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Twenty years of International Council of Ophthalmology fellowships: description of the programme and the impact on more than 1100 awardees
  1. Emilio A Torres-Netto1,2,3,4,
  2. Cordula Gabel-Obermaier5,
  3. Peter Gabel6,
  4. Balder Gloor7,
  5. Peter Wiedemann8,9,
  6. Hugh Taylor10,11,
  7. Clare Davey12,13,
  8. Nicola Quilter14,
  9. Berthold Seitz15,16
  1. 1 Ocular Cell Biology Group, Center for Applied Biotechnology and Molecular Medicine, University of Zurich, Zurich, Switzerland
  2. 2 Department of Ophthalmology, Federal University of Sao Paulo Paulista Medical School, Sao Paulo, Brazil
  3. 3 Faculty of Medicine, University of Geneva, Geneva, Switzerland
  4. 4 ELZA Institute, Dietikon, Zurich, Switzerland
  5. 5 Executive for ICO Fellowships, International Council of Ophthalmology, Munich, Germany
  6. 6 Department of Ophthalmology, University of Regensburg, Regensburg, Bayern, Germany
  7. 7 Department of Ophthalmology, University of Zurich Faculty of Medicine, Zurich, Switzerland
  8. 8 Klinik Und Poliklinik Für Augenheilkunde, Universitatsklinikum Leipzig, Leipzig, Germany
  9. 9 ICO President Since 2018, International Council of Ophthalmology, San Francisco, California, USA
  10. 10 Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
  11. 11 ICO President from 2014 to 2018, International Council of Ophthalmology, Melbourne, Australia
  12. 12 Head of ICO Exams since 2018, International Council of Ophthalmology, London, United Kingdom
  13. 13 Department of Ophthalmology, Royal Free Hospital, London, UK
  14. 14 Executive for ICO Exams, International Council of Ophthalmology, London, United Kingdom
  15. 15 Department of Ophthalmology, Saarland University Medical Center, Homburg/Saar, Germany
  16. 16 Head of ICO Fellowships since 2016, International Council of Ophthalmology, Homburg/Saar, Germany
  1. Correspondence to Emilio Almeida Torres-Netto, University of Zürich, Center for Applied Biotechnology and Molecular Medicine, Winterthurerstrasse 190, Zürich 8057, Switzerland;emilioatorres{at}me.com

Abstract

Background/Aims The International Council of Ophthalmology (ICO) offers fellowship programmes to help young ophthalmologists, mainly from low-resource countries, improve their practical or research skills in ophthalmology subspecialty areas. Using questionnaires, the objective of the present study was to evaluate how the ICO Fellowship Programme has impacted on improving knowledge, skills and the careers of young ophthalmologists from low-resource countries.

Methods From 2001 to 2019 overall 1140 ICO fellowships were awarded. A questionnaire was sent to ICO fellows after the conclusion of their fellowship and another 3 years later. Part 1 contained 26 questions, while Part 2 had 21 questions. The answers were collected through an online platform and analysed descriptively thereafter.

Results 1101 Part 1 questionnaires had been sent to former fellows, with a return rate of 47% (516 responses) and 829 Part 2 questionnaires with a return rate of 47% (390 responses). Overall, 98.3% strongly or somewhat agreed that knowledge in their subspecialty has improved considerably. Whereas only 19% of them held a lecturer, senior lecturer or head of subspecialty department position prior to the fellowship, 46% of them held such a position 3 years after the fellowship was completed.

Conclusions The ICO Fellowship Programmes aim to promote the enhancement of eye care delivery and eye health in low-resource countries, the professional development of young leaders and the improvement of eye care. The results of the current study confirm the expectation of such a positive impact. Moreover, almost half of the responding participants have been appointed to a local leadership position in their home country.

