The Work of a Surgeon
Dr. Mark Shrime is an outstanding surgeon who has focused on head and neck surgical oncology throughout his career and is an asset to the Mercy Ships surgical team. Mark serves at the Royal College of Surgeons in Ireland and lectures at Harvard Medical School where he has additional degrees in global health and health policy.
Mark’s credentials and accolades are only superseded by his passion for justice and working where health, impoverishment, and inequity intersect. When not in a classroom teaching, you can find Mark volunteering in the operating theatre on board a Mercy Ships vessel.
In this episode, Mark shares the complexities of the surgeries he performs, his journey to find his own purpose, and the impact Mercy Ships has had on him. Get ready to be blown away by this brilliant man and inspired by the intentionality with which he lives his life.
Dr. Mark Shrime has recently published a book entitled: Solving For Why: A Surgeon’s Journey to Discover the Transformative Power of Purpose.
For more information about Mercy Ships, go to www.mercyships.org
New Mercies Podcast Transcript
Welcome to New Mercies a podcast by Mercy Ships, where we’ll take you behind the scenes and on board our incredible hospital ships that are transforming lives all over the world. We invite you to join us each week as we sit down with our crew, patients, volunteers, and partners to hear their stories of life-changing hope and healing.
Today, my guest is Dr. Mark Shrime. He is a highly accomplished and awarded surgeon specializing in head and neck tumors. Mark’s resume and degrees are very impressive, but what will impress you more is his heart for the poor and his passion to make a difference in global health. Mark comes alive where health impoverishment and inequity intersect. And in this episode, Mark shares how Mercy Ships is just that place. Here is part one of my conversation with Dr. Mark Shriver.
Well, Dr. Mark shrine, welcome to New Mercies. First of all, where are you right now? And what are you doing?
Dr. Mark Shrime:
I am currently in Dublin, Ireland. I’ve just come back from three weeks on the ship finishing off a job here in Ireland as the chair of Global Surgery at the Royal College of Surgeons in Ireland.
You mentioned that you were just on board the Africa Mercy, I assume performing surgeries. So, tell us a little bit about some of the patients you just saw. But also, what was it like to be back after our premature departure in 2020, due to the pandemic?
Yeah, it was one of the harder and stranger field services I’ve been on. I’ve been coming to Mercy Ships since 2008. Coming a couple of times a year up until COVID. So, I spent a bit of time on the ship. And this was a very different time to be on the ship. both good and bad, restarting, you know, major operation like Mercy Ships after kind of two years, there’s some rust to shake off, which I think we all expected. So we’ve, I’d say wisely, the leadership have decided to restart a little bit more slowly, fewer cases this time around than last time. On the plus side, though, when we left in March of 2020, we left a number of patients that had been booked for surgery that didn’t get to have their surgeries.
So that’s been really nice to be able to come back and take care of those patients who were booked two years ago or at this point may have even been booked as much as three years ago. See some of the patients that we operated on back in 2019, who needed a scheduled or unscheduled revisions, it was great to be able to be back and take care of those issues and those problems and those patients. It’s been a very different field service than before positive and negative.
I think the restrictions that are in place, wisely, probably add a different dynamic as well to the crew. And even though as a surgeon, and in the hospitals, y’all wear masks and so forth, and you’re in protective gear, how did that dynamic change amongst the crew and just ship life for you?
Yeah, so there are differences, right? We’re wearing masks all the time, basically, all the time, unless you’re in your cabin, and you were wearing a mask, or if you’re eating that changes things. I’m gonna say though, after 14 years on Mercy Ships, I’ve seen a lot of changes on the ship. And at every change, there is always a fear that we will quote unquote, lose community. When I started on the ship, there was no internet besides in like on the whatever 10 computers that were in the internet cafe. And then WiFi like was in the public areas, and, “Oh my gosh, we were going to lose community because now WiFi is in the public areas.” And now it’s in the cabins and we’re going to lose community. Community forms, you know, it’s an organization of likeminded people there to do a pretty tough job and stuck together on a ship. Was this the easiest way to create community? No, it would have been easier if there weren’t masks. But did that prevent us from creating community? Absolutely not. I think the bigger prevention, or the bigger barrier, was probably between us and our patients.
