ICO SUBSPECIALTY COMMITTEE REPORT: STRENGTHENING SUBSPECIALTY DEVELOPMENT AND RELATIONSHIPS INTERNATIONALLY

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1 16 February 2010 ICO SUBSPECIALTY COMMITTEE REPORT: STRENGTHENING SUBSPECIALTY DEVELOPMENT AND RELATIONSHIPS INTERNATIONALLY BACKGROUND 1. Subspecialization and Ophthalmology Today Throughout ophthalmology in recent years it has become increasingly apparent that subspecialty organizations and subspecialization have been the major driver of most clinical advances in Ophthalmology. Furthermore, they have become a major reason for attending educational meetings in the United States and Europe. Rapid advances in various areas of the subspecialities ensure that subspecialist training is of foremost importance to virtually all current contemporary Ophthalmologists. The fact is that the field of Ophthalmology has become so broad and the knowledge base is expanding so rapidly, that it is impossible to be on the cutting edge of every ophthalmic discipline. Increasingly, the most important part of even general ophthalmology meetings tends to be their subspecialty forums as well as the subspecialty part of those individual meetings. While the advance of subspecialization may seem self-evident to some, in countries where there are few subspecialties, the opinion leaders may feel threatened by this trend. To suggest that subspecialists are necessary is to suggest that the local luminaries may not be the best in all fields of Ophthalmology. For those just starting a practice, the idea of subspecialty competition is also a concern in many parts of the world. Such

2 resistance needs to be recognized and addressed in a way that least threatens the Ophthalmologists in a country or region. 2. Subspecialization Critical for Clinical Training in Ophthalmology Ophthalmology training has become quite complex. The only way to gain good experience in any discipline is to learn from those doing the cutting edge work; the subspecialists. The advances in subspecialties mean that the residents must learn the current happenings in these fields to be well grounded in general Ophthalmology. Post residency fellowships have become common in almost all developed and increasingly so in developing countries as well. A shortage of skilled subspecialty training manpower is a rate-limiting step for all levels of ophthalmic training in much of the world today. 3. Development of Subspecialization Generally Follows Economic Development If we look at how subspecialties have evolved throughout the world today, it is clear that in the United States, Canada, and Japan that this is fully developed and there are subspecialists in virtually all areas of these countries who basically do all but the most straightforward cases in their individual subspecialties. This is also increasingly true in the metropolitan areas throughout Central and South America. Although not as completely instituted throughout Europe, increasingly this is also the case especially in Western Europe, Australia, and New Zealand. Even in some of the developing world, subspecialties are increasingly becoming important in particular in areas such as India and China as well as many other areas through Southeast Asia. Where subspecialization is largely nonexistent is in the developing areas that lack resources. In fact, the development of subspecialization and of general economic health closely

3 follow each other as we look at the world today. Clearly, in those parts of the world where the expense of this additional training is prohibitive, then we do not have subspecialists to enhance the ability to take care of both complicated cases and to teach to general ophthalmologists these core areas of ophthalmic knowledge. Furthermore, as a region increases the number of Ophthalmologists to better meet the needs of its citizens, a natural outcome is the desire and ability to provide subspecialty care. 4. Barriers to Development: There are many barriers to the development of subspecialties, which include: 1. An inadequate number of Ophthalmologists (both trainers and trainees); 2. An overwhelming burden of untreated eye disease; 3. The prohibitive costs of subspecialty instruments and supplies; 4. The lack of clinical programs especially for those in the developing world; and 5. The lack of resources to fund the local shortage while the individual is in training and the expenses of a fellowship. Because any map of subspecialization generally follows economic development, then it almost goes without saying that financial resources would be the single biggest barrier for subspecialization. Because training in the developing world is often nonexistent for subspecialization, then an ophthalmologist interested in becoming a subspecialist must go to the developed world where expenses are much higher than living in the developing world. Furthermore, there are significant travel expenses and, most importantly, the loss of income and productivity for an ophthalmologist in an area of the world where typically there is already a marked shortage of ophthalmologists. So

4 between the lack of financial resources and finding the time to train, even though many University faculty in the developing world see the need; they do not see the possibility. A further barrier, in particular in the United States, is that licensure issues make it virtually impossible for trainees from the developing world to do other than an observership. A key element of becoming a subspecialist is hands on experience, which is often impossible. There are areas in the world that certainly do a better job of allowing this hands-on experience; however, often these opportunities are limited. Another significant problem is that fellowships in the developed world often do not meet the needs of those in the developing world. Financial considerations are such that many of the surgical procedures would be impossible for the fellow to be able to even entertain as they return back to their country and the resources critical for a field such as neuro-ophthalmology (i.e. neuro-radiology) also is not possible. Otherwise excellent fellowships, therefore, are not tailored to the needs of those who want to teach and practice in the developing world. An additional concern is that fellowship candidates may be hesitant to return to their country of origin upon being exposed to the resources of a conventional fellowship in the developed world. The paucity of technology and other tools available in the developing world may be prohibitive for candidates to implement their practice effectively. For this reason, governments of the developing world may be resistant in allowing and/or funding individuals in pursuing subspecialty training. The very process of subspecialty training may mean that local resources actually end up depleted in the process.

