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
Every office should have a copy of Ocular Differential Diagnosis, Eighth Edition.

This manual contains extensive lists of common and uncommon ocular diseases
and their associated clinical findings.
• Text is fully referenced for further reading and study.
• Dr. Roy ’ s Ocular Differential Diagnosis, Eighth Edition, is fully updated and revised and is a trusted resource for thousands of ophthalmologists and eye care
providers.
• The book is organized for quick and easy reference.
Journal of Academic Ophthalmology
Aims and Scope: The Journal of Academic Ophthalmology (JAO) is a peer-reviewed journal that serves as a n ational and
international forum for the publication and scholarly exchange of ideas and information of interest to academic ophthalmology, including medical education, resident and fellow training, and research in health education, policy, and regulation. The
JAO has a diverse editorial board consisting of leaders in the field of academic ophthalmology. The JAO is interested in
publishing original education research, literature reviews, case reports illustrating ACGME competencies, and, by invitation
or solicitation, editorial, historical, or policy perspectives.
Editor-in-Chief
Andrew G. Lee, MD
Chair
Professor of Ophthalmology, Neurology, and Neurosurgery
Department of Ophthalmology
The Methodist Hospital and Weill Cornell Medical College
Houston, TX
Editorial Review Board
Anthony Arnold, MD
Program Director
Jules Stein Eye Institute
UCLA Geffen School of Medicine
Los Angeles, CA
Linda S.M. Lippa, MD
Director of Ophthalmology Education
The Gavin Herbert Eye Institute
University of California
Irvine, CA
J.P. Dunn, MD
Program Director
Wilmer Eye Institute
Johns Hopkins Medical Institution
Baltimore, MD
Eduardo Mayorga, MD
Chair and Program Director
Hospital Italiano de Buenos Aires,
Argentina
Steven Gedde, MD
Program Director
Bascom Palmer Eye Institute
University of Miami
Miami, FL
Neil Miller, MD
Chief, Neuro-Ophthalmology Division
Wilmer Eye Institute
Johns Hopkins Medical Institution
Baltimore, MD
Karl Golnik, MD
Program Director
The University of Cincinnati
Cincinnati, OH
Alfredo A. Sadun, MD, PhD
Program Director
Doheny Eye Institute
University of Southern California
Los Angeles, CA
Marko Hawlina, MD, PhD, FEBO
Professor of Ophthalmology
University Eye Hospital
Ljubljana, Slovenia
Ingrid U. Scott, MD, MPH
Professor of Ophthalmology
Penn State College of Medicine
Hershey, PA
Tara Uhler, MD
Program Director
Wills Eye Residency Program
Jefferson Medical College of
Thomas Jefferson University
Philadelphia, PA
Nicholas Volpe, MD
Chair
Northwestern University
Chicago, IL
Editorial Staff
Andrew Doan, MD, PhD
Managing Editor
Patricia Duffel
Assistant Managing Editor
Brooke Strickland
Editorial Assistant
The Journal of Academic Ophthalmology is published as an op en issue on the in ternet at www.academic-ophthalmology.com and twice
yearly by FEP International, Inc., 941 25th Avenue, #101, Coralville, IA 52241, e-mail [email protected].
Advertising and classifieds inquiries: [email protected]
Periodicals postage paid at Houston, TX and additional mailing offices.
POSTMASTER: Send address changes to FEP International, Inc., 941 25th Avenue, #101, Coralville, IA 52241 or e-mail
[email protected]
This journal is supported in
part by an unrestricted educational grant from:
Contents
Volume 4, Number 2, 2011
Original Articles
Teaching ≠ Learning: Changing Parameters in Resident Education
41
Competency-based Curriculum: More Than Just Words
46
An Objective Method of Teaching Fundoscopy
52
Education in Ophthalmology: Analysis of experience and opinion
57
Physician Attire and Patient Satisfaction in Ophthalmology Urgent Care
61
Factors Influencing Program Ranking by Ophthalmology Residency Applicants:
Perspectives from Ophthalmology Residents and Ophthalmology Residency
Program Directors
66
Predictive Characteristics and Factors Influencing Career Choices Amongst
Ophthalmology Trainees
73
Karl C. Golnik, MD, MEd
Gabriela Palis, MD
Harold E. Cross, MD, Joseph M. Miller, MD, MPH, Lansing Brown, MD
David Spokes, Richard Gale, Carolyn Atherley, Bruno Zuberbuhler, Susie Bloomberg, Ian Simmons
Thomas S. Shane, MD, James T. Banta, MD, Joyce C. Schiffman, MS
Justin M. Shaw, BS, Ingrid U. Scott, MD, MPH, Alen R. Kunselman, MA, Matthew R. Hosler, MD, PhD,
David A. Quillen, MD
Stacy L. Pineles, MD, Steven L. Galetta, MD, Stuart L. Fine, MD, Paul J. Tapino, MD,
Nicholas J. Volpe, MD
Effect of Period of Academic Year on Cataract Extraction Surgical Time
Kenneth J. Mortimer, MHA, MSW, T. Eugene Day, DSc, Krustyn J. Williams, MHA, Nicole L.
Mitchel, MHA, James Banks Shepherd III, MD, Nathan Ravi, MSc, PhD, MD
85
Competency Corner Case Report
Primary Carcinoid Tumor of the Inferior Rectus Muscle
90
Corneal Ulceration Due to Xerophthalmia Following Biliopancreatic Diversion
Bariatric Surgery
94
Iris Vascular Malformations in Evaluation of Spontaneous Hyphema
99
Jamison R. Ridgeley, MD, Daniel P. Schaefer, MD
Brian O. Haugen, MD, David C. Gritz, MD, MPH, Jean Hausheer, MD, FACS
Virginia M. Utz, MD, Daniel J. Pierre, MD, John J. Weiter, MD, PhD, Johnny Tang, MD
Correspondence
U.S. Citizens Attending Caribbean Medical Schools and the Ophthalmology
Residency Selection Criteria
Jimmy Nguyen, BS
103
About the Journal
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Guidelines: Please follow these guidelines carefully to assist the Editorial
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Examples of formatting for references:
Gasymov OK, Abduragimov AR, Yusifov TN, Glasgow BJ. Structural changes in
human tear lipocalins associated with lipid binding. Biochim Biophys Acta 1998; 1386:
145-156.
Yanoff M, Fine BS. Ocular Pathology. 5th ed. St. Louis, MO: Mosby; 2002. p. 311-329.
Cason, SA. “There is no right or wrong.” Mommy MD. http://www.mommymd.org/
Posted Nov. 19, 2006. [Accessed Jan. 1, 2008.]
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Journal of Academic Ophthalmology 2011, Volume 4, Issue 2
Teaching ≠ Learning: Changing Parameters
in Resident Education
Karl C. Golnik, M.D., M.Ed.
University of Cincinnati & the Cincinnati Eye Institute
In 1999 the Accreditation Council for Graduate
Medical Education (ACGME) announced the Outcomes Project[1]. Previously, accreditation was
based on demonstrating the potential of a program
to educate, the existence of adequate resources,
curriculum and a structured learning experience.
The Outcomes Project refocused accreditation on
whether residents were actually learning by looking
at outcomes of their education. In other words, the
ACGME is acknowledging that teaching ≠ learning. Programs have to show that residents are learning and not only that teaching is occurring.
Prior to 1762, American medical education consisted of unstructured apprenticeships. Ideally these
apprenticeships lasted for 3-4 years, but they were
highly variable in duration and content[2]. In 1762
the College of Philadelphia created a medical faculty (now the University of Pennsylvania), and in
1768 Kings College of Medicine was formed in
New York (now Columbia University)[2]. Harvard
Medical School was started in the 1780s—so by
the end of the eighteenth century, the three largest
cities in America had medical schools. By 1820
there were 17 medical schools, but these were intended to only supplement apprenticeship training
and one did not need to attend a medical school to
practice medicine. The standard course of instruction was two four-month terms of lectures—the
second term being identical to the first. There were
no written exams and students would graduate
without examining a patient or observing surgery.
There were no standards for admission except the
ability to pay tuition. Indeed, in 1871, the president
Journal of Academic Ophthalmology 2011; 4:41-45
Available via open-access on the web at http://www.
academic-ophthalmology.com
The author(s) have no personal financial interests in any of the
products or technologies cited herein.
©2011 Journal of Academic Ophthalmology
of Harvard Medical School suggested that written
examinations be required for graduation. Henry
Jacob Bigelow, professor of surgery, objected because only about half of the students could barely
write[3]! A very small number of medical students
and/or recent graduates would become “house pupils” (later referred to as interns or residents) selected by competitive exam. Postgraduate education was done by few and when done it occurred
mostly in Europe (Paris prior to the Civil War and
Germany afterward) as apprenticeships[4].
In 1871, Harvard initiated several reforms that
would change medical education forever. The
curriculum was increased to three years (three
nine-month terms) and emphasized the laboratory sciences (chemistry, physiology, microscopic
anatomy and pathology). Students had to work in
the laboratory. However, “the most spectacular innovation in the history of American medical education” occurred in 1893 with the opening of the
first modern American medical school—the Johns
Hopkins School of Medicine[4]. Reforms at Johns
Hopkins included: 1) requirement of a bachelor’s
degree for entrance, 2) a curriculum requiring two
years of basic science instruction followed by two
years of clinical instruction that included experience at the patient’s bedside, and 3) the concept of
the clerkship and the idea that the hospital would
be the medical school. This third concept was new
and indeed most medical schools had no control of
teaching hospitals at this time.
It was in this context that Abraham Flexner published his now famous report: “Medical Education
in the United States and Canada”[5]. This report was
initiated by the American Medical Association’s
(AMA) request to the Carnegie Foundation[4].
Flexner’s report consisted of two sections: the first,
modern principles of medical education, the second,
a description of each school in the United States
and Canada that he visited personally. Flexner concluded that the ideal medical school must have three
41
Teaching ≠ Learning - Golnik
characteristics: 1) excellent resources, 2) admission
of qualified individuals only, and 3) medical educators should also perform research. Historians argue
that Flexner was not the “father of modern medical
education” as some would assert, but that he did
impact the form that the medical school assumed.
Prior to the 1920s, routes to specialization included: a) working in a specialty clinic at a hospital
and ultimately being hired, b) apprenticeship to a
specialist, c) postgraduate study abroad, d) formal
course work (often consisting of only 1-2 weeks!),
and e) a residency following internship. The word
“resident” originated at Johns Hopkins in 1889 and
had the same definition that exists currently[4].
By 1923, the AMA had established guidelines for
specialty training to include: a) review courses of
applicable basic sciences, b) specialty clinics available for students, c) instruction courses on laboratory and operative technique, and d) assistantships
under the guidance of an expert in that specialty[6].
By the late 1930s residency training was the preferred path to specialization[4].
By 1937 there were 60 institutions offering residencies in ophthalmology, graduating 100 residents a
year. The experience was primarily clinical with
little basic science emphasis. In 1935, only three institutions had well developed courses including instruction in basic sciences[7]. Under the auspices of
the American Academy of Ophthalmology and Otolaryngology (AAOO), Dr. Harry Gradle suggested
a means to fill the basic science gap and to try to
standardize training, the home study course[8]. The
course consisted of monthly topics with readings
estimated to take 60-90 minutes per day. A test had
to be passed at the end of the month. An AAOO
Teachers’ Section was formed in 1930 aimed at improving the state of graduate education[8]. Questionnaires were developed to ascertain necessary
components of the undergraduate curriculum in
ophthalmology and otolaryngology. Recent residency graduates were polled as to the adequacy of
their training. Other questionnaires went to graduate teaching institutions and hospitals to try and ascertain exactly what was taking place[7]. Ultimately, the AAOO’s Teachers’ Section did conclude that
a well-trained specialist should have four years of
medical school, one year of internship and two to
four years of graduate specialty training. In 1957,
the American Board of Ophthalmology (ABO)
standardized ophthalmic postgraduate training as
one year of internship and three years of ophthal42
mology residency[9].
Three other factors helped shape the modern ophthalmology residency program. In 1968 the first
annual Ophthalmology Residency in-Training Examination was sponsored by the Association of
University Professors in Ophthalmology (AUPO).
In 1969 the AAOO took over sponsorship of this
exam, which was meant to be a means to determine
knowledge gaps and to help guide remediation[8] A
separate practioner assessment procedure, the Ophthalmic Knowledge Self-Assessment Program, was
developed in 1970. Subsequently, these two assessments were merged in 1972 to become the Ophthalmic Knowledge Assessment Program (OKAP). Another event was replacement of the AAOO Home
Study Course with the Basic and Clinical Science
Course (BCSC) in 1970. The BCSC was devised
to integrate basic science and clinical application
and is still used by all American ophthalmology
residency programs[8]. Finally; the ACGME’s ophthalmology residency review committee set and enforced standards of ophthalmology residency programs[7].
In 1999, the ACGME and the American Board of
Medical Specialties (ABMS) introduced a general
competency and outcome assessment initiative
known as the “Outcome Project”[1]. It is an effort
to enhance residency education and accreditation
effectiveness by increasing emphasis on educational outcomes as opposed to process. A major component of this project was the identification of six core
competencies of physician training: 1) patient care,
2) medical knowledge, 3) professionalism, 4) communication skills, 5) practice based learning, and
6) systems based practice. Residency programs are
supposed to assure competence in these domains by
collecting performance data that reliably and accurately depicts the resident’s ability to care for patients and to work effectively in healthcare delivery
systems.
Thus, the ACGME’s Outcomes Project represented
the first major change in postgraduate medical education since the early 1900s when residency training became mandatory. Having excellent training
resources and adequate numbers of patients was
no longer enough; now the residency program and
program director had to show that the resident is
competent in the six core competencies by completion of the residency. No funds or procedures for
accomplishing this educational paradigm shift were
provided; but rather medical educators were told
this was their opportunity to devise methods to
meet the mandate.
The ACGME mandate has been addressed by the
ABO, AAO, AUPO and individual medical educators. Prior to the introduction of the ACGME competencies, the majority of resident assessment was
done by faculty global rating of the residents and
through the OKAP examination. However, with the
introduction of the Outcomes Project, it became
apparent that new assessment tools must be developed. Shortly after introduction of the ACGME
Outcomes Project, a task force of program directors was formed under the auspices of the AUPO to
address ways to meet the ACGME mandate. They
began by revising an Attending Physician Global
Rating Form that became commonly used. Subsequently, the ABO formed a Competency Task Force
charged with developing assessment tools to help
fulfill the ACGME requirements and to avoid the
need for each ophthalmology program to duplicate
efforts. The Task force had six subgroups; one for
each competency. The “Patient Care” subgroup
developed a one page assessment tool, the Ophthalmic Clinical Evaluation Exercise (OCEX)[10].
This tool is completed by an attending physician
as s/he observes the resident performing a patient
history, examination and then presenting the case.
The OCEX has been shown to have content validity and inter-rater reliability[10,11]. Perhaps most
importantly the OCEX provides a method to give
residents immediate formative feedback on their
performance which is essential to change behavior.
Subsequently a variety of competency assessment
tools were developed by groups of individual ophthalmic medical educators. Several methods of surgical skill assessment have been devised. Cremers
and associates developed the “Objective Assessment of Skills in Intraocular Surgery” (OASIS), a
one-page objective evaluation form to assess residents’ skills in cataract surgery[12]. The form is
completed by an evaluator who directly observes
the surgical procedure and includes objective data
such as wound placement and size, phacoemulsification time, and total surgical time, etc. They
showed that the OASIS had both face and content
validity. To complement this objective assessment
the same group developed a subjective rating of
surgical skills named “Global Rating Assessment
of Skills in Intraocular Surgery” (GRASIS)[13].