Prior to the COVID. We weren’t wearing masks on the wards. We weren’t wearing goggles and aprons and all of the all the things. We were, as you said, wisely, this time around because all of us were vaccinated. Six percent of the patients are vaccinated, so we want to make sure that we’re not transmitting COVID to them… that I think was a little bit more difficult because you can’t you know, when you’re when you’re communicating across languages, you know, through translators, I think there’s a lot more that your body language and your facial language can say and that, I think, was the bigger barrier.
Yeah. And that is one of the special things about Mercy Ships is the bond that you get to build with the patients that I don’t think we see often in hospitals in the West. And so, I can imagine that that was a little bit disappointing, but yet the beautiful work that you get to do for those people will change their lives forever. So, that is so wonderful.
Tell us a little bit about when you first heard about Mercy Ships, and what caught your attention about the organization that caused you to want to go and volunteer.
I first heard about Mercy Ships in around 2006. I don’t remember the exact time, but it was around 2006, I was finishing my residency. I did a residency in ear, nose, and throat and knew I was going on to do a fellowship, a sort of a subspecialty training in head and neck tumors. It was in the middle of my last year of residency that a friend of mine, a new photographer that used to be on the ship, who’s now gone on to do other things. But this photographer was from New York City, we were all living in New York City. And he was having a basically a showing of the pictures, that he had taken and the stories that he had heard.
So, my friend dragged me to this… I did not want to go. I was exhausted — your residency is exhausting — didn’t want to go into this small art gallery. And he started showing these pictures. And yeah, it’s a lot of patient transformation pictures before and after and the stories of the patients and returning to their families and realizing that this is what I’m actually training to do is exactly this.
There aren’t a lot of organizations that do this sort of specialized surgery, and there weren’t back in 2006, there are a few more now. So, I was looking to, you know, take some time off and do some volunteer work. My choices were either do general medicine, which I mean primary care which okay, but I hadn’t done that since med school, or to work with an organization that worked in the specialty that I was in. And that was Mercy Ships.
That was that great connection.
You are a surgeon, and you said primarily with head and neck tumors, and I think in the US with cancers, and so forth. As a surgeon, you do some pretty amazing things with the human body. I think that surgeons are a little bit of a combination of a magician, an artist, and engineer all rolled into one. And without being too graphic, can you walk us through some of the things that you do in your complex surgeries?
You’re very kind because the other thing that you could say is that there’s probably a touch of psychopathy, and each of us.
Yeah, a little bit of Frankenstein stuff goes on. But you know…
Yeah! You know it really depends on the tumor, really depends on the case itself. When you operate in the head and neck. There, at any one time, two different things that are going on in your head, there is what we call the ablations of taking out the problem, then there’s the reconstruction. So, you’ve made you’ve made a hole, how do you fill that hole? In some cases, like cleft lip and palate, there’s no ablation, the hole is already there, you just got to reconstruct. In other cases, the tumor is fairly small, and there’s no real reconstruction you have to do, you just kind of take it out and sew it back together.
But you know, for some of the more complex cases that we do tumors of the lower jaw tumors of the upper jaw, then it becomes this sort of dance between taking the tumor out, making sure you’ve got it all out and then reconstructing the face with tissue from the area, bone from distant areas. You know, the face is such an interesting place, it’s eight inches, basically. And we as human beings, basically, that’s the entirety of the of the human being, you know. We react to people’s faces more than anything else. It’s your humanity in eight inches. So, it’s really important to recreate that as best as we can. Sometimes we can’t, we almost never can make it exactly right. But to make it as close to right as possible, and to take away the disfigurement of the tumor or the cleft itself, so that, as Gary Parker, one of the surgeons on the ship says, so that “these patients are given back their seat at the table of humanity.”
