My ophthalmology elective: East to West

7 May 2026 | Muzammil Ali Khan | EYE - General

Healthcare systems

In bustling Ho Chi Minh City, Vietnam, the outpatient departments at Cho Ray Hospital were alive with activity, filled with long queues of patients and the constant movement of staff. The atmosphere was busy, yet remarkably efficient, with the flow of patients geared towards rapid triage and swift intervention. The concept of waiting weeks for an appointment was unfamiliar; if treatment was needed, there were no layers of referral to navigate. Rather than first consulting a GP and then being placed on a waiting list, patients went directly to the appropriate specialist to address their condition. However, this accessibility came at a cost, as patients were required to pay for their care even within public hospitals.

In Swat, Pakistan, at Saidu Teaching Hospital – a regional hospital serving a largely rural population in a mountainous area – the environment was markedly different. Outpatient departments were busy but less streamlined, and resources were limited. A state insurance scheme provided households with an annual allowance for free healthcare, yet equipment shortages often meant patients had to purchase their own medical supplies. For instance, a cataract patient would attend the ophthalmology outpatient department, undergo a biometric eye test to determine the appropriate intraocular lens, check with the department administrator to see if the lens was in stock, and if not, visit a local pharmacy to buy one before returning for overnight admission and surgery the following day. The system demanded patience and persistence, both from patients and staff, highlighting the impact of resource limitations on care delivery.

Figure 1: Relationship between healthcare spending (% GDP) and cataract surgical rate (CSR) in the UK, Pakistan and Vietnam. Bubble size represents national population. Higher healthcare spending appears associated with higher CSR, although Pakistan demonstrates relatively high CSR despite lower healthcare expenditure.

At Bristol Eye Hospital, a large NHS teaching hospital, there was a strong emphasis on patient-centred care, shared decision-making and meticulous documentation, reflecting a system built around patient safety and long-term outcomes. However, this approach was also associated with longer waiting times; patients I observed undergoing cataract surgery had often been on waiting lists for several months. Access to specialist care typically required referral from a general practitioner, and appointments were scheduled rather than offered as walk-ins. While this structure may appear restrictive when compared to more direct access models, it also functions as a mechanism for managing demand, ensuring appropriate triage and maintaining clinical accountability within a publicly funded healthcare system with finite resources.

Outpatient consultations and confidentiality

In Vietnam and Pakistan, outpatient consultations often took place in busy shared clinical spaces, with several patients waiting to be seen in the same room. This meant that the level of privacy during consultations differed from that typically expected in the UK, where patient confidentiality is strongly emphasised. In these settings, maintaining strict confidentiality appeared challenging due to the extremely high patient volumes and limited clinical space, and consultations were often conducted with other patients present in the room. Consultations themselves were brief, sometimes lasting only three to four minutes, with highly focused history taking aimed at identifying key risk factors and examination findings.

A typical interaction could be summarised as: “What has brought you in today? Are you diabetic or hypertensive? Place your head on the chin rest of the slit lamp so that I can look into your eyes. You have (medical condition), so take this medication or get this surgery.”

While this approach allowed clinicians to manage very high patient volumes efficiently, it contrasted with the consultation style emphasised in the UK, where confidentiality, shared decision-making and patient autonomy are central principles of care. Observing these differences prompted me to reflect on how ethical standards such as confidentiality may be influenced by healthcare infrastructure, patient demand and available resources. The experience reinforced my appreciation for the emphasis placed on patient privacy within the NHS, while also highlighting the practical challenges faced by clinicians working in resource-limited environments.

Theatre resources

During my placement in resource-limited healthcare settings in Vietnam and Pakistan, economic constraints meant that disposable surgical gowns and drapes were not routinely used in theatre; instead, reusable materials were washed, sterilised and reused between cases. Although a sterile environment was maintained, the reliance on reusable consumables introduced additional logistical considerations, particularly in high-volume settings where theatre turnover was rapid and outpatient departments were frequently overcrowded. Reusable equipment can be more cost-effective in healthcare systems with limited resources, but it requires robust sterilisation processes and careful monitoring to ensure infection control standards are maintained. By contrast, disposable consumables, which are commonly used in UK theatres, can reduce the risk of cross-contamination and simplify infection control protocols, although they are associated with higher financial and environmental costs.

In the UK, infection prevention practices in surgery are guided by national standards, including NICE guideline NG125: Surgical Site Infections: Prevention and Treatment, which emphasises maintaining a sterile surgical field using appropriate sterile equipment, draping and infection control measures [1]. Observing different approaches to theatre consumables highlighted how clinical practice is often shaped by the balance between available resources, infection control requirements and healthcare system priorities.

Infrastructure limitations also affected surgical practice. On one occasion I observed a phacoemulsification procedure paused due to a power outage, during which the ophthalmologist remained calm and reassured the patient while power was restored. This highlighted the adaptability required of surgeons working in environments where technical resources cannot always be relied upon.