  • Medical Education
  • Public health
  • Vision

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INTRODUCTION

Since its foundation in 1857, the International Council of Ophthalmology (ICO) is the primary international body representing and serving 118 national, 8 regional and 42 subspecialty associations of ophthalmologists.1 The ICO works with professional ophthalmological societies, non-governmental development organisations and related organisations worldwide to improve ophthalmic education and the access to high-quality eye care with the aim to preserve and restore vision in both developed and developing countries.1 2

In 2001, over 135 million people had severe visual impairment and throughout the world approximately 45 million were blind.3 Furthermore, it was estimated that this number could double by 2020 if strategic actions were not taken.4 5 Encouraging excellence in eye care with a high standard of knowledge, in order to reduce blindness and vision loss around the world is the primary objective of the ICO.

In 2015, there were estimated to be some 233 000 ophthalmologists worldwide.6 7 Since 1995, more than 40 000 ophthalmologists from 84 countries have taken around 60 000 multiple ICO exams—there are four different ICO exams—to evaluate their knowledge in ophthalmology. In 1997, the ICO initiated the ‘ICO Assessments’ that evolved into today’s ICO exams.

The ICO Fellowship Programme was created to help young ophthalmologists, especially those from low-resource countries, improve their practical and in part their research skills in subspecialty areas as well as to broaden their perspective in ophthalmology.8 In 2000, the ICO agreed to start an ICO Fellowship Programme at the suggestion of Professor Dr Balder Gloor, and the Three-Month ICO Fellowship Programme began under his direction in 2001.1 From 2006 to 2016, Professor Dr Peter Gabel served as Chairman of the ICO Fellowship Programme. Under his guidance, new types of fellowships were implemented including in Ocular Pathology & Microbiology and Retinoblastoma. In addition, he was successful at bringing highly committed supports on board, such as the Eye Cancer Foundation (New York), the AIER Eye Hospital Group (China) and the Kinder Augen Krebs Stiftung (KAKS, Bonn). In 2016, Professor Dr Berthold Seitz took over as Chairman of the ICO Fellowship Programme. Since then the ICO-National Eye Institute One-Year Fellowship in Ocular Genetics and the ICO-Allergan Advanced Research Fellowship have started, and the sponsorship from industry and national (subspecialty) societies has markedly increased.

In the last 20 years, the programme has supported more than 1200 fellowships of 3 months duration and more than 30 fellowships of 1-year duration. Doctors from 88 home countries were able to benefit from professional exchange at more than 137 host institutes all over the world.

The recipients of the following fellowship programmes were included in this research: ICO Three Months Fellowship, ICO-Eye Cancer Foundation (ICO-ECF) Six Month Fellowship in Retinoblastoma, ICO-Retina Research Foundation (ICO-RRF), One Year Helmerich Fellowship and ICO-Fred Hollows Foundation One Year Fellowship. However, the recipients of more recent fellowships such as the ICO-Allergan Advanced Research Fellowship and the ICO-National Eye Institute/National Institute of Health in Bethesda (ICO-NEI/NIH) Fellowship in Ocular Genetics were not included in the survey since they were only offered in 2018 and 2019.

Every year, the ICO receives approximately 150–200 applications for these fellowships from highly motivated candidates, but only 35–50% of these can be accepted in the programme, depending on the funds that are available. The ICO exams (ICO Visual Sciences [formerly: Basic Sciences], Optics, Refraction and Instruments [formerly: Optics and Refraction], Clinical Ophthalmology [formerly Clinical Sciences] and the ICO Advanced Examination) play an important role in the selection process.

Numerous initiatives for ophthalmic education are available worldwide, although many of them have not been evaluated.8 9 However, we report here an evaluation of ICO Fellows after completion of their ICO fellowship opportunity. Using questionnaires, the objective of the present study was to understand how the ICO’s Fellowship Programme has impacted on improving the knowledge, skills and the careers of young ophthalmologists in low-resource countries.