Yeah. I know, in your book, which we’ll get to that in a little bit, because you have just written a phenomenal book that everyone needs to read. But you talk about a specific surgery that you went through, and you mentioned taking parts of skin grafts and bones from different parts of the body to reconstruct whether it be a jaw or, you know, parts of that face, as you mentioned… what are some of those things that you do? Again, not being too graphic for some non-medical people… but I just think it is extremely fascinating. And I think most people have no idea what kinds of things the human body is able to do that then surgeons are able to do through the human body.
Now, these are fascinating operations. This is why I love what I do. Let’s take as an example, let’s take a tumor of the lower jaw of the mandible. A really common thing that we see in West Africa. Often these are growing in the bone itself. So, the bone itself is the tumor, which means you can just kind of take the tumor out and leave the job behind, you end up taking the job because that’s where the tumor is. So, you take part of the jaw, which as you can imagine, leaves a fairly significant defect. There are a number of different ways to reconstruct that defect. What I learned when I was in my specialty training up in Canada, you can actually take bone from the leg with skin, if necessary, muscle if necessary, and specifically the vessels that feed that bone. So, you take the whole thing, the bone and the vessels and the other stuff, if necessary, bring that whole thing up into the neck, attach the vessels to the vessels in the neck, that gives supply to the bone, and then use that bone to recreate the jaw.
This is a technique called a free flap on the ship — I’ll explain why we do them more rarely on the ship. But on the ship, we do a little bit of a different approach, what we’ll do when we take out the jaw is we will just put a piece of metal in its place for a bit, that piece of metal holds the shape of the skin holds the shape of the muscles, we let everything heal. And then three months later, we will go and take bone from the hip, just by itself, no vessels or anything attached, take bone from the hip, put it back around that metal plate, the metal plate is made of titanium. Titanium has this weird property where it grows into bone. It sort of integrates itself with bone. And so, by doing that, you end up recreating a new jaw along that plate.
Oh, my goodness, it is absolutely incredible. And I think the complexities of the human body that even a part of the hip bone could be transformed into and take hold and adapt into part of the face. It’s unbelievable. And I just really think what you guys do, is mind blowing, and so extraordinary.
I’m sure that it has also impacted you seeing some of these severe cases in West Africa that we really don’t see in the United States. Tell us a little bit about some of the impact that the patients have had on you. And maybe even a specific patient that that left a mark on you.
Let me answer your first question first. And we’ll talk about a specific patient. I will just say outright that certain stories from certain patients have basically driven my entire career in terms of my research and the things that I write about. The fact is, sure, there’s a little bit of a difference in the types of things that we see between the U.S. and West Africa. But honestly, they’re not. It’s not that much. Most of the tumors that I take out in West Africa are the same as the tumors I take out in the U.S. It’s just that if you or I noticed a lump in our jaw, we would be in the doctor’s office, I don’t know within a week, two weeks, because we have access to care.
For many of these patients. It’s not like they don’t know that there’s a lump in their jaw… they know there’s a lump in their jaw, just it’s either too expensive, too far away, the quality is too poor. So, they sit on these tumors — through no fault of their own because that’s what the system that they’re living in is — they sit with these tumors for 20 years, 30 years. So, tumors grow, that’s what they do. And so, we end up seeing these really impressive cases that are made of exactly the same stuff, as the tumors in the U.S. or Ireland or wherever. All they are, really, all they are, the size is just a marker of inequity.
So, you know, hearing those stories, hearing the stories of patients, you know, this story I tell often when I’m giving talks is about a patient who had a particular disease that we actually don’t see in the U.S. But she had a particular disease, went to the hospital to get a treated, they weren’t able to treat it, but they kept her in the hospital trying to treat it as best as possible. And she stayed in the hospital until basically her family’s money ran out.
So, like you hear the stories, the other things that are happening with patients, in addition to the tumor or the cleft or anything, there’s, there’s the tumor, the cleft surfaces, the health effect that these things have on the patient. There’s the financial effect that these things will have on the patient and their family both by trying to access care. But also, as we talked about because you know, we embody everything in the face. If you’ve got, you know, you say you’ve got two stores side by side, one that’s owned and run by somebody who’s got a big tumor in their neck, and the other that’s owned and run by somebody who doesn’t, well, of course, as a consumer, you’re gonna go to the other one. So, we’ve got a financial effect that way. And then, you know, we’ve got the effects, the sort of fundamental issues of inequity and equitable access. So, I’m rambling here but listening to all these stories of patients, really starts to bring out these things that we talk about as hypotheticals are really real with patients.
