Georges Azzie

SickKids, Toronto, Ontario, Canada

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Publications (27)40.04 Total impact

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    ABSTRACT: Differences in opinion exist as to the feasibility of establishing sustainable laparoscopic programs in resource-restricted environments. At the request of local surgeons and the Ministry of Health in Botswana, a training program was established to assist local colleagues with laparoscopic surgery. We reviewed our multifaceted and evolving international collaboration and highlighted those factors that have helped or hindered this program.
    Annals of surgery. 06/2014;
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    ABSTRACT: IMPORTANCE Surgical conditions are an important component of global disease burden, due in part to critical shortages of adequately trained surgical providers in low- and middle-income countries. OBJECTIVES To assess the use of Internet-based educational platforms as a feasible approach to augmenting the education and training of surgical providers in these settings. DESIGN, SETTING, AND PARTICIPANTS Access to two online curricula was offered to 75 surgical faculty and trainees from 12 low- and middle-income countries for 60 days. The Surgical Council on Resident Education web portal was designed for general surgery trainees in the United States, and the School for Surgeons website was built by the Royal College of Surgeons in Ireland specifically for the College of Surgeons of East, Central and Southern Africa. Participants completed an anonymous online survey detailing their experiences with both platforms. Voluntary respondents were daily Internet users and endorsed frequent use of both print and online textbooks as references. MAIN OUTCOMES AND MEASURES Likert scale survey questionnaire responses indicating overall and content-specific experiences with the Surgical Council on Resident Education and School for Surgeons curricula. RESULTS Survey responses were received from 27 participants. Both online curricula were rated favorably, with no statistically significant differences in stated willingness to use and recommend either platform to colleagues. Despite regional variations in practice context, there were few perceived hurdles to future curriculum adoption. CONCLUSIONS AND RELEVANCE Both the Surgical Council on Resident Education and School for Surgeons educational curricula were well received by respondents in low- and middle-income countries. Although one was designed for US surgical postgraduates and the other for sub-Saharan African surgical providers, there were no significant differences detected in participant responses between the two platforms. Online educational resources have promise as an effective means to enhance the education of surgical providers in low- and middle-income countries.
    JAMA surgery. 02/2014;
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    ABSTRACT: Background Construct validity for the Pediatric Laparoscopic Surgery (PLS) simulator has been established through a scoring system based on time and precision. We describe the development and initial validation of motion analysis to teach and assess skills related to pediatric minimal access surgery (MAS). Methods Participants were asked to perform a standardized intracorporeal suturing task. They were classified as novices, intermediates, and experts. Motion in the four degrees of freedom available during traditional MAS (PITCH, YAW, ROLL and SURGE) was assessed using range, velocity, and acceleration. Results Analysis of motion allowed discrimination between the 75 participants according to level of expertise. The most discriminating motion parameter was the acceleration in performing the ROLL (pronation/supination) with values of 30 ± 27 for novices, 15 ± 5 for intermediates, and 3.7 ± 3 for experts (p < 0.001). Conclusions Tracking and analyzing the motion of instruments within the PLS simulator allows discrimination between novices, intermediates, and experts, thus establishing construct validity. Further development may establish motion analysis as a useful “real time” modality to teach and assess MAS skills.
    Journal of Pediatric Surgery. 01/2014;
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    ABSTRACT: To examine how a mass-gathering event (the Federation Internationale de Football Association World Cup, 2010, South Africa) impacts trauma and mortality in the pediatric (≤18 years) population. We investigated pediatric emergency visits at Cape Town's 3 largest public trauma centers and 3 private hospital groups, as well as deaths investigated by the 3 city mortuaries. We compared the 31 days of World Cup with equivalent periods from 2007-2009, and with the 2 weeks before and after the event. We also looked at the World Cup period in isolation and compared days with and without games in Cape Town. There was significantly decreased pediatric trauma volume during the World Cup, approximately 2/100 000 (37%) fewer injuries per day, compared with 2009 and to both pre- and post-World Cup control periods (P < .001). This decrease occurred within a majority of injury subtypes, but did not change mortality. There were temporal fluctuations in emergency visits corresponding with local match start time, with fewer all-cause emergency visits during the 5 hours surrounding this time (-16.4%, P = .01), followed by a subsequent spike (+26.2%, P = .02). There was an increase in trauma 12 hours following matches (+15.6%, P = .06). In Cape Town, during the 2010 Federation Internationale de Football Association World Cup, there were fewer emergency department visits for traumatic injury. Furthermore, there were fewer all-cause pediatric emergency department visits during hometown matches. These results will assist in planning for future mass-gathering events.