During my placement at Bristol Eye Hospital, intraocular pressure was routinely measured using Goldmann applanation tonometry, widely regarded as the gold standard for measuring intraocular pressure and recommended in the NICE guidance glaucoma diagnosis and management [2]. In Vietnam, however, I observed the use of a Schiotz tonometer, an older indentation tonometry technique that remains useful where access to more advanced equipment is limited. This contrast illustrated how diagnostic approaches are influenced by equipment availability and cost considerations in different healthcare settings.

Anaesthetics and subspecialisation

Although anaesthetics exists as a specialty in Pakistan, it is not as popular for medical doctors to train in. Something that I found quite confusing and almost alarming was that I didn’t meet a single anaesthetist during my placement, as the job of the anaesthetist was performed by an anaesthetic assistant – someone who had two years of formal higher education, had not been to medical school, and learnt most of what they knew about anaesthetics from practical experience. Although there were no complications requiring anaesthetic intervention during my time in theatre, I found it astounding that the responsibility to lead the team in resuscitation would fall onto the surgeon – something I hadn’t encountered before.

Generalists vs subspecialists

This also ties into my next learning point about the differences in the roles of generalists and subspecialists across the countries. At Bristol Eye Hospital, a large tertiary centre, most ophthalmologists were subspecialists, focusing on a specific area such as glaucoma, retina, cornea, oculoplastics or paediatrics. Apart from the eye casualty department, I rarely observed generalists managing a wide range of ophthalmic conditions.

In Vietnam and Pakistan, although subspecialists do exist, they are few and far between. Most ophthalmologists function as generalists, managing everything from cataracts to glaucoma, dealing with all ophthalmic conditions to the best of their expertise. At Saidu Teaching Hospital in Pakistan, for example, there was only one ophthalmologist who had completed a vitreoretinal fellowship, and in Cho Ray Hospital, there was a single cornea specialist in the whole hospital. This meant that most cases were handled by generalists who seemed to have encyclopaedic knowledge across a broad range of ophthalmic conditions.

The contrast between these systems was striking. In tertiary UK centres, the high level of subspecialisation allows for cutting-edge care, complex procedures and a structured training pathway for fellows. By comparison, in resource-limited healthcare settings, generalists must be adaptable, often relying on clinical acumen rather than technology or subspecialist support. In Pakistan and Vietnam, the ophthalmologists would see both adult and paediatric patients, but during my time in Bristol Eye Hospital only paediatric ophthalmologists would see paediatric patients. Observing these differences made me appreciate the value of both approaches: subspecialisation enables highly specialised care for complex conditions, while generalist practice allows clinicians to provide broad and accessible care in settings where subspecialists are limited. However, it is worth noting that my comparison is not entirely equivalent, as I was observing tertiary care in the UK versus secondary care abroad, and the UK also has generalists in smaller hospitals who manage a broader range of cases.

Training pathways

The ophthalmic training pathway differs significantly between the UK and the countries I visited. In the UK, ophthalmic specialty training takes approximately seven years, rotating across subspecialties followed by an optional fellowship in the chosen area. Trainees gain structured experience in subspecialty clinics, surgical procedures and simulation-based training. During my placement at Bristol Eye Hospital, I had the opportunity to use the Eyesi simulator to practise dexterity and learn the basic steps of cataract surgery in a risk-free environment.

In Vietnam and Pakistan, ophthalmology training is shorter and less structured, typically comprising four years of residency before a doctor is qualified as an ophthalmologist. Surgical training is largely hands-on, and many ophthalmologists learn cataract surgery directly on patients rather than through simulation. I was struck by the high level of surgical skill demonstrated in these settings, particularly given the limited access to microsurgical simulators.

Healthcare spending as % of GDP in the UK was approximately 11.1% as of 2024 [3]; in Pakistan it was 2.9% as of 2022 [4]; and in Vietnam it was 4.59% in 2022 [5]. The population of the UK is 69.3 million, in Pakistan it’s 256 million and in Vietnam 101.6 million [6]. The cataract surgical rate is the number of cataract operations per million population per year – in the UK it is 6948, in Pakistan it is 5307 and in Vietnam it is 1772 [7,8,9].

Conclusion

I had an incredible elective experience which reinforced my desire to pursue ophthalmology as a future career. I gained insight into how healthcare delivery varies across economic and cultural contexts. Beyond clinical skills, I developed cultural and practical adaptability, navigating high patient volumes, limited resources and unexpected challenges like power outages. I was able to draw lessons from different settings to inform my own practice, appreciating the strong foundational knowledge and versatility of doctors in Pakistan and Vietnam alongside the empathetic, efficient approach of doctors in the UK. I would strongly recommend future trainees undertake electives in multiple countries, as it provides the opportunity to learn from each system and incorporate the strengths of different approaches into their own practice. On a personal note, I got to try some fantastic food and have begun to use my left hand to brush my teeth and shave to start developing some fine motor control for my future endeavours.