Absolutely. And maybe that’s the bigger difference. As you mentioned, the tumors you see aren’t that different, except they’re bigger. But maybe the difference that you see more so is the inequality, you know that we are privileged to have access to medical care, whereas people in developing nations and specifically West Africa, they do not have that access. And if there is something, it will rob them of all that they have to potentially help them a little bit. Oftentimes, the outcome isn’t something that is favorable.
I was gonna say, I agree. Now, that’s not to say that it’s always not favorable, right. I don’t I really don’t want to make this impression that, you know, we’re the only ones that know how to do surgery, right? We obviously face you know, what in research, we call selection bias, we’re only seeing the patients that come to us, you know, if you get your tumor, or hernia or whatever treated at the local hospital, we’re obviously not seeing you. So, by definition, we are the patients that have come to us are a self-selected group of patients already.
But given that, yeah, those are the stories that we hear stories of inequity stories of have difficulty accessing the healthcare system. I have a benign, basically fat tumor on my shoulder that I’ve known, it’s been there for about five years, I know it’s there, I went to see the doctor, the doctor said, that’s what it is. And I’ve decided not to do anything about it. And for the moment until it gets too big. And that, in and of itself is a symbol of the privilege that we have. I can choose when I want to take this out. I know it’s there. I know, I have access to a surgical system whenever I want to, I can choose to wait on it. These patients don’t have the choice.
You mentioned that the things that you’ve been experiencing on Mercy Ships, has really fueled a lot of your research and a lot of the things that you’re a part of organizations and so forth, you talk about just the injustices of poverty, and what do you think are some steps forward to remedy the problem of a lack of healthcare for a huge portion of the world?
Great question with, as you can imagine, a somewhat complex answer. But I like to go back to the late Paul Farmer used to say that for true delivery, for true access to care, you need four things, you need space, stuff, staff, and systems. And I think that’s especially true with surgery. To give an example, let’s say we’re treating HIV and treating HIV is not easy. If it was then we wouldn’t have an HIV epidemic on our hands. But one of the easier parts of treating HIV is the drug development, in that you can develop and manufacture the drug somewhere, the U.S., Europe, India, China, wherever you can develop a new drug and manufacture it there. And then you can bring the drug itself, the pill itself, to the patient. Now getting you know, supply and compliance and all that sort of stuff. I agree that that’s a whole other issue. But with surgery, you don’t have that luxury, you’ve got to bring the entire means of production, close to the patient, you can’t just produce the surgery somewhere else, and then package it into a pill and give it to the patient, you’ve got to bring everything, the space, the stuff, the staff, and the systems closer to the patient.
In the public health world, we talk about horizontal and vertical interventions. Surgery is an annoyingly horizontal intervention in that you can’t just come in and train people, because if there aren’t hospitals and equipment and systems for them to work in it doesn’t help. You can’t just build hospitals, because if there aren’t people to work in them, it doesn’t help. You gotta be completely horizontal across this entire space, stuff, staff, and systems. Which means no one organization is going to do all those things. No one person is going to do all those things.
I think we and by we, I mean Mercy Ships, but we I also mean surgeons working in this arena in general, A kind of need to a realize what our strengths are, which I think a lot of organizations do, but then B realize where we aren’t as, as successful and partner with organizations that are and people that are. And then finally, this is something that is going to be really easy to say but you know, nobody can snap their fingers and make us happen. The U.S. healthcare system for all of its faults, or the Irish healthcare system, for all of its faults didn’t develop because well-meaning people from, I don’t know Nepal, decided to fly to the U.S. and say, “Okay, we’re going to build your healthcare system for you.” It developed because as the countries got more wealthy, as the individuals in the countries got richer, they demanded more.