METHODS

When the survey started candidates could apply for the Three Month, Six Month or One Year ICO fellowships. Candidates completed an online form with personal data and information on their work experience proven by appropriate documentation. When applying, candidates needed to be citizens of and work in a low-resource country and be less than 40 years old. They had to have completed their residency training in ophthalmology, passed their national ophthalmology exam and provide recommendations from their current programme director. They needed to show how they intended to apply the skills and knowledge to be gaining in their home institute on their return. In addition, completion of ICO exams and membership of their national society in the ICO were also considered.

The submitted information was reviewed by the ICO Fellowships Executive. After being determined eligible, a potential ICO Host Training Center was selected from the ICO Directory of Training Centers (URL: http://www.icoph.org/refocusing_education/fellowships/fellowship_host_directory.html) and the expectations and options discussed with the host specialist. If accepted by the host institution, a proposed start date was established. Then, the fellowship application was submitted for final assessment and a funding decision.

This final assessment had three steps: 1—formal criteria such as professional education, work experience, teaching and scientific activities; 2—the regional expert’s recommendation regarding relevance of the planned training for the home institute and cost–benefit relation; and 3—a third expert who compared and ranked all applications.

After each participant had completed the ICO Fellowship Programme, two evaluations were sent by email. Both evaluations were done using the online survey platform SurveyMonkey.com. This platform sends emails individually, and if there is no response in due time, reminders are triggered in order to increase the response rate. The questionnaires were sent between December 2016 and March 2019.

The first questionnaire (Part 1) was (1) sent shortly after the conclusion of the fellowship and after the participant returned to his/her home country, for the participants who completed their fellowship programme in December 2016 or after, or (2) sent in December 2016 for participants who served their ICO Fellowship between 2001 and December 2016. In order to obtain an evaluation at different stages in the fellow’s career, a second questionnaire (Part 2) was sent out around 3 years after the first one (see Appendix).

After the questionnaires were collected, the data were analysed through the software of URL: www.surveymonkey.com and descriptively using Microsoft’s Excel program (Excel for Mac, Subscription Office 365, 2019 and Excel for Windows, Subscription Office 365) and presented here. Each participant agreed in advance that his/her information was compiled anonymously. A retrospective analysis was performed anonymously and was conducted in accordance with the tenets of the Declaration of Helsinki regarding research involving human subjects.

RESULTS

In November 2019, the ICO formed a network of 136 host institutes in 33 countries (figure 1). This partnership allows the centres to regularly receive guest ophthalmologists from low-resource settings as ICO fellows (table 1).

Table 1

Origin of 1140 International Council of Ophthalmology fellows that were granted since the year 2000

Figure 1

Number of International Council of Ophthalmology host centres per country out of the 136 training centres around the world.

From 2001 to 2019, overall 1140 ICO fellowships were awarded.

In total, 1101 on-line links with questionnaires were sent to the participants in the first survey (Part 1). The response rate received from this phase was 47%, with 516 answers from 329 males (64%) and 187 females (36%).

Of all the respondents more than half (56%) had a position of senior resident or consultant prior to their ICO Fellowship Programme, while 6% were the head of a subspecialty department. Most of the alumni had taken at least one of the ICO exams, which are successive. Approximately, 65% of the candidates passed the ICO Basic Science Exam as their highest exam, 61% the ICO Optics, Refraction and Use of Instruments Exam, 55% the ICO Clinical Sciences Exam and 21% the ICO Advanced Exam before applying for the ICO Fellowship Programme.

Most fellowships were observerships (62%) due to local medical regulations, but some centres also allowed clinical (19%) or surgical exposure (19%) after appropriate registration with the local medical authorities in the host country.

Almost all the participants mentioned that they learnt new techniques of diagnosis (92%) or treatment (94%) or surgery (88%) during the period. As expected, access to the institution’s library (91%) and regular teaching events (90%) was high. Interestingly, even though most fellowships are classified as observerships, 60% could take part in hands-on contact with patients (in countries where there were no legal restrains to do so and after their supervisor asked the patients for permission) and 49% were allowed to observe their supervisor during surgery. Under no circumstances were ICO fellows allowed to undertake any diagnostic and treatment procedures on their own, if not allowed by the medical governing body.

