Eyeworld

EW CATARACT/IOL 60 March 2011 by Matt Young EyeWorld Contributing Editor Ophthalmology residents may need to perform more surgeries O phthalmology residents may not be performing enough cataract surgery by the time they gradu- ate. That's according to a report published online in August 2010 in Ophthalmic Surgery, Lasers & Imaging. "Our study suggests that resi- dents may need to perform at least 121 cases and the RRC [Ophthalmol- ogy Residency Review Committee] should consider reevalu ating their minimum requirements," reported lead study author Michael N. Wiggins, M.D., Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock. In 2007, the RRC increased the minimum number of resident-per- formed cataract surgeries to 86 upon graduation. New surgeons need more pha- coemulsification under their belt than that, according to Dr. Wiggins' analysis, which is based on resident operative times. More surgery needed? Dr. Wiggins' study is based on a ret- rospective chart review of 375 surgi- cal records of 25 ophthalmology residents. "Groups were compared with each other and to a published sur- geon," Dr. Wiggins noted. "The mean operative times of [resident] surgeries 43 to 47, 84 to 88, and 119 to 123 were 39.9, 30.0, and 27.2 minutes, respectively. Surgical time decreased 25% from the 45th to the 86th case (P=0.0002) and 9% from the 86th to the 121st case (P=0.2049)." Dr. Wiggins reported that a pub- lished surgeon's time of cataract sur- gery is 26.8 minutes. An extensive review of medical literature turned up five studies reporting operative time for phacoemulsification. The times ranged from 8.25 minutes to 26.8 minutes. "We selected the longest average total opera tive time for phacoemul- sification cataract surgery be cause this might be considered a reason- able compari son to a graduating res- ident," Dr. Wiggins said. Compared to that, resident times were significantly longer both at the 45th and 86th surgery, but "nearly identical" around the 121st surgery. Resident times were longer by 13.1 minutes around the 45th surgery and longer by 3.15 minutes at around the 86th surgery. Although performing surgery faster is not necessarily better, Dr. Wiggins suggested it is an indication of surgical proficiency. "As any skill is being learned, the proficiency of task completion must improve to some degree," Dr. Wiggins noted. Dr. Wiggins also suggested oper- ative time is a better gauge of surgi- cal proficiency than complication rates. "Complications or complica- tion avoidance are reflected in the total operative time," Dr. Wiggins re- ported. "Complication rates in a teaching institution are biased to the threshold of a supervising faculty surgeon to take a case out of a resi - dent's hands prior to complication occurrence. And, in our opinion, complication rates decreasing with expe rience have been adequately studied previously." Dr. Wiggins emphasized his view that 121 cases is the surgical case number to harbor competency. "Our study of surgical profi- ciency supports the de cision that 45 cases [the minimum prior to 2007] is not enough experience, but also sug- gests that the new minimum may also fall short," Dr. Wiggins con- cluded. "As educators, it is our duty to send new ophthalmologists into the community with enough experi- ence to per form common oph- thalmic surgeries at least at the min - imal proficiency level of a practicing ophthalmologist. Our study suggests that residents may need to perform at least 121 cases and the RRC should consider reevalu ating their minimum requirements." Dr. Wiggins suggested the 86th case is an important milestone in di- viding great gains in learning the surgical procedure from more mod- est gains, but more cases should be required for graduation. "Our findings suggest that al- though the greatest gains in profi- ciency occur prior to the 86th case, residents require more experience than the RRC's new surgical mini- mum to approach the proficiency level of a community ophthalmolo- gist on graduation," Dr. Wiggins concluded. Audrey R. Talley-Rostov, M.D., Northwest Eye Surgeons, Seattle, doesn't buy into the idea that 121 cases is the magic case number for residents to demonstrate compe- tency approaching that of a sea- soned ophthalmologist. "Just like any other skill, [surgery] is basically practice, prac- tice, practice," Dr. Talley-Rostov said. Mastery of such skills will vary be- tween individuals, she said. However, she did acknowledge that although the "mastery" mile- stone differs between individuals, competency can be established "more or less" around the 100th case. That number "sounds right" in terms of experience and also relating to having had some less-than-rou- tine cases by that point, she said. Experience, expertise, and confi- dence are three factors that Dr. Talley-Rostov believes make a good surgeon. Dr. Talley-Rostov said she has taught some surgeons with good manual skills and a calm demeanor who easily achieve their milestones, while others have been in practice a couple of years and still struggle. EW Editors' note: Dr. Talley-Rostov has no financial interests related to her com- ments. Dr. Wiggins has no financial interests related to this study. Contact information Talley-Rostov: Atalley-rostov@nweyes.com Wiggins: wigginsmichael@uams.edu

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