This one-page form allows the evaluator to assign
scores from 1-5 based on a behaviorally anchored
rubric to domains such as pre-operative knowledge,
microscope use, instrument handling, and tissue
treatment in addition to seven other areas. Thus the
use of the combination of the OASIS and GRACIS
provides objective and subjective evaluation of surgical skill. Feldman and Geist described the Subjective Phacoemulsification Skills Assessment as
an evaluative instrument designed specifically for
intraoperative assessment of resident phacoemulsification cataract extraction (PCE) surgery[14]. This
form delineates PCE into overall performance and
specific steps of the procedure (e.g. capsulorrhexis,
hydrodelineation, IOL implantation, etc). The performance was graded with a rubric defining a good
outcome at each step and asking the evaluator to rate
on a 1-5 spectrum from strongly agree to strongly
disagree. They were able to show a degree of interrater reliability. Other authors have investigated
surgical skills outside of actual human surgery.
Fisher and associates developed the Eye Surgical
Skills Assessment Test (ESSAT); a 3-station (skin
suturing, muscle recession, phacoemulsification/
wound construction and suturing technique) wet
laboratory surgical skills obstacle course for ophthalmology residents[15]. In contrast to other surgical assessments, the ESSAT is designed to evaluate
residents’ basic skills before entering the operating
room. Lee and associates developed an ophthalmology wet laboratory curriculum for teaching and assessing cataract surgical competency[16]. The curriculum includes pre- and post-tests of cognitive
skills in addition to a structured wet lab curriculum
with observed ratings of surgical skill. The same
group from Iowa has shown that changes in their
surgical curriculum have decreased resident complications during cataract surgery[17]. Thus, in at
least one institution, the ACGME mandate has led
to measurable improvement in outcomes.
Medical educators have also been devising methods
to teach and assess the other ACGME competencies. Lee and associates described an assessment
tool involving a structured assessment of journal
club that leads to assessment of practice based
learning and improvement[18,19]. Golnik and associates developed and showed validity of a tool to
assess resident on-call performance—the “On Call
Assessment Tool” (OCAT)[20]. The OCAT is a one
page checklist to be used retrospectively during
random chart review of on-call consultations. The
Program Directors Medical Education Research
Group (PDMERG) has been active in developing
43
written and video vignettes (as described in a previous section) to facilitate teaching and assessing
professionalism and communication skills[21,22].
Finally, many programs are using a “360 degree”
evaluation tool. The intent is to get feedback on
residents from all groups with which they interact.
Thus, faculty evaluations can be considered 90 degrees, patient surveys, ancillary staff and peer evaluations constitute the other 270 degrees. Some programs use self evaluations in addition. Of course,
patients and staff are not asked about the resident’s
medical knowledge but are asked about professionalism and communication skills. Harper and associates have reported a degree of reliability in their use
of the 360 degree assessment[23].
In 2005, the ABO Competency Task Force agreed
to assess developed tools and grade them as “approved” (shown to be valid) or “acceptable” (validity not yet established but good in principle)[24].
The OKAP, OCEX, Journal Club tool and Global
Attending evaluation form (developed by the
AUPO task force) were approved. The ESSAT,
OCAT, and surgical skills checklist were accepted.
The ABO Task Force was disbanded in 2007 when
it was determined that appropriate competency assessment tools had been developed. In 2008 the
ACGME Ophthalmology RRC recommended all
programs use a Global Performance Rating (Rotation Evaluations), OKAP, ABO Written and Oral
Examinations, 360 Degree Evaluation, Portfolio,
Procedural Skill Assessment, and Surgical Case
Log as the basic competency assessment tools[25].
The next logical step in documenting a resident’s
competence is to establish milestones of competency development in each specialty[26]. Milestones
would comprise a developmental progression of
defined behavior for each of the six competencies.
Programs would use the milestones to evaluate residents and to provide feedback as to their progress.
Additionally, milestones will guide curriculum development, provide national specialty benchmarking, and lead to standards of assessment. The American Board of Internal Medicine has already begun
the process[27].
The internet is becoming increasingly relevant to
resident education. The most comprehensive internet resource for program directors is the AAO’s
Resident Education Center (REC).* In 2008, the
AAO’s Ophthalmic News and Education (ONE)
network was launched. The REC exists on the ONE
network as a password protected area available only
44
to program directors. This resource is designed to
facilitate the residency program directors’ responsibilities. An AAO Committee for Resident Education advises the AAO on REC content. Currently
the REC contains a variety of functions and educational material including the ability for program
directors to create rotations, upload their own educational content that can be shared by everyone or
used only be their program, create tests from their
own material or any material on the ONE network,
assign existing ONE network assessments, notify
a resident when an assignment becomes available,
notify a resident when his or her assignment will
be past due in 48 hours, and notify the program director and coordinator when a resident completes
an assessment. The REC should be an excellent
resource for program directors to collaborate and
share resources.
The ACGME’s Outcomes Project is changing the
way physicians are educated and assessed in the
United States. The emphasis on educational outcomes and the six core competencies represents
the most significant change in medical education
in the United States since the early 20th century
when medical schools and hospitals became integrated allowing interaction between student and
patient and residency training became required for
specialization. The AAO, ABO, AUPO and ophthalmic educators have combined to meet the ACGME mandate by providing internet resources, new
teaching and assessment tools, and improving the
role of the residency program director. The internet
is allowing collaboration between ophthalmic educators globally and providing educational resources
previously unavailable. The intent of these efforts
is to improve the ophthalmologists’ education and
demonstrate that learning has occurred which will
hopefully translate to improved patient care.
Acknowledgements
This research was supported in part by an unrestricted research grant from Research to Prevent
Blindness, Inc., New York, New York, U.S.A.
*Note added in proof: Resident HubTM online portal replaces the AAO’s REC in the Fall of 2011.
References
1. The ACGME Outcomes Project. Available at:
www.acgme.org/outcome/comp/compCPRL.asp.
Accessed December 8, 2009.
2. Shyrock RH. Medicine and Society in America:
1660-1860. Cornell University Press, 1960.
3. Charles E. Public Health Service. Harvard Alumni
Bulletin 29 Jan, 1925, pg 527.
4. Ludmerer KM. Learning to Heal: The Development
of American Medical Education. Basic Books, New
York, 1985.
5. Flexner A. Medical education in the United States
and Canada. The Carnegie Foundation for Higher
Education. 1910.
6. King LS. American Medicine Comes of Age 18401920. American Medical Association, 1984.
7. Fenton RA. Report of the results of questionnaire on
graduate and postgraduate education in ophthalmology and otolaryngology. Bull Am Acad Ophthalmology Otolaryngol 1935;4:19-21.
8. Bryan SA. Pioneering Specialists: History of the
American Academy of Ophthalmology and Otolaryngology. Rochester, MN: American Academy of
Ophthalmology and American Academy of Otolaryngology—Head and Neck Surgery, 1982.
9. Cordes F, Rucker CW. History of the American Board of Ophthalmology. Am J Ophthalmol
1962;53: 243-264.
10. Golnik KC, Goldenhar LM, Gittinger JW Jr, Lustbader JM. The Ophthalmic Clinical Evaluation
Exercise (OCEX). Ophthalmology 2004;111:12711274.
11. Golnik KC, Goldenhar L. The Ophthalmic Clinical
Evaluation Exercise (OCEX): Interrater reliability determination. Ophthalmology 2005:112:16491654.
12. Cremers SL, Ciolino JB, Ferrufino-Ponce ZK, Henderson BA. Objective assessment of skills in intraocular surgery. Ophthalmology 2005; 112:12361241.
son T, Boldt C. Abramoff M, Olson R. Carter K. The
Iowa Ophthalmology Wet Laboratory Curriculum
for Teaching and Assessing Cataract Surgical Competency. Ophthalmology 2007 114:e21-26.
17. Rogers GM, Oetting TA, Lee AG, Grignon C,
Greenlee E, Johnson T, Beaver HA, Carter K, Impact of a structured surgical curriculum on ophthalmic resident cataract surgery complication rates. J
Cataract Refract Surg 2009; 35:1956–1960.
18. Lee AG. Using the American Journal of Ophthalmology’s website for assessing residency subcompetencies in practice-based learning. Am J Ophthalmol 2004;137:206-207.
19. Lee AG, Boldt CH, Golnik KC, Arnold AC, Oetting
T, Beaver H, Olson R, Carter K. Using the Journal
Club to Teach and Assess Competence in Practicebased Learning and Improvement: A Literature
Review and Recommendation for Implementation.
Surv Ophthalmol 2005;50:542-548.
20. Golnik KC, Lee AG, Carter K. Assessment of Ophthalmology Resident On-Call Performance. Ophthalmology, 2005;112:1242-46.
21. Golnik K, Thiagarajah C, Lee AG and PDMERG.
Video Vignettes for Teaching and Assessing
Professionalism and Communication Skills
in Ophthalmology Residency Training Programs. Available at: aao.scientificposters.com/
aaoView.cfm?pid=365&yr=2007. Accessed December 7, 2009.
22. Golnik K, Lee AG and PDMERG. Professionalism
Vignette conference to enhance residents’ professionalism education. Available at: aao.scientificposters.com/aaoView.cfm?pid=365&yr=2007. Accessed December 7, 2009.
23. Harper RA, Petty M, Turner SD. 360-Degree Global
Evaluation of Resident Performance: Three-Year
Experience. 2006. Available at: aao.scientificposters.com/aaoView.cfm?pid=365&yr=2007. Accessed December 5, 2009.
24. Minutes of the annual ABO Competency Task Force,
2005.
13. Cremers SL, Lora AN, Ferrufino-Ponce ZK. Global
rating assessment of skills in intraocular surgery.
Ophthalmology 2005; 112:1655-1660.
25. ACGME Ophthalmology RRC recommended portfolio components. Available at: www.acgme.org/acWebsite/notablepractices/default.asp?SpecID=41.
Accessed December 6, 2009.
14. Feldman BE, Geist CG. Assessing residents in
phacoemulsification. Ophthalmology 2007;9:15861588.
26. Nasca TJ. The next step in the outcomes-based
accreditation project. ACGME Bulletin. May
2008;2-4.
15. Fisher JB, Binenbaum G, Tapino P, Volpe NJ. Development and Face and Content Validity of an Eye
Surgical Skills Assessment Test for Ophthalmology
Residents. Ophthalmology 2006;113:2364–2370.
27. Green ML, Aagaard EM, Caverzagie KJ, Chick
DA, Holmboe E, Kane G, et al. Charting the Road
to Competence: Developmental Milestones for Internal Medicine Residency Training. J Grad Med Ed
2009;1:5-20.
16. Lee AG, Greenlee E, Oetting TA, Beaver HA, John-
45
Competency-based Curriculum:
More Than Just Words
Gabriela Palis, M.D.
Hospital Italiano de Buenos Aires, Argentina
email: [email protected]
Abstract
A competency-based curriculum for an ophthalmology residency program describes the educational experience
residents will go through during their training years, by the end of which they will have to be able to demonstrate the
ability to apply the knowledge, skills and attitudes inherent of ophthalmology to the care of their patients. This paper
outlines the steps and briefly describes some aspects to consider when adopting or developing a competency-based
curriculum.
Introduction
Competency-based medical education is a process
that involves the demonstration of having acquired
the ability to apply the knowledge, skills and attitudes inherent of the medical profession to the individual professional practice. Competency-based
residency education defines, according to the specialty, the requirements needed to be considered
‘competent’, to then verify that the trainee fulfills
those requirements and is able to assume an integral care of the patients of his/her professional
practice[1,2].
The competency-based curriculum describes a
planned and dynamic educational experience. It
includes the goals and objectives or outcomes to
be accomplished after the experience, linked to
the contents and methods that will help the trainee
achieve those objectives or outcomes (what will be
taught, and how), how the contents and methods
will be distributed during the time of the training
process (when they will be taught), and how the
outcomes of the proposed objectives are going to
be assessed[3,4].
46
This paper intends to synthesize and provide some
guidance about the steps to take when deciding to
adopt or develop a competency-based curriculum
for an ophthalmology residency program.
What does it mean ‘to be competent’?
Many definitions have been proposed for competence. Kane[5] defines professional competence as
the use by the individual of the knowledge, skills
and judgment associated with the profession to
perform effectively in the different situations that
define the scope of professional practice. Each situation will vary according to the context, the patient,
and the problem requiring professional intervention; being competent entails using the knowledge
and skills, and the judgment to combine both, to
arrive to effective solutions to the problems of individual patients.
Epstein and Hundert[6] propose that professional
competence is ‘the habitual and judicious use of
communication, knowledge, technical skills, clinical reasoning, emotions, values and reflection in
daily practice for the benefit of the individual and
community being served’.
Both definitions share the concept that being competent implies the practical application of knowledge and behaviors. According to Miller’s pyramid
of clinical competence[7], residents should not only
know what is needed to execute their professional
functions effectively (to know), and know how to
use this knowledge for the diagnosis and treatment
Competency-based curriculum - Palis
of medical conditions (to know how), but also be
able to demonstrate how they carry this functions
out (to show how) and, finally, do them in their
daily practice (to do). Therefore, demonstration of
professional competence has a cognitive component and a behavioral or performance component.
Competency-based curriculum
The traditional curriculum (Flexnerian model, apprenticeship model, or based in structures and processes), which was the column of medical education during earlier times, defines the educational
experience according to the exposure to determined
contents for a defined period of time[2]. The major
criticism to this approach is that in many programs
the educational process was distorted, since it was
mainly focused in providing residents with as many
exposures to theoretical knowledge and procedures
(lectures, cases, surgery) as possible, without later verifying that residents were able to apply that
knowledge to daily practice within quality standards. Besides, the time required to be trained as a
specialist was arbitrarily decided, without considering the actual time needed to learn a given procedure or treat a particular disease[1].
A competency-based curriculum defines and plans,
prior to and concurrent with the educational experience, the outcomes that should be expected with
residents’ education, searches for the most effective
strategies to achieve those outcomes, and defines
the most valid, accurate and reliable tools to determine, through and at the end of the process, that the
outcomes have been achieved.
The driving force of a curriculum based in structures
and processes is content (knowledge acquisition),
whereas a competency-based curriculum is driven
by the outcome (application of knowledge)[2].
Choosing the curriculum: should we start from
scratch or adapt one to suit our needs?
Depending on the available time and resources,
a curriculum may be developed in two ways: by
adapting an existing curriculum to the needs, resources, characteristics and peculiarities of the program, or by creating a completely new curriculum.
Green[3] suggests and offers guidelines on how to
use developed and proved curricula; he describes
how to identify them (he even provides a search
strategy in MEDLINE), how to critically assess
their quality and suitability (considering their development, residents and program characteristics,
learning goals and objectives, teaching methods,
viability, sustainability and effectiveness), and how
to implement the curriculum already being used by
other programs to the desired program.
The International Council of Ophthalmology has
published the document “Principles and Guidelines
of a Curriculum for Education of the Ophthalmic
Specialist”[8], which was written after reviewing ophthalmology residencies and programs curriculums from all over the world. This document
describes aspirational outcomes for cognitive and
technical skills for basic, intermediate and advanced
training of residents, and proposes the acquisition
of competencies according to the model of the Accreditation Council for Graduate Medical Education (ACGME) of the United States. This guideline
may be used as a basis to develop the ophthalmology curriculum, adapting it to the local needs, peculiarities and resources of the program[9]. Table 1
shows some guidelines and programs for ophthalmology curricula that may be downloaded from the
Internet.
