Rob Henderson was awarded the Keeler Scholarship by the Royal College of Ophthalmologists for his fellowship plans to specialize in paediatric vitreo-retinal surgery. He spent a year at the world-renowned Hospital for Sick Children (‘Sick Kids’), Toronto, and is going on to a fellowship in VR at the Royal Victorian Eye & Ear Hospital in Melbourne before coming back to London to compete his training
As I walked in to clinic for the last time I saw, sitting in the waiting room, the slightly gaunt and angular frame of the first patient I had met at Sick Kids. Rachel looked up at me with a smile of recognition and, as I caught up with her progress – she had been accepted into university and started coaching tennis again – I reflected on how far both she and I had come during this last year.
Rachel was a 17 year old girl with a pre-existing history of JIA and aphakia who, in the spring, had acquired a small Fusarium contact lens related keratitis which cleared up with topical amphotericin. Her rheumatologist then started her on Humira (adalumimab), which reactivated her keratitis with endothelial plaques and a hypopyon. With a unicameral eye, fungal endophthalmitis was a distinct possibility. She was treated with topical, IV, oral, and intracameral antifungals – all to no avail. She eventually required a therapeutic PK, followed by a second, vision restoring, graft. Now, some 10 months later, her vision was 20/40, she was not taking any anti-fungal medication, and she was back to considering starting Humira again.
Her case initiated me in to a hospital where ophthalmology is deeply integrated into the care of many of the complex needs patients. We were four paediatric ophthalmology fellows and, in addition to the clinic and Operating Room (OR) duties, were responsible for covering the ‘consult service’. The admitting services in this 370 bed quaternary referral center often requested input from other specialties. There were multiple consults daily to rule out both common and vanishingly rare associations – whether it be KF rings for Wilsons; posterior embryotoxon for alagille; or vitreous findings for sticklers. There were dysmorphology exams; endless papilloedema checks for the neurosurgeons; conjunctival biopsies; non-accidental injury exams; sedated exams in MRI or IGT for the young JIA patients. There was a relentless onslaught of rare conditions that frequently had one running to Google for help but as the year passed these esoterica, which often accounted for less than a line in a textbook, became less foreign.
The four fellows rotated departments every three months through four main firms – anterior segment, ROP, strabismus, and retinoblastoma. There were further clinics in retina, neuro-ophthalmology, oculoplastics, and oculogenetics. Additionally, we had additional required sessions that were to be spent in electrophysiology, orthoptics, and in the children’s rehab centre. The clinical diversity and amount of pathology was extraordinary. In one week I saw new presentations of Peters anomaly, congenital cataract, a Sturge Weber associated and uveitic glaucoma, a new retinoblastoma presentation, and a child with posterior Coats disease. This quantity of pathology was surprising to me at first until I realized that while in the UK we have a population twice as big as that of Canada, the cases are divided amongst ten times as many hospitals; Sick Kids drains the case load from almost two thirds of Canada with no competition due to its concentration of expertise and the exalted place it occupies in the firmament of Canada’s health care system.
From the outset, the attitude to training was different to the apprenticeship style that I was used to. A number of fellowship requirements were stated including: research projects that to be completed and written up; additional supernumerary clinic sessions to be attended; journal clubs and teaching sessions to participate in. The implied threat was that, were one not to fulfill these requirements, we would not ‘graduate’. It swiftly became apparent that this was not a fellowship that relied upon ad hoc teaching and ‘on-the-job’ learning opportunities: we were very much there to be taught and to learn. It was said to us when we first started in clinic: “It is not your responsibility to make sure the clinic is finished – that is the job of the Staff [Consultants]; your responsibility here is to learn as much as possible.” There was a service provision element of course, but every case had to be presented to the Staff, whether the diagnosis was simple or complex. This occasionally slowed clinic progress to a level of inefficiency that reached screaming point for both patients and fellows alike. For the most part, though, it meant that every case we saw had a learning point. The strabismus clinics were good examples because, in general, we did all our own orthoptics and refractions. Each duction and version, each over and underaction was checked by the strabismology consultant; it was an amazing way to calibrate one’s technique. As a way to see large numbers of patients, however, it was painfully slow and waiting lists to see the great man were well over a year as a consequence.
All the major Toronto hospitals are affiliated with the University and staff, therefore, have teaching titles – with most starting as Associate Professor. At the end of our year the fellows at Sick Kids had each attended approximately 240 separate teaching sessions! These happened at the beginning and end of the clinical day meaning that days were often long (7am-8pm), sometimes testing our endurance levels. Dinner was often provided with journal clubs though, and occasionally took place in restaurants around the city. In addition, there were pastoral sessions where the fellows were taken out, at the department’s expense, and a guest speaker would talk on subjects such as ‘how to have an academic career’; ‘working in the developing world’; or ‘surgical innovation’ whilst dinner was served. There were also quarterly ‘fellows-breakfasts’ when we met the fellowship director over waffles, bacon and maple syrup to identify if there were any problems. From a didactic teaching perspective this year was an extraordinary experience, and one that I cannot imagine being able to emulate in the service provision culture of the NHS.
