Fellowship Training in Haiti
A training program in Port-au-Prince brings retina education to an area of need.
In previous installments, we have explored various methods for expanding retina care into resource-poor settings. These have ranged from focused surgical interventions in the short term to stints as expatriates in the long term. Another model also deserves attention.
Consider the following questions: To expand retina care into our own communities, what means do we use? How do we confirm when young surgeons have picked up a new skill set? How do we integrate new retina specialists into a larger community of practitioners?
The answer to each of those questions is fellowship. We have all benefitted from our own fellowships, and we are acquainted with the four main elements of this phase of medical training:
• significant treatment breadth;
• high clinical volume;
• direct, repetitive observation; and
• the pairing of capable mentors with teachable fellows.
It stands to reason that a similar format can play a central role in expanding retina care internationally.
The Skills Transfer Initiative
This belief is the impetus behind the skills transfer initiative in Port-au-Prince, Haiti, a passion project for Joseph M. Coney, MD. As a retina specialist in Cleveland, Ohio, Dr. Coney had interacted with numerous Haitian ophthalmologists through his involvement with the National Medical Association (NMA), and he had been invited to participate in site visits to Haiti.
He eventually agreed to such a trip on one condition—that the clinic be outfitted with equipment sufficient to begin surgeries on his first visit. He thought this challenging request might serve as a delaying tactic. But, acting quickly, members of the NMA, along with Daniel C. Alter, MD, a retina specialist in Des Plaines, Ill., obtained clinical materials, surgical supplies, and a vitrectomy machine for a clinic in Port-au-Prince. A short time later, Dr. Coney was packing his bags for his first trip to the Haitian capital.
“The project would not have happened if not for the efforts of Dr. Alter and Surgical Eye Expeditions [SEE] International,” Dr. Coney said. “Dan, who is a practicing retina surgeon in Chicago, was the driving force responsible for getting the vitrectomy machine for Haiti.”
In collaboration with the NMA, donations from several foundations provided significant capacity for care delivery. With clinic volume bolstered by referrals from other Haitian ophthalmologists, Dr. Coney had already encountered two of the aforementioned elements of fellowship training.
But how was Dr. Coney to find a teachable fellow to include in his Haitian experience? In a country where ophthalmology residencies are often understaffed, the prevailing selection model for fellows—a candidate matching program—clearly would not work.
“You want someone young in their career with good surgical hands,” Dr. Coney explained. “And you want someone who’s going to stay after their training. They need to be entrusted and committed to their community.” Reginald Taverne, MD, a practicing Haitian ophthalmologist who was interested in expanding into surgical retina, was identified as a suitable candidate.
Drs. Coney and Taverne started their first week of training on April 24, 2016. Using Dr. Taverne’s existing clinic and staff, they began the week with a clinic full of potential surgical candidates, which led to days of full retina surgery schedules. Patients with severe ocular trauma, advanced tractional retinal detachments (TRDs), and other conditions causing vision loss were evaluated.
“This is where you must have the proper groundwork to get the clinic ready because, at this point, you have to be able to intervene,” Dr. Coney emphasized.
He approached Dr. Taverne’s training in retina surgery as though he was “teaching a first-year fellow, except he was going to pick it up faster,” given his already extensive surgical experience, Dr. Coney said. Port placement, core vitrectomy, peripheral shaving—each skill was taken in turn as they worked together on each case.
By the end of the week, dozens of patients had been treated. Dr. Coney returned to Cleveland and left Dr. Taverne and his staff to perform postoperative care. But where did that leave the remaining element of fellowship—direct, repetitive observation?
“Once you get it set up,” Dr. Coney explained, “then you really have to commit. The key is continuity. Find six to eight other surgeons who can give 1 week of their time over the next few years, and you can train someone.” SEE International helped arrange follow-up trips with other vitreoretinal surgeons, and a rhythm of retina surgery outreach was established at the clinic in Port-au-Prince.
The return Trip
Dr. Coney visited again a year later. By that second trip, Dr. Taverne had advanced considerably in his surgical skill. His training progressed to macular surface work and TRD dissection.
The most compelling story, however, came in the months between the scheduled outreach trips. A young Haitian nurse, blind and phthisical in one eye due to failed giant retinal tear surgery in the Dominican Republic, presented to Dr. Taverne’s clinic with a new giant retinal tear and detachment in her other eye. Unwilling to travel out of the country again, she asked Dr. Taverne to do her surgery. He did, successfully, salvaging 20/40 vision and allowing her to return to her job and her family.
Herein lies the heart of the mission: surgical education preventing blindness in Haiti and the validation that a fellowship training model can be reliably employed on an international scale. Dr. Coney’s second outreach trip finished with a similar degree of success, and, when he returned home, he was already working the next round of teaching trips into his busy clinical schedule.
“Until you just do it, you’re never going to feel like you have the time,” he said.
Why do it? Dr. Coney quoted Nelson Mandela to sum up the beliefs that drive him: “There can be no greater gift than that of giving one’s time and energy to help others without expecting anything in return.”
For more information about Dr. Coney’s work, please contact him at firstname.lastname@example.org.
Section Editor Benjamin J. Thomas, MD
• retina specialist at the Florida Retina Institute
• financial interest: none acknowledged
Joseph M. Coney, MD
• vitreoretinal surgeon at Retina Associates of Cleveland, Ohio
• financial interest: none acknowledged