The most attended regular teaching events were case presentations (68%), clinical sessions (67%) and morning rounds (62%). Only 17 alumni (3%) reported not attending any teaching event during their entire ICO fellowship period. Participation in publications was low with less than a quarter producing a scientific publication during their period abroad—only 23% of had a chance to participate in a scientific publication. Despite this, the degree of satisfaction was extremely high (98.3%) with 79.5% ‘strongly’ and 18.8% ‘somewhat’ agreed that knowledge in subspecialty has improved considerably. There was no significant difference between males and females on the degree of satisfaction, and 90% would recommend colleagues to apply for an ICO fellowship award.

The last questions of Part I of the survey referred to the administrative process. Approximately, 94% of the participants rated both the information on the website and the eligibility process and the communication with the executive secretary as extremely or very good. The 3-month programme was the one that served most of the recipients (92%) followed by the programme lasting 6 months (4%) and 1 year (4%). Regardless of whether the duration of the fellowship was 3 months, 6 months or 1 year, if the training included hands-on experiences 70% of the alumni shared the opinion that the programme should be longer. However, for observations only, 3 or 6 months were thought to be a long enough duration (Part 1, questions 22–24, open answers).

The Fellowships’ longer-term impact was analysed through the second questionnaire or Part 2 of the survey. It was carried out 3 years after the first one and was sent to 830 recipients. The response rate was similar to Part I, around 47%, from which 262 were males (67%) and 128 were females (33%). Overall, 98%, of those who responded had had Three-Month Fellowships. In addition, we compared the email addresses of those who have completed Part 1 with those who have completed Part 2. We could verify that 374 of those who have completed Part 1 have also completed Part 2—this means that 96% (374 of 390) who has answered Part 2 has also answered to Part 1. The distribution of the chosen subspecialties is shown in figure 2.

Figure 2

Distribution of International Council of Ophthalmology fellowship’s subspecialties chosen by participants (Part 2, question number 7).

The vast majority of ICO Fellowship Alumni (98%) continued to report that the experience gained during fellowships helped their daily practice. ‘After my ICO training, I am able to diagnose glaucoma cases on time. Nowadays we have a project of free cataract surgeries in Afghanistan and I was able to diagnose many cases of the undiagnosed glaucoma’, one of the participants said. A Romanian participant stated, ‘excellent clinical exposure, decision making in treatment, including surgical approach, surgical techniques never tried before alone’. Another testimony comes from an Indian ophthalmologist: ‘This fellowship improved my organisational skills, work ethic, and problem-solving abilities. It provided me with a very good learning experience which helped me in updating myself in the specialty’.

The impact on particular areas of personal practice has also been accessed. The service delivery and academic training had ‘some’ or ‘a lot’ of impact for 91% and 88%, of respondents. On the other hand, research training was a matter that modestly impacted the fellowship: 31% referred ‘a lot’ of impact, 24% had ‘some’ impact, 19% had a ‘neutral’ impact and 16% ‘none or very little’ impact on research (figure 3). Another interesting point was whether contact with the training centre was kept after 3 years of follow-up. Although this collaborative work was not maintained frequently, clinical cases continued to be discussed ‘on a regular basis’ by 11% and ‘quite often’ in 27% of participants. Twenty-eight per cent of participants continued to receive support in teaching ‘on a regular basis’ or ‘quite often’.

Figure 3

How much impact did the International Council of Ophthalmology fellowship training have on particular areas of the alumni’s personal practice of in his/her organisation? (Part 2, question number 12).

Bringing young ophthalmologists to leadership positions is one of the goals that was successfully achieved through identifying promising alumni from the ICO Fellowship Programme. A total of 35% of fellows joined a subspecialty department at their home institute and 21% were promoted to be team leaders of a (subspecialty) department in their home institute. While only 19% of them had a lecturer, senior lecturer or head of subspecialty department position prior to the fellowship, 46% of them were able to hold such a position 3 years after their ICO fellowship was completed (figure 4).