    The Journal of pediatrics 11/2013; · 4.02 Impact Factor
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    ABSTRACT: The Pediatric Laparoscopic Surgery (PLS) simulator is the only validated tool for pediatric Minimal Access Surgery. Construct validity (the ability to discriminate between novice, intermediate and expert) for the PLS simulator had previously been established on the basis of the total PLS score, as well as the individual performance on three of the five tasks. We describe the process and methods used to establish independent construct validity for a fourth task: pattern-cutting. After considering various options for the possible modifications of the task itself, we retrospectively altered the way the pattern-cutting task was scored by modifying the weighting of precision versus time without changing the task itself. This was subsequently tested prospectively at the 2011 Canadian Association of Pediatric Surgeons meeting. Modification in the scoring metrics allowed differentiation within a previously tested cohort of 84 candidates (20 novices: score=48±16, 19 intermediates: score=59±18, 45 experts: score=69±12 p=0.01). This was validated prospectively in a cohort of 18 experts and 7 intermediates (65±8, 54±17 p=0.03). Construct validity for the pattern-cutting task was established by modification of the scoring metrics. This was validated both retrospectively and prospectively.
    Journal of Pediatric Surgery 10/2013; 48(10):2075-2077. · 1.38 Impact Factor
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    ABSTRACT: BACKGROUND: Constipation in children is a commonly encountered problem with a broad variety of causes. Constipation caused by a narrow pelvis has, to our knowledge, not been reported in the human literature. METHODS: Retrospective review of patient chart, in depth follow-up appointment with the patient and review of literature. RESULTS: A 15year old girl with sacral agenesis and significant co-morbidities was referred for consideration of cecostomy tube placement to manage her constipation. Digital rectal exam revealed a very narrow pelvic outlet and CT scan confirmed abnormal configuration of the bony pelvis. Discussions with orthopaedic colleagues concluded that bilateral pelvic osteotomies to widen her pelvis may relieve her constipation. The procedure was uneventful and radiologic follow-up confirmed widening of the pelvic outlet and increased pelvic volume. Her stooling pattern improved postoperatively and she was satisfied with the result on follow up at one year. CONCLUSIONS: Although previously described only in the veterinary literature, surgical widening of a narrow pelvis can be considered for the management of constipation in the rare patient with appropriate physical and radiologic findings.
    Journal of Pediatric Surgery 05/2013; 48(5):e29-e31. · 1.38 Impact Factor
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    ABSTRACT: Abstract Fibroblastic and myofibroblastic tumours constitute an important group of neoplasms in children and adolescents. These span the full spectrum of clinical behaviour ranging from benign, to intermediate and malignant. We report a case of a benign mesenchymal tumour with myofibroblastic differentiation in a 9-year-old girl arising in the left groin which met the histologic features described for myofibroblastoma in adults. Two types are recognized in adults, namely angiomyofibroblastoma and mammary-type myofibroblastoma of soft tissue. Our case shared features of both these subtypes but was not typical of either one, and we therefore designated our case simply as 'myofibroblastoma'. Our case showed expression of estrogen receptor protein characteristic of adult lesions but not a deletion of 13q14 as has been reported in some adult cases. In a review of the English literature, only six cases have been reported in patients under 21 and all were teenagers except one. Pediatric surgeons, oncologists and pathologists should be aware that such a benign entity can occur in this patient population and could be confused with other lesions including malignant ones.
