to link there to Barron’s book waking up safer. And so this set you on this trajectory of being a global citizen as well as a, you know, an expert clinician and anesthesia. Talk about how your perspective, your, your desire to prioritize global access to anesthesia as part of your life’s work evolved.
Dr. Berend Mets (05:14):
So it’s almost like going home, if you will. I understand from a, you know, starting off in Indonesia and then starting with very rudimentary anesthetic techniques because South Africa like so many low and middle income countries around the world has basically two Tia medical systems. You know, there’s the university private practice systems, which are highly functional and modern. And then there’s the secondary rural systems which, which is very rudimentary. And that’s often where many of the problems do occur in terms of access and in terms of mortality, which is a huge issue. But I’ll get to that. So I started in one of those low access environments. And so, but it was of course and trained in you know, super specialist hospital and [inaudible] hospital in Cape town. But in that, during my training I already started volunteering. So we went out with a group to do cleft palate surgery and anesthesia.
Dr. Berend Mets (06:08):
Of course you need that for that. And, and the too, which is inbounded by, by South Africa borders. And so that’s really where I started as I was a young resident or registrars we call those in South Africa. And then it, it, it really progressed as I advanced of course. And in the clinical sense in, in, in one of the top hospitals in the world to Columbia university where I started in, in anesthesia, in the States, it progressed and I started feeling that I would like to contribute to global health as well as being able to understand how we do it at the top centers in the world. I have a very deep understanding and appreciation for how it can be done in less resource environments. And that’s really where I started getting involved and I got involved with the world Federation societies of anesthesiologists. I’m now on the board there for the last 22 years or so, working on various committees, going to various countries, Vietnam, China, going to lecture and and in other countries again I provided clinical services.
Got it. And would you say were there any, as you look back, especially in those early years, were there any experiences that stand out in your mind where you were maybe helping a patient or working in a, you know, a small clinic or something and saying this, this experience, this past couple of days has made me realize I want to really put my weight behind and my effort behind building pathways to global anesthesia access.
Dr. Berend Mets (07:32):
I guess it would probably be that first trip to the zoo too when I was really, you know, a young resident and I was wicking, came out of a foster university hospital to a less sophisticated environment. It was great fun. They flew us out there in a private jet, which was great. And then, and then we got to do a lot of complex surgery. Obviously on cranial facial types of surgery pallets and the anesthesia is such an integral part of the success of these patients. And you get to see these patients and also you see the effects of your work. I mean we see this generally anyway in the first world, but it’s almost as if in the developing world, but now we call the low and middle income countries. It’s, it’s so much more appreciated what you do. And I think that that probably is part of how I I got into this anymore. It’s truly appreciated what we do and we can do so much more, you know. So that’s one of the reasons I got into that.
Yeah. So you’re currently among your other leadership roles. The chair of the ASA is global humanitarian outreach committee. As we mentioned right before we jumped on the call here with Dr. Anna Crawford, who’s been a past guest of the show. Talk a little bit about the initiatives that the ASA, this ASA committee has undertaken to try to expand global access.
Dr. Berend Mets (08:50):
Well, one of the most important things is that we have done is tried to advocate for the global anesthesia crisis that I just, I witnessed in my previous statements. That’s the first thing. But it’s not enough to just talk about it. The other thing is that you have to put plans and implement plans. And so what we’ve done is we’ve focused in a number of different areas. The first is to extend the work of the overseas training programs. So the overseas training program was really a program to help build capacity around the world, launched by the ASA, by going to certain countries and then helping support the training locally. And this has had a storied history since 1991. So the current committee has, was renamed from the overseas training program to the global humanitarian outreach committee. And we’ve continued that work in two countries in Guiana and in Rwanda.
