WIRE - Wills Eye International Resident Experience Stack

In February 2018 I traveled to Tenwek Hospital which is just outside Bomet, Kenya. It is a large missionary hospital located about a 4 hour drive from Nairobi. The hospital has been caring for patients since the 1950s and has developed into a multi-specialty center for a large geographic area. I spent the majority of my time with my host, Dr. Ben Roberts, a retina-trained ophthalmologist who has been at Tenwek for 12 years, as well as Drs. Troy and Farrah Newman who joined Tenwek about one year ago. 

The week at Tenwek begins with a busy clinic day on Monday on which we admit all of our surgeries for the week (around 25-30). It is impossible to know what will walk through the door that day and patients have often traveled from great distances for evaluation.  Every patient who walks through the door at Tenwek has a problem to treat. The effort it takes to come to clinic means that patients sometimes have to wait until a problem is very advanced until it is seen. The doctors and staff did such an amazing job moving through a busy day and were eager to help in every way (especially language interpretation for me!).

Tuesday through Thursday are spent mostly in the OR doing cataract, retina, glaucoma, and trauma cases among others. We performed many surgeries in my two weeks highlighted by learning manual small incision cataract surgery (MSICS). It was a great learning opportunity for me as I hope to participate in global ophthalmology in my future practice. Getting a solid foundation for MSICS during training is a huge benefit of our Wills residency program and I am thankful for the chance to visit. 

In addition to learning surgical and clinical skills, the time at Tenwek allowed my to experience and learn the great burden of global eye care. So many patients are in need of care but access and resources are limited. I was able to see the incredible benefit of Tenwek to its community, not only in the provision of care, but I think more importantly in education. The eye center is constantly swimming with learners - ophthalmology residents from Nairobi, clinical officers, nursing students, ophthalmic technicians - all eager for training to eventually go serve their community apart from Tenwek. This is where we as U.S. ophthalmologists can have a huge impact on global eye care by training and educating around the world. I was proud to represent Wills and what it has meant and will continue to mean for ophthalmology education worldwide. We even listened to Chiefs' rounds together on Friday afternoon!

Dr. Roberts was an amazing example to me in our time there. He is kind and caring to his patients on top of his already excellent knowledge and technique. He is slow to become angry or frustrated when things break or do not go as planned, and always looks to fix things on his own. He is constantly working to improve the care of patients at Tenwek. It was a wonderful opportunity to work with and learn from him. 

Thank you to the Wills Alumni Society, Dr. Haller, Joe Bilson, and all the supporting attendings for the opportunity to visit Tenwek through the WIRE program. I had an amazing time and hope to continue representing Wills in global ophthalmology in the future. 

My trip to Kenya was an amazing educational experience. I spent two weeks in Bomet Kenya at Tenwek Eye Hospital learning Manual Small Incision Cataract Surgery (MSICS) as well as participating in skills transfer to local Kenyan eye physicians. In contrast to how cataract surgery is performed in the US, this type of cataract surgery is common in third world countries where resources are limited. Before this experience, I was not sure if I had the skillset to take surgical trips in the future, but Dr. Ben Roberts and the Tenwek team helped me gain a competency that will allow me to continue international work as an ongoing part of my career. I was very proud to participate and in a very small way, help those less fortunate regain their sight.

The ultimate goal of these experiences is to help local ophthalmologists assume management and care of their communities. To this end, part of the trip involved educational sessions with local doctors, ophthalmic officers, and nurses. Having the opportunity to teach medical management of glaucoma and suturing under a microscope was truly rewarding. I hope it will lead to the next generation of first class ophthalmic care at Tenwek Hospital.

My WIRE trip to Haiti was easily the highlight of my entire residency experience. During my time there I made lifelong friends and had the opportunity to learn from some of the best when it comes to delivering ​​quality eye care in high needs, under-resourced areas. Haiti is a beautiful country filled with amazing people, and I hope that I will be able to return one day and contribute in a meaningful way to Dr. Dupuy's community, using the skills that he so graciously passed on to me and countless other residents before me!

This spring, I had the opportunity to travel to Cap-Haitien, the second largest city in Haiti, with Dr. Reed Kindermann, a Wills ophthalmologist, his wife Greta, and Dr. Jeremy Joseph, an ophthalmologist from the United Kingdom. This was the inaugural trip to Haiti for the Wills International Residency Experience (WIRE). Haiti, the poorest country in the Western Hemisphere, faces unique challenges in regards to eye care, including extreme poverty, high rates of glaucoma, and a limited number of ophthalmologists; there are only 56 ophthalmologists in the whole country, serving 10 million people!

Our host ophthalmologist, Dr. Guerline Roney, runs the ophthalmology practice called Vision Plus Clinique in the middle of Cap-Haitien. It is a unique hybrid between charity care and private practice, and one of the goals of the ophthalmologists who work there is to meet the eye care needs of the poor as well as those with means to pay.  Downstairs there is a waiting room and exam lanes for “social” patients, or those in need of charity care. The clinic for the paying patients is upstairs. The facility also has an operating room with two operating tables and two microscopes.  The Haitian ophthalmologists who work in the practice (there are four) use funding gained from donors and from the paying patients’ care as well as assistance and supplies provided from overseas visitors (like us) to provide care for the social patients.