    Pediatric and Developmental Pathology 08/2012; · 0.86 Impact Factor
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    ABSTRACT: BACKGROUND: The global burden of surgical disease and severe shortage of trained surgeons around the world are now widely recognized. The greatest challenge in improving access to surgical care lies in sub-Saharan Africa, where the number of surgeons per population is lowest. One part of the solution may be to create programs to train surgeons locally. We present our experience with an approach to designing a contextually appropriate surgical curriculum in Botswana. METHODS: Surgical logbooks from the largest tertiary care center in Botswana, dating from 2004 through 2010, were analyzed to yield total case numbers within clearly defined categories. Case numbers and local surgical opinion were combined to design a contextually relevant curriculum, with the Surgical Council on Resident Education curriculum as a template. RESULTS: Logbook analysis revealed that general surgeons in Botswana manage burns and perform a large number of skin grafts and extremity amputations. However, they perform few colonoscopies and complex laparoscopic procedures. The new curriculum included greater emphasis on surgical subspecialty procedures and surgical management of locally relevant conditions, such as the complications of infectious diseases. Less emphasis was placed on management of uncommon conditions such as inflammatory bowel disease. CONCLUSIONS: There are important differences in the scope of general surgery and the knowledge and skills required by general surgeons in Botswana compared with their North American counterparts. We present a simple and inexpensive approach that could serve as a potential model for designing contextually relevant surgical training programs in other low-resource settings.
    World Journal of Surgery 08/2012; · 2.23 Impact Factor
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    ABSTRACT: Although a validated simulator exists for adult laparoscopy, there is no pediatric counterpart. The objective of this study is to develop and validate a pediatric laparoscopic surgery (PLS) simulator. A PLS simulator was developed. Participants were stratified according to level of expertise and tested on the fundamentals of laparoscopic surgery (FLS) and PLS simulators. A subsequent group was tested exclusively on the PLS simulator. The PLS intracorporeal suturing score was lower than its adult counterpart (P = .02). The PLS pattern-cutting score was higher than in the FLS simulator (P < .001). If the latter was eliminated from the calculation, the revised total FLS score was significantly better than the revised PLS score. When all participants were combined, total PLS scores as well as performance on 3 of 5 tasks allowed differentiation between novice, intermediate, and expert. The PLS simulator was able to discriminate between the novice, intermediate, and expert using the total PLS score and the performance on 3 of the 5 tasks, thus providing evidence for construct validity. The other 2 tasks will require formal modification or a change in the scoring metrics to establish their independent construct validity.
    Journal of Pediatric Surgery 05/2011; 46(5):897-903. · 1.38 Impact Factor
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    ABSTRACT: Surgical conditions account for a significant portion of the global burden of disease and have a substantial impact on public health in low- and middle-income countries. This article reviews the significance of surgical conditions within the context of public health in these settings, and describes selected approaches to global surgery delivery in specific contexts. The discussion includes programs in global trauma care, surgical care in conflict and disaster, and anesthesia and perioperative care. Programs to develop surgical training in Botswana and pediatric surgery through international partnership are also described, with a final review of broader approaches to training for global surgical delivery. In each instance, innovative solutions, as well as lessons learned and reasons for program failure, are highlighted.
    Mount Sinai Journal of Medicine A Journal of Translational and Personalized Medicine 05/2011; 78(3):327-41. · 1.99 Impact Factor
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    ABSTRACT: Telesimulation is a novel concept coupling the principles of simulation with remote Internet access to teach procedural skills. This study's objective was to determine if telesimulation could be used by pediatricians in Toronto, Ontario, Canada, to teach a relatively new intraosseous (IO) insertion technique to physicians in Africa. One simulator was located in Toronto and the other in Gaborone, Botswana. Instructors and trainees could see one another, see inside each other's simulators, and communicate in real time. Learner's opinions and skills were evaluated. Before and after the curriculum, physicians completed a self-assessment questionnaire, a multiple-choice test, and during session 3, a demonstration of competence using an IO infusion system was timed and scored locally and via the Internet. Twenty-two physicians participated. The scores on the pretest ranged from 1 to 12 out of 15. The range of scores on the posttest was 10 to 15 out of 15. The mean (±SD) score on pre- and post-multiple choice testing increased by +5 (±2.75; 95% confidence interval [CI] for mean difference = 3.92 to 6.35). Based on McNemar's chi-square test, physicians reported a significant improvement in their comfort and knowledge inserting IO needles (p < 0.01), familiarity with the EZ-IO infusion system (p < 0.01), and knowledge handling the IO equipment (p < 0.01). Postintervention, all physicians reported that telesimulation teaching was a worthwhile experience, and 95% felt more prepared to manage pediatric resuscitation. There was no evidence of a difference in scoring or timing of IO insertion tasks whether measured locally or remotely (mean ± SD score difference = -0.11 ± 1.22 [95% CI = -0.66 to 0.43]; mean ± sd time difference = 0.01 ± 0.15 seconds [95% CI = -0.06 to 0.08 seconds]). Telesimulation is a novel method for teaching procedural skills. The session improved physicians' knowledge, self-reported confidence, and comfort level in inserting the IO needle. Accurate scoring is possible via the Internet. This modality offers potential for teaching other procedural skills over distances.
