Nick Koutroumanos Report

Never drive away without a shovel, a blanket and some tea candles in your car. What they tell you if you dare driving around the Canadian countryside in December. For a Mediterranean-made Londoner seeking further Ophthalmology training, this far away country, and Vancouver, its wet and furthermost Pacific city seemed at face value, a little too far a voyage.

The missing detail however, is that in Vancouver resides a centre which has for many decades been one of the most renowned, having trained dozens of surgeons currently leading in the field of oculoplastic surgery across the globe.

With its fellowship known as an extremely competitive one, the application to attend the Oculoplastics Department at the University of British Columbia (UBC) is a lengthy process requiring significant forward planning and an affinity for paperwork. My desire to apply there having come several years before completing my residency programme in London, meant that planning was less of an issue and consequently,
paperwork was more of an issue. Looking back however, time has shrunk in a way that it feels like I hardly spent an hour filling in those forms.

Being now so terribly thankful that none of these obstacles stopped me, I try my best to encourage those who are still in training to actively pursue their own dreams for international further training.

Weekend skiing aside, the bitter Canadian winter combined with the often unbelievable wetness of the Northwest coast, offers a newcomer clinical fellow both a shock and an unexpected reminiscence of the British winter. More gainfully however, it offers ample time for studying and little desire for time spent outdoors.

My week was mostly spent in surgery and clinics at the Vancouver General Hospital’s Eye Care Centre, its main operating rooms and the newly built, gigantic and incredibly well kitted British Columbia’s Children’s Hospital.

In Canada’s publicly funded Medicare, an efficient healthcare system due to its administrative simplicity, most services are offered by privately practicing doctors. The doctors’ office bills -and is remunerated by- the provincial government and thus the Canadian patient does not get involved with paying, billing or reclaim at all. Procedures or therapies not covered by Medicare can still be offered and paid outof-pocket or through certain insurers.

This kind of hybridisation between what we know in the UK as a fully nationally funded health service and the fully private health system in their neighbouring United States, allows clinicians to offer high quality healthcare without the need for patients to have expensive insurance schemes, while avoiding the inefficiencies which come with administratively complex fully nationalised systems.

From the perspective of a fellowship surgeon training in Canada, this system is ideal for many reasons: All treatments are offered under one roof, without need to distinguish between the public and private patient. The working life is efficient and the absence of unnecessary bureaucratic steps and endless paperwork permits one to focus on clinical practice. At the same time, as a part-private system, the trainer’s level of involvement in surgery is high and so working with an attentive and experience professor is very likely to allow for highly dynamic and constructive surgical training.

Throughout my time with Professor Dolman, my fellowship’s director and one of the world’s foremost voices in oculoplastic surgery, I was privileged to be exposed to adult and paediatric orbital surgery with a focus in Thyroid Eye Disease and oncological surgery. Equal exposure was gained in functional and aesthetic eyelid and periocular surgery as well as in unique minimal access techniques in lacrimal

Minor, or sometimes major variations in surgical approaches and perioperative management were often visible between Canada and the UK. Every one of those different techniques or approaches was in essence a small cause for celebration and a vindication of my decision to leave a lot behind and spend a year so far away.

Another fact I am often keen to point out to my junior colleagues is the need for fellows to treat their time abroad as truly their own. Fellowship programmes differ in variety and intensity and are mostly very well thought out to cater for the average fellow; not necessarily for every fellow. As time is limited and often the thirst for knowledge intense, one may want to go out of their way to work with their
preceptor in adjusting their curriculum.

The flexibility of training offered to me by the University of British Columbia also allowed me to organize training periods in other centres, which also greatly benefited and personalized the experience I gained:
Working with Dr Rona Silkiss in San Francisco provided me with a further invaluable set of surgical techniques and tips in aesthetic eyelid surgery as well as an interesting exposure to the Californian healthcare model.

A formal visiting observership at the Memorial Sloane Kettering Cancer Centre in New York under the mentorship of Dr Vivian Yin offered me an excellent exposure to complex Periocular and orbital cancer medical and surgical management. Operating with the Moh’s Dermatological Surgeons in Vancouver, taught me a lot in the area of facial skin cancer reconstruction.

Besides all the new things that I saw, learnt and practiced during my fellowship in Vancouver, what I also brought back is the reassurance and confidence that –though variations in practice will always exist and are healthy – the level of subpecialty medicine we practice in the UK is indeed very much on a par with the brilliant experts who I was so privileged to learn from last year.