Whether we decide to use an already developed
curriculum or to create our own, we may follow
Table 1. Guidelines and programs to help developing an ophthalmology residency curriculum. These
guidelines and programs can be the basis to develop or adapt a local ophthalmology residency curriculum.
Guideline/Program
Principles and Guidelines of
a Curriculum for Education
of the Ophthalmic Specialist
Curriculum for Ophthalmic
Specialist Training
Vocational Training Program
Entity
International Council of
Ophthalmology
Web page
www.icoph.org/pdf/icocurricres.pdf
www.icoph.org/pdf/icocurricressp.pdf (Spanish)
The Royal College of
curriculum.rcophth.ac.uk
Ophthalmologists (UK)
The Royal Australian
www.ranzco.edu/training/6-curriculum-standards
and New Zealand College of Ophthalmologists
47
the guidelines proposed by Kern, Thomas and
Hughes[10], who propose developing the curriculum in 6 steps:
1. Problem identification and general needs assessment;
2. Targeted needs assessment (i.e. residents and
residency program);
3. Goals and objectives;
4. Educational strategies;
5. Implementation;
6. Evaluation and feedback.
Below, I will briefly describe how to carry them out.
Problem identification and general needs assessment
This may be considered the most important step,
since it directs and focuses the curriculum according to the particular needs, strengths and weaknesses of the program that is planning to use it. It should
be a moment of reflection and research about the
reasons leading us to re-design our curriculum[3],
beyond those merely ‘mandated’:
Goals are general statements of intention. They describe “in general” the intention of the acquisition
of the competencies the resident will have by the
conclusion of a given educational experience (eg.
a rotation, course, year, etc.). Objectives are more
concrete, specific and measurable statements about
what the resident will be able to do by the end of
such experience.
When writing the objectives for a given competency, it is better to use terms that are easy to understand, evaluate and measure by a third party
(i.e. open to few interpretations). For example: A
resident that “knows” the structures of the anterior
chamber will be able to describe/draw/sketch them;
in consequence, these are the verbs that should be
used to write the objective: ‘By the end of the rotation the resident will be able to describe the structures of the anterior chamber’. If the statement just
read: ‘The resident will know the structures…’ it
would not specify how the resident is going to demonstrate he/she knows it, and the concept of ‘knowing’ could be open to too many interpretations. To
‘know’, ‘understand’, ‘learn’, ‘be able’, ‘appreciate’, involve many processes; such verbs may be
used for defining general learning goals, but it is
advisable to use more concrete and specific terms
to describe objectives[13].
•
Needs of society[11,12]: new diseases, economic and financial crisis; public demand of
accountability, responsibility and quality from
the medical profession; increased number of
lawsuits and legal actions against the medical
profession.
•
To improve residents education: since the training time for residents is proportionally shorter
for the increasing volume and complexity of
medical knowledge and the rapid progress of
diagnosis methods and surgical techniques, it
is necessary to adopt the best strategies that, in
the shortest possible term, allow them become
competent and competitive professionals for
the world where they will have to perform.
Objectives are usually grouped in three domains:
cognitive (knowledge and intellectual skills), psychomotor (physical skills – for technical and surgical procedures) and affective (feelings and attitudes). Since, as already mentioned, medical
competence entails the use of knowledge, skills and
judgment, it will be necessary to define learning
objectives comprising all facets (knowledge, skills
and attitudes) of medical competence.
•
New educational theories: modern theories
in education and behavior, aimed at educating young doctors into capable and accountable professionals, are increasingly being researched and tested.
•
Targeted needs assessment (of residents, of the
residency)
At this stage, decisions are made as to which competencies residents need to acquire, which ones
they already have and what they need to improve,
according to the research and decisions made on the
previous step.
48
Goals and objectives
The adequate, conscientious and sensible determination of goals and objectives:
•
•
constitutes the basis on which contents, teaching strategies and assessments articulate;
provides transparence to the curriculum[14]:
all parties involved know what to expect about
what may be obtained;
may be seen as the “lighthouse” of the educational process, guiding residents and teachers
to the desired outcomes.
Educational strategies
In line with the objectives proposed, we will choose
content and decide on the most effective (and suitable to our possibilities) educational strategies that
allow us reach those objectives[15]. Adult learning
theories promoting student-centered approaches
(experiential, task/problem-centered, meaningful),
should guide the selection of educational
strategies[2,16].
Even though teaching theoretical knowledge (eg.
lectures, readings, cases) and technical and surgical
skills (eg. wet-labs, simulations, videos, practices)
is usually well covered in most programs, ‘nontechnical’ competencies such as communication,
professionalism, ethics, doctor-patient relationship,
leadership, etc., which are also important in medical practice, are sometimes not considered for the
same formal training. Strategies like small group
discussions, brainstorming sessions, mentorships,
discussion forums, reflective narrations, etc. may
be used for that purpose[17].
A key process that should be reinforced in residents
is reflection. This skill allows the resident not only
to demonstrate what he/she has learned, but also
how this outcome or this learning has been achieved
(‘metacognition’). Therefore, this reflection and
analysis of what was learned becomes a new learning that ideally will influence improvements in their
future practice[18]. Learning portfolios where residents record and reflect on key events and experiences are an ideal tool to promote this reflective
process, key to professional development[19].
It should also be noted that there are five stages for
the acquisition of competence, as proposed by the
Dreyfus brothers in 1980[16,20]: novice, beginner,
competent, proficient, expert. Going through each
of them will require the use of different educational
strategies, which will help the resident progress
as he/she moves forward into stages of increasing
complexity.
Implementation
At this stage of planning, decisions are made as to
when the changes proposed are going to take place,
which resources will be necessary (financial, teaching, of staff, time), how they are going to be negotiated with authorities, etc.
Evaluation and feedback
This very important stage includes evaluation of
residents, of the curriculum, and of the program in
general.
Competency assessment will allow an inference
of the resident’s ability to appropriately apply the
knowledge, skills and judgment acquired through
the learning process, in order to perform effectively
in his/her professional practice[1,5].
The evaluation of residents should determine the
achievement of competence proposed when defining the goals and objectives. One of the most
difficult and controversial decisions to take, is to
choose the most valid and reliable evaluation tools
that measure the achievement of the competencies,
which are also rapid to perform and cost-effective.
Unfortunately, there is not one single method that
considers all aspects of such a complex construct as
professional competence. Several authors recommend the use of more than one assessment tool for
the evaluation of the same competency[2,4,6,7,21].
A ‘toolbox’ of these instruments for ophthalmology residencies can be found in the paper by
Lee et al.[4], which contains a list of instruments
for each of the domains of competence defined by
the ACGME.
Assessment tools should also reflect what is happening in real practice, so they should be based in
observations of the resident’s daily practice. The
Ophthalmic Clinical Exercise (OCEX) developed
by Golnik et al.[22] allows observation and evaluation of many domains of competence, by means of
a spreadsheet with rubrics.
Criterion-referenced measures are recommended
and preferred to norm-referenced measures for the
assessment of competency[2,7]. A criterion-referenced test allows determining if the resident has
attained competence or not, by matching what he/
she is doing to pre-defined and explicit standards
(or objectives); conversely, a normative-referenced
test would determine only if the resident performs
better or worse than others in the group, but would
not evaluate what he/she can or cannot do.
Evaluation may be summative (to provide the
resident a ‘grade’) or formative, to let the resident know how he/she is performing. Feedback
is a strategy not only for evaluation but also for
teaching, since it lets the resident know and reinforce those areas in which his/her performance is
adequate or outstanding, and improve and change
unacceptable behaviors or performances that fall
below expectations[23].
The assessment of residents’ performance allows
also evaluation of the curriculum in order to deter49
mine weaknesses needing improvement[6], to recommence the process from the first stage.
•
Implement changes gradually. If you try to
change the whole program in three months you
have little chances to make it (and make lasting changes). Introduce first, for example, the
learning portfolio, then the evaluation tools
with observation, rubrics and feedback, etc.
•
Do it. If you wait until perfection and ideal conditions you will never start. Do the best with
the resources you have, and improve with your
own experience.
Some tips when the decision is ‘voluntary’
Not all residency programs are ‘compelled’ to adapt
their curriculum to a competency-based one. Many
ophthalmology residency programs in Latin America, for example, are free to design their curriculum
at their best discretion. I present below some tips
learned from the experience of having decided to
change our department’s curriculum to a competency-based one.
•
Consider why you need to do it. “Because everyone does it” is not a sound reason to decide
to change your curriculum. The needs of individuals, the institution and society in general
should be the reasons for curricular change.
You will need to justify this to all those potentially participating in the process.
•
Involve your chair of department. If your boss
is aware of the values associated to the residency and supports you, it will be easier to get
support from the rest of the faculty, and the resources needed to carry out the project.
•
Request assistance from your Department of
Teaching and Research. If your University or
Hospital has such an office, ask them for help
(and resources) and involve them in the process.
•
Raise awareness in the rest of the faculty. If you
can convince your colleagues that the changes you are planning will be of benefit for the
whole department, you will get real help for the
implementation of the curriculum.
•
•
50
Support the teachers. Not all educators have
been trained for teaching; many of them do it
intuitively or the way they learned it from their
elders. Meet them, listen to their difficulties
and suggestions, and help them implement the
new tools.
Adapt an already developed and tested curriculum. To ‘reinvent the wheel’ demands a lot
of hard, expensive work, and you risk getting
frustrated and abandoning the project. Take a
curriculum (the guidelines of the International
Council of Ophthalmology provide a good basis), analyze it with your faculty, and adapt it to
your own needs and resources.
Conclusions
Migrating from a curriculum based in processes and
structures to a competency-based curriculum is an
arduous, reflective, patient and fascinating process
if we consider all the factors that have been outlined in these pages. It requires, above all, keeping
focus on the fundamental reason that drives us to
make this decision: the best possible care and promotion of health and quality of life for our patients.
By offering our residents opportunities to develop
to their utmost, both as doctors and as persons, we
will educate individuals professionally competent,
with tools to keep updated for their lifetime, capable of working in a team, ethical and compassionate, who put their patients’ interests ahead of their
own, and striving to reconcile their interests with
those of the society in which they live and the systems in which they perform.
References
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K, Martin C. Shifting Paradigms: From Flexner to
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3. Green ML. Identifying, Appraising and Implementing Medical Education Curricula: A Guide for Medical Educators. Ann Intern Med 2001;135:889-896.
4. Lee AG, Oetting T, Beaver HA, Carter K. The ACGME Outcome Project in Ophthalmology: Practical Recommendations for Overcoming the Barriers
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Professional Competence. JAMA 2002;287:226235.
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TA, Abramoff M, Carter K. Teaching and assessing
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51
An Objective Method of Teaching
Fundoscopy
Harold E. Cross M.D., Ph.D.*, Joseph M. Miller M.D., M.P.H., Lansing
Brown M.D.
University of Arizona College of Medicine, Department of Ophthalmology and Vision Science, Tucson, Arizona
*Corresponding Author and e-mail: [email protected]
Abstract
Purpose: To develop and evaluate a method of teaching direct ophthalmoscopy to medical students that enables
objective assessment of acquired skills.
Methods: First year medical students in small groups of three to 7 attended two-hour supervised sessions in which
they were taught how to examine the ocular fundus through undilated pupils. A standard fundus photograph of each
student’s right eye was taken and students were then asked to match these with the views they obtained by direct
visualization of the fundi of their peers.
Results: One hundred and nine students from the class of 2013 at the University of Arizona College of Medicine
participated. Out of 508 possible correct fundus photograph/fundus view matches, 88.2% were correctly matched.
Students in groups of five or less reported 93.6% correct answers while those in groups with 6 or more identified
correct matches only 85.4% of the time.
Conclusions: We have developed, tested, and applied a format that successfully teaches direct ophthalmoscopy
skills to first year medical students. The structure of our program using small groups with direct supervision by
experienced ophthalmologists generated enthusiastic participation by students. By monitoring how successfully
students matched fundus photographs with clinical views, we were able to objectively evaluate how well students
learned to apply their skill. At the same time, by using a small group format we were able to personally emphasize
the important role that non-ophthalmologists have in the prevention of common blinding disorders. Our technique
can be applied to the teaching of other medical personnel as well.
Introduction
As ophthalmologists we are aware of the importance of early intervention in sight preservation.
However, we are often dependent upon timely referrals by our colleagues in other specialties such
as family practice and pediatrics. Many academic
programs in ophthalmology have only limited input into the medical curriculum with the result that
a substantial number of medical school graduates
lack proficiency in basic skills required for examination of the eye. The finite amount of time availJournal of Academic Ophthalmology 2011; 4:52-56
52
able in medical school curricula requires medical
educators to maximize resources by using the most
effective teaching methods. Once in practice, time
constraints often reduce the incentive to do comprehensive physical examinations, and, as a result,
the ocular fundus is frequently neglected[1]. This
is particularly unfortunate as the major causes of
blindness in the United States, such as diabetic
retinopathy, glaucoma and age-related macular
degeneration, can be detected by examination of
the posterior pole with the widely-available direct
ophthalmoscope. Ophthalmologists can enhance
referral behavior by emphasizing to medical students that prevention of blindness is a cooperative
endeavor in which all physicians play a collaborative role. One way to do this is to ensure that direct
fundoscopy skills are taught in such a way that students become proficient and confident enough that
they will incorporate these in their future practices.
The educational objectives in teaching ophthalmos-
Teaching Fundoscopy - Cross et al.
copy include:
Methods
•
Emphasizing the importance of fundoscopic
examination as an essential component of the
physical examination
•
Understanding the mechanics and operation of
instruments used to view the fundus
•
Acquiring the skills necessary for successful
fundus visualization
Our program was first developed and tested on the
113 members of the freshman class of 2012. Based
on the enthusiastic feedback of students in this class,
and the favorable outcomes of our technique, we
made minor modifications and applied the revised
format to the 109 members of the class of 2013 for
which we summarize and report the results here.
•
Gaining self-confidence in examination skills
through practice and demonstration which will
lead to consistent application
•
Learning about variations of normal in posterior pole structures
•
Developing a systematic technique for the
evaluation of the optic nerve, blood vessels,
pigmentation and the macula
The skills required for effective examination of the
fundus cannot be mastered through didactic means
but requires ‘hands-on’ direct experience. Too often, though, as instructors we are unable to observe
the success or failure of our instructional approaches and instead are dependent upon students’ verbal
responses. We have developed a teaching format
that includes active participation in direct ophthalmoscopy with immediate and objective feedback
that reinforces the learning objectives. Our goals
were:
•
To design a block of instruction incorporating
didactics, demonstrations, and practice that
could be incorporated into the medical school
curriculum as a mandatory course for all students
•
To develop an efficient and effective system of
instruction that allows individualized supervision of students in small groups
•
To format the experience in such a manner
that enables first year students to feel directly
involved in a medical activity through direct
participation and immediate, positive feedback
•
To structure the activity in a manner that enables instructors to objectively determine the
success or failure of each student, and to provide immediate, effective remedial instruction
This report describes our protocol and early results
based on experience with small groups of first year
medical students at the University of Arizona utilizing the direct ophthalmoscope to examine the
fundus.
We obtained IRB approval for the use of privileged
health information (fundus photographs) and informed consent was obtained from each student.
