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HomemifeatureDifficult, Loud, Frustrating… and Incredibly Rewarding

Difficult, Loud, Frustrating… and Incredibly Rewarding

Growing up in Mumbai, India, as the only child of two paediatrician parents, Dr Shivanand Sheth absorbed the behavioural mannerisms, techniques, and skills that seasoned paediatricians use to engage young children.

He tells mivision about his fascinating journey to become a specialist paediatric ophthalmologist.

My childhood home was an apartment right next door to my parents’ general paediatrics and neonatology practice. They managed their own neonatal intensive care unit (NICU) where some of the sickest premature babies and neonates were looked after.

The proximity of my home to my parents’ practice meant I spent much of my childhood hanging out in the background of their clinic, observing my parents’ interactions with sick infants and children of all ages. I soaked in the behavioural mannerisms, techniques, and skills that seasoned paediatricians use to engage young children and not make them anxious, while getting meaningful examinations, even from crying, uncooperative children. During my school years in the late 1980s and early 1990s, I remember being fascinated by how small premature babies are – some so tiny that their whole bodies could fit into my palm!

A challenge for my parents was to arrange eye care for their young patients, particularly for the NICU babies to check for retinopathy of prematurity (ROP), a potentially blinding but treatable condition. This demanded specialised knowledge and skills that were rare to find. Few ophthalmologists possessed the expertise, interest, or time to handle the intricacies of ROP screening and treatment of paediatric eye conditions, making the search for the right specialist a stressful task for my parents. This got me thinking; why not become a paediatric ophthalmologist? The need for these specialists was evident, and I was drawn to the rewarding journey of caring for young patients.

A LONG EDUCATIONAL ROAD

Becoming a paediatric ophthalmologist (or any subspecialist ophthalmologist) requires an extensive educational journey and the road is long and demanding. I first had to complete medical school, which included six years of rigorous training, including a year of internship, followed by a four-year ophthalmology residency program with an additional year of mandatory rural service.

Inherent aptitude and personalities play a big role in deciding which subspecialty one ends up pursuing. While many of my peers found paediatric eye exams too much of a challenge, and instead leaned toward becoming refractive specialists, adult retinal surgeons, or glaucoma specialists, I found my passion in examining and treating children’s eyes. I also developed a deep interest in strabismus and neuro-ophthalmology. Following my general ophthalmology training, there was much more to learn to become a fully qualified paediatric ophthalmologist.

And so, I embarked on a series of fellowships, gaining clinical and surgical expertise under the mentorship of renowned experts.

These fellowships covered paediatric low vision, visual electrophysiology, and retinopathy of prematurity at the LV Prasad Eye Institute in Hyderabad. I then pursued three international fellowships in paediatric ophthalmology, strabismus, and neuro[1]ophthalmology from esteemed institutions in the United States and Australia.

After 15 years of training since I started medical school, I finally achieved my goal of becoming a fellowship-trained paediatric ophthalmologist, strabismologist, and neuro-ophthalmologist. Melbourne, Australia, became my new home after my admission as a fellow of the Royal Australian and New Zealand College of Ophthalmology (RANZCO).

FORMING PATIENT BONDS

My childhood growing up with paediatrician parents probably nurtured some of my love for paediatrics. Children are pure natured, fun to engage with, and sometimes say and do the darndest things.

The paediatric eye exam is a unique challenge. It can be difficult, loud, frustrating, sometimes non-productive. Unlike adults, children often do not realise that there may be a problem with their vision and cannot communicate their discomfort or symptoms effectively. They resist examinations and make it challenging to gather necessary information.

Examining young children often requires you to rely on your own objective skills with very little subjective inputs, especially if your patient is pre- or non-verbal.

Practising paediatric ophthalmology has been an incredibly rewarding journey. I cherish the daily interactions with children, as I provide them with the essential eye care they need.

Conversations with my young patients range from discussing popular songs and TV shows, like Baby Shark, Peppa Pig, and Bluey to learning about their favourite school activities, sports, and hobbies. As paediatric eye care professionals, we form a unique bond with our patients and their families, as we often begin caring for them at a very young age and continue following their development as they grow into their own individual personalities. From prescribing glasses to babies, to treating strabismus, managing infantile cataracts and glaucoma, addressing complex retinal diseases, oculoplastic issues, eye tumours, and a myriad of medical and surgical paediatric eye problems, all while dealing with the intricacies of the neurology of the developing visual system, this career path is fascinating.

WORKFORCE SHORTAGES

One of the significant challenges in paediatric ophthalmology is the scarcity of specialists.1 The shortage of paediatric ophthalmologists leads to longer wait times for patients seeking care, a problem observed globally. RANZCO conducted a survey revealing a severe workforce shortage in Australia and New Zealand, with many specialists nearing retirement age and a lack of trainees entering the field.

The shortage of paediatric ophthalmologists can be attributed to limited exposure during the training period, where trainee ophthalmologists typically spend only about three months of their five-year program in a dedicated paediatric ophthalmology term.

Additionally, the imbalance in Medicare Benefits Schedule (MBS) remuneration poses another challenge. Paediatric ophthalmology demands more time for outpatient reviews compared with adult patients, but MBS remuneration for common paediatric ophthalmology procedures lags behind that of cataract surgery, despite the former taking significantly longer to perform.

This imbalance in MBS remuneration undervalues paediatric ophthalmology as a subspecialty and discourages young ophthalmologists from pursuing it. It also results in high out-of-pocket costs and extended waiting periods for patients, which is particularly concerning given the critical period of visual development that tapers off rapidly around the age of seven. Timely treatment of conditions like amblyopia (lazy eye) is much more effective during the window of early childhood, and any delay can lead to permanent visual impairment and even blindness.

Efforts are being made to address this shortage by collaborating with federal and state governments to create more training positions and fellowships in paediatric ophthalmology, especially in public hospitals. These initiatives aim to attract more specialists to the field and reduce the burden on patients.

A COMMITMENT TO THE NEXT GENERATION

As an experienced paediatric ophthalmologist, I’m committed to training the next generation of registrars and fellows. I strive to make paediatric ophthalmology and strabismus fun and comprehensible, passing on essential skills and knowledge. My hope is to inspire and encourage young trainees to choose paediatric ophthalmology as their future specialty, contributing to the growth of this vital field.

Despite the challenges and shortages, I find immense satisfaction in providing eye care to young patients, forming lasting connections, and contributing to their visual wellbeing. As I continue my practice in Melbourne, I remain dedicated to nurturing the next generation of paediatric ophthalmologists, ensuring that this critical field receives the attention and expertise it deserves.

Dr Shivanand Sheth MS FRANZCO is an ophthalmologist who specialises in paediatric ophthalmology and strabismus. He also has a special interest in neuro-ophthalmology.

He did his medical and ophthalmology training in Mumbai, after which he undertook further advanced training and fellowships in India, the United States, and Australia.

He practises at The Royal Children’s Hospital in Melbourne and has appointments to the Ocular Motility Clinic (squint) and Neuro-ophthalmology clinic at The Royal Victorian Eye and Ear Hospital. He is involved in teaching, clinical, and surgical training of ophthalmology registrars and fellows, along with mentoring medical students.

Reference

  1. RANZCO’s Vision for Australia’s Eye Healthcare to 2030 and Beyond. 1 October 2022