    Academic Emergency Medicine 04/2011; 18(4):420-7. · 1.76 Impact Factor
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    ABSTRACT: The management of patients with colorectal disease in the pediatric population is challenging. Such management is all the more challenging when facing the constraints imposed by an environment with limited clinical resources. Three types of colorectal problems are highlighted in this article: anorectal malformations, Hirschsprung's disease, and acquired rectovaginal fistula in the human immunodeficiency virus-positive population. Through the use of illustrative cases, the authors discuss the pitfalls and challenges encountered in the diagnosis, treatment, and appropriate disposition of these patients. The bulk of the experience used to write this article was acquired in low- and middle-income countries in Africa. The authors hope that the lessons learned will help others manage such patients in the context of limited resources, but recognize that challenges will vary from place to place. There is no substitute for local, contextual expertise.
    Seminars in Pediatric Surgery 05/2010; 19(2):118-27. · 2.40 Impact Factor
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    ABSTRACT: The global disparities in both surgical disease burden and access to delivery of surgical care are gaining prominence in the medical literature and media. Concurrently, there is an unprecedented groundswell in idealism and interest in global health among North American medical students and trainees in anesthesia and surgical disciplines. Many academic medical centers (AMCs) are seeking to respond by creating partnerships with teaching hospitals overseas. In this article we describe six such partnerships, as follows: (1) University of California San Francisco (UCSF) with the Bellagio Essential Surgery Group; (2) USCF with Makerere University, Uganda; (3) Vanderbilt with Baptist Medical Center, Ogbomoso, Nigeria; (4) Vanderbilt with Kijabe Hospital, Kenya; (5) University of Toronto, Hospital for Sick Children with the Ministry of Health in Botswana; and (6) Harvard (Brigham and Women's Hospital and Children's Hospital Boston) with Partners in Health in Haiti and Rwanda. Reflection on these experiences offers valuable lessons, and we make recommendations of critical components leading to success. These include the importance of relationships, emphasis on mutual learning, the need for "champions," affirming that local training needs to supersede expatriate training needs, the value of collaboration in research, adapting the mission to locally expressed needs, the need for a multidisciplinary approach, and the need to measure outcomes. We conclude that this is an era of cautious optimism and that AMCs have a critical opportunity to both shape future leaders in global surgery and address the current global disparities.