The class was divided into 20 small groups (average size 5.45 students) and each met for two hours
under the supervision of two ophthalmology faculty members. The first 20 minutes were didactic
and explanatory in nature with emphasis on the importance of posterior pole examination as part of a
complete physical examination, plus a description
of the normal fundus, and a brief introduction to the
signs of glaucoma, diabetic retinopathy, and agerelated macular degeneration. Fundus photographs
and clinical demonstrations were used to illustrate
fundus anatomy and techniques of fundoscopy. This
was followed by an explanation of helpful settings
on the direct ophthalmoscope which, for the most
part, was limited to the standard Welch-Allyn™ direct ophthalmoscope although the PanOptic™ instrument was briefly explained as well.
The ophthalmologist/instructor next demonstrated
the proper technique using a student volunteer as
the patient. Pupils were not dilated. We emphasized
the importance of proper positioning and stability
of both patient and observer to enhance success in
viewing of fundus structures. Patient comfort considerations were stressed as well. Because the optic disc is the most easily identifiable structure and
provides a consistent landmark for anatomic orientation, we began by illustrating how to first locate
the disc. Using the neutral dioptric setting on the
direct ophthalmoscope, and beginning 15 degrees
temporal to the visual axis from a distance of about
12 inches from the eye, students were instructed to
center the red reflex in the field of view and rapidly
close the viewing distance to within one inch. If the
disc was not in view at this point, the instructor suggested slight modifications to the technique and the
maneuver was repeated until the angle of approach
consistently and immediately brought the disc into
view. Using graphics and verbal explanations, students were encouraged to apply a standard routine
53
for examination of the disc to evaluate color, sharpness of margins, patterns of peripapillary pigmentation, and vascular morphology. The importance of
estimating cup size and morphology was emphasized. Once the disc was consistently identified and
described, students were encouraged to follow the
major vessels into the four quadrants, then returning to the disc and scanning temporally to view the
macular area.
Following this introductory session, students practiced by examining the fundi of their classmates
under the direct supervision of an experienced ophthalmologist. Each student was required to examine
both eyes of each of his/her peers attending the session. A fundus photograph of each student’s right
eye was taken with a Topcon TRC-NW6S nonmydriatic retinal camera and photographs printed
on 8.5 x 11” paper. These were coded to maintain
anonymity and copies supplied to each examination
station.
Students were asked to match fundus photographs
to the fundus views of each of their peers and record the matches for tabulation at the end of the two
hour session. Students were instructed to keep their
matches private and instructors monitored discussions at the examination stations to ensure objectivity. Each student was also allowed to keep a copy
of their personal fundus photograph at the end of
the sessions.
Results
One hundred nine freshman students (out of 117 total students) in the class of 2013 appeared for the 20
two-hour sessions. Five students were present at 8
sessions, 6 at 7 sessions, 3 sessions had 7 students,
and only 3 students were present at 2 sessions. Students, of course, could not self-match their fundi
with a photograph so that 508 correct fundus/photograph matches were possible.
Correct matches were made in 448 or 88.2 percent
of attempts. We found that two hours for practice
and identification were adequate for the majority of
students. Clearly, though, some students were less
proficient and could have used more time. To determine if time was a significant factor in accuracy of
the matches, we also analyzed results by group size.
Ten sessions had 5 or less students in attendance
and correct matches were made for 161 of 172 (93.6
percent) fundi. The remaining 10 sessions had 6 or
54
7 students and correct matches were made in 287 of
336 (85.4 percent).
Discussion
The curriculum at the University of Arizona College of Medicine does not include a dedicated block
of time for ophthalmic instruction. Third year students do have an elective period of one month in
the second half of their year during which they may
spend two to four weeks working in ophthalmology clinics. Fourth year students have the option
during their general surgery rotation to select a subspecialty such as ophthalmology for an elective period of two weeks. Our curriculum has been revised
recently but about 20 percent of students generally
receive some introduction to clinical ophthalmology via these elective opportunities. A considerably
smaller number of students are also, at some point,
engaged in clinical and basic science research during their four years.
Recognition of risk factors for vision loss and understanding the need for prompt referrals should
be a collaborative effort among all physicians. The
conditions responsible for the majority of new cases of blindness in this country including glaucoma,
diabetic retinopathy, and macular degeneration, can
be diagnosed or at least suspected from direct examination of the fundus. Given that early intervention is vital for vision preservation in these conditions, and that signs of clinical disease may begin
long before symptoms bring the patient to us, we
can and should require that direct ophthalmoscopy
skills be taught to all physicians to enable earlier
detection.
Others[1] have documented that many practicing
physicians, while they consider ophthalmoscopy
important, are not confident in their skill and rarely perform it in their patients. In one survey, only
three percent of patients had chart documentation
of a fundoscopic examination although half of their
patients had concerns about their eyesight[1]. Reflecting changes in curricula, older physicians are
more likely to do fundus examinations than younger practitioners. Insufficient time and lack of skill
are among the most frequently cited reasons for not
examining the fundus.
Lacking mandatory curriculum time for the teaching of ophthalmology, we elected to focus on direct ophthalmoscopy as the most useful ophthalmic
skill in general medical practice. It is documented
that formal teaching of ophthalmoscopic skills results in enhanced performance of fundus examinations both immediately and subsequently[2]. Our
aim was to develop and implement an efficient
format of teaching direct ophthalmoscopy that was
demonstrably effective and sufficiently appealing
to medical students that it would be incorporated
into the medical curriculum. Ultimately, we hope
more students will acquire sufficient competence
and confidence in their fundoscopy skills that they
will incorporate these into their practices.
We elected to use subjects (student peers) rather than
eye models for several reasons. Certain aspects of
the clinical examination such as positioning of the
observer and patient, the need for stability during
the examination, patient comfort considerations,
etc., can be taught best using human subjects. More
importantly, the positive feedback from successful
fundus visualization in a simulated clinical setting
we found to be a strong factor in learning motivation. Further evidence of successful viewing came
from the many questions about subtle variations of
the posterior pole that students noted. Having both
photographs and fundus views of young, healthy
adults allowed us to explain a variety of normal
variations in fundus pigmentation, vascular patterns and the morphology of the disc and optic cup.
A more minor advantage of our technique was the
subjective experience students gained about the patient’s perspective by being a subject.
Using undilated pupils, more closely simulates the
real world environment in which the future physician will work. It has been found[1] that those physicians who do attempt fundus examinations do not
dilate pupils. This is unlikely to change given the
time constraints in which they practice. Learning
effective skills enables physicians to acquire a useful view of the fundus through undilated pupils in
the vast majority of patients and our results, at least
in young adults, corroborates this. Whenever the
fundus cannot be visualized, and in high risk cases,
it is hoped that ophthalmological evaluations will
be requested, of course.
Since many academic ophthalmologists do not
have the amount of teaching input considered ideal,
they can still design programs to teach examination
skills useful for the early detection of clinical signs
of eye disease. For example, we should emphasize aspects of the medical history that all physicians recognize as indicative of high risk for significant ocular disease, such as a family history of
glaucoma, and risk factors for diabetic retinopathy.
And while we may not be able to teach all medical students the nuances of a slit lamp examination
or how to measure intraocular pressure, we should
teach fundoscopy skills as part of physical diagnosis courses. It is our strong opinion that no student
should graduate from medical school without the
skills and the confidence needed to examine the
posterior pole with the direct ophthalmoscope. This
is especially important for the generalist and hospitalist as the number of older patients and those
likely to be covered under the new health legislation increases.
We certainly do not minimize the importance of didactics in ophthalmology or, for that matter, direct
exposure to patients in clinical settings. The reality
for many of us, though, is that curriculum time is
limited, academic programs of ophthalmology are
generally small, and most clinicians have limited
time available for teaching clinical ophthalmology.
By focusing on aspects of our specialty that are
most likely to benefit those at risk for blinding disorders we can hopefully reduce the number of new
cases of blindness occurring each year.
Our approach provides a quantifiable method to
teach direct ophthalmoscopy that, within two hours,
enables the majority of first year medical students
to successfully visualize the posterior pole through
undilated pupils (at least in the age group studied).
We were surprised at the enthusiastic feedback from
virtually all students. Members of the class had previously been introduced to direct ophthalmoscopy
by non-ophthalmologists using the PanOptic™ instrument. Few reported that they were successful in
actually visualizing the fundus during this portion
of their physical diagnosis course. They were, however, eager to gain more experience and enthusiasm
for our program grew as they communicated their
successful experience to classmates.
Our data suggest that the program successfully
taught first year medical students to visualize the
ocular fundus using the direct ophthalmoscope.
Even allowing for some sharing of answers, results
indicate that the majority mastered the use of the
Welch-Allyn direct ophthalmoscope and for the
first time were able to visualize fundus structures
successfully. It is likely that the slightly higher success rates for smaller groups were the result of the
need to make fewer matches as well as increased
time available for individualized instruction but the
difference in the number of correct matches among
55
different group sizes was small.
We can also report that this instruction module will
now be a part of the medical curriculum for each
entering class. We anticipate applying minor modifications to our protocol based on additional experience, such as changing the group sizes and including more fundus photographs of clinical conditions.
The cohort for this report consisted of students in
their first year having limited exposure to clinical
medicine but our protocol can be applied to others
as well and might be even more effective among
more experienced medical personnel.
Acknowledgements
We are grateful to Jill Brickman-Kelleher BS, AAS
for expert technical and administrative assistance.
This study was supported in part by a Center Grant
from Research to Prevent Blindness (JMM).
University of Arizona IRB 09-0964-00 approval
11-06-09.
References
1. Roberts, E, Morgan, R, King, D, Clerkin, L. Funduscopy: a forgotten art? Postgrad Med J 1999;
75:282-284.
2. Cordeiro, MF, Jolly, BC, Dacre, JE. The effect of
formal instruction in ophthalmoscopy on medical student performance. Medical Teacher 2003;
15:321-325.
56
Education in Ophthalmology:
Analysis of experience and opinion
David Spokes*1, Richard Gale2, Carolyn Atherley3, Bruno Zuberbuhler4, Susie
Bloomberg5, Ian Simmons1
Leeds Teaching Hospitals NHS Trust, 2York District Hospital, 3Clayton Eye Centre, Wakefield, 4Manchester Royal
Eye Hospital, 5Frimley Park Hospital NHS Foundation Trust
1
*Corresponding author and email: [email protected]
Abstract
Purpose: Ophthalmological complaints are common in primary care and most cases are managed by non-specialists.
Ophthalmology is increasingly considered a postgraduate specialty and as the undergraduate curriculum becomes
more crowded the time devoted to ophthalmology is limited. This study assesses the perceived adequacy of ophthalmology training received by General Practitioners (GPs) and identifies which topics GPs perceive are most important.
Methods: A postal questionnaire was sent to GPs in West Yorkshire. Non-respondents were sent a second questionnaire. Recipients were asked to rank seven conditions and seven examination techniques in order of importance for
undergraduates to be taught. They were also asked whether they felt the ophthalmology training they had received was
sufficient and to offer suggestions for improving the undergraduate curriculum.
Results: 432 questionnaires were sent and 152 were returned (35%). 28% of respondents (42/152) described their undergraduate ophthalmology training as sufficient but only 21% (32/152) regarded postgraduate training as sufficient.
The topic most often ranked most important for undergraduates was “the red eye” followed by glaucoma. The examination skill most often ranked most important was fundoscopy followed by visual acuity assessment.
Conclusions: GPs generally consider that their training in ophthalmology is insufficient. Undergraduate curricula
must be designed to ensure adequate education and this study identifies topics to prioritise. Changes have subsequently
been implemented in Leeds to prepare undergraduates better for the requirements of their future patients. The response
rate was disappointing and may reflect the perceived low importance of ophthalmology to GPs.
Keywords: Undergraduate Medical Education, Ophthalmology, Primary care, Questionnaire
Introduction
Ophthalmological complaints are common in primary care, accounting for 1.5% of all consultations
in one 12-month study[1]. Most cases are managed
by non-specialists and it is known that confidence
in diagnosing and managing such conditions is low
among general practitioners (GPs)[2]. A large proportion of medical undergraduates will go on to a
None of the authors has any proprietary or financial interest
in this study. No research funding was received in respect of
this study.
The authors declare that they have no conflict of interest.
This work was presented as a poster at the Royal College of
Ophthalmologists’ Annual Congress 2008, Liverpool, UK.
career in primary care so it is particularly important
that this cohort receive sufficient education both at
undergraduate and postgraduate levels to enable
them to manage patients appropriately in this setting.
Ophthalmology is increasingly considered a postgraduate specialty and as the undergraduate curriculum becomes more crowded the time devoted
to ophthalmology is limited. This study assesses
the perceived adequacy of ophthalmology training
received by GPs and identifies which topics they
perceive as most important. It also provides GPs
with an opportunity to influence changes in the undergraduate curriculum in order to address these issues.
Method
A postal questionnaire was sent to all GPs in West
Yorkshire with a stamped addressed envelope to encourage participation (Figure 1). Non-respondents
were sent a second questionnaire. Recipients were
57
Education and ophthalmology - Spokes et al.
asked to rank seven ocular conditions and seven
ophthalmological examination techniques in order
of importance for undergraduates to be taught. The
topics were selected to represent (1) a broad range
of conditions which might present via primary care,
and (2) examinations which a primary care physician might be called upon to perform.
They were also asked whether they felt the ophthalmology training they had received was sufficient
at both undergraduate and postgraduate levels and
were invited to offer their suggestions for improving the undergraduate curriculum.
Results
432 questionnaires were sent, of which 152 were returned (35%). 17 respondents (11%) had not clearly
indicated one condition or examination as most important and these were excluded from analysis.
Forty-two of the respondents included (28%) described their undergraduate ophthalmology training
as sufficient but only 32 (21%) regarded postgraduate training as sufficient. Many respondents made
suggestions regarding how training could be approached and which topics they would like training
to cover. These are illustrated in Table 1 and provide some insight into the type of ocular conditions
most often encountered in primary care.
The topic most frequently ranked most important for undergraduates to be taught was “the red
eye” followed by glaucoma. Ocular tumours were
deemed least important (Figure 2a). The examination skill most often ranked most important for undergraduates to be taught was fundoscopy followed
by visual acuity assessment. Competence with
slit lamp examination was ranked least important
(Figure 2b).
Of the GPs who responded, two made positive
comments about their undergraduate experience,
three made comments which could be described as
neutral and three made negative comments. When
asked for feedback on their postgraduate experience there were four positive comments, five neutral and seven negative.
Discussion
GPs generally consider that their training in ophthalmology is insufficient. This finding is in keeping with a previous questionnaire study[2] which
also reported that only 22% of GPs found their
58
undergraduate ophthalmology training to be sufficient. This was consistent across a wide age range,
suggesting that this is not a new problem. There
thus appears to have been little improvement in
the situation since Shuttleworth and Marsh[2] published their findings over a decade ago.
Undergraduate curricula must be designed to ensure adequate education and this study identifies
topics to prioritise. Results of another questionnaire
study[3] were in agreement that measuring visual
acuity and fundoscopy were important skills, but
also stressed the importance of diagnosing anterior
segment disorders as these are likely to represent a
greater proportion of primary care ophthalmology.
This would necessitate a change away from the
“traditional” approach to undergraduate ophthalmology in which conditions such as diabetic and
hypertensive retinopathy and retinal vascular occlusions were emphasised.
