April 2008

 

CATARACT/ IOL

 

Perspective In Lens & IOL Surgery: EyeWorld Dialogue

Young physicians and residents discuss their training, real-world challenges, and more


 

ABOUT THE PARTICIPANTS

Moderator

Elizabeth A. Davis, M.D., is adjunct clinical assistant professor, University of Minnesota, Minneapolis. Contact her at 952-888-5800 or eadavis@ mneye.com.

Parag Parekh, M.D., M.P.A., is fellow, Minnesota Eye Consultants. Contact him at pdparekh@ mneye.com.

J. Bradley Randleman, M.D., is assistant professor of ophthalmology, Emory University, Atlanta. Contact him at 404-778-2264 or jrandle@ emory.edu.

Sherman Reeves, M.D., M.P.H., is in practice at Minnesota Eye Consultants. Contact him at swreeves@ mneye.com.

Jason E. Stahl, M.D., is assistant clinical professor, Kansas University Medical Center, Kansas City. Contact him at 913-491-3330 or jstahl@ durrievision.com.

 

Lens and intraocular lens implant surgery, are increasingly merging with corneal refractive surgery. A medical manpower shortage looms as baby boomers soon become Medicare eligible. Accelerating technology challenges our ability to keep up. Medicine is a compassionate, altruistic profession, and at the same time, its practice is a business endeavor. The interplay of all of these forces can create ethical dilemmas. How well does the current training of ophthalmologists in the United States prepare the new practitioners to meet this challenge? This month’s column addresses such issues by young ophthalmologists well-positioned to provide answers. The discussion is led by Elizabeth Davis, M.D., a young, very talented, and internationally acclaimed surgeon, teacher and clinical researcher. She is relatively recently out of her own training, and yet is very accomplished. What many of you may not know is that Liz is my goddaughter. And a proud godfather I am!

I. Howard Fine, MD, Column Editor

Elizabeth A. Davis, M.D.: I was the former chairperson of the ASCRS Young Physicians and Residents Committee, and the purpose of this roundtable is to discuss the current and future status in the field of ophthalmology for young physicians. To begin with, I would like to have each of you introduce yourself, give your names, where you currently work, how many years out you are from training or if you are still in training, and what sort of interaction or teaching responsibilities you currently have with young ophthalmologists. I am in Minnesota, and I completed my cornea, cataract, and refractive surgery fellowship at Minnesota Eye Consultants [Bloomington, Minn.] in 2000. I then joined the practice here. We have an anterior segment fellowship program within our practice. We all work with the fellows in clinic and surgery, and I also attend surgeries at the VA hospital for the University of Minnesota, working with cornea fellows.

Parag Parekh, M.D.: I am currently a fellow with Dr. Davis at Minnesota Eye Consultants, and previously I was a resident at the Johns Hopkins Wilmer Eye Institute [Baltimore]. My current teaching responsibilities are minimal—I take calls for the local trauma center, and when there is a trauma, I’ll operate with the resident. That’s really my main teaching responsibility. We also run courses through Minnesota Eye Consultants where I have the opportunity to teach other fellows as well as more senior physicians in certain technique. For example, we taught a LASIK course and a DSEK course this year.

J. Bradley Randleman, M.D.: I am at Emory University [Atlanta], I’m an assistant professor, and I completed my Cornea External Disease and Refractive Surgery fellowship in 2004. I have been on faculty at Emory since then, and I am the currently director of the Cornea Fellowship. We have 18 residents, and I work directly with them in my clinics, at the county hospital, and in weekly teaching sessions. I am also the current chair of the ASCRS Young Physicians and Residents Clinical Committee.

Sherman Reeves, M.D.: I also am at Minnesota Eye Consultants, and I am in my first year of practice. I finished the Cornea and Refractive Fellowship at Minnesota Eye Consultants in July of 2007. I did my residency at the Duke University Eye Center [Durham, N.C.], where I also served for a year on the faculty as the chief resident after my residency had ended. As far as teaching responsibilities, I instructed residents full time for my year as chief at Duke, and I currently instruct University of Minnesota [Minneapolis] residents at the county hospital in a weekly clinic.