And so honestly, you the longer I work in health, the more I think the most sustainable way for us to improve healthcare systems. The space the stuff, the staff, the systems are all important, but the most sustainable way to do it is to improve education and the economy of a country. Because the true driver, the true sustainable driver is going to be not from external factors, it’s going to be internal.
Yeah, you guys do a lot of educating. I know that Mercy Ships is really big on my medical capacity building. And you have been a part of that. Tell us a little bit about what that looks like for you in being an educator to the local people.
Yeah, so I’m the Medical Capacity Building on Mercy Ships… when I started back in 2008, we didn’t do any of that. And probably over the last, I want to, say, seven to 10 years, and Michelle White, and I don’t know if you’ve spoken with Michelle… Michelle was one of the big drivers of building the Medical Capacity Building on Mercy Ships. And it’s really like, I’m so glad she did, it’s really become the like, second pillar of what we do. And it’s really important, because that addresses the staff question in Paul Farmers, you know, little formula. There’s a tension and I think, not as important tension as we think it should be, but there is a tension between these ideas of relief and development. In other words, the most sustainable way for us to do these things is to build the space, stuff, staff, and systems, that’s going to take a really long time. And in the meantime, there are a bunch of people who have tumors and clefts and bowed legs that, you know, if we only worked on developing things, then they would fall through the cracks. So, what I like about the Mercy Ships approach is that we try to do both.
We try to deliver relief in the operating room and also deliver development primarily on the workforce side in the MCB department. You know, my favorite times on the ship, are when I get to work with surgeons from within the country. And it really, there is a tendency to frame this as well, “Let me teach you how to do things,” which is horribly colonialist, and also not actually true. What you end up, and what I’ve ended up finding, is that we’re working with fully trained surgeons, and they’re working with fully trained surgeons, we’re both fully trained surgeons. There are techniques that I know that maybe they don’t and there are techniques that they know that maybe I don’t. And that’s what happens when it’s done best. That’s what happens in the operating room is this knowledge exchange.
It’s understanding, you know, how this this surgeon that you know, has been working in… you name a country… has been working in Liberia for 30 years with like, a knife, fork, and spoon. How is he approaching this tumor when I come from a place with all sorts of technology? And what are the tricks that that he or she has in approaching this tumor? One last thing I know, I’m rambling. But one last thing is we also develop our relationships with these surgeons. It doesn’t always happen. But there are a couple of surgeons that I can think of one from Togo, one from Senegal, that I am still in fairly regular contact with by email or WhatsApp, with, you know, questions about how do we approach this case? What should we do here? And I think that’s also one of the best parts of this MCB.
Yeah. And I love that you mentioned going into it with a teachable spirit yourself, not being there saying, I have something to offer you, so go ahead and listen. But really having this teachable spirit that comes and says, “What can I learn from you as well, let’s have this equal exchange of knowledge and experience.” That must be so empowering, really, for both of you, you know, on both sides to affirm that you both have value, you both have something to offer. I just love that. I think that’s such an important model and an important posture to take in education in general. What is it about Mercy Ships that has caused you to return time and again, 2008 was your first time on board? Why do you keep going back? What has captured your heart, if you will, about Mercy Ships?
So, that’s a really great question. And I think there’s a number of ways that I can answer it sort of self-centered: this is an organization that does the specialty that I’m working in. And that really helps. But I think there are a couple of things that keep me coming back. One is that, you know, I believe in the results that we get. Now, we’re only just probably in the last few years starting to really, objectively, look at these results. That side of our house hasn’t been developed as much, but we’re starting to develop it. You know, we get good results like this isn’t a fly by night operation. There’s been going on for 44 years like you’d hoped we would have figured some things out… and that’s another thing that keeps me coming back is that there are things that have been figured out. You know, I’ve worked with other organizations or other hospitals, every organization has its good parts, and its underbelly and Mercy Ships is the same.
But a lot of stuff has been figured out and is done well. And then this sense of community. I have said this before, it really feels like, you know, when I’m on the ship… down in the hospital specifically, it is, you know, medicine as it’s supposed to be. There is much less. There’s no billing or medical legal considerations like we have in the U.S. There’s much less ego. We’re really — they’re all volunteers all trying to do the same thing. So, it’s medicine, stripped of all the stuff that I hated when I was practicing in the U.S.