Opinions expressed in response to another previous questionnaire study[4] favoured emphasis on
the recognition of treatable sight-threatening conditions and the role of primary care physicians in
the management of common external eye disorders.
These opinions are consistent with the findings of
our study, with requests for training in the management of conditions perhaps deemed less significant
by ophthalmologists but which evidently present
frequently to primary care physicians and prove
difficult to manage.
Changes have since been implemented locally to
ensure undergraduates are better prepared for the
requirements of their future patients. Lectures,
small group seminars and scheduled time in ophthalmology out-patient clinics and operating theatres are part of the fourth year of the undergraduate curriculum and examination skills are tested
formally during the final year clinical exams. This
approach is supported by evidence from other studies which found that (1) problem-based learning
appears to be more effective than purely lecturebased programmes[5,6], (2) formal training in direct ophthalmoscopy improves performance, which
is maintained when subsequently retested[7], and
(3) reinforcement of examination skills throughout
undergraduate clinical years results in greater proficiency[8].
The response rate to the questionnaire was disappointing and may reflect a perceived low importance of ophthalmology to GPs. The authors ac-
Have a say in Ophthalmology Education at Leeds University!
We are revisiting undergraduate ophthalmology education at Leeds University and would be very grateful
for your help in selecting content based on your experience.
Please rank the following in order of importance. Put number 1 against the topic you feel is most important
for undergraduate medical students to be taught and number 7 against which you think is the less important.
Subject Matter
The red eye
Cataract
The watery eye
Glaucoma including acute presentation
Macular degeneration
Ocular tumours
Paediatrics / squint
Examination Techniques
Visual acuity
Fundoscopy
Fluorescein staining
Visual fields
Pupil reactions
Slit lamp
Ptosis
Are there any other topics you would like to see included?
Do you have any other suggestions for undergraduate ophthalmology teaching?
Did you consider your ophthalmology training to be sufficient? Undergraduate Y/N
Postgraduate Y/N
Please return this sheet to us in the envelope provided. Thank you for your help in shaping the future of
Ophthalmology education.
Richard Gale SpR Medical Ophthalmology
Carolyn Atherley Locum Consultant Ophthalmologist
Susie Bloomberg Pre Registration House Officer
Ian Simmons Consultant Ophthalmologist and HST Program Director
Figure 1. Questionnaire sent to GPs
59
knowledge that the low response rate may be seen
as a weakness of the study, and that attempts to
characterise non-responders were not made. However, it is also apparent that there is a definite need
and desire among GPs for postgraduate education
and updates in ophthalmology and it is up to the
ophthalmological community to meet that need.
The result of this would be to enhance relationships
between GPs and ophthalmologists, improve the
quality of correspondence (in both directions) and
lead to better care for the patients.
References
1. Sheldrick JH, Wilson AD, Vernon SA, Sheldrick
CM. Management of ophthalmic disease in general
practice. Br J Gen Pract 1993;43:459-462
2. Shuttleworth GN, Marsh GW. How effective is undergraduate and postgraduate teaching in ophthalmology? Eye 1997;11(5):744-750
3. Ah-Chan JJ, Sanderson G, Vote BJ, Molteno AC.
Undergraduate ophthalmology education survey
of New Zealand ophthalmologists, general practitioners and optometrists. Clin Exp Ophthalmol
2001;29(6):416-425
4. Vernon SA. Eye care and the medical student: where
should emphasis be placed in undergraduate ophthalmology? J Royal Soc Med 1988;81(6):335-337
5. Devitt P, Smith JR, Palmer E. Improved student
learning in ophthalmology with computer-aided instruction. Eye 2001;15(5):635-639
Figure 2a. Percentage of respondents ranking each
topic as most important
6. Farrell TA, Albanese MA, Pomrehn PR Jr. Problem-based learning in ophthalmology: a pilot program for curricular renewal. Archives Ophthalmol
1999;117(9):1223-1226
7. Cordeiro MF, Jolly BC, Dacre JE. The effect of formal instruction in ophthalmoscopy on medical student performance. Medical Teacher 1993;15(4):321325
8. Lippa LM, Boker J, Duke A, Amin A. A novel
3-year longitudinal pilot study of medical students’
acquisition and retention of screening eye examination skills. Ophthalmology 2006;113(1):133-139
Figure 2b. Percentage of respondents ranking each
examination as most important
60
Physician Attire and Patient Satisfaction in
Ophthalmology Urgent Care
Thomas S. Shane, M.D.*, James T. Banta, M.D., Joyce C. Schiffman, M.S.
Bascom Palmer Eye Institute, Miami, Florida
Abstract
Purpose: To determine if physician attire influences patient satisfaction in ophthalmology urgent care.
Methods: Patients satisfaction surveys were administered following urgent-care encounters during which physicians
were assigned to wear business attire or surgical scrubs, with or without a white coat. Survey questions evaluated
patient impressions of their physician’s attire, professionalism, and competence.
Results: 355 surveys were collected over three months. Patient satisfaction was equal on the primary study endpoint,
“My physician was appropriately dressed” (P=0.25, one-way analysis of variance). Physicians with scrubs and a white
coat were more often categorized as friendly and courteous than those in scrubs alone (P = 0.041). Thirty percent of
patients did not recall their physicians’ attire.
Conclusion: Ophthalmology urgent-care patients are equally satisfied with their care regardless of physician attire.
Introduction
Methods
Humans generally judge a book by its cover. It is
therefore no surprise that patients evaluate physicians based on their physical appearance, including
the clothes they are wearing. Previous studies have
investigated the definition of “appropriate” physician attire, but with mixed results[1-8]. Recent trials involving emergency department patients have
focused on patient preference for doctors dressed in
formal clothes versus surgical scrubs. The results
of these studies indicate little difference in patient
satisfaction between the two styles of attire[4-8]. To
date, no study has specifically addressed the effect
of physician dress on an ophthalmology emergency
department patient population. The purpose of our
study is to determine whether physician attire influences patient satisfaction in an ophthalmology
urgent care setting.
We surveyed adult patients and patient guardians at
the ophthalmology emergency department (OED)
at Bascom Palmer Eye Institute in Miami, Florida.
Surveys were administered by trained administrative staff during weekday business hours between
March and May 2008. Eligible patients for the
study included those aged 18 years or older, as well
as guardians for patients less than 18 years of age.
Subjects were asked by the administrative staff
to consent for participation immediately after the
completion of their care in the OED. They were allowed to respond to the survey only once.
None of the authors has any proprietary or financial interest
in this study. No research funding was received in respect of
this study.
This study approved by University of Miami IRB
Consenting patients were presented with an anonymous 1-page questionnaire asking for the patient’s
age, gender, and ethnicity. Subjects were then asked
to respond to the following questions using a 5-point
Likert scale, ranging from 5 (strongly agree) to 1
(strongly disagree): “My doctor was knowledgeable,” “My doctor was professional,” “My doctor
was friendly and courteous,” “My doctor was appropriately dressed,” and “I would return to this
doctor in the future” (Figure 1). Lastly, the patients
were prompted to indicate in a multiple choice format, “What did your doctor wear during this visit?”
Administrative staff recorded the physicians’ true
attire on a separate form that was attached to the
patient survey upon completion.
61
Physician Attire - Shane et al.
Figure 1. Patient satisfaction survey
Figure 2. Study categories of physician attire
62
For the duration of the survey, residents, fellows,
and attending physicians in the OED were assigned
to wear each of four categories of attire: business
attire, business attire with a white coat, surgical
scrubs, and surgical scrubs with a white coat (Figure 2). Attire assignments were modified over the
course of the study in an attempt to obtain equal
number of patient visits for each physician in each
category of attire. The requirements for the four
modes of attire were delineated clearly for all participants (Table 1).
courteous (P = 0.041). Subsequent analysis demonstrated a patient preference for scrubs with a
white coat over scrubs alone for this question. In
the remaining categories, there was no statistically
significant difference between the four modes of
physician attire. Across all categories, scrubs with
a white coat had the highest scores (4.84, SD=0.45)
while scrubs alone had the lowest (4.57, SD = 0.64).
Thirty-two percent of patients incorrectly identified
the attire that the physician was wearing at the time
of the clinical encounter.
The primary outcome in the study was the difference in Likert scores in response to the statement
“My physician was appropriately dressed.” Secondary outcomes included Likert scores for the remaining survey questions, as well as the accuracy
of patient responses when asked to recall what their
physician was wearing. Participating physician attire preferences were also recorded.
Among the 34 participating physicians, 15 (44%)
preferred scrubs with a white coat, 10 (29%) business attire with a white coat, 6 (17%) scrubs alone,
2 (6%) business attire alone, and 1 (3%) was unknown.
Descriptive statistics were calculated for patient demographics. Likert scores were compared among
the different categories of physician attire with oneway analysis of variance. This study was conducting with IRB approval from the University of Miami Human Subject Research Office.
Results
A total of 355 patients completed the patient satisfaction survey over a 3-month period. No completed surveys of eligible patients were excluded. The
demographics of the study patients and physicians
are shown in Table 2.
Of the 355 respondents, 104 were exposed to business attire with a white coat, 61 were exposed to
business attire only, 129 were exposed to surgical
scrubs with a white coat, and 61 were exposed to
surgical scrubs only. The primary endpoint of the
study was the patients’ response to, “My physician
was appropriately dressed” (Table 3). Overall, patient scores in response to this statement were high,
with a mean Likert score of 4.81 and SD of 0.56.
There was no statistically significant difference
in the primary endpoint between any of the four
modes of physician attire. Among the attire categories, business attire alone had the highest score
(4.87 ± 0.34), with scrubs alone having the lowest
score (4.70 ± 0.64).
The mean scores for the other questions are shown
in Table 4. Statistical significance was reached in
the category of “My physician was friendly and
Discussion
Our study showed that patient satisfaction was
largely unaffected by physician attire. Both business attire and surgical scrubs, with or without a
white coat, were acceptable to the patients in the
OED. There was, however, a trend disfavoring
scrubs alone across all categories, which reached
statistical significance in response to the question,
“My doctor was friendly and courteous.”
There are many potential reasons why patients are
insensitive to physician attire in the OED. Given
the urgent and distressing nature of their problem,
an OED patient may pay less attention to what their
physician is wearing. This is evidenced by the fact
that 32% of our study population incorrectly identified their physicians’ attire, even when asked immediately following the encounter. Cultural factors
are likely to contribute also. These include today’s
increasingly casual dress in the workplace and popular television programs showing doctors dressed
in surgical scrubs, both of which may influence patient acceptance of this attire.
While business attire has been the standard dress in
ophthalmology clinical care for decades, there are
potential advantages to wearing surgical scrubs in
the OED. Surgical scrubs are more easily washable
and replaceable than business attire. Scrubs are also
less cumbersome during minor surgical procedures.
In addition, physician comfort is enhanced with the
looser-fitting, oftentimes more-breathable fabric of
surgical scrubs. On the other hand, scrubs lack the
tradition, formality, and identifiability of business
attire in clinical care.
63
Table 1. Physician attire requirements by category
Attire
Business Attire
Men
Women
Surgical Scrubs
White Coat
Description
Dress pants, button down shirt, tie tightened up to collar, shoes (not tennis shoes,
sneakers, sandals), no earrings
Dress, skirt and blouse, button down shirt and dress pants, or pants suit, shoes
(not tennis shoes, sneakers, sandals).
Hospital issue scrub top and bottom (with or without undershirt), shoes, sneakers, or clogs.
Open or buttoned
Table 2. Patient and physician demographics.
Patient Demographics (n=355)
Age (y) (n=333)
Gender
Male
Female
Ethnicity
Hispanic
Black
White
Other
45 (SD=19) range1-88
161 (48%)
176 (52%)
201 (59%)
81 (24%)
51 (15%)
9 (3%)
Physician Demographics (n=34)
(Expressed as number of surveys collected)
Average Age
29 (range 26-50)
Gender
Male
199 (56%)
Female
154 (44%)
Ethnicity
White
205 (58%)
Indian
101 (29%)
Hispanic
45 (13%)
Other
2 (0.6%)
Level of Training
Resident
291 (82%)
Fellow
37 (10%)
Attending
25 (7%)
Table 3. Primary endpoint: Patient responses to “My physician was appropriately dressed.”
Number of surveys with Likert scores 5-1
Attire Category
5
4
3
2
1
Mean Score*
Business attire with white
88
13
1
0
2
4.78 ± 0.65
coat
(n=104)
Business attire alone
(n=60)
Surgical scrubs with white
coat
(n=128)
Surgical scrubs alone
( n=61)
Total (n=353)
52
8
0
0
0
4.87 ± 0.34
115
11
0
1
1
4.86 ± 0.51
46
14
0
0
1
4.70 ± 0.64
301
46
1
1
4
4.81 ± 0.56
* P = 0.25, one-way analysis of variance
64
Table 4. Mean Likert scores for responses to other survey questions
Business attire
w/ white coat
(n=104)
Business attire
only (n=61)
Scrubs w/ white
coat (n=129)
Scrubs only
(n=61)
P-value*
Total (n=355)
My doctor was
knowledgeable
My doctor was
professional
My doctor was
friendly and
courteous
Total
4.72 ± 0.69
I would
return to this
doctor in the
future
4.73 ± 0.76
4.75 ± 0.69
4.75 ± 0.68
4.72 ± 0.55
4.82 ± 0.47
4.79 ± 0.55
4.77 ± 0.64
4.77 ± 0.52
4.79 ± 0.53
4.88 ± 0.45
4.88 ± 0.45
4.84 ± 0.50
4.84 ± 0.45
4.67 ± 0.65
4.67 ± 0.65
4.64 ± 0.71
4.70 ± 0.64
4.67 ± 0.64
0.63
4.75 ± 0.60
0.099
4.79 ± 0.57
0.041
4.78 ± 0.60
0.48
4.77 ± 0.63
0.24
4.77 ± 0.58
*one-way analysis of variance
Our study is limited by several factors. Physicians
were not blinded to their attire or to the fact that
they were being evaluated, which is a potential
source of bias. Secondly, immediate patient surveys tend to return higher satisfaction scores than
delayed surveys, which may have inaccurately inflated our results[9]. In addition, we were unable
to completely balance the number of patient visits
for every physician wearing each of the four attires.
This potentially skews results towards physicians
who get higher patient satisfaction scores regardless of their attire. We were also unable to control
attire for all physicians, leading to larger number of
physicians wearing white coats during clinical encounters. Lastly, our patient population is unique in
that they are largely Hispanic and uninsured, which
may not be generalizable to the OED’s in other
parts of the United States.
In conclusion, patients are equally satisfied with
their care in the OED regardless of whether physicians are wearing business attire or surgical scrubs,
with or without a white coat. While patient satisfaction scores were high in all categories, larger studies may be needed to confirm a trend disfavoring
scrubs alone.
Acknowledgements
This study was supported by research grants from
the National Eye Institute (Grant No. EY014801),
National Institutes of Health, Bethesda, Maryland;
and Research to Prevent Blindness, Inc., New York,
New York.
4.74 ± 0.69
References
1. Bianchi MT. “Desiderata or Dogma: What the Evidence Reveals About Physician Attire.” J Gen Intern
Med. 2008; 23(5):641-3.
2. Cha, Ann, Hecht BR, Nelson K, Hopkins MP.
“Resident Physician Attire: Does it Make a Difference to our Patients?” Am J Obstet Gynecol. 2004;
190(5):1484-8.