Dr. Berend Mets (09:48):
Now in Rwanda, Dr. Crawford is in charge of helping support their residency training program in Rwanda and we’d be very successful. So we collaborate with the Canadian society and the American society of anesthesia in building residency training programs. In those different countries in Rwanda, we’ve been quite successful and that we’ve been there for approximately eight years and we now have graduates from that program then are now training their own residence and back into the system in Rwanda. So that sets up the virtuous cycle of a self sustaining process of building anesthesia capacity in a particular country. So that’s one area we’ve been involved in. And then the other one we have are launched over the last four years is in Guiana South America. Got it. One of the biggest challenges that you’re facing as part of this committee towards either maintaining current programs or perhaps expanding into other places.
Dr. Berend Mets (10:50):
So it’s all always crucial whenever you start any program that you have a very strong local champion. And because it all ultimately rests on their shoulders and the momentum that’s created, it has to be sustained by a local champion, otherwise it isn’t sustainable and it can’t grow from there. So in Ghana we have Dr. Alex Harvey. So I met dr Alex Havi some years ago when I was involved again on the global humanitarian outreach committee that just as a foot soldier, not as the chair and development of the Lightbox program. So Lightbox is, many of you probably know is a pulse oximeter program, which basically sought to bridge the gap of operating rooms around the world where there were no pulse ox amateurs. This was great. It through the w FSA also through the Harvard medical school and a few others, a GBI England. And from that came this life box, this physical box yellow box, which is a pulse oximeter.
Dr. Berend Mets (11:56):
Got it. As part of this program, we distributed a Lightbox. Pulse oximeter is around the world, but it had to be, people had to be trained on using this new technology because they had been trained with this. So the ASA gho committee sent out people to different countries, not only to present individuals with this Lightbox, but also to train them on how to use this pulse oximeter. And so I was in Guiana together with an a few other ASA volunteers and we were launching this Lightbox program with Alex Harvey. So Alex Harvey was the local champion. She’s a Giannis English trained anesthesiologist and she was helping coordinate this light box program for her country. Got it.
And how did you first come in contact with Dr. Harvey?
Dr. Berend Mets (12:45):
Well, I, I was referred to her because as I said what we always need to do is find a good local champion, somebody who’s interested in helping develop a program within their own country. And she is particularly motivated because she wanted to create a own residency training program, which didn’t exist or was in a very nice and form in Guiana in Georgetown, which is the capital of Ghana, again, as a small country, about 800,000 people. So it’s not a big car. I mean it’s a massive country, but very sparsely populated. And so we met we met by by email of course initially, but subsequently we became friends. And when I was there for that first time, she said, you know, I need your help. I want to start a residency program. She had that visit vision. And so when I was, became the chair of the ASA gho committee, I decided that I would try and figure out a way, whether we, how we could potentially build an overseas training program with an Indian. And so we have done that and we now have four successful years behind us with with graduating residents who are now faculty within that department, training the residents, setting up this vicious vicious cycle again.
Awesome. so I am a finance guy, so I’m hearing all of the things you’re talking about and thinking this is really interesting, but I know that flying all over the place and creating, you know, educational programs for young physicians in other countries costs a lot of money. So I’m curious, how are these endeavors funded and with other, with what other organizations do you partner to do this?
Dr. Berend Mets (14:17):
Yes. So the American society of anesthesia has been very generous with this and realizing the need that the crying need out there. And also realizing that we need to build capacity, we need to train the trainers basically. And so the American society of anesthesia as supports both of these two programs as I said in Rwanda and Guiana, and we do this in collaboration with the Canadian society. And so together we fund the support for the volunteers to go out there to fly there and to stay there. So that’s part of the way we support that. It’s actually very difficult to get donations for programs and the director of partnerships for the world Federation. I’m on the board and part of my job is to try and get donations, support for programs to the world Federation. And it is a tall order. It’s a very difficult because people do not understand the concept and the importance often of anesthesia, you know, with this hidden speciality, we were quietly behind the scenes and as I just talked about the access and the low launch Lancet commission.