    World Journal of Surgery 03/2010; 34(3):459-65. · 2.23 Impact Factor
  • Allan Okrainec, Oscar Henao, Georges Azzie
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    ABSTRACT: Several challenges exist with laparoscopic skills training in resource-restricted countries, including long travel distances required by mentors for onsite teaching. Telesimulation (TS) is a novel concept that uses the internet to link simulators between an instructor and a trainee in different locations. The purpose of this study was to determine the effectiveness of telesimulation for teaching the Fundamentals of Laparoscopic Surgery (FLS) to surgeons in Botswana, Africa. A total of 16 surgeons from two centers in Botswana participated in this 8-week study. FLS TS was set up using two simulators, computers, webcams, and Skype software for eight surgeons in the TS group. A standard FLS simulator was available for the eight surgeons in the self-practice (SP) group. Participants in the TS group had one remote training session per week with an FLS proctor at the University of Toronto who provided feedback and demonstrated proper technique. Participants in the SP group had access to the FLS DVD and were instructed to train on FLS at least once per week. FLS post-test scores were obtained in Botswana by a trained FLS proctor at the conclusion of the study. Participants in the TS group had significantly higher post-test FLS scores than those in the SP group (440 +/- 56 vs. 272 +/- 95, p = 0.001). All trainees in the TS group achieved an FLS simulator certification passing score, whereas only 38% in the SP group did so (p = 0.03). Remote telesimulation is an effective method for teaching the Fundamentals of Laparoscopic Surgery in Africa, achieving a 100% FLS skills pass rate. This training platform provides a cost-effective method of teaching in resource-restricted countries and could be used to teach laparoscopic skills anywhere in the world with internet access.
    Surgical Endoscopy 07/2009; 24(2):417-22. · 3.43 Impact Factor
  • Allan Okrainec, Lloyd Smith, Georges Azzie
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    ABSTRACT: The use of laparoscopy in resource-restricted countries has increased in recent years. Although simulation is now considered an important adjunct to operating-room-based training for learning laparoscopic skills, there is very little literature assessing the use of simulation in resource-restricted countries. The purpose of this study was to determine the feasibility and impact of a 3-day Fundamentals of Laparoscopic Surgery (FLS) course in Botswana, Africa. A total of 20 surgeons and trainees participated in a 3-day FLS course. A pretest FLS score was obtained for each subject, followed by 2 days of practice with feedback. A final FLS posttest score was then obtained. Participants also watched the FLS instructional CD-ROM and took the written test on day 3. Mean posttest scores were significantly higher than pretest scores for each FLS task and for the total normalized FLS simulator score (285 +/- 94 versus 132 +/- 92, p < 0.001). The mean score on the written test was 242 (116). In total, only two surgeons achieved a passing score on both the cognitive and skills assessment required to obtain FLS certification. To our knowledge, this is the first time the FLS program has been taught in Africa. We have shown that giving the FLS course in a resource-restricted country is feasible and resulted in a significant improvement in FLS technical skills after 3 days. Most surgeons, however, still did not reach FLS passing scores, indicating that more than 3 days will be required in future courses to help surgeons obtain FLS certification.
    Surgical Endoscopy 04/2009; 23(11):2493-8. · 3.43 Impact Factor
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    Journal of Pediatric Surgery 01/2009; 43(12):2273-4. · 1.38 Impact Factor
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    ABSTRACT: The aim of this study was to identify and qualify the ethical dilemmas faced by pediatric surgery trainees. An online survey was sent to pediatric surgery trainees graduating between 2005 and 2008. Consent was obtained, and study investigators were blinded to the identity of the respondents during data analysis. Of the 40 respondents, only 59% felt they had received adequate training in bioethics to handle ethical issues pertaining to the care of critically ill children. Although 83% of respondents routinely participated in palliative care discussions, 30% of respondents desired to have more opportunities to discuss end-of-life issues with their staff. Moral conflicts were resolved through direct discussions with the medical staff, family, or friends. Despite the presence and awareness of institutional policies on ethical behavior, 58% of respondents did not believe that ethical conflicts were resolved as a result of these policies, whereas 31% of respondents felt that reporting of unethical conduct would result in personal reprisals. Pediatric surgery trainees face ethical and moral conflicts, but some are fearful of reprisals if these concerns are reported. A neutral forum to raise such issues may facilitate open discussions and eventual resolution of these conflicts.