3. Douse J, Derrrett-Smith E, Dheda K, Dilworth JP.
“Should Doctors Wear White Coats?” Postgrad Med
J. 2004; 80(943):284-6.
4. Boon D, Wardrope J. “What Should Doctors Wear in
the Accident and Emergency Department? Patients’
Perception.” J Accid Emerg Med. 1994; 11(3):175-7.
5. Li SF. Haber M. Birnhaum A. “Physician Dress
and Patient Satisfaction in the ED (abstract). Acad
Emerg Med. 2003; 10:550
6. Li SF, Haber M. “Patient Attitudes Toward Emergency Physician Attire.” J Emerg Med. 2005;
29(1):1-3.
7. Pronchik DJ, Sexton JD, Melanson SW, Patterson
JW, Heller MB. “Does Wearing a Necktie Influence Patient Perceptions of Emergency Department
Care?” J Emerg Med. 1998; 16(4):541-3.
8. Fischer RL, Hansen CE, Hunter RL, Veloski JJ.
“Does Physician Attire Influence Patient Satisfaction in an Outpatient Obstetrics and Gynecology
Setting?” Am J Obs Gyn, Feb, 2007; 186.e1-e5
9. Gribble RK, Haupt C. “Quantitative and Qualitative
Differences between Handout and Mailed Patient
Satisfaction Surveys. Med Care 2005; 43:276-81.
65
Factors Influencing Program Ranking by
Ophthalmology Residency Applicants:
Perspectives from Ophthalmology Residents
and Ophthalmology Residency Program
Directors
Justin M. Shaw, B.S.,1 Ingrid U. Scott, M.D., M.P.H.,*1,2 Allen R.
Kunselman, M.A.,2 Matthew R. Hosler, M.D., Ph.D.,1 David A. Quillen, M.D.1
Penn State Hershey Eye Center, Penn State College of Medicine, Hershey, Pennsylvania, 2Department of Public
Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
1
Abstract
Purpose: To investigate ophthalmology residents’ and residency program directors’ perspectives regarding the most
important factors influencing the rankings of ophthalmology residency programs by applicants.
Methods: An email invitation containing a link to an anonymous web-based survey was emailed to each of the 115
ACGME-accredited ophthalmology residency programs in the United States. Data regarding demographic factors,
USMLE score ranges, and opinions regarding the importance of various factors to applicant ranking of ophthalmology
programs were collected. Factors were rated on a scale of 1 (very undesirable) to 5 (very desirable).
Results: Surveys were completed by 218 residents (16.9%) and 17 program directors (15.2%). Factors which ophthalmology residents considered most desirable to residency applicants were high degree of satisfaction of current
residents (mean rating=4.67), high quality of clinical faculty (4.56), and positive impression of current residents at interview (4.56), high number of surgical cases achieved per resident (4.37), positive impression of faculty at interview
(4.36), advantageous geographic location (near family/ hometown, type of neighborhood, etc.) (4.30), good program
reputation (4.28), and positive impression of program director at interview (4.20). Least desirable factors were regularly scheduled Saturday lecture series (1.80), in house call (2.15), requirement to cover multiple satellite facilities on
call (2.22), and high workload after hours (heavy/frequent call) (2.31). Marital status and the number of dependents
had a significant effect on the desirability of several factors. There was a statistically significant positive correlation
between the desirability of a residency class size ≥4 and USMLE step 1 score range (P=0.003) and USMLE step 2
score range (P=0.01). Program directors perceived significantly higher desirability to residency applicants than residents reported with regards to four factors: wide variety/breadth of surgical techniques taught (P=0.02), above average
salary (P=0.04), regularly scheduled Saturday lecture series (P=0.05), and higher perceived chances of matching at
that program (P=0.04).
Conclusions: Factors which ophthalmology residents considered most desirable to applicants when ranking residency programs relate predominantly to subjective impressions of the workplace environment; the most unpopular factors
relate to workload after hours. These findings are similar to those of past studies in other specialties. Ophthalmology
residency program directors and residents have a generally concordant perception of which factors are most important
to applicants when ranking ophthalmology residency programs.
66
Introduction
Each year over 700 applicants apply for approximately 460 ophthalmology residency training positions through the Ophthalmology Residency
Match[1]. While much has been written on the
residency selection process, including ophthalmol-
Factors influencing program ranking - Shaw et al.
ogy residency[2,3], relatively little has been written
on applicants’ preferences in ranking programs on
their match list[4]. In ophthalmology, such data are
lacking. Although certain factors have been shown
to be valued highly across many medical specialties, including current resident satisfaction[5-8],
geographic location[4,5,9-12], and program reputation[6,8,13-15], differences across specialties
exist[4,6,9,12,16,17]. The lack of objective evaluation in the literature regarding the appeal of certain aspects of ophthalmology residency programs
to applicants warrants investigation. Such information would be valuable to both residency directors
and applicants in honing the interview process, as
well as finding the best fit between applicants and
programs. Additionally, such a survey might offer
insight into recent data suggesting that graduates
from larger residency programs tend to have lower
first time failure rates on the written and oral ophthalmology board exams[18] by evaluating characteristics of residency applicants who place importance on a larger residency program size. The
objective of the current study is to investigate ophthalmology residents’ and residency program directors’ perspectives regarding the most important
factors influencing the rankings of ophthalmology
residency programs by applicants.
Materials and Methods
An anonymous web-based survey consisting of 14
questions was developed, and the study was approved by the Penn State College of Medicine Institutional Review Board. Using a web-based service (Survey Monkey: www.surveymonkey.com)
to collect responses anonymously, an email invitation containing a link to the survey was sent to the
ophthalmology residency program coordinator at
each of the 115 ACGME-accredited ophthalmology
residency programs to be forwarded to all current
residents and the residency program director; three
programs were excluded due to outdated contact
information on the San Francisco Match website
(www.sfmatch.org/residency/ophthalmology). The
initial email invitation was followed by 3 email reminders, the first sent 1 week after the initial invitation, and the others sent at 1 month intervals.
Demographic data were requested of each recipient. Residents were asked to rate the desirability of
various factors to ophthalmology residency applicants, on a 5-point scale of very undesirable to very
desirable, when ranking ophthalmology residency
programs. Ophthalmology residency program directors were asked to rate the same factors based
on the perceived level of importance to residency
applicants. Each choice was weighted numerically;
very undesirable was assigned a value of 1, undesirable 2, neutral 3, desirable 4, and very desirable
5. The Wilcoxon-Mann-Whitney test was used to
compare the desirability rankings of each factor
between residency program directors and residents
as well as between categories of demographic factors, such as marital status. The Spearman correlation coefficient was used to assess the strength
of the relationship between USMLE score ranges
and the desirability ratings of the factors in ranking ophthalmology programs. All hypotheses tests
were 2-sided and all analyses were performed using SAS software, version 9.1 (SAS Institute Inc.,
Cary, NC).
Results
A survey invitation was emailed to a total of
1290 residents, and 218 were completed (16.9%).
Eighty-two of the respondents were PGY-2, 75
were PGY-3, and 61 were PGY-4. One hundred
twenty eight were male, 90 were female. One hundred thirty four residents were married; 83 were
single. One hundred thirty three residents had no
dependents, 29 residents had one dependent, and
45 had two or more dependents. Seventeen of 112
program directors contacted completed the survey
(15.2%).
Results of the resident survey are summarized in
Table 1. The most desirable factor was “high degree of satisfaction of current residents,” followed
by “high quality of clinical faculty” and “positive
impression of current residents at interview.”
Marital status was significantly associated with
lower desirability of high work load after hours
(P=0.006), in house call (P=0.02), and regularly
scheduled Saturday lecture series (P=0.02). Marital status was not significantly associated with the
desirability of advantageous geographic location
(P=0.14). Access to theater, concerts, and nightlife near residency location was more important to
single than to married residents (P<0.001). Positive faculty-resident rapport (P=0.05) and multiple
faculty per subspecialty (P=0.05) were more desirable to single than to married residents.
The presence of dependents was significantly associated with the desirability of several factors
67
Table 1. Resident responses to survey questions in order of most desirable to least desirable, by average rating.*
Response options
Very desirable
Desirable
Neutral
Undesirable
Rating
average
(SD)
High degree of satisfaction of current
residents
69.7% (152)
28.9% (63)
0.5% (1)
0.0% (0)
0.9% (2)
4.67(0.59)
High quality of clinical
faculty
60.1% (131)
37.2% (81)
1.8% (4)
0.5% (1)
0.5% (1)
4.56 (0.61)
Positive impression
of current residents at
interview
61.0% (133)
35.8% (78)
1.8% (4)
0.5% (1)
0.9% (2)
4.56 (0.65)
Wide variety/breadth
of surgical techniques
taught
50.0% (109)
45.0% (98)
4.6% (10)
0.5% (1)
0.0% (0)
4.44 (0.61)
Positive faculty-resident rapport
48.6% (106)
45.0% (98)
5.5% (12)
0.5% (1)
0.5% (1)
4.41 (0.66)
High number of surgical cases achieved
per resident
47.2% (103)
47.2% (103)
7.8% (17)
1.4% (3)
0.0% (0)
4.37 (0.69)
Positive impression of
faculty at interview
45.9% (100)
46.8% (102)
6.0% (13)
0.5% (1)
0.9% (2)
4.36 (0.70)
Advantageous geographic location (near
family /hometown,
type of neighborhood,
etc.)
50.9% (111)
30.3% (66)
16.5% (36)
2.3% (5)
0.0% (0)
4.30 (0.83)
Good program reputation
42.7% (93)
44.5% (97)
11.5% (25)
0.5% (1)
0.9% (2)
4.28 (0.75)
Positive impression
of program director at
interview
36.2% (79)
49.1% (107)
13.8% (30)
0.5% (1)
0.5% (1)
4.20 (0.72)
Clinically oriented
program
33.5% (73)
53.7% (117)
11.0% (24)
1.8% (4)
0.0% (0)
4.19 (0.70)
Positive reputation of
full-time faculty
30.7% (67)
52.3% (114)
16.5% (36)
0.0% (0)
0.5% (1)
4.13 (0.71)
Recent resident success in fellowship
match
28.9% (63)
52.3% (114)
17.0% (37)
1.4% (3)
0.5% (1)
4.08 (0.74)
Positive impression
of chairperson at
interview
26.1% (57)
46.3% (101)
27.1% (59)
0.5% (1)
0.0% (0)
3.98 (0.74)
Multiple faculty per
subspecialty
21.1% (46)
55.0% (120)
21.1% (46)
2.8% (6)
0.0% (0)
3.94 (0.73)
* Bolded responses represent the most frequently selected response option
68
Very
undesirable
Table 1. continued
Response options
Very desirable
Desirable
Neutral
Undesirable
Very
undesirable
Rating
average
(SD)
48.6% (106)
30.3% (66)
6.4% (14)
0.9% (2)
3.68 (0.83)
Access to theater,
13.3% (29)
concerts, nightlife near
residency location
33.5% (73)
47.2% (103)
5.0% (11)
0.9% (2)
3.53 (0.82)
Class size >=4
10.6% (23)
33.0% (72)
41.7% (91)
13.8% (30)
0.9% (2)
3.39 (0.88)
Higher perceived
chances of matching
at that program
7.3% (16)
32.1% (70)
55.0% (120)
3.7% (8)
1.8% (4)
3.39 (0.76)
Community service
opportunities
5.5% (12)
33.9% (74)
55.5% (121)
4.6% (10)
0.5% (1)
3.39 (0.69)
Opportunity to treat
underserved patient
population
5.5% (12)
34.9% (76)
53.7% (117)
4.1% (9)
1.8% (4)
3.38 (0.74)
High average OKAP
scores of current
residents
6.4% (14)
24.8% (54)
63.8% (139)
4.6% (10)
0.5% (1)
3.32 (0.68)
Presence of fellows
3.2% (7)
27.1% (59)
54.6% (119)
13.3% (29)
1.8% (4)
3.17 (0.76)
Above average salary
5.0% (11)
15.6% (34)
68.8% (150)
8.3% (18)
2.3% (5)
3.13 (0.72)
Structured research
requirement
5.0% (11)
18.8% (41)
49.1% (107)
22.9% (50)
4.1% (9)
2.98 (0.89)
Research oriented
program
3.7% (8)
24.3% (53)
36.7% (80)
28.9% (63)
6.4% (14)
2.90 (0.96)
High work load after
hours (heavy/frequent
call)
1.8% (4)
8.3% (18)
28.9% (63)
41.3% (90)
19.7% (43)
2.31 (0.94)
Requirement to cover
multiple satellite facilities on call
1.8% (4)
3.2% (7)
30.3% (66)
44.5% (97)
20.2% (44)
2.22 (0.87)
In house call
1.8% (4)
4.6% (10)
28.9% (63)
35.8% (78)
28.9% (63)
2.15 (0.95)
Regularly scheduled
Saturday lecture
series
2.3% (5)
1.4% (3)
15.6% (34)
35.8% (78)
45.0% (98)
1.80 (0.91)
Abundant didactic
teaching/lectures
13.8% (30)
* Bolded responses represent the most frequently selected response option
69
when the rankings of residents with 0 versus >1
dependents were compared. The following factors were significantly less desirable to residents
with dependents: regularly scheduled Saturday
lecture series (P=0.001), in house call (P=0.02),
access to theater, concerts, nightlife near residency location (P<0.001), community service opportunities (P=0.008), structured research requirement (P=0.04), class size greater than or equal to
4 (P=0.05), high average OKAP scores of current
residents (P=0.02), and positive faculty-resident
rapport (P=0.05).
Self-reported USMLE scores were classified using the following scale: 1 (scored <200), 2 (scored
200-215), 3 (scored 216-230), 4 (scored 231-245),
5 (scored >245). Residents who rated a class size
≥4 desirable or very desirable had a higher average range of USMLE Step 1 scores (3.92) than
those who rated this undesirable or very undesirable (3.47) (P=0.02). A similar phenomenon was
seen with USMLE Step 2 scores (3.73 and 3.25,
respectively, P=0.03). There was a positive correlation between desirability of class size ≥4 and
USMLE Step 1 score range (Spearman correlation
coefficient = 0.20, 95% confidence interval [CI]:
0.07-0.32, P=0.003). A similar positive correlation
was seen between desirability of class size ≥4 and
USMLE Step 2 score range (Spearman correlation
coefficient = 0.17, 95% CI: 0.07-0.29, P=0.01).
Program directors predicted the following four factors to be significantly more desirable compared to
residents’ ratings (Table 2): wide variety/breadth of
surgical techniques taught (P=0.02), above average
salary (P=0.04), regularly scheduled Saturday lecture series (P=0.05), and higher perceived chances
of matching at that program (P=0.04). There was
no significant difference between residents and program directors when any of the other factors were
compared.
Discussion
In the current study, factors which ophthalmology
residents considered most important to applicants
when ranking ophthalmology residency programs
involved positive impressions of program personnel, breadth and abundance of surgical exposure,
geographic location, and program reputation, all
top-rated factors in previous studies in other medical specialties[4-7,9-11,16,19-23]. The higher priorities involved the character of colleagues and
70
workplace environment, namely factors relating
to faculty and residents. In the current study, ophthalmology residents perceived the satisfaction of
current residents as the single most important factor when ranking an ophthalmology program. This
finding is not surprising, as it is both intuitive and
was shown to be the most important factor in other
medical specialties[4,17], and indicates the importance of applicants’ interactions with residents during the residency program interview process. Interestingly, higher perceived chances of matching at a
program was desirable for many residents, which
may indicate a lack of understanding of the match
algorithm, as the match is an “applicant-proposing”
process in which applicants are matched to the
highest program that is willing to accept them[24].
