American Surgeon in Western China: An Interview with Dr Ronald Krueger
This interview, conducted by Lei Zang, Editor, will be published in the March 2011 issue of Ophthalmology World Report in China.
In July 2010, a young patient in the capital city of Mongolia, Ulan Bator, who was at the risk of blindness from a severe corneal ulcer, came to Gansu Province to receive a corneal transplant. The surgeon who did the surgery for him - Dr Ronald Krueger from the Cleveland Clinic, one of the top refractive surgeons in the world - flew to China with the donor cornea. The humanitarian organization he is involved with, GANSU, INC., brought the young man to China for the procedure.
Besides his busy practice at the Cleveland Clinic, Dr Krueger dedicates his passion to the charitable organization, GANSU, INC., which focuses on Gansu and Qinghai, two under-developed provinces in western China. Beyond that, helping China establish an effective and efficient residency training system has become his greatest interest.
Ophthalmology World Report spoke with Dr Ron Krueger during Beijing APAO, unveiling what GANSU, INC. is doing in the western part of China and as a newer generation eye doctor, what he sees about how to solve the physician education problems here.
GANSU, INC. has been working in Gansu Province for over 20 years. What is the working model of this organization?
In 1990, Dr William Christie Conrad, an ophthalmologist and his wife Peggy, an ophthalmic nurse founded GANSU, INC. The organization is dedicated to promoting and delivering eye care to the people of remote, rural, northwest China through education and activity of eye care. Dr Conrad, the grandson of William and Jessie Christie who were missionaries in Gansu Province early last century, whose mother also lived years there as a child, has a heart for this part of China. After visiting the place where the Christies lived and seeing the lack of health care in Gansu Province in 1987, as an ophthalmologist, Dr Conrad founded GANSU, INC. which has been working closely with Gansu Health Bureau.
Patients come because the health department lets them know. When the patients come to the hospital, adjacent to where the mobile surgical trailer is set up, they are first screened. They are then brought to the trailer, and assisted onto a stretcher beneath the microscope, where we perform the cataract surgery. We mostly perform small incision cataract surgery, because the cataracts are very dense and are more effectively removed than emulsified… We set up our trailer adjacent to a rural hospital for the whole summer, from late May until September. Multiple surgical teams come for a month at a time, and perform the surgery, operating everyday during the week, except weekends. We don’t perform a super high volume, but consistently do a steady number, and have been doing so for 20 years. We provide the surgeries free of charge, but the local hospital does charge for routine blood tests, screening and after care.
But what will be after you have left? Have you thought of training a local team as a more sustainable way?
Yes, but limitations exist in training such a team. What we have been doing is providing a service to the poor and underserved, and we have been doing this consistently every year for 20 years. We generate good will, helping people in need and building relationships. We also love to train people, and encourage the local ophthalmologist to come work with us and see what we are doing. But training has not been the main focus of our model. Many rural ophthalmologists are nonsurgical, and there has been no hospital infrastructure or incentive for them to get access to or even seek out surgical training. This is where things in the Chinese system need to change.
Over the years, we have performed sight saving cataract surgery on over 6000 patients without a single documented infection. Although we don’t see many potential complications, due to a lack of consistent follow-up, we believe they would come back and seek attention if a serious problem arose. A number of them, however, do come back in the following year, and those with PCO are able to get a Nd:YAG laser capsulotomy. That’s pretty much all they need.
Do you want to change this model that has been applied for 20 years?
I am one of the newer generation physicians involved with GANSU, INC. and have been involved as the president of the Board for the past 5-6 years. The older generation set up the model, and it has been effective in meeting our goals of helping people, and having a positive influence in the community for many years. But, as I look at the next 20 years, I believe we should do greater case numbers and more education. Currently, we are not set-up to be educators, even though we have hosted 5 multi-subspecialty teaching teams in Gansu provincial hospitals over the past 13 years. But to be effective, and build on our 20 years history, I’d like to partner with other organizations that can help set up standardized educational programs within private hospitals that can train the next generation of qualified ophthalmologists and ophthalmic surgeons. I believe that privatization of health care is the model that will succeed in the future, and building educational (Ophthalmology Residency) programs within the efficiently run private hospitals is one way to assure this success. We have been talking with one of these successful eye hospital groups in trying to establish an educational partnership with the goal of establishing Western style Eye Residency programs.