During our time in Cap-Haitien, we spent our days at Vision Plus Clinique; our days started with seeing patients referred to us by VOSH PA, a group of Pennsylvania optometrists performing screenings in nearby villages and rural areas. Most patients were referred for glaucoma or cataracts, or both. Those patients in need of surgery stayed until we were done seeing patients in the clinic, and then we did surgery until the day’s end.  While in Haiti, I performed 10 extracapsular cataract extractions, a tube shunt, and a conjunctival mass excision. I also was able to assist and observe Dr. Kindermann and Dr. Joseph perform cataract surgery, pterygium surgery, glaucoma surgery, and even surgery for trachoma.  In total, our team performed 66 surgeries during our five days in Haiti.

My trip to Haiti was a very valuable experience.  This was my introduction to global ophthalmology, to thinking outside the box and recognizing the difficulty of practicing ophthalmology in a setting with limited resources and the satisfaction of helping patients in need.  I am grateful to the Wills Alumni Society, the WIRE Committee, and Dr. Haller, Dr. Uhler, and Mr. Bilson for making this trip possible. I look forward to my next trip abroad to learn more about global ophthalmology, and to contribute to improving global eye health.

This past month, I was fortunate enough to spend two weeks serving at Tenwek Hospital in Bomet, Kenya as part of the Wills International Resident Experience (WIRE). Tenwek Hospital is a Protestant missionary hospital in southwestern Kenya and is the largest in the area, providing care to approximately 600,000 people within a 20-mile radius and serving as a major referral center for the region. I spent my two weeks under the guidance of Dr. Ben Roberts, a retina-trained ophthalmologist who has served at Tenwek for the past 7 years and Dr. Michael Chen, a cornea specialist who will be serving at Tenwek for the next 2 years. Dr. Roberts has been kind enough to host Wills residents for the past 3 years, generously providing one of the most rewarding educational experiences of the residency.

I arrived at Tenwek and was met by Dr. Roberts and his wife, Jenny Roberts, in Nairobi. Together we made the 4-hour journey to Bomet and arrived on the hospital grounds by mid-day Sunday. Tenwek hospital has a steady stream of visiting physicians that come from all around the country in all different subspecialties. As a visiting physician you say in the Guesthouse where you enjoy a lovely spacious room, complete with a coffee maker, that is a mere 100 yards from the hospital. Every night a delicious meal is prepared by Livingston, a man who has served at Tenwek for over 30 years, and all of the visiting physicians get to dine together, sharing stories from the day.

On Monday I was introduced to the ophthalmology team. Dr. Roberts and his staff are truly among the most welcoming, gracious and kind people that I have ever come across. There is a true sense of team among the staff and a shared commitment to delivering the best care possible to the people of Kenya. Monday is one of the main clinic days. Together, with Dr. Roberts and the staff, we spent the day seeing patient after patient until we had gotten through the seemingly endless line of people. As Dr Roberts says, the sign of a good Monday is when the hallway where patients wait is covered in mud by the end of the day!

Patients travel from all over the region; some have traveled up to 6 hours to be seen! We work in one room with 5 slit lamps set up, which provides for a very nice sense of camaraderie. There was a retina specialist to my right and a cornea specialist to my left, which made for some very efficient referrals! The goal of these very busy clinic days, where over 100 patients are examined, is to treat problems that can be managed medically and admit patients requiring surgery. On that first Monday we admitted close to 30 patients, all of who required cataract, retina, glaucoma or trauma-related surgery. We documented all of this on the brand new EMR system set up by a few months earlier by Patrick Rapuano!

The rest of the week was devoted to the OR where we began at 7:30 and work until around 5 or 6 taking on case after case. The Kenyans, however, have a healthy understanding of work life balance and so even on the busiest OR days there was always time for a mid-morning chai tea and mandazi break (the Kenyan equivalent to a donut). Additionally, the entire hospital makes an effort to observe a lunch break at 1:30. At this time, physicians and hospital staff have the chance to return home to enjoy lunch with their families. As a visiting physician, I was invited to a different missionary’s home each day for a home-cooked lunch. We would return in the afternoon and continue with cases. In between, we would see post-operative patients and check in on clinic, which is always open and staffed throughout the week by Kenyans who have been trained by Dr. Roberts and are superb clinical ophthalmologists.

In my two weeks at Tenwek I assisted with and performed a lot of surgery and saw remarkable pathology. Access to care is very limited and as a result patients are often forced to wait until their problems are very advanced. The work that Dr. Roberts and his team do each and every day is truly life changing for their patients. It was rare to see a cataract that was not at least count fingers vision. Cataract surgery for one patient whom I was fortunate enough to meet meant that she was able to leave her home alone fro the first time in months. My experience operating in Kenya opened my eyes to the entirely unique set of obstacles faced when delivering healthcare in the developing world. Resources are scare and precious and nothing is wasted! You think about every step and how you can conserve. What struck me, however, was that excellent care was never compromised. Dr. Roberts and his team use what is available and make it work. I learned more in two weeks then I ever could have imagined. I worked with and treated some of the most gracious, intelligent and appreciative people that I have some across in my training. This experience has solidified my commitment to international work throughout my career. I was so proud to represent Wills Eye. We have had physicians donate their time, expertise and supplies and on my final day each and every one of the team at Tenwek made sure I returned and expressed their gratitude for all the Wills has done for Tenwek. I am in awe of the work being done at Tenwek and look forward to continuing to give back. I want to thank Dr. Haller, Mr. Bilson and the Wills Alumni Society for giving me this opportunity through WIRE. Asante sana! (Swahili for ‘thank you very much!’)