Dr. Berend Mets (15:28):
It’s only now that people are realizing how important essential surgery and anesthesia is to the world community. Yeah. I would like to translate this for you and into economic terms because you’re an economist. Yeah. So the lights had commission reported that and the commission was basically the two 20 commission and was projecting out the lost cost that would occur over the next 10 years. Two 20 to two 30 2030 of not implementing the plans for essential surgical and anesthesia services around the world and in lost economic costs in terms of people being disabled, say a club foot that isn’t being prepared or die as a C-section. That can’t occur because there’s no surgery, no decision. The patient dies as 12 point $3 trillion in lost economic costs across the world. And what I would need is a $3 billion investment to provide 143 million surgeries needed a year to avoid this. But I think I’ve given you some idea of the scope of the problem and also the potential solution. But I’ll, I’ll talk a lot more about the potential solution, if you will.
Yeah. So I’m, so I just want to play that back for a second, make sure I understand. So the Lancet commission recommended a 3 billion with a B dollar investment over the next 10 years to create the infrastructure necessary to save. Did you say 12 trillion with a T 12 point $3 trillion of lost economic impact through surgeries that either go wrong or people don’t have access to?
Dr. Berend Mets (17:13):
Well, yes. So for example, somebody has a maimed arm from trauma and it can properly be prepared and so they, they are removed from the workforce. That’s a good example.
Yeah. And so these numbers are so compelling. I mean, if we look at it investment terms, we have this phrase, ROI, return on investment. If we could spend 3 billion to save 12 trillion, that sounds like a slam dunk. So I’m wondering, you know, in the context of your role as the director of partnerships with, when you have these numbers in your back pocket, why do you think it is that it’s difficult to raise funds for this kind of work? Well, you know,
Dr. Berend Mets (17:49):
Because numbers often don’t speak to people. Yeah, that’s absolutely true. It’s stories that speak to people, you know? And so that’s what what we did. We tried to do is through the Wolf Federation and also the ASD gho committee. [inaudible] Tell stories, success stories of the many programs that we deliver literally around the world that I’ve just told you about. The two programs for the ASA, a gho committee. The other one that I just wanted to illustrate as well for that committee is particularly for our resonance in America, we S we credited the resident international anesthesia scholarship over the last four years. Again, and this is an opportunity competitively to apply for six bucks a year for senior residents to go to three sites, cure hospital sites around the world. One being in Ethiopia, which is where I have been and I can talk cogently about, but they are in a pediatric hospital under supervision.
Dr. Berend Mets (18:47):
We have the opportunity for residents to rotate a month. And as part of this resident international anesthesia scholarship, it has, it’s, it’s done extremely well. We now have already 40 graduates from this program and American visits that have become faculty and many of them are now on or a number of them are now on our gho committee. I mean they was inspired often by this program. And that’s another way that we built a global interest or a particularly interest in our own country here in America of residents coming in and volunteering and supporting global health. Yeah. What is the resident experience like as participants in that program? Well they tell me that it’s great. So it’s a pediatric orthopedic hospital. I, I’ve been there, it’s a lovely place. And of course they, they, they collaborate with their if European resident colleagues in the same hospital.
Dr. Berend Mets (19:45):
So it’s a, you know, it’s a mutual exchange which works very well, but they also help train nurses there and anesthesia as well. So they are also trainers. They trained to be trainers and of course they’re working in a less intensively resourced environment. And that is a whole new set of skills that people need to develop. And this is why we always have senior residents go there. I found it that, you know, a junior resident just hasn’t got the way with all yet to do this. And that’s why we not only encouraged, we mandate that they are senior visits. Got it. So that you just used a phrase there that I want to key in on him. It’s solving problems and under-resourced environments. So you mentioned in your Kevin MD article that sometimes you have these complex problems where you’re resource constrained and you are sometimes able to, whether it’s an administrative issue, a systems issue, or even like a clinical issue, you’re able to work through, troubleshoot and solve these problems with a straightforward and simple solution.