Jason E. Stahl, M.D.: I practice at Durrie Vision in Overland Park, Kansas. I completed my refractive fellowship with Dr. Daniel Durrie [M.D.] in 2001 and later joined the practice. I’m an assistant clinical professor at Kansas University Medical Center [Kansas City]. Residents rotate through our practice and I also give monthly lectures to them. In addition, we have a fellow every year that spends time with both Dr. Durrie and myself in surgery and clinic.

Training

Dr. Davis: Let’s start the discussion with the current training in the U.S. When we talk about training, let’s try to focus on residency training of ophthalmologists because not everybody goes on to a fellowship, although you can allude to a fellowship if you want to elaborate on that. If you think that in certain cases fellowship training is beneficial or provides things that were lacking in the residency then feel free to discuss this, but all of us attending in an accredited three-year ophthalmology residency in the United States probably think that U.S. residencies are excellent, but of course technology is changing at a dramatic rate. I want to know what each of you think about whether residency programs have been able to keep up with technology. I mostly want to emphasize, at this point, the medical and surgical aspects of training. We will talk in a moment about the business aspect of medicine, but in terms of the medical and surgical aspect of residency, do you think that the current training is adequate? Are there any deficiencies, and if so, what are they, and what would you do to change that?

Dr. Randleman: I think that ophthalmology residencies in the United States do a very good job overall. Three years is a very limited amount of time to train in our field. There is always the time constraint issue against which residencies are trying to balance various aspects of training. I think that in terms of what we specifically see and think about in our own practices, residencies generally do a very good job of teaching the basics of cataract surgery, but I think more advanced techniques, more advanced equipment, and more advanced understanding of intraocular lenses and surgical planning is probably lacking to a certain extent in many training programs. Part of that depends on how many cases the residents get and how experienced the staff is in modern techniques that are training those residents. The other glaring area of training deficiency is in refractive surgery. I just don’t think that the majority of residents are getting adequate exposure to refractive surgery, and even if an individual does not finish their residency and practice refractive surgery, they are inevitably going to be confronted with refractive surgery patients and management situations. So that is an area that should be drastically improved.

Dr. Davis: When you refer to refractive surgery, are you referring to both corneal and lenticular refractive surgery?

Dr. Randleman: I am primarily referring to corneal refractive surgery because that’s certainly the area in which more residents will practice or encounter in their practice. In corneal refractive surgery, it’s important to understand the nuances of the patient population and screening and the complications that can arise from those things. Cataract surgery and refractive surgery are emerging as one field as technology advances, and phakic intraocular lenses make up the minority of procedures from this group.

Dr. Reeves: I would echo what Dr. Randleman said. There is a large deficiency in refractive surgery training and the residency programs as they are today. A large part of the future of ophthalmology is in refractive surgery, at least for the anterior segment. At this point, I think the vast majority of practicing ophthalmologists have gotten their corneal refractive surgery training on the job, and they may go to a weekend course and then just start using the laser. In the future, we have to change it so that experience comes in a more standardized, supervised setting in the residency program.

Dr. Stahl: I agree with what you both have said. The way I try to approach this with our residents is to teach them the basics of what to look for in individuals who have had refractive surgery and are presenting with a complaint; for instance, understanding how to recognize and treat DLK and epithelial ingrowth in a LASIK patient. I want residents to have some basic knowledge of the procedure, so when patients come in with complaints, they know what to look for.

I agree that corneal refractive and lenticular surgery are becoming one specialty. Corneal refractive skills are needed, especially now as we see what’s happening with the Baby Boomers not wanting to wait to have a visually significant cataract and instead electing to have refractive lens exchange surgery with presbyopia-correcting IOLs. Residents need to understand the principles of refractive surgery, such as how to pick the IOL powers and who to perform surgery on, because expectations are much higher with presbyopia IOLs. Then they need to know how to deal with any residual refractive error, which will most likely be dealt with on the cornea. I think if our residents had a better basic knowledge of corneal refractive surgery prior to completing their residency and prior to performing presbyopia-correcting IOL procedures, the learning curve will not be quiet as steep as it currently is for most surgeons.

Dr. Randleman: The days of the average cataract patient tolerating three-quarters of a diopter or more of ametropia post-operatively are nearing an end, and you are going to have to have some mechanism to treat of that postoperatively.

