Health care systems in many developing countries are rapidly evolving to respond to urbanization and shifting epidemiological profiles, creating an environment favorable for subspecialty development. The struggle for developing nations to train and retain highly skilled clinicians within academic institutions has highlighted the need for creative approaches to subspecialty education in these regions. The "Sandwich fellowship" is an educational model in which a fellow completes rotations at an academic institution in the developed world as well as in his or her home environment. An important component of the model is the expansion of institutional capacity at the fellow's home institution to create an enabling environment to practice newly acquired skills. The fellowship provides experience in diverse geographic and cultural contexts under the guidance of a preceptor from an institution in the developed world who teaches in both settings. Preceptors are given opportunities to continue professional growth and gain from exposure to pathology not commonly seen at home. Successful pilots of a Sandwich fellowship took place in ophthalmology and orthopedic surgery at the University of Ottawa in 2007-2008 and required funding from multiple sources with bilateral institutional support. Emphasis was also placed on teaching, leadership, management, and research so the fellows could return home and lead the development of their subspecialty areas. Early contact between administrations enables the model to serve as a gateway to a long-term partnership between developed world academic establishments and developing world institutions. Such a relationship yields a mutually beneficial exchange of knowledge and skills. Beneficiaries include the hospitals, their staff, and patients at both institutions.