DEC 2012

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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34 EW FEATURE February 2011 ahead December 2012 Innovation: A look Residency continued from page 32 lated,��� Dr. Steinert said. ���You would be a doctor and you thought you were trained, but there was no systematic identification of what it is you���re supposed to learn, which is the first step, and then the second step is being able to measure whether people are learning it and to be evaluated on your ability.��� Surgery minimums In addition to the core competencies, the ACGME establishes surgical minimums for all ophthalmology residency programs. In 2012, the most surgeries required in residency training programs per resident were for cataract, at 86 cases, followed by oculoplastic and orbit surgery at 28 cases and panretinal laser photocoagulation laser surgery at 20 cases. Other minimums include corneal surgery at three cases, glaucoma filtering/shunting procedures at five cases, and retina/vitreous surgeries at 10 cases. However, many residency programs have higher surgical rates, especially for cataract surgery, Dr. Steinert said. In his institution���s residency program, residents perform a total of 200-250 cataract surgeries by the end of their 3-year residency. That rate is one of the highest in the U.S., he said, although other programs have a similar amount. According to Dr. McLeod, data from the ACGME shows that the national average is closer to 148 cataract cases per resident. The same holds for other procedures, including new glaucoma microincisional techniques and treatments for retina cases. ���What residency programs are doing for a lot of these subspecialty areas is providing exposure. I think with our procedures becoming more complex and more demanding, the assumption is that for many procedures in the subspecialties, fellowship training is probably going to be considered a standard,��� Dr. McLeod said. Mitchell P. Weikert, M.D., assistant professor, Cullen Eye Institute, and medical director, Lions Eye Bank of Texas, Baylor College of Medicine, Houston, said cataract surgery is mainly divided by phaco and extracapsular cataract extraction in the ACGME cataract minimum category. Residents are mainly learning phacoemulsification, he said, and variations on techniques for phaco such as divide and conquer, splitting or chopping. Residents are essentially learning the same new techniques as faculty surgeons, including dealing with complications and special cases, and using all the techniques and devices that can assist with those, he said. ���Within the realm of phaco, you start to look at, are we going to phaco white cataracts or use capsular stain or very dense brunescent cataracts, which present their own challenges. Are we going to do capsules with zonular problems, where we might have to use a capsular tension ring or capsular tension segment. Are we going to do small pupils, where we might have iris retractors or Malyugin rings (MicroSurgical Technology [MST], Redmond, Wash.),��� Dr. Weikert said. ���So there���s a lot beyond a bread and butter standard cataract on a 20/50 eye.��� New technologies offer cutting-edge improvements A dvances and potential advancements in cataract surgery and innovations in cornea, glaucoma, and retina were assessed by Robert H. Osher, M.D., Cincinnati, and a panel of key opinion leaders. Dr. Osher presented videos and information about new technologies in the Cataract Surgery: The Cutting Edge symposium at AAO-APAO. He moderated a panel of six physicians, leading discussions on the topics. One of the longer panel discussions regarded femtosecond laser-assisted cataract surgery. ���I think all the technologies you���re going to show today are going to make things better. The question really is how much,��� said panel member David F. Chang, M.D., Los Altos, Calif. ���This is the one that has a click fee, where the patient has to decide, with the guidance of the doctor, and I think we sorely need the evidence, and a lot more evidence, which is going to take time to accumulate. I think it���s worth keeping a very open mind, and I think we can be very hopeful that this is going to make a difference, but right now I think for many people, the appropriate concept of waiting is a good one. Because I don���t think the evidence is out there and ultimately, your patients want you to make that assessment based on science���is this really worth the extra cost for them.��� Editors��� note: Dr. Chang has financial interests with Alcon, Bausch + Lomb, and LensAR. Dr. Osher has financial interests with Alcon and Bausch + Lomb. In cataract surgery, residents are required to be the operating surgeon; with retina and refractive cases, residents are allowed to be attending or operating. Refractive surgery for residents is a special case, Dr. Weikert said, because it is an elective procedure with serious ramifications if not performed properly. It is often difficult to find refractive patients willing to have an operating resident surgeon, he said. ���If we see patients at different hospitals who are willing to do resident refractive surgery, we try to funnel them to the residents. We actually give a discounted price. And a lot of places I���m sure do that, just to make it more attractive,��� Dr. Weikert said. He said that all surgeries in his institution are fully staffed, including refractive cases. ���I always tell residents, ���When I was a resident, it was like the Wild West, back 15, 20 years ago. There would be staff maybe in the general vicinity of the hospital.��� But now they���re always in the room, or next door toward the end of the training,��� he said. Femtosecond laser-assisted cataract surgery One new technique in cataract surgery that residents could be learning within the next 2 years is femtosecond laser-assisted cataract surgery, Dr. Steinert said. He said this could significantly impact the way that residents learn cataract surgery and obtain key surgical skills. ���The laser is doing some of the steps that are the most challenging of the manual surgical skill set, such as the anterior capsulotomy, which is generally regarded as one of the most challenging things for residents to learn how to do. But if the laser is doing it, that diminishes the number of cases where they���re learning those skills,��� he said. Another potential issue for residents will be learning how to divide the nucleus, Dr. Steinert said. ���It���s one thing for a surgeon who���s done thousands of cases to have the laser doing big parts of the surgery, but it���s a whole other thing when trainees are having the volume of their own training impacted by the laser,��� he said. Future challenges As of June 2012, 490 ophthalmologists were entering practice in the U.S. with 1,350 residents in training and 350 leaving practice, according to the International Council of Ophthalmology. But that amount could rapidly change in the coming years, said Peter J. McDonnell, M.D., director and William Holland Wilmer professor of ophthalmology, Wilmer Eye Institute, Johns Hopkins University, Baltimore. ���People have been [saying] for a long time that there is a demographic tidal wave coming. And what I would say is that it���s here. At our institution, the number of patients that we���re seeing is growing at about 20% annually. In addition, our society is asking doctors to care for more patients,��� he said. With the upcoming potential increase in insured patients in the millions and the baby boomer population aging, treating the large Medicare population in ophthalmology will be a major challenge, Dr. McDonnell said. Residency training positions have gone up by only 8% over the last decade, he said. ���Residency slots in the United States are funded through the federal government���s payments to hospitals, and not only is there not a lot of interest in increasing that, but there���s talk about decreasing it,��� he said. ���If we really do hit this fiscal cliff and funding is cut, the projections that some organizations like the American Academy of Ophthalmology have that we will have a dramatic shortage of physicians in the United States may come to pass.��� He said organizations are predicting a possible shortage of ophthalmologists up to 30% in the coming decade. With that potential, it could become vital for residents to learn how to work with nurse practitioners, physician assistants, and optometrists in a new practice model. ���I think one of the key issues here, the challenge for our young generation of ophthalmologists, is to respond to this need of our society,��� Dr. McDonnell said. ���And I think one of the important needs is for institutions like mine and professional organizations to acquaint our residents with practice models that will leave them well prepared for this future, to meet the needs for eyecare in their communities.��� EW Editors��� note: Drs. McDonnell, McLeod, Steinert, and Weikert have no financial interests related to this article. Contact information McDonnell: 443-287-1511, Pmcdonn1@jhmi.edu McLeod: 415-514-3987, Mcleods@vision.ucsf.edu Steinert: 949-824-0327, roger@drsteinert.com Weikert: 713-798-5143, mweikert@bcm.tmc.edu

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