An eyes-only rotation in Thailand

A previous accident had already cost the Thai fisherman his sight in one eye when a fish jumped from a bucket and slapped him in the face. The blow ruptured the fisherman’s remaining “good” eyeball.

It was a late evening in March when the injured man arrived at Mettapracharak Hospital and Eye Institute west of Bangkok. The resident on call invited two visiting Yale medical students to watch what she thought would be an interesting case.

Esther S. Lee, M.D. ’12, and Xuejing Chen, M.D. ’12, hurried downstairs from the hospital’s third floor, where they were living alongside the hospital’s nine ophthalmology residents, to watch the open globe repair. Afterwards, the fisherman could see well enough to count fingers and discern movement. “He was pretty lucky,” said Lee.

The chance to witness a high–stakes surgery like the fisherman’s procedure is one of the reasons that the School of Medicine has established an ophthalmology rotation at Mettapracharak Hospital, said Susan H. Forster, M.D., HS ’81, FW ’82, director of medical studies in ophthalmology and visual science. Students chosen for the rotation are matched with mentors at what Forster calls the best eye care facility in Thailand. “It is a referral hospital for all Southeast Asia,” she said. “The quality of care they provide is excellent.”

Since Forster established the program in 2010, five students including Chen and Lee have done rotations at the hospital. They are among the 30 to 35 Yale medical students who complete rotations in Asia, Africa, and Latin America each year. At Mettapracharak, Forster said, “They see pathology you wouldn’t see here. They see much more advanced disease, because people cannot get to care as quickly.” (Thailand has 15 ophthalmologists per million people, compared to 83 per million in the United States.)

Each morning when the hospital doors opened, Chen and Lee saw hundreds of people waiting under the trees, most of them seeking eye care. Patients moved from station to station inside the eye clinic, carrying their own charts. After seeing a technician for an acuity test, and perhaps waiting in a third line for a blood test, they waited to see the attending physician. “It’s almost an assembly line, which makes it possible to see 500 to 600 patients a day,” said Chen.

She and Lee had opportunities in the operating theater that they couldn’t have had back home. The surgeons allowed them to suture the patients’ conjunctivae—the membranes that line the eyelids and cover the sclera, the white part of the eyeball. “I’d barely even touched an eyeball before,” said Chen. Lee stitched an eyelid, another first for her.

“Should medical students be allowed to stitch up a lid or not?” asks Forster. “When I was a medical student, I stitched up lots of lids under the supervision of a more experienced physician, of course. Medical students were allowed more independent participation in patient care than they are today.” She believes that the greater latitude permitted to students visiting Mettapracharak Hospital may better prepare them for future challenges in health care including physician shortages that may arise as the baby boomers age. This looming problem may require task–shifting—allowing less–trained personnel to take on work now done by experts—that is already the norm in Thailand. Physicians there, Chen noted, share more responsibility with nurses, nurses’ aides, and technicians: “They trust the ancillary staff to do things that they don’t do in the States.”

Lee and Chen also observed that nearly everything in the Thai O.R. is reusable. “The main things that they throw away are gloves, needles, and Q –tips,” said Chen. “In the States, after we have an operation, we have bags of trash. Here they have a tiny garbage can and it’s not even full.”

Reusing materials is one way that the hospital keeps expenses low; it is a government hospital with a commitment to serving all comers, so its budget is tight. Most Thai citizens get free or inexpensive health care.

Surgeons also control costs by making substitutes for expensive devices. For instance, they crafted a prosthetic eyeball out of porous polyethylene, the material used in commercial implants. “They kind of tweaked it,” said Lee, “and what would be $1,000 in the States costs $50 here.” The staff also invented a low–cost version of a capsular tension ring—a device that a makes cataract surgery possible for patients with weak connective tissue. The surgeons’ version, made of suture thread, costs $2, while the commercial equivalent goes for $120.

“It’s valuable to witness firsthand how innovation helps to deliver good care,” said Paul Gaudio, M.D., HS ’01, a clinical assistant professor of ophthalmology who spent a year doing research in Bangkok during medical school. During his residency at Yale, he heard about Mettapracharak’s director, Pannet Pangputhipong, M.D., an ophthalmologist who is highly regarded in Thailand. Gaudio, who is fluent in Thai, spent a year at Mettapracharak in 2002 and introduced Forster to Pangputhipong.

While in Thailand, Gaudio met Abbot Phra Ubali Khunupamajarn, who used funds from his monastery to build the hospital on the monastery grounds in the late 1970s. The Buddhist abbot named his hospital Mettapracharak—Thai for “compassionate care for the people”—and donated it to the government in 1989. The monastery, Wat Rai Khing (“Ginger Farm Monastery”), owes its wealth to donations from visitors who come to pray before its sculpture of Buddha; according to legend, the golden Buddha was found floating in the local river.

Pangputhipong said that rather than build big temples, “the abbot said he would give the money that had been donated back to the people in a way that benefited them.” Added attending physician Puwat Charukamnoetkanok, M.D., known as Dr. Puwat, “The abbot could have easily siphoned the funds for personal gains. However, ’til his death [in 2008], he lived in a small room with few personal possessions.” A sign on the door to the abbot’s room read: “Know when to be content. Cultivate happiness everywhere.”

Charukamnoetkanok, who supervises the Yale students at Mettapracharak, said that American students and Thai residents find the program mutually beneficial. Apart from the clinical opportunities they enjoyed, the Yale students also had a chance to explore Thai culture and learn some of the language. The Thais enjoy showing their culture to visitors, and they get a chance to practice their English. “English is access to opportunity,” Charukamnoetkanok said. “If you’re confident about your English, you can go to a conference or watch a webcast.”

Chen and Lee’s clinical experience extended to southern Thailand, where they went with a hospital team on a four–day mission to a rubber farming area near the Malay border where the majority of people are Muslims. There the team screened 800 patients for eye problems, and matched people with used eyeglasses as part of a medical “camp” that also included dentists and rehabilitation specialists. This trip was one of the hospital’s routine medical missions that screened 6,000 patients during 2011. The aim is to attract people for screening and then to refer those needing care—ideally, to local doctors.

Lee and Chen began internships this summer and have been matched for residencies in ophthalmology. Lee will get her training at the Doheny Eye Institute at the University of Southern California, and Chen at the Jules Stein Eye Institute at the University of California at Los Angeles.

Both plan to keep in touch with their Thai colleagues. “We’ll see each other at conferences,” said Chen. “Maybe they’ll come to the U.S. for fellowships and I’ll meet them then. Maybe I’ll do international work, and maybe I’ll do it in Thailand. …You never really know where your career is going to take you.”

–Cathy Shufro is a freelance writer in Woodbridge, Conn. She traveled to Thailand as a fellow with the International Reporting Project, an independent journalism program in Washington, DC.