Dr. Berend Mets (20:44):
Yeah. So can you give me maybe a couple of examples or stories of how that’s been? So yes, I’ll tell the story that I said and Kevin MD. So I’m back in Guiana now for at three years later after the Lightbox episode of that I related. And we have now established this residency training program there that Dr. Alex Harvey had envisaged. And I’m in the operating room as a foot soldier teaching anesthesia residents together with the faculty there. And we were doing a complex kidney transplant in the hospital in Georgetown. And we had the pulse oximeter and now, because of course they came from Lightbox, but we didn’t have an arterial line, a radio catheter that we use to monitor the blood pressure critically from second to send it a second. And a patient with a kidney transplant has kidney disease and this patient had malignant hypertension, a blood pressure that can swing Grapey and could increase the mortality or morbidity from this procedure.
Dr. Berend Mets (21:42):
But we didn’t have the arterial line and monitoring device, which is a complex electronic device in order to measure this accurately. So instead I’ve put into practice something that I’d learned in the university of Cape town many years ago, which was just a user say line at thin tube. [inaudible] An essence where do you do is you just have a catheter which you raise above the patient’s heart, fill it with say line, inject a little, a methylene blue so you can clearly see it, attach a tape measure, and then insert an arterial line in the radial Audrey and connect this [inaudible] so that you can see the level of the water, which will then show you the blood pressure from second to second that you would experience with a far more sophistic electronic device. It works very well. And so we applied best and, and it’s one of those ideas that is what really makes a anesthesia work.
Dr. Berend Mets (22:34):
You know, we often have to trouble shoot very simple problems or complex problems and have simple solutions for them. One of the beauties of anesthesia. So I’m curious, whenever you made that recommendation for the Menominee [inaudible], how long had it been since you had done it previously? Oh, well I hadn’t done it for a very long time. And I have to tell you a story because you know, you may have heard of the blood pressure hitting the roof if you ever heard that term. Well, any anesthesiologist will know about this, but most don’t know where it comes from, whether it comes from these Salen Menominees, Zaylen, [inaudible], nominators would you know, they’d be colored with this methylene blue. And I tell this story in my book, waking up safe, exactly the same kind of story. And what happens is you know, when the blood pressure shoots up for whatever reason, of course, it shoots out the top of the capita and hits the ceiling. And so in this ICU that I worked in, you would literally have the blue methylene blue spots all over the ceiling from where the blood pressure had hit the roof. And that’s where the whole idea comes from. That’s so interesting. So I’m not an anesthesiologist, so I haven’t heard that phrase specifically, but I’m sure most of the people listening to this podcast are going to be connecting these dots. Yeah.
So you’ve worked, you know, a long time with a lot of different organizations, a lot of different doctors. Are there any others who are sort of your brothers in arms, so to speak, who are doing good work in this same space that you would want to highlight and maybe tell a few stories about some of the things that they’re able to accomplish?
Dr. Berend Mets (24:02):
Yeah, so I would say obviously having worked with the world Federation, I mean we are you know, in the business of uniting anesthesiologists around the world does about 500,000 of us around the world. And the world Federation is a Federation of the societies of anesthesia around the world. So there’s 130 societies of anesthesia, and so we represent them. The world Federation of course, is particularly interested in building anesthesia capacity around the world capacity and safety, and does this through multitudes of educational programs as well as publications that champion education. For example we have created in the order of 50 fellowships around the world. So what our fellowships fellowships are training opportunities for individuals from three months to a year in an adjacent neighboring country so that they can return to their country of origin after having been trained in intensive care in chronic pain management in pediatric anesthesia, which is a dynamic need around the world.
