Daniel Morris and the Keeler Scholarship

Keeler Awards Scholarship

Daniel Morris has been awarded the £20,000 Keeler Scholarship administered by The Royal College of Ophthalmologists.

Using the scholarship money, Daniel will travel to The Vancouver General Hospital & Health Sciences Centre, Canada to undergo an oculoplastic, orbital and lacrimal fellowship for 6 months to develop his skills in this area in one of the most renowned fellowship programs in the world and bring new techniques back to the UK.

Following on from this, Daniel plans to travel to northern Kenya to investigate surgical intervention for cictrical entropion caused by trachoma using a controlled trial.
"I am so thrilled to have been awarded this very generous scholarship from Keeler. It allows young ophthalmologists like myself to broaden their experience for the benefit of their patients back in the United Kingdom and carry out interesting research for the good of the global community."

Richard Keeler, Trustee and past Chairman of the company, commented on Daniel's award:
“Daniel has an impressive resume and attitude and is a very worthy recipient of this Fellowship award. The Keeler Scholarship was set up in 1990 to enable young ophthalmologists, who might not otherwise be able to afford it, to study at specialist centres of excellence overseas or in the UK. We wish Daniel all the best with his research."

Sea to Sky: an oculoplastic fellowship in Vancouver

If you like the great outdoors, then Vancouver is the place for you. Fortunately they also have four world-class oculoplastic and orbital surgeons, making it also the perfect place for an oculoplastic fellowship. I arranged to spend six months in the department after finishing my training and an excellent fellowship last year in Newcastle.
We arrived in Vancouver just before Christmas and it didn’t stop snowing for the first two weeks. The city itself is not used to much snow so the place ground to a standstill, just like London earlier this year, as buses slithered across the main roads and commuters found themselves unable to get to work. Still, it was an exciting start and the kids enjoyed building snowmen on the beach. Since then the weather has slowly improved and now the cherry blossom is out and we are basking in the spring sun. Soon the outdoor pool will be open at the beach to unwind in after a long day at the office.

Oculoplastics in Vancouver

I am primarily working with Dr Peter Dolman but also spending some time with Drs Rootman, Buffam and Rossman. They all have offices within the Eye Care Centre which is adjacent to Vancouver General Hospital near the middle of the city, but we also spend some time operating at the Children’s Hospital and the University Hospital. Apart from becoming proficient with general oculoplastic techniques, there are many weird and wonderful tertiary referral cases from all over Canada and the rest of the world. The schedule is pretty gruelling with long days and emergency cases out of hours but with usually four days a week in the operating theatre there is plenty of hands-on cutting experience. There’s also night skiing less than half an hour from the hospital, which makes up for any long day!

The case load is very similar to any other centre around the world: entropion, ectropion, ptosis etc, but we also see some more unusual pathology. Similarly the emergency cases are comparable to those seen in the UK, Canadians also like to get drunk and punch each other in the eye with beer bottles, although eyelid laceration from a bear’s paw is not so common at home.

Dr Dolman has developed the VISA classification system for thyroid orbitopathy, which is a useful tool in the management of this difficult disease so we see many thyroid patients and regularly perform orbital decompressions both for rehabilitation and optic neuropathy secondary to apical optic nerve compression. The timing of intervention for these patients is critical and watching how other people treat thyroid patients has been very useful.

Dr Dolman has also championed the non-endoscopic endonasal approach for dacryocystorhinostomy (DCR), which I thought would be very difficult. In fact, the anatomy is well displayed and accessible without an endoscope so that learning the technique has been very satisfying; it also helps that I have a teacher with endless patience. This low-tech approach has excellent results and is fast to perform with minimal instrumentation so I hope it will benefit my patients back in the UK.

Dr Rootman is well known worldwide as an authority on the orbit; he is an excellent teacher and has an encyclopaedic knowledge of all things orbital. Particularly impressive is his management of orbital varices, notoriously difficult to deal with because they are often large with many vascular connections and they bleed heavily. He has developed techniques to image and glue them with the help of the interventional radiologists which makes them much easier to remove.

Collaboration

One good thing about working in an internationally renowned unit is that you get some really interesting cases, often requiring multi-disciplinary input. We recently saw a gentleman who had left proptosis with some loss of visual function. The scan showed a growth at the nasal side of the orbital apex which looked benign but was causing some pressure on the optic nerve. A tumour in that position is difficult to access using the traditional approaches that an orbital surgeon might use and as it was adjacent to one of the sinuses we asked one of the ENT surgeons who specialised in functional endoscopic sinus surgery for his opinion.