Alternatively, it is likely that “higher perceived
chances of matching at a program” coincides with
feeling well-liked at a program, which might make
a program more appealing to an applicant simply
on the basis of being “liked.” “Higher than average salary” was rated as only slightly above neutral
and was similar to applicants’ ratings in other specialties[4,6,10,14,16,25]. Emphasis on salary might
have been expected to increase as the result of increasing medical school tuition fees and debt over
the years[26].
The “research oriented programs” factor showed
a marginally negative desirability. It showed a
wide spread of responses, most of which were
neutral (36.7%). Studies in other fields have
found applicants to consider research a neutral
consideration[5,10,14,16].
Least desirable factors in residents’ ranking of ophthalmology programs focused primarily on Saturday lecture series, demanding call requirements,
and research oriented programs; this points out the
importance to applicants of lifestyle considerations.
Marital status and the presence of dependents were
demographic factors significantly associated with
undesirability of in house call and Saturday lecture
series, while single residents rated theater, concerts
and nightlife near the residency location significantly more desirable than married residents; these
findings again suggest the importance of lifestyle
considerations to applicants. The decreased desirability to married residents of positive faculty-resident rapport, multiple faculty per subspecialty, and
high average OKAP score of current residents, do
not have an apparent explanation, except to indicate
that other factors (such as lifestyle considerations)
Table 2. Comparison of responses of residents and program directors that were significantly different.
Director
Median (25th, 75th percentile)
P-value
Wide variety/breadth of surgical 4.50 (4.00, 5.00)
techniques taught
5.00 (5.00, 5.00)
0.02
Above average salary
3.00 (3.00, 3.00)
3.00 (3.00, 4.00)
0.04
Regularly scheduled Saturday
lecture series
2.00 (1.00, 2.00)
2.00 (1.00, 3.00)
0.05
Higher perceived chances of
matching at that program
3.00 (3.00, 4.00)
4.00 (3.00, 4.00)
0.04
Factor
Resident
Median (25th, 75th percentile)
are more important to married residents. The fact
that married residents ranked class size ≥4 as “significantly less desirable” than single residents may
be due to lifestyle and financial considerations with
respect to raising children in larger urban areas,
which may be more likely to have larger residency
program sizes.
Results of the current study indicate that ophthalmology residency program directors and residents
have a relatively concordant perception of which
factors are most important to applicants when
ranking ophthalmology residency programs. This
is consistent with studies by DeLisa et al.[7] and
Lindauer et al.[17], which found no or few significant differences between the responses of program
directors and trainees of programs in the fields of
physical medicine and rehabilitation, and orthodontics. In the current study, program directors perceived higher desirability to residency applicants
than reported by residents with regards to the following factors: wide variety/breadth of surgical
techniques taught, above average salary, regularly
scheduled Saturday lecture series, and higher perceived chances of matching at that program.
The current study suggests an explanation of the
recent observation that graduates of larger ophthalmology training programs have a lower first time
failure rate on their oral and written board examinations[18]. Compared to residents with lower
USMLE Step 1 and 2 score ranges, residents with
higher USMLE Step 1 and 2 score ranges reported a
significantly higher desirability of larger programs.
Assuming that an individual’s ability to perform on
the USMLE translates into an ability to perform on
the ophthalmology written and oral board exams,
this correlation between preference for a larger program and USMLE scores might explain, at least
in part, the difference in first time failure rates between graduates of larger versus smaller programs.
This hypothesis is consistent with the results of a
study by Norcini et al.[27], which showed that preresidency performance on the NBME part 2 exam
(the predecessor of the USMLE step 2 exam) was
an important predictor of the internal medicine certifying examination outcome.
Limitations of the current study include a suboptimal response rate and the potential for recall bias.
Higher response rates may be achieved in future
studies by contacting participants directly and
with a briefer survey. In order to avoid the potential for recall bias, future studies could be aimed at
medical students applying to ophthalmology residency programs.
In summary, factors which ophthalmology residents considered most desirable to applicants when
ranking ophthalmology residency programs relate
to subjective impressions of the workplace environment. Academic experience was of lesser importance, and the most undesirable aspects relate to
workload after hours. These findings are similar to
those of past studies in other specialties. Ophthalmology residency program directors and residents
have a generally concordant perception of which
factors are most important to applicants when ranking ophthalmology residency programs.
References
1. Ophthalmology Residency Match Report – January 2009. San Francisco: Ophthalmology Residency
Match, 2009.[rev. October 29, 2009; Accessed on
November 6 2009] www.sfmatch.org/residency/
ophthalmology/index.htm.
71
2. Lee AG, Golnik KC, Oetting TA, et al. Re-engineering the resident applicant selection process in
ophthalmology: A literature review and recommendations for improvement. Survey of Ophthalmology
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Predictive Characteristics and Factors
Influencing Career Choice Amongst
Ophthalmology Trainees
Stacy L. Pineles, M.D.,*1,2 Steven L. Galetta, M.D.,1,2 Stuart L. Fine, M.D.,1 Paul J.
Tapino, M.D.,1 Nicholas J. Volpe, M.D.1,2
Departments of 1Ophthalmology and 2Neurology, University of Pennsylvania School of Medicine
Abstract
Purpose: To determine characteristics of medical trainees associated with a higher likelihood of choosing an academically-based career in ophthalmology, and to understand the factors that influence trainees in making this decision.
Methods: Graduates of the University of Pennsylvania School of Medicine who entered ophthalmology residencies
and graduates of the Scheie Eye Institute ophthalmology residency at the University of Pennsylvania were solicited
to complete an online, anonymous survey consisting primarily of multiple choice questions regarding career choice.
Results: Of the survey respondents, 42% currently hold an academic position. Individual characteristics associated with a higher likelihood of an academic career choice include earning a PhD before or during medical school
(P=0.01), considering neurology as an alternate career choice (P=0.01), and a higher number of publications prior to
residency (P=0.03). Of those respondents who currently practice in non-academic settings, 72% had plans to pursue
academic careers prior to starting their residency. Important influences on career choices amongst these trainees included financial considerations and negative perceptions of academia (i.e. inefficiency or political bureaucracy). In
addition, there was a higher likelihood of academic practice amongst trainees who have pursued fellowship training in
certain subspecialties, including neuro-ophthalmology, uveitis, oncology, oculoplastics, and pediatric ophthalmology.
Conclusions: In our cohort, the majority of trainees initially intended to pursue academic careers. Reducing financial disparities in certain subspecialties, better mentoring of trainees interested in academic pursuits, and improving the perception of lifestyles in academia will increase our success in recruiting the next generation of academic
ophthalmologists.
Introduction
The importance of maintaining capable and inspiring leadership in academic ophthalmology cannot
be overstated, as academic institutions provide the
training grounds for all ophthalmologists and serve
as centers of guidance and innovation for research.
However, in the current healthcare climate in the
United States, it has become challenging to attract
applicants into academic careers, given rising finan-
cial constraints, as well as attractive private practice
opportunities that seem to provide better balance
between personal and professional responsibilities,
which is reportedly more important to current generations[1, 2]. To understand the necessary steps required to continue to attract trainees into academic
careers, one must first understand the factors that
influence career choice. To that extent, features of
individual trainees and training programs that steer
trainees away from academic careers warrant exploration. In addition, since some residency programs place emphasis on and are better resourced
to train future academicians, it is important not only
to define factors that influence career choice, but
also to determine whether there are any characteristics of residency applicants that are associated with
a higher likelihood of choosing an academic career.
In a study attempting to determine these characteristics amongst neurology residents, a significant
73
Career Choices in Ophthalmology - Pineles et al.
association of academic productivity with preresidency publication record was noted[3]. Since
several studies have shown that trainees’ interest in
academic medicine wanes over time[4-6], we feel
that it is vital to our field to explore the reasons why
this might occur as well in ophthalmology.
recruited via an email message that provided an introduction to the nature of the proposed study, and
detailed the intended use of the collected data. A
link to the survey website was included at the end
of the email after a declaration that participation in
the study was completely optional and anonymous.
We designed a survey to be administered to graduates of the University of Pennsylvania School of
Medicine who entered ophthalmology residencies,
and graduates of the ophthalmology residency program at the Scheie Eye Institute at the University of
Pennsylvania. This group represents two relatively
homogenous cohorts, with one group of medical
students who entered different residencies after
having completed the same medical school curriculum, and a second group of residents from various
medical schools, all of whom completed the same
residency curriculum. Our goals for the survey were
(1) to define trainee characteristics that are associated with a higher likelihood of an academic career
path, (2) to define factors that influence trainees to
choose careers in academia or in private practice,
and (3) to define training program-specific characteristics associated with trainees pursuing academic
careers.
Data were collected anonymously. All respondents
were categorized as holding “academic” or “nonacademic” positions. In the survey, an “academic”
position was defined as a “full time position at an
academic institution with medical students, residents, and/or fellows.” For comparison, the residency program director at the Scheie Eye Institute
(NJV) reviewed the entire list of Scheie graduates
during his tenure who had been solicited for the survey, regardless of whether they had responded, and
stated from his personal knowledge whether each
candidate was currently in an academic or nonacademic position. These data were used only to
compare the overall percentage of graduates holding academic positions with the percentage from
the survey. For the purpose of data analysis, those
respondents who indicated that they held a volunteer/adjunct position with an academic department
were considered to hold “non-academic” positions.
The US News and World Report’s annual ranking of
medical schools was utilized to determine the rank
of each individual respondent’s medical school[7].
Schools that were ranked in the top 20 at any time
during the years analyzed were considered “top 20”
schools. In addition, the Ophthalmology Times annual ranking of ophthalmology residencies[8] was
used to assess whether a respondent’s residency
program was considered a “top 10” program; in
order to be considered in the top category, a residency program had to be listed in any of the “Best
Residency” or “Best Program” categories during
the years analyzed.
Methods
This study was granted exempt status by the University of Pennsylvania institutional review board.
The study and data accumulation were in conformity with all country, federal, or state laws, and the
study was in adherence to the tenets of the Declaration of Helsinki.
Survey
A 46-question anonymous survey was created using
SurveyMonkey.com. The survey consisted of questions directed at current and previous employment
positions, individual characteristics, residency-program characteristics, and specifics regarding factors influencing career choice (Supplemental Material). The majority of the questions were multiple
choice, but some questions allowed for additional
open-ended comment. Subjects were recruited
from a database of institutional alumni, all graduates of the University of Pennsylvania School of
Medicine who entered ophthalmology residencies
between the years of 1992 and 2005, or graduates
of the Scheie Eye Institute ophthalmology residency at the University of Pennsylvania between the
years of 1994 and 2007. Survey respondents were
74
A publication score was calculated for each respondent as the number of manuscripts published since
residency (including fellowship time) divided by
the number of years since completion of residency
training.
Statistical Analysis
Logistic regression analysis was performed to examine the association of continuous variables with
an “academic” vs. “non-academic” career choice.
For categorical variables, a Fisher’s exact test was
used to assess associations with an academic career
choice. Additionally, linear regression models were
utilized to evaluate the association of individual
respondent characteristics with a higher publication score. An unpaired Student’s t-test was used to
compare mean values amongst the 2 groups. Statistical analysis was performed using Stata 10.0 statistical software (StataCorp, College Station, TX).
A type I error level α=0.05 was used for statistical
significance.
Results
Survey Respondents
During the years included in the survey, 76 trainees
graduated from the residency program at the Scheie
Eye Institute and 71 University of Pennsylvania
medical students entered ophthalmology residencies. A total of 126 surveys were sent via email
(there were 18 trainees who matriculated at both
the University of Pennsylvania School of Medicine
and the residency program at the Scheie Eye Institute and 3 email addresses that could not be determined). The solicitation email was sent three times,
separated by at least one week. Sixty-nine (54%)
of the graduates completed the survey. Eighty-three
(66%) of the surveys were sent to males, while
forty (59%) of the survey respondents were male
(Table 1).
Figure 1. Post-residency training in survey respondents. Gray bars represent survey respondents who
currently hold academic positions, while black
bars represent those who hold non-academic positions. * P<0.05 for association with the chosen subspecialty training and an academic career
At the time of the survey, 39% of the Scheie Eye
Institute graduates, and 44% of the University of
Pennsylvania medical students held full-time academic positions. In addition, 22% of the Scheie
graduates and 17% of the University of Pennsylvania medical students held volunteer faculty adjunct positions at academic institutions. There were
5 additional survey respondents who
had previously held full time acaTable 1. Characteristics of the survey respondents
demic positions, but had left academia
Percentage or
for private practice. Cited reasons for
Characteristic
mean±standard
these changes in practice settings indeviation
cluded financial issues (n=2), family
Before Residency:
obligations (n=2), and geographical
Gender, Male
59%
constraints (n=1). In reviewing the enAttended a top 20 medical school
64%
tire list of Scheie graduates, the residency program director was aware of
Entered medical school immediately after college
70%
the current position in all cases, and
Earned a PhD prior to residency
20%
found that 36% are currently in acaEarned an advanced degree other than a PhD
7%
demic positions.
Total number of publications before residency
2.6 ± 3.0
During Residency:
Total number of publications during residency
Award for clinical excellence
Award for research excellence
After Residency:
Pursued fellowship training
Received NIH or similar funding
Publication score
Ever held an academic position
Currently hold an academic position
3.3 ± 3.5
26%
37%
89%
17%
2.0 ± 3.0
48%
41%
Associations with selection of an academic position
Amongst the survey respondents, 35%
of men and 46% of women held academic positions. This difference was
not statistically significant (P=0.4).
Of all respondents who were in academic careers, 52% were male and
48% were female. Of the non-academic providers, 64% were male and
75
Table 2. Percent of physicians in academic and non-academic careers with various individual characteristics
Characteristics
Current Position:
% or mean±SD
Non-Academic
Academic
Pa
(n=28)
(n=41)
Gender (Male/Female)
52%/48%
64%/36%
0.8 (0.5, 1.2)
0.4
College major, science
89%
74%
2.0 (0.7, 5.6)
0.2
Entered medical school immediately after college
64%
74%
0.8 (0.4, 1.4)
0.4
Attended a top 10 medical school
75%
56%
1.7 (0.8, 3.4)
0.1
82%
83%
1.0 (0.5, 2.1)
1.0
7%
10%
0.8 (0.3, 2.6)
1.0
36%
10%
2.1 (1.3, 3.5)
0.01
7%
8%
1.0 (0.3, 3.0)
1.0
15 % Neurology
0 % Neurology
2.7 (1.9, 3.7)
0.01b
Publications before residency
3.7 ± 3.0
1.8 ± 2.7
1.3 (1.1, 1.5)
0.04
Publications during residency
3.6 ± 3.2
3.0 ± 3.7
1.0 (0.9, 1.2)
0.5
Publications after residency
21 ± 29
8.2 ± 27
1.02 (1.0, 1.04)
0.03
>75% surgical teaching by fulltime faculty
86%
73%
1.6 (0.7, 4.0)
0.2
Pursued fellowship trainingc
96%
84%
3.3 (0.52, 20.4)
0.1
19%
1.1 (0.56, 2.1)
1.0
46%
0.8 (0.4, 1.4)
0.5
35%
0.5 (0.2, 1.2)
0.08
27%
1.7 (0.99, 2.9)
0.07
Attended a top 10 residency
program
Year-off during medical school for
research
Earned a PhD degree prior to
residency
Earned an advanced degree other
than PhD
Other fields considered before
residency
Financial debt influenced career
21%
path
Ever received an award for teach36%
ing excellence
Ever received an award for clini14%
cal excellence
Ever received an award for re50%
search excellence
CI: confidence interval; Bolded numbers are P-values < 0.05.
a
P-value derived from of logistic regression model evaluating the association of various characteristics with
holding an academic position and increased publication score.
b
P-value listed is for Neurology; other sub-specialties did not reveal significant associations with an academic career choice using a linear regression model
c
See Figure 1 for further analysis of fellowship sub-specialty and its association with an academic career
36% were female. There were several factors that
were associated with an academic career choice
(Table 2), including having earned a PhD prior to
residency (P=0.01), and the number of publica76
Odds ratio
(95% CI)
tions before (P=0.04) and after (P=0.03) residency.