Figure 4

What positions did International Council of Ophthalmology Alumni hold before the training and what positions they hold at the time of the survey? (Part 2, question number 14 and question number 15).

Part 2 of the survey also evaluated the teaching activities of the former fellows. Approximately, 80% were involved in teaching activities either with students, medical residents, medical or paramedical staff. Among the teaching activities, 80% spent between 1 and 5 hours with medical or paramedical staff, while less than 10% engaged in teaching for more than 10 hours per week in such groups. On the other hand, the contact with residents was higher: 47% spent 1–5 hours a week teaching residents, 31% between 6 and 10 hours and 22% more than 10 hours a week. The training experience at the host institution helped the returning fellows incorporate regular teaching activities into three quarters of their home institute programmes.

DISCUSSION

Through its fellowship programmes, the ICO aims to achieve not only the enhancement of eye care delivery and eye health but also the development of young leaders and the improvement of communities notably in the low-resource countries.10 11 The results of the current evaluations confirm the expectation of a positive impact that professional exchange may bring to the ICO Fellowship Programme participants.12 In addition to the training that has helped in daily clinical practice, many participants report an improvement not only in service delivery, but also in academic training, research and management. Moreover, a considerable number of them are now in local leadership positions.6

Ophthalmic education programmes are common in many countries, with medical residency and fellowship programmes offered for their nationals.13 On the other hand, there are few opportunities for international exchange in ophthalmic teaching. As an initiative of the Academia Ophthalmologica Internationalis (AOI), under the command of Professor Gullapalli Rao, the Global Directory of Training Opportunities was created and currently serves as an online resource of the American Academy of Ophthalmology, which helps fill this shortage by listing opportunities for overseas training for post-residency ophthalmologists.8 In addition, other educational programmes for different levels of ophthalmic care may also take place. Global initiatives to prevent preventable blindness have emerged.1 3 6 11 Tso et al have reported prevalent of blindness in the Asia-Pacific region and stressed the importance that ophthalmic education has in the delivery of preventive and therapeutic medical services.9

As the ICO has formed a network of host institutes in 33 countries, such partnerships allow the centres to regularly receive guest ophthalmologists from low-resource settings as ICO fellows. Some countries, such as India, Iran, Brazil and China, have host institutions and also provide fellows. This dual role is because these countries have both important teaching institutes that accept ICO fellows, and also less developed areas where ophthalmologists seek more advanced training.

Through the ICO exams, it is possible to assess the knowledge of participants around the world. This is particularly important in investigating possible accreditation practices in order to improve patient care.11 Therefore, the completion of the standardised ICO exams is encouraged and helps the candidate in the selection process. More than half of the ICO fellows in this study had previously passed the ICO Standard and Advanced Exams. As the number of applicants grows each year, this selection criterion becomes even more relevant in view of the limited financial recourses of the ICO.

Overall, 36% of the ICO fellowships went to women. This is the same proportion of women as in those who applied. From informal discussions with female participants, it is clear that female ophthalmologists, often being mothers, have fewer opportunities to go abroad than their male colleagues. Although it was not the purpose of this study to evaluate the gender ratio of the selection process, it is important to keep a balance between male and female recipients of ICO fellowships.

The vast majority of all respondents (93%) completed a Three-Month Fellowship. The short duration of 3 months probably explains the modest number of publications by participants—less than a quarter were able to scientifically produce and participate in any publication. However, it has to be stressed that this is not the primary goal of the ICO Fellowship Programme. The primary goal is to improve ophthalmic education in a subspecialty area and to bring these qualifications back to their home countries to benefit their patients and trainees.14 15

In contrast, in 2019, a new 1-year fellowship programme has been offered that was specifically dedicated to research, the ICO-Allergan Advanced Research Fellowship. It is open to candidates from all countries and allows the ophthalmologist to undertake basic or clinical research (preferably translational), preferably in a foreign country. One of these 50 000US$ fellowships is awarded each year.

