EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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EW FEATURE 50 The changing face of medical education December 2014 by Michelle Dalton EyeWorld Contributing Writer The numbers do not necessarily worry Sumit (Sam) Garg, MD, interim chair of clinical ophthal- mology and medical director, Gavin Herbert Eye Institute, University of California, Irvine. "In the U.S. most of these lenses involve an out-of-pocket cost for the patient. Depending on where you train, most institutions are not proactively offering these sort of advanced technology lenses to the residents," he said, with the notable exception of the Veterans Affairs hospitals that try to provide training on every type of lens for each of its residents. Dr. Garg said in the U.S., it is typical for companies to provide a handful of premium (multifocal and toric) lenses to trainees, but not every resident will have access to the lens. "It may be an access issue," Dr. Yeu said, or it may be related to the additional testing and calculations that are needed to properly plan for a toric lens. Dr. Garg agreed, saying some curriculums may not empha- size premium technology; instead, they are concentrating on "the basics" of cataract surgery. "There's a lot more to toric lenses that has nothing to do with implanting the lens," he said. "If people in the bigger centers don't believe in this type of advanced technology lens or don't have the additional chair time needed to treat these patients, they may not be implanting these lenses. That means residents are not going to get hands-on experience." Fewer than half of all respon- dents have never implanted a presbyopia-correcting IOL, which is also not unexpected, Dr. Yeu said (see Figure 2). "If surgeons in general aren't using more advanced technology, it's doubtful they'll hand the reigns over to a resident. Again, it's an access issue," she said. Dr. Garg said he tends to avoid using these lenses when he is teach- ing residents in the beginning of the academic year. "I'm trying to teach the nuances of cataract surgery. For me, that's the major goal. If residents learn good cataract surgery then they can add in the lens specifics later. But the cataract surgery is the critical part of that whole equation," he said. "Is it our job to teach the nuances of every technology out there, or teach them to be the best cataract sur- geons they can be?" He advocates for exposure to the advanced lens technology, but realizes most residents will not get extensive exposure to premium patients. "You want residents to have good cases so they get confident and are able to use that confidence to perform better surgeries," he said. "You don't want their confidence shaken because they had a bad experience that translates into nervousness in the OR that may lead to some untoward complication." When it comes to laser ex- perience, more than 80% of U.S. residents gained exposure to LASIK procedures, compared with only 67% outside the U.S. (see Figure 3). "The numbers don't surprise me with respect to the U.S. exposure," Dr. Garg said, but he is surprised that "there is not as much penetra- tion [with] femtosecond as would have been expected. For instance, I was never even trained on micro- keratomes, only femtosecond." Young physician training, experiences differ with refractive technologies Figure 2: How many presbyopia-correcting IOLs (pseudoaccommodating or multifocal) have you implanted? W hen it comes to elective refractive procedures (including toric IOLs, presbyopia- correcting IOLs, and laser vision correction), attitudes and feelings about the level of resident training among U.S. and non-U.S. residents are variable. The 2014 ASCRS Clinical Survey found 40.4% of all respondents rate their residency experience with toric IOLs as inadequate (see Figure 1). More than half (52.9%) of non-U.S. respondents rate their residency experience with toric IOLs as inadequate. According to Elizabeth Yeu, MD, in private practice at Virginia Eye Consultants, Norfolk, "The differences may be a result of their training institution. They may not be getting the patient population where they can actually get access to patients for such exposure." What was surprising, however, was that a greater number of people felt more adequately exposed to toric lenses than corneal relaxing incisions, she said. Figure 1: How would you rate your residency experience with toric IOLs? 2014 ASCRS Clinical Survey Inadequate experience U.S. U.S. 0 1 to 5 cases 6 to 10 cases More than 10 cases Non-U.S. Non-U.S. Overall Overall Appropriate experience Excessive experience