Bridging borders in ophthalmology: Reflections on international medical training

The importance of experience becomes apparent early in medical training. Yet experience is shaped not only by time—it is also defined by the places where one practises. It soon became clear to me that to fully nurture and complement my academic career, I needed exposure across diverse settings and countries.

With this goal in mind, I have been fortunate to practise across a wide spectrum of medical environments in Mexico: from public institutions serving the general population, to government-sponsored programmes, private hospitals and medical brigades reaching marginalized communities with little to no access to healthcare. Even within a single country, the disparities are striking.

I have also had the opportunity to experience medicine in Austria, the UK, and, more recently, during my uveitis fellowship at the Johns Hopkins Hospital in the US. I hope to share some of the perspectives I have gained from these diverse environments and, in doing so, inspire readers to explore ophthalmology abroad.

Geography and disease

One of the most fascinating aspects of practising across borders is observing how strongly geography influences disease prevalence and presentation, particularly in uveitis. Even conditions that are common worldwide can present quite differently depending on the setting. In resource-limited environments, patients often present at more advanced stages of disease, which introduces additional diagnostic, therapeutic and surgical challenges.

A practical example is the continued use of extracapsular or manual small-incision cataract extraction in Mexico, where many patients present with only light perception due to long-standing cataracts.^1,2

Resourcefulness in limited settings

Yet the greatest difference I have observed is not epidemiologic but logistical—i.e., resource availability. Limited resources often restrict the ability to order a full battery of diagnostic tests, requiring clinicians to rely on clinical findings and intuition to narrow the differential diagnosis and select the tests with the highest yield.

Similarly, treatment decisions must balance clinical presentation, cost and risk-benefit considerations, sometimes necessitating empiric approaches guided by experience and judgment. Practicing medicine under such constraints cultivates sharpness, creativity and resourcefulness.

Challenges in research

Research faces a unique set of challenges that could easily warrant an entire discussion on its own. At many institutions, the lack of a centralized database means each patient record must be manually located and reviewed to identify those relevant to a study.

Moreover, much data is still recorded on paper and must be retrieved manually. Even when these logistical challenges are addressed, publication bias can prevent valuable research from reaching a wider audience—a problem well-documented across medicine, including ophthalmology.^3-5 Although scientific advancement continues at a rapid pace, progress is often concentrated in high-income settings, and guidelines or recommendations derived from these contexts may not be directly applicable or reproducible in other populations.⁶

These limitations are not uniform across Mexico. Private hospitals, for example, more closely resemble US clinics that serve insured patients. However, the majority of the population lacks access to such care and relies on underfunded public institutions or charitable foundations. From my experience, the healthcare model in Europe falls somewhere in between: care is largely government-funded, and patients receive the same standard of treatment regardless of income or insurance status. Resources are managed efficiently, without compromising patient outcomes.^7-9

The human factor in medicine

Although the challenges of healthcare delivery vary across countries, we all share the same goal: providing patients with the best possible care and outcomes. Despite financial and systemic limitations, I have come to realize that the most valuable asset—and the factor that can ultimately make the greatest difference—is the human resource.

At the Wilmer Eye Institute, I have been consistently impressed by the dedication and professionalism of every team member—from front desk staff and technicians to nurses, optometrists and physicians. Everyone works with the patient’s best interest at heart. I have come to believe that, above all, human resources are the cornerstone of medicine and the foundation for meaningful growth and development.

Lessons from moving abroad

Moving abroad in pursuit of opportunity and growth is often challenging and frustrating, as many international students can relate. I would like to share a few lessons from my experience, including the following:

• Plan, but stay flexible. Plans are important, yet things rarely unfold exactly as expected. Focus on preparing thoroughly and be satisfied with your effort—it is the one thing fully under your control.
• Learn to handle failure. Pursuing ambitious goals inevitably involves setbacks. Doubt and discouragement are normal, even expected. The difference lies in how quickly you recover and continue moving forward.
• Ask for help—and offer it. Do not hesitate to seek support when needed, and equally, be generous with your own assistance. Teamwork is essential for both patient care and personal growth.
• Embrace feedback. As one mentor told me, “Criticism will make the smart wiser, but it will make the stubborn your enemy.” Seek out feedback as a valuable tool for improvement.
• Step outside your comfort zone. Growth rarely happens in familiar territory. In medicine, advancing often means feeling like a beginner again. I was recently asked about the hardest part of my fellowship, and I answered, Starting over. After 12 years of training, entering a new environment can be daunting, but patience, perseverance and hard work turn discomfort into growth.
• Keep your main goal in focus. Careers will have setbacks—missed opportunities, rejected manuscripts, mistakes—but remember why you began: to help patients. It is easy to get absorbed in professional pressures, yet patient care must remain at the heart of your work.

Looking beyond borders

The pursuit of personal and academic growth often leads us to institutions with cutting-edge technology and state-of-the-art medicine. However, I encourage others to seek experiences in different realities, through medical brigades or rotations in under-resourced settings. The contrasts can be striking, and the experience profoundly eye-opening. After all, these are the environments where much of the world’s population lives, and where collective efforts can have the greatest impact.

To me, the present is international, with students and physicians traveling to leading institutions to acquire knowledge and skills they can bring back to their home countries. My hope is for a future that will be transnational—defined by collaborative research, science that transcends borders and a shared commitment to improving healthcare delivery worldwide.

Eugenia M. Ramos-Dávila, MD

E: [email protected]

Ramos-Dávila is an ocular immunology and uveitis fellow in the Division of Ocular Immunology at Wilmer Eye Institute, The Johns Hopkins University School of Medicine in Baltimore, Maryland, USA, and an ophthalmology resident at Tecnológico de Monterrey, School of Medicine and Health Sciences, Institute of Ophthalmology and Visual Sciences in Monterrey, Mexico.

References

1. Que L, Zhu Q, Jiang C, Lu Q. An analysis of the global, regional, and national burden of blindness and vision loss between 1990 and 2021: the findings of the Global Burden of Disease Study 2021. Front Public Health. 2025;13:1560449. doi:10.3389/fpubh.2025.1560449

2. Fang R, Yu YF, Li EJ, et al. Global, regional, national burden and gender disparity of cataract: findings from the Global Burden of Disease study 2019. BMC Public Health. 2022;22(1):2068. doi:10.1186/s12889-022-14491-0

3. Melhem G, Rees CA, Sunguya BF, Ali M, Kurpad A, Duggan CP. Association of international editorial staff with published articles from low- and middle-income countries. JAMA Netw Open. 2022;5(5):e2213269. doi:10.1001/jamanetworkopen.2022.13269

4. Caleon RL, Nziyomaze E, Imaniriho JD, et al. Geographic representation of authorship in ophthalmic research from low- and middle-income countries. Ophthalmic Epidemiol. 2024;31(5):478-487. doi:10.1080/09286586.2023.2291802

5. Ramos-Dávila EM, Domínguez-Varela IA, Ruiz-Lozano RE, et al. Underrepresentation of low- and middle-income nations in ophthalmology journals: a critical analysis on diversity, equity, and global representation. Transl Vis Sci Technol. 2023;12(10):9. doi:10.1167/tvst.12.10.9

6. Hemmerich C, Jones G, Staggs J, Anderson RM, Bacani R, Vassar M. Inequities and research gaps in ophthalmology: a scoping review. JAMA Ophthalmol. 2023;141(1):63-70. doi:10.1001/jamaophthalmol.2022.5237

7. Mohajer-Bastami A, Moin S, Sweetman B, et al. A comparison of the United Kingdom’s and Switzerland’s healthcare financing systems for achieving equity and efficiency goals. Swiss Med Wkly. 2025;155:4101. doi:10.57187/s.4101

8. Papanicolas I, Woskie LR, Jha AK. Health care spending in the United States and other high-income countries. JAMA. 2018;319(10):1024-1039. doi:10.1001/jama.2018.1150

9. Atun R, de Andrade LOM, Almeida G, et al. Health-system reform and universal health coverage in Latin America. Lancet. 2015;385(9974):1230-1247. doi:10.1016/S0140-6736(14)61646-9