Dr. Berend Mets (25:15):
Because you know, as you know, a pediatric, a child, a particularly a very young child, is a much more complex anesthetic to give. And so often we need to enhance people’s training in this, especially this area. So these programs are literally around the world, 50 of them a year and that we managed to build anesthesia capacity. So great work gets done through that. Then there’s another organization, a health volunteers overseas, which I was the anesthesia director for for four years some 10 years, 10 years ago. It isn’t another group that actively seeks volunteers. So this I think is very important for your audience. Actively seeks volunteers who can help go to about six countries. Again, volunteering this, their support, volunteering their anesthesia services and their expertise. So this is another very good organization to consider.
Excellent. Yeah. So as you’re talking about the pediatric anesthesia need, I was thinking, I have a couple of friends who are doing some work. There’s a training hospital in Kenya with Dr. Mark Newton from Vanderbilt and I know they were doing, it sounded like a similar thing. They were there training some, some Kenyan physicians and there were other other from the African continent elsewhere that were there as well. And I remember them saying, I think it was Liberia where there was a couple of pediatric anesthesiologists there and they were pretty much the only ones in the entire country with, with the pediatric training. And you know, you said there’s hundred thousand anesthesiologists in the world. I’m doing the math in my head. I think there’s about 55,000 members of the ASA. So obviously in the U S it’s very dense and there’s, it’s a big world out there. We’re 4% of the global population here in the United States. So it sounds like just from sheer number of anesthesiologists lacking elsewhere, that’s a, that’s a big part of the,
Dr. Berend Mets (27:04):
That’s a very big part of the problem. And let me just pick up on two things there. Firstly, Mark Newton is a fantastic man. He’s also part of the world Federation societies of anesthesia and also received the global humanitarian outreach award from the ASA gho committee. We we provided an award once a year to somebody who has made the, the largest impact on global health and Mark magnesium received that two years ago. Then just to give you a comparison, you, you said quite rightly the number of anesthesiologists here. It’s in the order of 50,000 in the United States, and we have a population of this, this side of 300 million. Let’s use that as an example. This, let’s move now to Ethiopia. Ethiopia has a population of 80 million people. It has lost count 67 anesthesiologists. Wow. And about 400 nurse anesthetists that are trained through the black lion hospital where I was talking about, you know, we send people to as well.
Dr. Berend Mets (28:10):
So that is one of the problems. The problem is that there aren’t enough qualified people to give anesthetics around the world. And so this is what we call capacity building, you know, as step by step by step setting up programs that allow people to be trained at all types of levels in order that they can give as safe anesthesia as possible. Yeah. How does this another very important statistic and trend, which is a very concerning and that is as the surgeons become more trained and more competent in, let’s call it a low low middle income countries, they are braver about doing particularly more complex surgery. The problem is that often the anesthesia capacity doesn’t advance at the same time. And so while we see that surgical mortality is improving, anesthesia mortality is not improving at the same rate. In other words, there are just not the right number of individuals to provide the safe anesthesia obviously that the patients deserve. And so that’s another critical problem that we have to try and address. Hmm.
Can you talk a little bit specifically how this relates to the, the OB anesthesia? Because I know childbirth, labor and delivery has its own sort of separate set of considerations. Talk about the, the, you know, your work in that context.
Dr. Berend Mets (29:33):
Yeah. So, you know, the biggest concern there of course is that you have a mother and a child and they’re in labor. And so there’s lots to worry about in many places around the world, the mother might go into something we call obstructed labor so the baby can’t come out. And the only solution we have is a C-section. And if you don’t do a C-section, the mother dies from the labor and the baby does it, then they both die. So a big problem around the world is that the laboring mother does not have access to either surgery and anesthesia because you can’t do the surgery without an incision. And so they just die. And the figures are something like 80,000 or more a year dying like this. And that’s probably a low number compared to what’s actually happening. So this is a crucial concern and this is why the launch that commission pulls together surgical obstetric and anesthesia services are needed around the world. So the statistics that I’ve been quoting you are for surgical obstetric anesthesia requirements around the world.
