David Roye, MD, St. Giles Professor of Pediatric Orthopaedic Surgery at Columbia University, Attending Orthopaedic Surgeon at New York-Presbyterian Hospital, Director of Pediatric Orthopaedic Surgery at Morgan Stanley Children's Hospital of New York and Executive Medical Director of the Columbia Cerebral Palsy Center, has had a passion for humanitarian medical care since the beginning of his career. With a focus on pediatric orthopedics and scoliosis deformity, Dr. Roye has traveled to several countries around the world to provide care and teach fellow surgeons new techniques.
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He is medical director of the Children of China Pediatric Foundation, a non-profit organization which provides medical teams to perform surgeries to correct disfigured birth defects and disabilities of children in China, and founder of the International Healthcare Leadership, a non-profit organization which designs and implements educational programs in healthcare management and policy in emerging nations. He serves on the scientific advisory board for "A Foundation Building Strength," dedicated to funding research for Nemaline Myopathy.
Dr. Roye has been recognized with the Order of Merit Award from the Orthopaedic Research and Education Foundation and the 2009 Humanitarian Award from the American Academy of Orthopaedic Surgeons. Here, Dr. Roye discusses his work and what surgeons should know to become more involved in the future.
Q: How did you first become involved in humanitarian spine care efforts?
DR: I've been involved in global healthcare for my entire career, beginning in 1983 doing general orthopedics in Nairobi. After several years, I transitioned into Eastern Europe and spent time there. About 15 years ago I began going to China with Children of China Pediatrics Foundation, a small group that travels all over the country. My work has significantly expanded there and I've traveled to China six times this year already.
I founded a second not-for-profit whose goals are to create products for teaching Chinese healthcare managers how to better manage resources, allocate resources and improve quality and safety for their patients. That effort takes more and more of my time today.
Q: What elements of these programs make them so successful?
DR: When I travel to teach another spine surgeon, I choose a hospital with an experienced spine surgeon. My modus operandi is to establish a relationship with a surgeon at the hospital who is doing spine surgery, who can truly invest in new techniques. I often choose someone who has skills in operating on spinal deformity cases. Those skills have more appeal because when I give a lecture or talk about developing a new technique, I know it will be applied by surgeons who have the basic skill to master it.
Q: What obstacles do you face as a surgeon doing humanitarian work?
DR: I met a number of obstacles in China because the Chinese healthcare system is basically cash and carry. The families can only afford to pay for one operation, which meant when I first traveled to China surgeons fused every child for a single operation. That wasn't the standard in the United States or Europe; surgeons there were using growing rods. We started teaching the growing system four or five years ago and within a year, they did more than 300 procedures with the growing rods.
However, you have to be at a hospital where they can understand the technique and innovate by using the instrumentation they have available to create an implant design that will allow for the surgery without breaking the bank.
There are different models of providing care in under-developed countries, but China is not a third-world country. It has relatively sophisticated infrastructure and the hospitals are new and well-equipped with imaging technology. What they really need is the software, teaching and skill set to perform advanced procedures. They also don't have residencies and fellowships for their surgeons.
I've been offering visiting fellowships at Columbia for three to six months at a time and encourage the visiting surgeons to observe adult as well as pediatric spine operations, along with neurosurgery procedures. The visiting fellowships are important, especially since you aren't training them from scratch. They are already-trained surgeons who spend a few months learning about diagnoses, going to conferences and getting additional training.
Q: Why is this experience of visiting other countries so important? Does it translate to spine surgeons from the United States as well?
DR: When I first became an attending surgeon at Columbia, I spent six months away in Europe doing visiting fellowships at important spine centers and it was a very good experience for me. I was exposed to different techniques and ideas I would not have been exposed to in the United States. When I appreciate how that experience helped me, I crafted the program at Columbia that I now run.
Q: Are there any lessons you've learned from performing surgeries overseas that you brought back to your practice in the United States?
DR: The basic lesson for anyone who does work overseas is that we are very fortunate to have so much in the United States. We are so wealthy that we can be relatively wasteful in the way we apply the designs of implants. Since performing cases overseas I use less implant density than did before I started traveling to China. When I'm designing an implant there I have to think about the fact that families are paying for each screw in a way that doesn't happen here. That's the difference between having a child treated or not treated, or returning to the operating room multiple times for the growing system, depending on how you place the implant.
The other thing I've learned when performing in other parts of the world is how to do a safe and effective surgery with less. Many times in third-world countries we have fewer instruments and you have to carry everything in and teach the surgeons what you do. I can do my entire case with a single box of implants overseas as opposed to 10 or 15 like I do at home. You have really specific planning for each case and pay attention to what you consume.
Q: Throughout your career, what have been the most significant changes you've seen for surgeons performing humanitarian cases overseas?
DR: One of the things that made the most difference in my career also happens to be one of the most important changes in spine surgery — deformity surgery in particular: the design and implementation of growing systems in terms of specific products available. We have non-fusion techniques for children that allow for continued growth of the spine, trunk and chest wall and continued growth for the lung. These are really important concepts.
It excites me that we've been able to implement these implants in a way that allows for them to be applied in emerging economies and medical systems. That, to me, is the biggest single contribution I've made and why I continue to stay active in spine surgery.
Q: What advice do you have for spine surgeons who want to become more involved in humanitarian and overseas spine care efforts?
DR: Choose the location and projects most fulfilling for you. When I was in Africa, there was no infrastructure for medical spine care, so I always felt like I was putting out fires. I was always on edge because of safety issues and lack of adequate informationflow. Everything was fraught and I felt like I was there with a skillful team, but we weren't making much of an impact beyond the few kids we were able to treat because we took the portable infrastructure with us when we left.
I was unhappy because I wanted to do what I did in New York City for people overseas. China was the perfect place for me because it has the emerging infrastructure; what it really needs is the teaching and experience. The most important thing for someone looking overseas is to understand their comfort level in working without a support team.
We need a lot of people who are comfortable going to the edge and performing spine care, but that wasn't my comfort level. I wanted to secure follow ups for patients when I left the country and feel satisfied that the surgeons understood my techniques and could apply them when I left. Spine surgery is not something that should be done in a tent. You need a relatively sophisticated medical environment, whether that requires going to another country that has it or building something, as Dr. Oheneba Boachie-Adjei has done in Ghana.
There is also a real necessity for surgeons to understand they are ambassadors for their country and must be culturally sensitive. They must understand that everything they do will reflect on them and their country, as well as the medical profession. As much as working overseas is a really opportunity to help and teach, it requires focus and doing your homework on what will work with each individual cultural situation.
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