    Journal of Pediatric Surgery 07/2008; 43(6):986-93. · 1.38 Impact Factor
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    ABSTRACT: Children with gastroesophageal reflux disease (GERD) often have associated feeding difficulties that warrant the insertion of a feeding gastrostomy at the time of the antireflux procedure. Options for gastrostomy tube insertion at the time of laparoscopic Nissen fundoplication (LNF) include laparoscopic gastrostomy, percutaneous endoscopic gastrostomy (PEG), and classic open gastrostomy. The complication rate of PEG may be decreased if it is placed under laparoscopic supervision. The purpose of this paper is to describe our experience with laparoscopically supervised PEG tube placement at the time of antireflux procedure. A retrospective chart review was conducted on all children undergoing a PEG tube placement at the time of the LNF. Perioperative complications were recorded. Forty-four patients had attempted PEG tube placement at the time of the LNF. In 3 (7%) cases, laparoscopic supervision was crucial in the prevention of a complication. No major PEG-related complications were recorded. In 43% of patients, minor PEG tube problems arose in the postoperative period: all were transient and/or easily correctable. Management of all these problems was in an outpatient setting. Follow-up ranged from 11 to 41 months. PEG tube placement at the time of a LNF is safe and effective. A combined laparoscopic and endoscopic approach minimizes complications. This method also allows for an intra- and extraluminal evaluation of the fundoplication at its completion.
    Journal of Laparoendoscopic & Advanced Surgical Techniques 03/2008; 18(1):136-9. · 1.07 Impact Factor
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    ABSTRACT: Purpose Until 1996 the South Island of New Zealand had limited access to specialist paediatric surgical services. The establishment of a comprehensive paediatric surgical outreach service has allowed children to receive specialist advice and treatment close to home. This study outlines the structure of the service, its effect on the smaller hospitals and on patient outcomes.Methodology Trends in the referral patterns and effects on outcome for indicative conditions (including hernia, undescended testis, pyloric stenosis, Hirschsprung disease) were analysed.Results Since 1996 there has been a steady increase in the number of children being treated by the service in all the region’s public hospitals. Regular clinics and day surgical lists are held according to local demand, and organised locally. Audit has demonstrated improvements in clinical outcome.Conclusion The advantages of a well-organised and funded paediatric surgical outreach service include: 1. improved access to quality treatment for children close to their home; 2. fewer complications of surgery and less unnecessary surgery; 3. better identification of cases that require transfer; and 4. better support to the rural surgeon and paediatrician who still have to cope with acute paediatric surgical problems.
    ANZ Journal of Surgery 04/2007; 77(s1):A74 - A74. · 1.50 Impact Factor
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    ABSTRACT: We report two cases of thoracoscopic resection of esophageal duplication cysts. Both patients underwent successful thoracoscopic excision. They were discharged on postoperative day 2 and 4, respectively. They made uneventful recoveries and were completely asymptomatic at 1-month followup. One child was lost to long-term follow-up. In the other child, barium swallow study 10 months after surgery demonstrated a pseudodiverticulum at the site of cyst excision. Thoracoscopic resection of esophageal duplications is safe. Complete excision is possible even if the cyst shares a common muscular wall with the esophagus. Pseudodiverticulum may develop at the site of excision: follow- up is necessary and consideration should be given to closure of the muscular defect at the time of excision. To help avoid esophageal injury and, should it occur, recognize esophageal perforation, we recommend performing the dissection under intraesophageal endoscopic supervision.
    Journal of Laparoendoscopic & Advanced Surgical Techniques 09/2006; 16(4):418-21. · 1.07 Impact Factor

Publication Stats

167 Citations
40.04 Total Impact Points

Institutions

  • 2009–2014
    • SickKids
      • Department of Surgery
      Toronto, Ontario, Canada
    • Toronto Western Hospital
      Toronto, Ontario, Canada
  • 2013
    • University of Ottawa
      Ottawa, Ontario, Canada
  • 2009–2013
    • University of Toronto
      • • Division of General Surgery
      • • Faculty of Medicine
      • • Hospital for Sick Children
      • • Department of Surgery
      Toronto, Ontario, Canada
  • 2011
    • Edmonton Clinic
      Edmonton, Alberta, Canada
  • 2010
    • Queen's University
      • Department of Surgery
      Kingston, Ontario, Canada
  • 2008
    • University of New Mexico
      • Department of Surgery
      Albuquerque, NM, United States
  • 2002–2007
    • Canterbury District Health Board
      • Department of Paediatric Surgery
      Christchurch, Canterbury, New Zealand