Understood. So there’s obviously a lot of work to be done. I’m sure there’s probably people listening out there that are thinking, I want to maybe today or maybe tomorrow take a very practical first step to say, I want to do my part as an anesthesiologist or an anesthesia resident or fellow to start to either help an under-resourced areas or developed systems that can be replicated elsewhere so that we can train you know, local physicians to be able to provide these very needed services. If you had to give one or two very practical, here’s something you can do today, here’s a place you can go, here’s an organization you can talk to. How would you direct somebody who was interested in that?
Dr. Berend Mets (31:14):
Well, I think as I just said, health volunteers overseas is a great opportunity to go to health volunteers overseas because they are actively seeking volunteers. Then on our, our gho website we have what we call gho alerts. So we post on there and there, I just looked at it yesterday. There’s a whole lot of alerts I posted there for where, where people are critically needed. For example, we post on there that we need volunteers for our two programs in Rwanda and Guiana and so that’s another opportunity but we keep posting at those sites. Then operation smile and smile, train to different organizing stations are always seeking volunteers, supervised anesthesia, particularly for a cleft palates. So that’s another opportunity. And then you can always, you can always provide the nations to Lightbox or to the world Federation. We have a fund, the fellow program, I just told you a little bit about the fellows and and of course over time you can try and get involved with the world Federation of course with our LSA G H O committee. As you can imagine, our committee is a well subscribed and a lot of people wish to be honest and so we try our very level best to comment those, those requests. Excellent.
So you just threw out a lot of great information. I’m going to make sure we capture all of that in the show notes. So anybody who’s interested, anesthesia, success.com/ 41 we’re going to have links to all these resources that Berend is referencing here and would love to be able to make this as easy as possible for anybody who’s wanting to really get involved to do so. Okay, well I want to wrap things up here, Berend. Don, I really appreciate your time today. In closing, you are a man with vast experience flying all over the place, training people in a bunch of different countries doing clinical and administrative and systems work all over the globe. So I want to just close with a personal story. Take me to a moment when you know you’re really, you’re focused, you’re exerting, you’re sacrificing a lot. And take me to a moment when things were transpiring in a way where you’re able to reflect and say, all the work that I’ve put in, all the systems that I’ve been trying to construct, the people with whom I’ve been collaborating in this moment, I see it working. I see some fruit being born and it’s really a beautiful thing to behold.
Dr. Berend Mets (33:33):
Yeah. You know, I see that best in the smart smile of a global scholar who’s been you know, to one of our programs. So the global scholars programs, the ASA, they come from a different country. They’re selected, they rotate through a particular hospital. And then after that they come to the ASA meeting and they talk to me and they say, yeah, I’m inspired and I’m going to go home and I’m going to fix things, you know. And that’s when I realized that this is great because I actually had that opportunity when I was in South Africa. I came to the States on a scholarship when I was a young resident. And you know, the importance of these things is letting individuals see how it can be. And so, you know, we are very good here in the United States and they get the opportunity to see how it can be and so they can develop that vision for them cells or for their countries. And they can go back. And when I hear, for example, that one of our volunteers, our American volunteers in Guiana is meeting with the minister of health in Guiana to help solve their problems. That puts a smile on my face because then I know that we’ve started to connecting and making a real difference in that country, not just to the anesthesia, but for helping structure the efficiency and safety of surgical and anesthesia and obstetric services. So those, those are the the moments that I look forward to.
Excellent. Well, dr. Mets, thank you very much for joining us today. It’s been a pleasure speaking with you on the anesthesia success podcast.
Thank you very much. Pleasure to be here. If you liked what you heard this week, head on over to anesthesia success.com where you can find more content and free resources to help you build a successful career in anesthesiology and pain management. If you want to leave a review in iTunes, I would also really appreciate it. Thanks for using some of your valuable time to join me today on the anesthesia success podcast.