Who do you partner with locally?
The health department itself is our local partner. We communicate with the Gansu Health Bureau, and also most recently with the Qinghai Health Bureau, months before our arrival to establish details concerning transportation and our work surroundings. We have a good relationship with them, and they tell us the city we should be going to each year. They also help us to store our trailer each year at the end of the Summer, so that it is protected from the weather and environment in the Winter months, and we have a functional unit when the following Spring arrives. The local health department knows that we are a respectable Christian based organization that has no hidden agenda. We come with good motives of love for the poor people, and they want to help us in any way they can. The Gansu Health Bureau even has a “line item” expense for GANSU INC in their annual government budget.
Once we arrive, the local hospital becomes our partner in the daily work of screening and evaluating patients. The hospital workers are all very friendly and many are eager to work with us. That’s key because it gives us a greater possibility for doing more, and for building cohesive working relationships. The question now is how we add a greater educational component to that relationship.
We also have partnership with U.S. eye surgeons, subspecialists and non-surgeon volunteers, who dedicate their time and resources to faithfully work with us each year. They are the heart and soul of the organization. Although our surgeons are generally most experienced with phacoemulsification, we do most of our cases as a small incision extracapsular extraction, which is very effective and works well for patients with truly blinding cataracts (ie. 20/400 or worse). Most of these cataracts are a little too hard to do with phaco, which is also more expensive, and yet shows similar results.
We are certainly willing to teach the techniques of phacoemulsification to those doctors who wish to learn, but teaching them phaco is basically teaching them how to perform an advanced cataract surgery that is more attractive to those patients who have cataracts that are not so dense and who have money to pay for it. We feel they first need to learn basic small incision extracapsular extraction, which is essential for those who are have mature and hypermature cataracts, and these are also among those who are too poor to have gotten their cataracts removed sooner. With no money and poor vision, there is a loss of hope and greater dependence on family. This is where the government should be stepping in, and doing something to help, but the government doesn’t know how to help when the infrastructure for surgical training has never been well developed. This is were nongovernment organizations (NGO’s), like GANSU, INC., have come along to try and fill the gap, but the gap has become too great, and newer partnerships will be needed to make a real difference in the future.
Do you also partner with the industry?
Yes, and among several others, Alcon has been the greatest help to our organization throughout the 20 years. They have faithfully donated surgical supplies, IOLs and other gifts-in-kind on an annual basis. Actually, over the past 20 years we have got over $1 million in donated supplies from Alcon, and we really appreciate it.
Have you been criticized for not being a very cost-effective service?
Although no one has criticized our organization, some might say that we should be doing higher volume surgery, like 100 cataract surgeries a day. They need to understand that our organization is not about a short-term surgical strike and then departure. Rather, we have both surgeon and nonsurgeon volunteers that become part of a community for an entire Summer, and sometimes we come back to that same community for several Summers. Our way is perhaps not the most cost-effective way, but it is a consistent way that has weathered the test of time.
Although we perform only 5 to 10 cataract surgeries per day, we do that for the entire summer on a regular basis. We believe that it is important to not just come into a community as a high volume “chop shop”, and operate on as many cases as possible before leaving. We rather try to integrate into the community, provide a consistent level of care, establish a good reputation among the people and build relationships and friendships over time. Coming back every year to similar or neighboring communities allows us to restore more than just physical sight to those in the community, but social, emotional and spiritual sight, as well. Our model is also better educationally, and we are striving to use our consistent presence as a time for mentoring promising young nonsurgeon ophthalmologists into capable ophthalmic surgeons, even though limitations do exist.
Our multiple teams stay in the community for 3-4 months each year, and each team typically comes for one month at a time. Occasionally, we split the role of the surgeon in a team into two weeks each, since the surgeon usually has the greatest difficulty in leaving his practice back home for a whole month. The rest of the team, which is composed of a nurse, a resource person who sets up the generator, a “Cindarella” who helps with cleaning instruments between cases, and a translator, usually are dedicated to the full month to help establish continuity within the group. All teams come from the United States.
You have actually been doing the education.