We decided on a combined approach mainly through the nose, but with us on hand to push the tumour out from the other side and advise on the best place to enter the orbit causing the least collateral damage. The ENT surgeons were using a new electromagnetic guidance system so they knew exactly where their instruments were in relation to the scan and we eventually removed a sizeable benign haemangioma using their approach through the nose and sinus wall. The patient was delighted and made a full recovery. Technology and collaboration at its best!

Ophthalmology training in Canada

Medical training in Canada is similar to the American system where students do a University degree before entering medical school for four years, then doing a residency in the specialty they are interested in. Medical students are a little more earnest than their British counterparts, possibly because they are older and have to work hard to get through in four years. Exposure to ophthalmology in medical school is as bad as it is in the UK, about a week if they are lucky but it is still a highly competitive residency to get into, especially in a desirable place like Vancouver. The training takes four years and is equivalent to our six year specialty training so the residents are busy, typically having teaching at seven every morning and regular assessments throughout their training. They often then do a fellowship although many become general ophthalmologists doing mainly cataract surgery. During their training they are usually expected to perform a couple of hundred cataract operations, more than American residents but less than British trainees.

Canadian health care

Health care in Canada is funded and delivered through a publicly-funded health care system, with most services provided by private entities. So residents of British Columbia are eligible for Medical Services Plan (MSP), known locally as “the Plan” which is funded by the Government of British Columbia and insures basic medical services provided by physicians, laboratory and diagnostic services.

All residents of British Columbia must register under the Plan, so you get a care card and personal health number. It costs about £30 a month with discounts for low earners. You have to pay for your prescriptions and there is a way of subsidising high drug costs called Pharmacare, also based on income. As the Plan only covers basic medical costs most people have additional coverage. Dental care and even a trip in an ambulance can be very expensive. Health benefit packages are sometimes offered by employers or you can buy your own.

Considerable attention has been focused on two issues: waiting times and human resources. There is also a debate about the appropriate ‘public-private mix’ for both financing and delivering services. From the point of view of physicians working in the system the big difference between the UK and Canada is that British doctors are paid a salary, whereas Canadian doctors are paid per patient. So there is an incentive to work hard and efficiently! The downside is that they are not allowed to earn more privately as British doctors can. There are definitely pros and cons to both systems; Canadian ophthalmologists work harder than their British counterparts but are usually considerably wealthier…

Sea to sky city

Vancouver is on the Pacific coast of Canada in the province of British Columbia. With a population of 2.5 million people it is the largest city in Western Canada and it was named after the British explorer George Vancouver. Originally settled in the 1860’s as a result of the Fraser Canyon gold rush it rapidly became a metropolitan centre and a major seaport. The economy traditionally relied heavily on forestry, mining, fishing and agriculture but now has diversified into software development and biotechnology, an ever growing tourism industry and has also become one of the largest film production centres in North America, earning it the nickname Hollywood North.

Vancouver jostles with Sydney for the accolade of most desirable city in the world to live in. Unfortunately this makes housing very expensive but quality of living is high and access to outdoor pursuits is unparalleled. You can ski in the morning and sail in the afternoon, making it very attractive to those who love the great outdoors and earning it the sea to sky nickname. Ice hockey is the Canadian equivalent of football back home; the local premier league team are the Canucks, followed obsessively by most locals. Jogging appears to be a popular city pastime, but with such close proximity to ocean, mountains, rivers and lakes, you can take your pick of activities, from big wall rock climbing at Squamish, skiing at Whistler to some of the best salmon fishing in the world.

Vancouver’s climate is unusually temperate by Canadian standards with mild wet winters and warm summers, similar to the UK, perhaps explaining why so many Brits choose to emigrate to Vancouver.

Vancouver is a city of neighbourhoods, each with a distinct character and ethnic mix. Historically people of Scottish, English and Irish origins were most common and elements of British society and culture are still highly visible. Nowadays the Chinese are the biggest ethnic group in the city. Getting around Vancouver is easy and everyone is encouraged to leave their car at home with a good electric bus network, a sky-train, a sea-bus and a dedicated network of bicycle routes, which is how I get to work now it has stopped snowing.

Although Canada is officially bilingual, Western Canada is predominantly English speaking, one good reason to work in Vancouver. Or so I thought…until you realise that North American medical ‘English’ is different in many ways to the good old Queen’s English back home in Britain. Depending on which side of the pond you hail from, this could be taken as corruption or sophistication. No comment. Another very Canadian trait is to describe items by their trade name rather than their official descriptive noun, for example a tissue is a Kleenex. It is interesting how language evolves when separated by a large body of water. The huge benefits of spending time over here easily outweigh any mild amusement I cause my colleagues with my old-fashioned grasp of the English language.