Dr. Parekh: I think there are also some kind of deeper, more fundamental issues with the way that our residency and medical education is structured. If some of these were addressed, it would help ophthalmology, as well all other fields in medicine. For example, it seems to me that the whole medical education process is just too long —not only the total number of years, but also in terms of distribution that time. Here we are as ophthalmologists—we have done four years of an undergraduate degree, four years of a medical degree, one year of internship, and but just three years of ophthalmology, and I wonder if medical school could be cut down by six months or a year, undergraduate could be cut down by six months or a year, and we could put the balance of that time toward more training in ophthalmology. Three years is a short time to pack in so much. We have all been talking about things that we wish we could add to the residency curriculum. That time has to come from somewhere, and it seems like the distribution of time could be done in a much smarter way. The issue is surgical volume. My impression is that there is something of a bimodal distribution, with some residents doing 150 to 300 cataract cases on average, while there are some programs where residents do just the bare minimum, about 55 or 65 cases. With those programs on that lower end, that’s a serious deficiency in my opinion. Having high surgical volumes is really integral to being a good surgeon, and I think that’s something that some programs could certainly improve.

Dr. Davis: How can residency programs change to address the experience for residents with LASIK surgery? Many LASIK patients are highly educated about the procedure and particular about their selection of their surgeon. How can programs direct patients toward an inexperienced surgeon or surgeons in training?

Dr. Randleman: We have a model at Emory where we have a structured didactic and wet lab experience for the residents followed by their availability to perform surgery as they recruit patients. They get to perform this surgery at a significantly discounted rate compared to our attendings, and they get to perform surgery using the latest technology just like I use under the direct supervision of myself or one of the other faculty members. We found this to be a successful model, and many residents have been able to generate a fair number of cases in those circumstances when they are motivated to do so.

Dr. Reeves: That sounds like an excellent model in Emory. However, there are probably some departments that just haven’t had it as part of their game plan to increase the residents’ exposure surgically to these patients. It certainly can be done; it just takes the motivation of the chairman and the power structure of the department to look for a workable plan and to put that into action. Refractive surgery is a fairly young field, and I think that there is still some more distance within academic departments to the field itself even though I think that’s melting away quickly. I think that to a large degree, these problems of getting residents more contact with refractive surgery patients can be overcome if there is enough determination by departmental power structures.

Parag Parekh: I think the financial discount model is probably the smartest way to go. That allows the resident to see his or her own patients and establish a patient-doctor relationship. Obviously, there is attending supervision, but the resident is the primary contact with the patient. The problem, however, becomes when the department’s refractive program starts coming into competition with the residents’ ‘discount program.’ Obviously refractive surgery is a good source of income for these departments, oftentimes helping to offset the cost of resident education and resident clinics, which were often not such big moneymakers. So there is a fine balance there that the chairman and the program director have to strike with the residents and their patients.

Dr. Stahl: About eight years ago, my partner, Dr. Daniel Durrie, spearheaded an effort with some of the Midwestern residency programs to develop a program called MARC, Midwest Academic Refractive Consortium. This includes University of Kansas [Lawrence], University of Missouri-Kansas City, University of Missouri-Columbia, University of Nebraska [Omaha], University of Iowa [Iowa City], University of Oklahoma [Oklahoma City], and St. Louis University [Missouri]. On an annual basis, the residents and corneal refractive faculty of these institutions meet for a day of didactics and wet-labs devoted to refractive surgery. The didactics include clinical topics as well as basic science topics, such as corneal healing and biomechanics, and the wet-lab includes creating LASIK flaps, excimer lasers, CK, topography devices, wavefront devices, and anterior segment OCT.

At Kansas University, it’s very similar to what we are hearing about the discounted surgeries at other programs. Many of the patients are house staff or employees at the university hospital. Residents are trained on our femtosecond and excimer lasers prior to performing surgery. In our program there is no structured resident refractive clinic, so residents have to be motivated to find their own patients. We have also initiated an IRB-approved resident refractive surgery study to evaluate LASIK safety and outcomes when performed by resident surgeons.

Editors’ note: None of the physicians who participated in this dialogue have financial interests related to their comments.

Interested in learning more about what today’s young physicians think of ophthalmology? Curious what pearls they have to offer? The second half of this EW Dialogue will appear in the May issue of EyeWorld.

Young physicians and residents discuss their training, real-world challenges, and more Young physicians and residents discuss their training, real-world challenges, and more
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