5 5. Lack of Subspecialty Organizations as a Resource for the Developing World: One of the key elements of the subspecialties in the developed world has been regional and national organizations that have provided a forum for discussion and scientific presentation. These have become very important avenues of support and success for the development of subspecialties. These are sorely lacking in the developing countries, in particular, to discuss their specific issues and concerns. Special interest organizations that focus on the needs of a practitioner in the developing world would be effective in bridging the gap. A PLAN OF ACTION So after discussion and debate among the subspecialty committee of the ICO we have come up with a plan of action to enhance the coordination internationally of subspecialists, to help train subspecialists in particular in the developing world, and as a means to enhance organizations that specifically support the differing needs of developing regions in the world. 1. Help Foster Regional Training Centers in the Developing World There are multiple centers of excellence that have emerged in the developing world that meet a very special need. They often have developed a model of cost sharing such that they can deal with the needs of the very poor as well as the more affluent members of their society. Such an approach can become self-sustaining and very efficient in dealing with the local society s ophthalmic needs. An excellent example of this in the world today would be the Aravind system in India. Not only has this been superb in regard to the vast quantity of patients of all economic classes that have been taken care of in

6 India, but it has also been a phenomenal source for training of the sort that specifically meets the needs of the developing world. It is clear that the emerging sub-specialists in the Aravind system help enhance the overall training, and their care of complicated cases has also been a great success story. There are many other Centers scattered around the world. We propose creating a list of regional training centers (appendix A), and a system whereby these centers and emerging training centers can work together to enhance a network that essentially would cover all areas of the globe. So that there would be no elitism, all centers can apply, and if they meet the basic definition of being an ICO Training Center (basic criteria in appendix B), any center that meets the criteria elucidated will be so designated, as long as they continue to meet this definition. Being designated an ICO Training Center will be a badge of honor and a beacon of light for the region. 2. Partner with these regional centers to enhance training opportunities We recommend that the ICO partner with these ICO Training Centers in developing subspecialty training programs that in particular stress hands-on experience in the developing world. We should encourage partnerships with academic centers in the developed world and these ICO Training Centers. What is evolving in the developing world are new techniques that stress efficiency as a low cost alternative to subspecialty procedures in the developed world. The Aravind system has already invested in research and development of new and inexpensive equipment and supplies that are better used in the developing world. We should also work to enhance this kind of effort. As part of this, hybrid fellowships that are tied to an ICO Training Center, often with an observership at academic centers in the developed world interested in an international outreach could be developed. Most or all of the hands-on experience

7 would occur at the ICO Training Centers in the developing world. This should also include visiting faculty positions between the partnership programs in the developed and developing worlds to create dynamic relationships of support. With the latest telemedicine capabilities, video-conferencing and real-time consultation would all be possible at a fraction of the cost of the present system. 3. Hybrid Fellowships that cater to the needs of the trainee While the classic subspecialty training has been either twelve or twenty-four months in the developed world, unfortunately, taking away an entire year is not always possible. The breadth of advanced pathology and the significant quantity of surgical cases in the developing world would make a six-month intensive fellowship more efficacious. As a six-month hiatus from practice may be economically and logistically not feasible for a prospective fellowship candidate, an attractive option would be to separate the sixmonth commitment into two three-month blocks. The time between the blocks would allow the candidate to begin to implement practices learned and identify, through trial and error in their own practice, gaps in knowledge in order to concentrate attention in the subsequent block. Furthermore, the shorter blocks would allow candidates to maintain their local practice without significant absence. There are many Ophthalmologists that have started developing subspecialty interest and recognition locally for their expertise but have had no formal training. A list of modules should be created that provide specific areas of expertise in finite blocks of time. This would allow a self-trained subspecialist to perfect lacking skills and gain formal training in areas where they could not develop expertise on their own. Both a list and centers where the expertise might be gained should be generated.