With ICO fellowship programmes it was possible to bring young ophthalmologists to leadership positions in their home countries. It might be expected that without the Programme some natural progression within the respective hierarchy would be experienced. Although this could not be specifically confirmed here due to a missing control group, we strongly believe that the impact on training and the collected experiences cited by the participants may have played a favourable role in this regard.

The current study has some limitations. For both parts of the study, only 47% of the questionnaires were answered, which would produce bias. Nevertheless, it has been stressed in the literature that typically internal surveys (ie, asking, for example, employees) generally receive 30–40% of answers, compared with an average of only 10–15% response rate for external surveys.16 17 A further possible limitation may have been some confusion in terminology. Although clinical and surgical exposure were possible in some countries like India and Iran, more than half of participants of the ICO Fellowships Programme had clinical exposure only as observers. Our aim should be to acquire more host places where hand-on training is allowed by the medical governing body, especially for candidates from Sub-Saharan Africa. In addition, one limitation concerns the duration of fellowships. It would have been interesting to compare outcomes between 3-month or 1-year observerships. However, the vast majority of respondents completed 3-Month Fellowship and when the evaluation on SurveyMonkey’ was configured, we did choose not to divide according to the different durations. Therefore, although desirable, this evaluation was not possible. In addition, it would have been interesting to verify the career performance of those who were not selected for the fellowships versus those who were selected. This comparison, however, was not scope of this work.

Finally, another limitation is that this paper only evaluated a possible unidirectional effect. In other words, the paper presumes that the beneficial effect happened from the host institutions to the fellows and their sponsoring home institutes. In reality, a factor ignored by the study is the benefits that hosts would have with intercultural professional and social exchanges. Different realities of global eye care bring to light numerous reflections on young trainee ophthalmologists of the host institutions. Therefore, although the study only evaluated the benefits of the programme in the ICO exchange students, we believe that the exchange of experiences potentially has also benefited the host institutions.

In conclusion, the International Council of Ophthalmology Fellowship Programme appears to be helpful not only in improving knowledge and skills in ophthalmologists from low-resource countries, but also helping young ophthalmologists to take on leadership roles on their return. Although ICO fellows are all recognised as ‘Specialist in Ophthalmology’ in their countries they come from 88 countries with strongly differing educational concepts and from all different levels of eye care facilities. The idea of the ICO Fellowship Programme is to support the individual needs in eye care delivery of the fellows, it aims at finding individual answers to individual challenges ICO Fellows face in their daily routine. Further studies are needed to assess the impact of the programme on eye health within local communities. It must be our goal to create a durable relationship between ICO fellows and hosts over years to keep in touch on a regular basis and exchange experience and advice. Certainly, the funds for support of the ICO Fellowships Programme should be increased by joint ventures with industry and national societies to increase the percentage of acceptance of the typically very good applications.

Appendix: Part 1 and Part 2 of the questionnaires

Part 1 included 26 topics to be completed by former fellows. The first questionnaire was sent shortly after the conclusion of the fellowship and after the participant returned to his home country. The questions are listed as follows:

  1. Please type your complete name

  2. Please reconfirm your postnominals

  3. Do you have a new or preferred email address? Please enter it here.

  4. Mailing Address including Street, City, Country and Postal Code.

  5. Year of birth

  6. Gender. Answer choices: female and male.

  7. Current home institute

  8. What was your position before your ICO Fellowship training? Answer choices: Senior Resident; Consultant; Assistant Lecturer; Lecturer; Senior Lecturer/Professor; Head of (Subspecialty-) Department; Other.

  9. Which ICO Exams did you pass before starting your application for the ICO Fellowship Program? Answer choices: Foundation Assessment; ICO Basic Science Exam; ICO Optics and Refraction and Use of Instruments Exam; ICO Clinical Sciences Exam; ICO Advanced Exam.