Yes, we are doing it, but on a smaller scale. What we’d like to do is partner with others in formalized residency training. It would be great to have a hospital to set up a true western-style 3-year residency with didactic teaching and hands-on training.
In the current Chinese model, relatively few people are equipped to become good eye surgeons, and those mostly are in Eastern China. But you’ve got millions of people blind with cataract, who are not being taken care of in the West of China. What is needed is a western style residency program, wherein a qualified medical doctor can be trained in 3 years into a fully equipped, experienced ophthalmologist, who has the medical knowledge to make proper diagnoses, and knows how to provide the surgical care in the treatment of the disease.
In rural China, you just need to train good general ophthalmologists, who know how to perform cataract surgery with great results. But, in many places where we go to provide cataract surgery, the ophthalmologist is nonsurgical. If we could build up standardized training programs like in the U.S., we could begin to see this tendency change. If successful, Ophthalmology could be the model for the rest of the medicine too. It’s unique enough as single organ specialty. If you could make it successful, the government may say, “this is the model we have to follow.”
I would love to find a scenario whereby a progressive Chinese hospital could partner with an institution like the Cleveland Clinic, and doing something significant educationally with exchanging information between the East and West.
Maybe you will have your Cleveland Clinic China Branch in the future.
That will be great! I really would love to see something like that, and would be excited to be involved in that process.
What makes you excited in your daily work?
I am excited when performing laser, cataract and corneal surgery, as I love both the technical steps of the surgery, and the positive response and care of the patients, postoperatively. I am giving people wonderfully restored vision all the time. But, I also recognize that in my local Cleveland community, I take care of patients who have the possibility to find another good doctor, if I were not present. This is why I also seek to make a difference as an educator. I am involved in teaching of residents and fellows at the Cleveland Clinic, and also among my colleagues in medical conferences around the world. Yet, despite my success in performing and teaching refractive, cataract and corneal surgery, I get excited over the possibility of caring for patients and enhancing the educational level in places that don’t have easy access to a well trained doctor, such as in Western China. Because of my connection to China through GANSU, INC., I would like to participate in the care of Chinese patients who have a more profound loss of vision, due to limited access of care, and also leave a lasting legacy by being involved in changing the education structure of that region, so that future access is possible when I’m long gone. .
It seems that a lot of your energy has been put into humanitarian tasks.
The humanitarian side of my job gives me a great sense of satisfaction. I enjoy it and I really feel I am making a difference beyond what I otherwise do in the U.S. Although I also perform research and travel internationally as an educator, teaching new technology and techniques in refractive surgery such as femtosecond lasers, custom laser profiles and cornea collagen cross-linking, I still like the simplicity of giving back my time and skills to the least cared people in the world. Dealing with my first world American patients pays the bills, but my passion in making a difference lies in dealing with the charitable side, the people no one else is taking care of.
Ronald Krueger, MD
Ronald Krueger, MD is Medical Director of Refractive Surgery and Professor of Ophthalmology at the Cleveland Clinic. He has performed over fifteen thousand refractive surgery procedures, and has authored more than 150 peer-reviewed manuscripts and many more abstracts, book chapters and trade journal articles. He has 27 years of experience in excimer laser research, including the first physical descriptions of the effects of the excimer lasers on corneal tissue and many more developments. He is also an early pioneer of ocular wavefront customized laser vision correction, having coauthored the first book on the subject, and cohosted an international “wavefront congress” each year since 2000. He also has more than 15 years of research experience in pico and femtosecond laser photodisruption of ocular tissue, and is involved in research investigating the correction of presbyopia and restoration of accommodation.
He was a former Secretary of Education and board member of the International Society of Refractive Surgery (ISRS) prior to its merger with the American Academy of Ophthalmology (AAO), and he now serves in both the executive and program committees of the new ISRS/AAO. He is the Associate Editor for the Journal of Refractive Surgery for more than 16 years, and he has lectured on refractive surgery in over 40 nations.
Dr. Krueger has received various honors and recognitions, including the American Academy of Ophthalmology Senior Achievement Award (2006), the Kritzinger Memorial Award of the ISRS/AAO (2007) and the Lans Distinquished Award of the ISRS/AAO in 2008.
He has served on the board of GANSU, INC for the past 13 years and as president of the board for the past 4 years.