The darker side of Vancouver

Every city has a down side and Vancouver is no exception. There is a large drug problem which spills onto the streets on the east side of the city centre. Police are very tolerant towards the use of marijuana (in fact you can occasionally feel quite light-headed after a walk along the beach through clouds of green smoke) but the harder drugs are the cause of many problems, such as homelessness, mental health issues and crime. There is a concerted effort on to sort out the city’s drug and homeless problem before the worlds spotlight descends on Vancouver next year for the Winter Olympics.

Recently a spate of gangland shootings across the city has threatened to burst the cosy bubble over Vancouver. This escalation of gang violence has apparently been caused by disruptions to the supply of illegal drugs. Unseasonably bad weather ruined large parts of the marijuana crop and the Mexican drug war has limited the amount of cocaine available. The gangs have been feeling the pinch and by the end of the first quarter of this, an unprecedented 14 people had been killed and 34 wounded.

Olympic fever

The 2010 Winter Olympics and Paralympics will be held in Vancouver and Whistler so the whole city is already reaching a state of fever pitch, despite the Games still a year away. There has been huge investment in the city, with a new train link between the airport and the city centre, complete overhaul of the road up to Whistler, a new affordable housing development which will serve as the Olympic village and a general sprucing up of the city.
As usual, the Games are dogged by controversy: the logo, environmental destruction, development on indigenous land, soaring costs in the face of global recession (estimated at $6 billion), security, even down to how to safeguard the ski patrol’s avalanche bombs. It all sounds very familiar and maybe it is just the media digging for a story or perhaps the Olympics really are getting a bit out of hand?

Organising a fellowship abroad

For anyone who is interested in organising a similar experience, you need to start planning at least two years in advance. Popular cities or departments are booked up many years in advance and make sure you talk to your mentors and peers to make sure the fellowship is right for your training needs. There is even more pressure on fellowships with the current dearth of Consultant jobs as Registrars finish their training and drop into the fellowship ‘holding pattern’ for much longer than before. So make sure you start getting those emails and letters off sooner rather than later.

Some fellowships have a formal application and interview process; others are simply arranged through meetings, telephone calls and emails. Clearly, it shows willingness if you visit the department and speak to the staff and current fellow. Once a position has been secured (and get it in writing), the country you are visiting will have certain visa requirements, as will their equivalent of the GMC for working there. Europe is much easier to arrange than North America, for instance I had to have a full medical examination (including a charming examination of my testicles) and a chest x-ray to get a Canadian work visa. I also had to dig out every certificate I owned and get them stamped by a Notary Public at vast expense. In fact I’ve never filled out so many forms in my life. And don’t forget about immunisations, travel / health insurance and local medical indemnity. All this costs money and although most fellowships in the UK are funded, many abroad are not, so then you have to apply competitively for scholarships and grants.

It was an enormous amount of work to arrange this fellowship and uproot my wife and two young daughters. On top of this it is unpaid so it is hard to make ends meet. Thankfully the Royal College of Ophthalmologists and Keeler very generously awarded me the Keeler Scholarship, which has made the fellowship possible.

It has been an incredible learning experience which I have no doubt has improved my ability to serve my patients back in the UK, added to which we have had the privilege of living in Vancouver for six months, an experience I would recommend to anyone.

UPDATE: Keeler Scholarship Winner Continues his Journey in Northern Kenya

Keeler Scholarship Award Winner Daniel Morris has completed the first leg of his 2 stop journey and has recently arrived in Africa.

The Keeler Scholarship is awarded every 2 years by the Royal College of Ophthalmologists to enable study, research or acquisition of special skills, knowledge or experience for the subsequent benefit of ophthalmology in the UK.

Using the scholarship money, Daniel has spent the last 6 months at the The Vancouver General Hospital & Health Sciences Centre, Canada to undergo an oculoplastic, orbital and lacrimal fellowship to develop his skills in this area. He completed his fellowship in July and has recently arrived in Africa where he plans to travel to northern Kenya to investigate surgical intervention for cictrical entropion caused by trachoma using a controlled trial.

On arrival Daniel has found the Samburu tribal community has suffered from an outbreak of cholera which creates urgent primary care challenges. Daniel has been blogging about his journey thus far and although access to the internet is now limited, he will continue to blog where possible during his next 3 months in Northern Kenya. His blog can be found at http://eyetravel.wordpress.com/

Figure legends

Figure 1: Downtown Vancouver from the hospital helipad.
Figure 2: Operating with the ENT surgeons. Note the unorthodox footwear on one of the trainees, first time I have seen a real cowboy in theatre.
Figure 3: Family fun in the Rockies.
Figure 4: Some of the activities Vancouver has to offer- night skiing, cycling, paragliding and ice climbing.