Yeah, I think you’ve, you’ve touched on it a little bit how Mercy Ships has impacted you. I know that in your book, which is called Solving for Why: A Surgeons Journey to Discover the Transformative Power of Purpose — brilliant book — you talk about Mercy Ships in there a little bit. How has Mercy Ships changed your life? Personally.
I didn’t want to be a doctor, like, you know, actively, adamantly didn’t want to be a doctor. Primarily, I wanted to be a rock star, I wanted to be a philosopher, I wanted what I really wanted to be was a linguist, I wanted to work for Wycliffe Bible Translators and you know, disappear for 20 years into the jungles of Papua New Guinea and translate the Bible, and maybe Shakespeare, and you know, come back out when my job was done.
But I am the firstborn son of an immigrant family. And immigrant children know that we have three options: doctor, lawyer, or failure… So you know, I went into med school, kind of because I needed to, because I was told to, and hated it. Really tried to quit, you know, I started med school in August of a year that I’m not going to say, because it’ll tell you how old I am… By September of that year, like I was already trying to quit, and I tried to quit over and over and over again.
And I kept being told by, you know, senior people stick it out, you know, it gets better, it gets better, it gets better. And it does, like as you go through training, it does get better. But I kept getting to better and still hating it. And this continued for 15 years, between the time I graduated high school, to the time I first went to the ship was 15 years of education and training in stuff that I to a large degree didn’t like.
There were a few years in there that I did enjoy them, but really just like, hated it. Hated what I was doing hated the path that I was on. I remember really clearly the first time walking down the red staircase at the front of the ship. And if you’ve been on the ship, you know this red staircase taking a right and a left and walking into the wards and seeing a dozen patients with head/neck tumors, you know, at various stages in recovery, pre op, post op, and having this road to Damascus moment of, “oh my gosh, this is what I’ve been training for 15 years to do. And I didn’t even know it.”
You know, that experience. I hate the phrase life changing. But it was life changing. It literally changed the direction of my life. I went back finished my training, did the whole, you know, be a surgeon at an academic center and you know, big city in the U.S. and continued to realize that that was not the direction that I wanted to go. Now, it took me 10 years between that epiphany moment and the time I finally quit my practice in the U.S. to fully devote myself to this Global Health thing. So, it wasn’t this, you know, experience and then oh my gosh, the scales have fallen off and I have been transformed. I’m still a very… what’s the word? I’m not a brave man. But yeah, that’s really, it. Really, that experience made a 90 degree turn in my life.
Yeah. Well, I think it’s true that anybody who steps foot on one of the ships is impacted in some way. Their life is not the same when they leave, and we talk a lot about the patient’s lives being changed. But really, the crew, the doctors, the surgeons, the housekeepers, no matter who it is going on that ship and having the experience, it really changes you in some way.
There used to be… back when I first started on the ship… one of the nurses on the ship, she was the OR supervisor. She used to sort of recommend she used to advise that everyone keep in mind that our mission is our mission. And the ship may or may not be part of that mission, but the ship itself is not is not your mission. I think that’s really true. You know, I talk about this my book, you know my own, Why.. Solving for my own Why is about all these inequities in the injustice that we were talking about before.
And the ship for me has been an incredible way of living that out. And it’s true for a lot of us that come onto the ship. It’s not true for everyone, even if it’s not true for people, very often, it’s the first time that you’ve been confronted with these inequities. And that’s life changing.
Absolutely. Well, thank you so much for all that you continue to do for Mercy Ships. And thank you so much for taking the time today to share with us a little bit.
Thanks for having me.
Mark has just given us a lot to think about and consider, but there’s still more to come. Next week, you’ll get to hear part two of my conversation with Mark, where we’ll talk about his new book entitled: Solving for Why: A Surgeon’s Journey to Discover the Transformative Power of Purpose. I’ve just finished reading it myself and it is phenomenal. You won’t want to miss Mark telling all about his new book.