8 In general our approach to training should be flexible and inclusive to meet the broad and significant needs of many areas of the world. The perfect solution is the enemy to the good in this regard and any contact is an important first step in cross-fertilization of showing what is possible and in creating partnerships to develop new and innovative approaches to old problems. Some on the committee are concerned that these shorter fellowships would be regarded as second-class citizenship, and those who have completed them may have trouble with acceptance and licensure when they return. So this solution may not be practical in all regions. Core leaders, in particular those who are going to teach in new, emerging ICO training Centers, should complete a twelve-month fellowship, which would include a two to four month developed world observership and then eight to ten months at an ICO Training Center. This would be very important in regions in which there are no subspecialists. It would be understood that in return for this kind of fellowship that the newly minted subspecialist is expected to use their expertise to help grow emerging Training Centers. This, obviously, would have to be funded accordingly. 4. Developing Financial Support for Foreign Fellowships Governmental funding for subspecialty training would be an important means of identifying the demand for specific subspecialties in a developing country and gauging the interest of the government in supplying this expertise to their population. By elucidating the discrepancy between supply and demand and its impact on public

9 health, prospective fellowship candidates or ICO Training Centers can request financial support. In addition, the requirement of public health service in the developing country offering financial support would provide incentives for the government to partner with ICO Training Centers in fellowship training. Donations from charitable organizations, private corporations, and individual donors along with governmental support will allow for a greater number of fellowship positions. Other important funding sources that should be developed are with the partnering developed world Ophthalmic Center. There is no reason why we should not task any partnering center with help in raising the needed capital to make this program work. This is much easier to find philanthropy in the developed world for such financial support and many centers are doing this already as recognition of their international responsibility in Ophthalmology. An additional resource would be subspecialty societies. Many have the resources and are already raising and expending funds to assist the developing world. This effort should be coordinated, recognized, encouraged and expanded. 5. Work on Content in Key Areas of Knowledge for Subspecialists While making the content too complicated and difficult may be self-defeating, having no standard whatsoever, unfortunately, could lead to mediocrity. We, therefore, propose as a committee that we outline a general content of what is expected in a subspecialty experience. This content may evolve into preferred practice patterns specifically designed for a practitioner in the developing country. Once adopted as a standard of care, these practices can be used to support specific subspecialty admittance criteria. This would allow for a more unified and enhanced quality of care.

10 Subsequently, subspecialty training standards would increasingly converge between the developing and developed world. Residency and fellowship training programs in the developing world will incorporate modern techniques while allowing for gaps in access to technology. In order to attain subspecialty proficiency, evaluation of diagnostic and surgical expertise could be devised utilizing direct observation, written/oral examination, or critique of recorded procedures once the process in any country or region starts to mature. A group of experts from the developed and developing world will be responsible for establishing the outline of required content so as to make any subspecialty standards the most apropos for each locale. We recommend, as a starting point, the excellent list of basic knowledge needed for a well-trained Ophthalmologist that has been created by the ICO Residency Training Committee. At the least, a subspecialist would be expected to be knowledgeable for all areas of residency training in that particular subspecialist s discipline. Any list of core criteria should strive to be inclusive and not exclusive as we work to raise the standards throughout the world. We cannot appear to be elitist about this process! 6. Develop Regional Subspecialty Organizations Under the umbrella of the ICO, we recommend that developing national regional subspecialty organizations be proposed and given seed funding to get started. There is no stronger incentive for subspecialties to thrive than having regional support. This often results in having individuals to whom one may turn for advice by modern telecommunication, as well as opportunities to meet and discuss issues specifically relevant to different regions of the world. While these may encompass very large

11 regions to start with, eventually in many areas they could become national. What is needed is a starting point and some nurturing as the process evolves. 7. Work on Subspecialty Liaisons We also propose that we work with national and international organizations, particularly those that are well advanced, to specifically reach out to the developing world and the developing new subspecialty organizations. Partnerships with specific responsibilities should be created. Many are already engaged in this activity and others need only encouragement and support to begin this work. 8. Work with other key National and International players in this field We endorse the World Health Assembly on prevention of blindness and human resources for health, the new action plan for the prevention of blindness and visual impairment 2009 and the Global Initiative for the Prevention of Blindness. We support and want to work within the framework of national human resource planning for the development of subspecialists as part of their national health plans. Our effort will be tailored to the varied needs around the world in conjunction with and supportive of any national, regional or global effort that already exists. CONCLUSION While in many parts of the world the creation of subspecialty organizations and the development of subspecialists certainly need no support from the ICO, it is clear that in order to enhance the state of our profession, to be able to take care of more complicated cases, and do a better job of training ophthalmologists, in particular in the developing

12 world, we feel that these are a series of steps that are both doable and, if completed, would dramatically enhance the state of our specialty in the world today. Appendix A: Proposed ICO Regional Training Centers The Aravind System in India Tilganga Eye Hospital in Nepal Others to be added! Appendix B: Criteria for acceptance as an ICO Regional Training Center 1. Willingness to take part in the program as outlined and developed. 2. Recognition as a regional center for ophthalmic care and training. 3. Sufficient clinical volume to provide an adequate subspecialty experience. 4. Development of subspecialists in their system with core clinical expertise (meets the minimum criteria of the ICO resident education training standards in their subspecialty). 5. Government support for involvement in international training. 6. A local ophthalmic leader desirous of engaging in the process and in building their program to meet this new need.

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