  10. How was your fellowship training classified? Answer choices: Observership; Clinical exposure; Surgical exposure.

  11. Who was the sponsor of your ICO Fellowship award? Answer choices: ICO; ICO Foundation; The Fred Hollows Foundation; The Lifeline Express Foundation; Academia Ophthalmologica Internationalis (AOI); Swiss Ophthalmological Society; CBM; Rotary Club; Carl Zeiss Meditec AG, Heidelberg Engineering GmbH; German Ophthalmological Society; Austrian Ophthalmological Society; Private Sponsor; AIER Eye Hospital Group Ltd.; Eye Cancer Foundation, USA; Children’s Eye Cancer Foundation (KAKS) Germany; Others; I did not receive funding for my training.

  12. Accommodation during your fellowship: Did your host's office help finding/arranging accommodation? Did your accommodation meet your needs? Did you encounter any problems obtaining visa? Did you encounter adequate help from the ICO? Answer choices: Yes and No.

  13. Learning experiences during your fellowship: Did you learn techniques in diagnosis that were new to you? Did you learn techniques in treatment that were new to you? Did you learn techniques in surgery that were new to you? Did you have hands-on contact with the patients? Were you allowed to assist your supervisor during surgeries? Did you have access to the institute's library? Did you take part in regular teaching events? Answer choices: Yes and No.

  14. Which teaching events did you attend? Please check all that apply. Answer choices: Morning Rounds; Grand Rounds; Clinical Sessions; Journal Club; Lectures; Case Presentations; None; Conferences of Complications; Video Conferences; Research Conferences; (Subspecialty) Seminars/Tutorials; Symposia; Surgery Conferences; Other (please explain).

  15. During your ICO Fellowship, did you have the chance to participate in a scientific publication? Answer choices: Yes and No.

  16. Where has your article been published? Open answer.

  17. What is the exact title? Open answer.

  18. Please describe how much you agree with each of the following statements about knowledge and skill acquired: I increased my knowledge in my subspecialty; I feel more confident now in my subspecialty; The training helped me improve my decision making; The training helped me improve my soft skills (e.g. working in a team), I felt well-integrated into the host institute; I would recommend to my colleagues to apply for an ICO Fellowship award; I was able to cover my expenses with the ICO Fellowship grant; Given the same subspecialty; I would recommend my colleagues to apply with the same host; The training helped me improve my management skills; The overall impression of teaching quality in my host institute was excellent. Answer options: strongly agree, somewhat agree, neutral, somewhat disagree, strongly disagree.

  19. Please add any comments regarding fulfillment of your expectations and achievement of your goals from the fellowship. Open answer.

  20. Please rate the ICO Fellowship Program processes in terms of how easy they were to access and use: Information on the website; Eligibility process; Finding a host; Communication with the Fellowships Executive during the application process and fellowship. Answer options: Extremely good, Very good, Moderately good, Not very good, Very bad.

  21. Please tell us how you think the ICO could improve the ICO Fellowships Program. Open answer.

  22. Please answer to this question only if you have completed a Three Months ICO Fellowship. Should the training have a different duration? Answer options: It should be longer—how long and why? It should be shorter—how long and why?

  23. Please answer to this question only if you have completed a Six Months ICO Fellowship. Should the training have a different duration? Answer options: It should be longer—how long and why? It should be shorter—how long and why?

  24. Please answer to this question only if you have completed a One Year ICO Fellowship. Should the training have a different duration? Answer options: It should be longer—how long and why? It should be shorter—how long and why?

  25. Do you know that ONLY those who have passed the ICO Advanced Exam are allowed to use the acronym FICO? Answer choices: Yes and No.

  26. Are you member of the ICO Fellowship Alumni Group on Facebook? Answer choices: Yes and No.

Part 2 of the evaluation survey, sent three years after the first one, included 24 questions to be answered by the alumni. Similarly, the first five questions had an identifying character. The following questions are detailed below:

  • 6. What ICO fellowship opportunity did you serve? Answer options: ICO Three Month Fellowship; ICO-Six Month Fellowship in Retinoblastoma; ICO-RRF Helmerich Fellowship; ICO-Fred Hollows Foundation One-Year Fellowship; ICO-SAARC One-Year Subspecialty Fellowship.