A criticism that I have often heard of North American trainees is that they are all very book smart (and with all that teaching one could hardly fail to be!), but less clinically ‘savvy’ and less experienced surgically. The Canadian trainee, like his American counterpart, goes to medical school for a 4-year post graduate degree. They choose their specialty during medical school and apply nationally for a residency program. In Canada, once accepted on to this, residents in ophthalmology have a 5-year specialty training program that includes one year of general medical and surgical internship. In Ontario, at the start of Post Graduate Year (PGY) 2, all ophthalmology trainees are enrolled on a 6-week intensive course taking place in Toronto. During this they are exposed to a complete overview of ophthalmology – the basic and clinical science – taught by the clinicians. Years 2 and 3 are spent in clinic with very limited surgical exposure. The PGY 4 and 5 trainees are then given unobstructed access to the Operating Room time. At Sick Kids, certain cases were designated as resident only cases (all horizontal strabismus for example). This meant that, in Ontario, trainees had surgical numbers that were not significantly less than their UK counterparts, and in provinces where there are no fellows and very few departments eg Saskatchewan or Alberta, the surgical numbers are far greater. All trainees had an exam three times a year; all took the same exam regardless of experience, and were expected to perform better the more senior they became. In addition, most took the North American wide MCQ exam (OCAP) yearly to give themselves the option of working across the border. All of this resulted in residents who were highly drilled for their final exit exam and failure rates were low. One might argue that some lacked a little of the clinical acumen that comes of the years spent at the coal-face in the UK. However, the aphorism ‘you only really start learning when you become a consultant’ bore out when I paused to consider that my fellowship director, a man of hugely impressive clinical and surgical prowess, had been staff for 5 years already and, at 39, was only 2 years older than me!
Many residents, on completing their training, elect to go into general practice without further need of fellowship. Those wanting to sub-specialise further are often in the unenviable position of looking for ‘dead man’s shoes’ Staff positions – there being no compulsory retirement age in Ontario. This was frequently the case in Toronto: two of my senior staff colleagues were in their seventies with no obvious signs of wanting to slow down or make way for younger trainees.
Physicians in Ontario have, by and large, retained their autonomy from the state/federal government to a far greater degree than in the UK. This has enabled doctors to shape their practice to a much larger extent. There are many fewer government edicts about waiting times, audit practice, or clinical governance in general since there is little way to enforce them. Salaries are, on average three times that of their NHS equivalents (though a parallel private practice sector does not really exist). The feeling, therefore, one is left with is that the practice of medicine is more comfortable for physicians and surgeons, though, it is possible the patients have a less good deal.
The Ontario Health Insurance Plan (OHIP) covers all hospital stays, inpatient medications, and clinic visits but outpatients are forced to rely on their own work based ‘benefits’ programmes to subsidise drug costs. Frequently, parents would choose to hold off getting their children new glasses until the new ‘benefits’ year. Those without one of these programmes often faced crippling drug bills that were unaffordable and, while the hospital and social services made some provision for the least well off, there were many that had less than ideal treatment as a consequence. On the flip side there were no qualms about ‘topping up’ with all hospitals advertising the pros and cons of different IOLs that were available to upgrade to.
Despite the sense that Doctors have a better quality of life in Ontario all those that I met at Sick Kids were immensely dedicated. The hospital, like many such institutions has a huge international presence and strives to better the lives of children not only in Canada, but worldwide. The retinoblastoma program run by Dr Brenda Gallie is one such example, with links forged with institutions in Kenya, Egypt, China and India amongst others. The remit is to teach, advise and improve the quality of care, and form collaborations that enable international multicenter treatment trials. The only exception was that the hospital, by and large, refused to treat patients from the US owing to the risks of litigation
The Sick Kids brand is a phenomenon: it was rebuilt during the 1980s based mainly on fundraising and good will from local Torontonians. The ‘Main street’ down the centre of the hospital is lined with plaques dedicated to ‘benefactors’, ‘grand benefactors’, and even more rarified VIPs who are accorded special status if their children became unwell. The money-making and marketing machine is a behemoth: for their new research and learning tower they obtained donations of $750,000 from each member of the executive board alone. Every day there were new fund raising initiatives: lotteries, sales of clothing, jewellery, or leather goods in booths down the ‘Main street’. Volunteers abounded in clinics, on the wards, in the children’s library, or in the surgical waiting room looking after anxious parents. The hospital was awash with gifts and endowments: at Christmas, the number of presents donated to the inpatients was so large that often toys were diverted to less well known institutions to provide for their children.
Overall, the impression one gets is of an enormously well funded hospital replete with all the latest technology, electronic patient records, and computer systems that offers the very best care to patients from all over Canada and further afield; and takes huge pride in its status as one of the premier teaching institutions in North America.
I left Sick Kids having learnt a huge amount, having seen an amazing amount of pathology both in general medicine and paediatric ophthalmology, but most of all I felt tremendously impressed at the dedication to and quality of teaching that we received and so very grateful for having had the opportunity to go to this amazing institution.
Article first published in Eye News 2011;18(3):26-9. © Pinpoint Scotland Ltd. All rights reserved.