  • 7. What subspecialty did you choose? Answer choices: Cataract Surgery; Community Eye Health; Comprehensive Ophthalmology; Cornea and External Diseases; General Ophthalmology; Glaucoma; Low Vision and Rehabilitation; Medical Retina; Microbiology, Ocular Pathology and Ocular Oncology; Neuro-Ophthalmology; Ocular Oncology; Ocular Pathology, Oculoplastic; Ophthalmic Genetics; Pediatric Ophthalmology; Pediatric Ophthalmology and Strabismus; Research Labs in Neurodegeneration and Ophthalmic Genetics; Retinoblastoma; ROP and Pediatric Retina; Strabismus/Adult Strabismus; Trauma; Uveitis; Vitreo-Retinal Surgery; Others.

  • 8. Has the experience of the ICO Fellowship training helped you in your daily practice? Answer choices: Yes and No.

  • 9. If yes, please explain why: Open answer.

  • 10. What aspects of your current practice, if any, were specifically influenced by your ICO Fellowship training? Open answer.

  • 11. If the ICO Fellowship training had not helped you in your daily practice, please explain why: Open answer.

  • 12. How much impact did the ICO Fellowship training have on these particular areas of your personal practice or in your organisation? Service Delivery; Academic Training; Research; Management. Answer options: No impact, Very little impact, Neutral, Some impact, A lot of impact.

  • 13. Do you maintain contact with your training centre after completion of your ICO Fellowship for assistance or collaborative work? In what way? Possible areas: Discussing Cases; Support in Research Work; Support in Teaching; Joint Meetings or Conferences; Visits from Host Institute; Visits to Host Institute.

  • 14. What position did you hold before your ICO Fellowship training? Response options idem question 8 of Part 1.

  • 15. What position do you hold now? Response options idem question 8 of Part 1.

  • 16. What is your current home institute, including city and country?

  • 17. What happened after your ICO Fellowship training? Please choose the most appropriate answer. Answer options: Nothing changed—I resumed my old position at the same professional level; I joined the subspecialty department at my institute; I started working in a different department at my institute; I was promoted to be team leader/head of (subspecialty) department; I started working at another institute; Other (please specify).

  • 18. Are you a teacher? Answer choices: Yes and No.

  • 19. If yes, who do you teach? How many hours per week? Answer options: Students; Residents; Medical Staff; Paramedical Staff.

  • 20. Did you incorporate regular teaching events in your home institute that you experienced during your training at your host institution? Answer choices: Yes and No.

  • 21. If you are a teacher, do you know about other ICO Educational Programs? Answer choices: Yes; NO, I am not a teacher.

  • 22. Please tell us how you think the ICO could improve our fellowships program. Open answer.

  • 23. Are you interested in serving on an ICO Committee? What is your area of interest? Open answer.

  • 24. Are you interested in participating in one of the ICO educational initiatives? Please specify. (For more information about ICO educational initiatives, please go to http://www..icop.org/refocusing/education/educational/programs.html.) Open answer

REFERENCES

Footnotes

  • Contributors EAT-N: data analysis/interpretation, drafting and critical revision of the manuscript; CG-O: concept and design, data acquisition, statistical analysis, data analysis/interpretation, critical revision of the manuscript; PG: concept and design, data acquisition, critical revision of the manuscript, and supervision; BG, PW, HRT, CD: concept and design, critical revision of the manuscript, and supervision; NQ: concept and design, and critical revision of the manuscript; BS: data analysis/interpretation, concept and design, critical revision of the manuscript, and supervision.

  • Funding Torres-Netto was recipient of the inaugural International Council of Ophthalmology Advanced Research Fellowship Award. Theother authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information.

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