When respondents were analyzed based upon their
chosen fellowship sub-specialty, there were several
fields that were associated with an academic career
choice (Figure 1), including neuro-ophthalmology
(P=0.007), pediatric ophthalmology (P=0.003),
oculoplastic surgery (P=0.008), uveitis (P=0.04),
and ocular oncology (P=0.04). In addition, a significant association with an academic career choice
was noted in subjects who initially planned to pursue a fellowship in neuro-ophthalmology prior to
commencing their residency, regardless of whether
they actually matriculated in a fellowship in this
field (P=0.001).
Amongst the survey respondents who elected to
take a year out of medical school to pursue research, 33% held academic positions. Common
reasons cited for taking the research year included: enhancement of portfolio and improvement of
chances of “matching” into a residency program
(33%), lifestyle reasons (33%), and to learn more
about research techniques (33%).
Associations with higher publication record
A higher publication score was significantly associated with obtaining a PhD prior to residency
(P=0.01), the number of publications prior to and
during residency (P=0.02 for both comparisons),
obtaining a research award prior to residency
(P=0.01), and fellowship sub-specialization in neuro-ophthalmology (P=0.001) or uveitis (P<0.001).
Individual factors influencing trainees’ career
choices
Several survey questions were aimed at determining the underlying reasons for trainees’ career
choices (Table 3). Of those respondents currently
holding non-academic positions, 43% stated that
they would have chosen an academic position
if salaries were equivalent. However, financial
debt contributed to career choice in only 21% of
academic and 19% of non-academic physicians
(P=1.0). In addition, there was no significant difference in the proportion of academic vs. non-academic respondents who were leaning towards an
academic career prior to beginning their residency.
However, during residency, the proportion of those
leaning towards academic careers in respondents
currently in non-academic positions dropped from
72% to 49%. Cited reasons for this change included
financial implications (36%), perceived difficulty
of success in academia (18%), and role models in
both academia (18%) and private practice (27%).
Although the level of career satisfaction was not
different amongst groups, the reasons cited for ca-
reer satisfaction were different, and most commonly included intellectual stimulation and teaching in
academic practices and intellectual stimulation and
financial rewards in non-academic practices.
Training program factors influencing trainees’
career choices
Several features of residency programs were evaluated to determine associations with trainee career
choice. Both groups of respondents had overall
positive perceptions of the lifestyles of their academic role models; however, those respondents
who currently hold non-academic positions were
more likely to perceive academia as being “inefficient” and “political”. Matriculation at a “top 10”
residency program was not significantly associated
with an academic career choice. Additionally, there
were no residency program-specific associations
with academic career choices, including a research
requirement (P=0.4), coverage of travel expenses
for scientific meetings (P=0.6), or surgical teaching
by full-time faculty members (P=0.2).
Discussion
There is a widespread belief that the changing economic climate in the United States healthcare system has led to an attrition in the academic workforce
in various subspecialties[9,10]. It is vital to the
future of ophthalmology to maintain and enhance
the academic ophthalmology workforce in order to
provide leadership, teaching, and a framework for
research innovation for future generations. In attempting to define individual factors and influences
that determine whether a trainee chooses a career
in academia, our goal was not to imply that an academic career path is more rewarding than private
practice, but simply to better understand the factors
important in selecting and training the next generation of academic ophthalmologists. Given that 72%
of the respondents who went on to hold non-academic positions were initially leaning towards an
academic career prior to their residency, we sought
to find the factors that influence trainees to change
their career trajectory, and eventually choose a position outside of academia.
Our survey suggests that there are several characteristics of residency applicants that may predict an
academic career path. These characteristics include
obtaining a PhD, publications before residency, and
the intention of pursuing a neuro-ophthalmology
fellowship after residency. The findings of a PhD
77
Table 3. Possible individual factors associated with trainees’ decision to pursue an
academic career.
Current position:
% or mean±SD
Query:
Pa
Academic
(n=28)
Non-Academic
(n=41)
If salaries were equal, would
choose an academic career
94%
43%
<0.001
Financial debt played a role in
career choice
21%
19%
1.0
47%
0.2
28%
10%
0.12
0.0002
Career Satisfaction:
Extremely Satisfied
54%
Amongst top 2 reasons for career satisfaction
Complicated patients
46%
Teaching
54%
Access to other
Specialists
14%
23%
0.5
Ease of practice
Intellectual stimulation
Financial rewards
11%
86%
7%
18%
48%
40%
0.2
0.002
0.002
During internship, leaning
towards academics
93%
72%
0.06
During residency, leaning
towards academics
93%
49%
0.0001
Positive perception of academic faculty members’ lifestyle
89%
85%
0.7
Open-ended question: factors that most influenced your career choice
Perception that
academia is inefficient
0%
15%
and/or political
Desire for teaching
and/or intellectual
41%
10%
stimulation
Financial
considerations
0%
15%
0.04
0.05
0.03
Bolded numbers are p-values < 0.05.
a
P-value from Fisher’s exact test
and publications prior to residency being associated with an increased likelihood of having an academic career have been demonstrated in studies of
trainees in other medical sub-specialties[3,10,11].
However, other characteristics defined in other
specialties, such as medical school reputation and
marital status, did not appear to play a role in our
cohort. Although not statistically significant, we
did note a higher proportion of females in academic
than non-academic positions. This finding should
be considered as we develop policies in ophthal78
mology departments, as women in academia may
have different needs than their male counterparts
with respect to career planning. In addition to the
above described findings, we found that there were
multiple sub-specialty fellowships within ophthalmology that were associated with academic careers,
including neuro-ophthalmology, oculoplastics, pediatric ophthalmology, uveitis, and ocular oncology. Perhaps related to this finding is that those
fields that were not associated with an academic
career (i.e. cornea and retina) may be more lucra-
tive in the private sector. This financial discrepancy
may play a role in the relative disparity in the ratio of academic practitioners amongst the different
ophthalmic subspecialties.
Of those respondents who entered non-academic
positions, almost half of them decided not to pursue
an academic career during residency. These respondents appear satisfied with their career choices for
reasons including intellectual stimulation and financial gains, but seem willing to sacrifice in areas
such as teaching and access to complicated patients.
Interestingly, although financial debt did not play a
role in most cases, almost half of the clinicians in
this group stated that they would have chosen an
academic position had salaries been equivalent.
Using the residency program at the Scheie Eye Institute as an example of one that endeavors to be
a highly “academic” program, affording students
and residents the best opportunities for academic
pursuit, we have been successful in only 40% of
cases. In comparison, the neurology residency at
our institution, which is equally academic and rigorous, has a much higher track record of graduates
entering academic careers (88%)[3]. The reasons
underlying this discrepancy are undoubtedly multifactorial, and are likely to include factors related to
academia in general as well related specifically to
the field of ophthalmology. Given the high number
of survey respondents who initially planned for a
career in academic ophthalmology, there may be
a lack of successful mentoring in our training programs to keep trainees interests committed. However, the observation that academic interests wane
over time has been demonstrated in other medical
subspecialties[4,5,9]. The perception that success is
too difficult to achieve in academia is likely a result
of attitudes and outlooks conveyed directly or indirectly by mentors and role models. Finally, trainee
perceptions of academia as being “inefficient” and
“political” influenced many in our cohort to choose
non-academic positions, and reflects the current
stressors facing academic departments.
There are several ophthalmology-specific factors
that may contribute to our lower rates of graduates holding academic positions. Over 40 years
ago, in 1965, Dr. Francis Heed Adler insightfully
pointed out an important pitfall that occurs as a
result of the isolation of academic ophthalmology
departments: “Whenever there is not close contact between the department of ophthalmology and
other departments in the hospital, the residents suf-
fer from lack of exposure to other medical disciplines, and ophthalmology itself tends to become
isolated and loses its status in the medical world.
The general physician, lacking daily contact with
ophthalmologists and the opportunity to discuss
general medical subjects with them, begins to feel
that the ophthalmologist is someone who has left
the fold. He regards him more of a technician, and
no longer thinks of him as a physician treating only
one part of the body”[12]. This “academic isolation” of ophthalmology departments may play a
role in the attrition of academic interests in trainees over time[13]. After the holistic experience of
medical school and internship, residents are often
thrust into stand-alone ophthalmology departments
with very little access to the rest of the academic
medical community. With less interaction comes
less collaboration and stimulation for research and
innovation. Additionally, for many ophthalmology trainees, internships in internal medicine and
general surgery have given way to “transitional”
or “rotating” internships, which are often based in
non-academic settings. This may be an early factor
contributing to the trend away from non-academic
medicine. Finally, the alternative to an academic
career in ophthalmology is quite attractive in that
many of our “non-academic” respondents continue
to pursue research endeavors, teach, and have access to cutting-edge technology, and feel that the
ease with which they practice contributes to their
career satisfaction.
While the present study points out several trends,
we suggest that those training programs which have
a strong desire to train future academicians must
carefully consider how best to mentor medical students and residents towards their goals. If training
programs can simply retain those trainees who are
already on an academic trajectory upon entering the
program, then we would certainly see an increase
in the number of academicians in our field. In addition, there are several systems-based changes that
can be made to improve the number of candidates
seeking academic positions. First, administrators
should work towards reducing financial disparities
between academic and non-academic positions.
This is especially important for fields that are more
lucrative in the private realm, including retina,
cornea, and glaucoma. In addition, trainee perceptions of an academic lifestyle must be changed; this
could be addressed by improving upon the way that
trainees begin to understand metrics for academic
79
success during their residency training. The numerous opportunities for scholarship within academics,
including clinical practice, research, teaching, and
administrative roles should be supported within
departments and emphasized to trainees. In addition, the emphasis placed on residency education
and mentorship is currently undervalued in academic institutions as evidenced by the difficulty in
obtaining promotions for those academicians who
focus mainly on teaching[14]. The creation of academic tracks that emphasize teaching and mentorship will likely improve the current situation by
exposing residents to positive role models who are
motivated to teach, and are rewarded academically
for their contributions. Finally, for those residency
training programs that aim to train future academicians, specific applicant characteristics, such as
publication rate and a PhD, can be used to identify
promising candidates, and specialized mentoring
programs can be initiated early in training. Unlike
most other disciplines in medicine, ophthalmology
can be practiced at the highest level (including research and teaching endeavors) and frequently with
greater financial success in the private realm; therefore, to maintain our academic institutions, we must
consistently work at the administrative level to improve the quality of academic positions offered to
trainees and to continue intensive mentoring for
students with academic potential, as well as young
faculty members whose attitudes and biases often
influence trainees the most.
The results of our study should be understood within the context of its limitations. First, our medical
school and residency programs are not necessarily
representative of other programs, and therefore our
data may not be generalizable; our sample size is
also relatively small despite using a 13-year cohort.
In addition, we did not receive responses from 46%
of the graduates of our programs – this may create
an inherent, but unavoidable, selection bias towards
respondents who are more interested in academic
pursuits. However, based upon the program director’s knowledge of the current positions held by
the graduates of his program, this selection bias
is unlikely, given the small difference in the percentage of people currently holding academic positions (39% of Scheie graduates based on survey
responses vs. 36% of all Scheie graduates based on
the personal knowledge of the program director).
A multi-center prospective study would likely provide a larger and more diverse sample.
80
In spite of these limitations, our study represents
the first attempt to determine trainee characteristics that are associated with academic careers in
ophthalmology and to define factors that influence
trainees’ career choices. Our findings suggest that
residency program applicants who have a strong
publication record or a PhD are most likely to enter
full time academic positions. We also report several
factors that appear to act as disincentives to academic careers, including financial considerations,
negative perceptions of academia, and role models both in academics and private practice. These
findings should stimulate discussion regarding the
optimal residency program curricula and the importance of mentoring students and residents who are
inclined to pursue an academic career.
Acknowledgements
Funding/Support: Dr. Fine has received grant support from the NEI/NIH CATT grant.
References
1. Dorsey ER, Jarjoura D, Rutecki GW. Influence of
controllable lifestyle on recent trends in specialty choice by US medical students. JAMA 2003;
290:1173-1178.
2. Lower J. Brace yourself, here comes generation Y.
Crit Care Nurse 2008; 28:80-85.
3. Dorsey ER, Raphael BA, Balcer LJ, Galetta SL.
Predictors of future publication record and academic rank in a cohort of neurology residents. Neurology 2006; 67:1335-1337.
4. Abelson HT, Bowden RA. Women and the future of
academic pediatrics. J Pediatr 1990; 116:829-833.
5. Savill J. More in expectation than in hope: a new
attitude to training in clinical academic medicine.
BMJ 2000; 320:630-633.
6. Watanabe M. How to attract candidates to academic
medicine. Clin Invest Med 1992; 15:204-215.
7. www.usnews.com. Best Graduate Schools. 2010:
US News & World Report; 2010.
8. www.ophthalmologytimes.com. Best Residency
Programs. 2010.
9. Balboni TA, Chen MH, Harris JR, Recht A, Stevenson MA, D’Amico AV. Academic career selection
and retention in radiation oncology: the Joint Center
for Radiation Therapy experience. Int J Radiat On-
col Biol Phys 2007; 68:183-186.
10. Straus SE, Straus C, Tzanetos K. Career choice in
academic medicine: systematic review. J Gen Intern
Med 2006; 21:1222-1229.
11. Grewal NS, Spoon DB, Kawamoto HK, Jones NF,
Da Lio AL, Crisera C, Benhaim P, Bradley JP. Predictive factors in identifying subspecialty fellowship applicants who will have academic practices.
Plast Reconstr Surg 2008;122: 1264-1271; discussion 1272-1263.
13. McLeod D. What future for academic ophthalmology? Br J Ophthalmol 1995; 79:5.
14. Thomas PA, Diener-West M, Canto MI, Martin DR,
Post WS, Streiff MB. Results of an academic promotion and career path survey of faculty at the Johns
Hopkins University School of Medicine. Acad Med
2004; 79:258-264.
12. Adler FH. The education of an ophthalmologist.
Tr Am Acad Ophth Otol 1966; 70:17-24.
Supplemental Information
1. Do you currently hold an academic position? Yes / No
If yes, please further characterize your position:
[ ] Full-time practice based at an academic institution (with medical students, residents, or fellows)?
[ ] Adjunct, volunteer position?
2. If you currently hold an academic position, what is your present title?
[ ] Instructor
[ ] Assistant Professor
[ ] Associate Professor
[ ] Professor
[ ] Other:_________________
3. What is the name and location of your current institution or practice (optional):_________________________
4. For how long have you been in your current position? __________ years
5. What proportion of your time is spent in:
Clinical practice ___%
Research ___%
Teaching ___%
Administration ___%
6. If you are currently not in an academic position, have you held an academic position previously? Yes / No
7. If you answered yes to #6, for how many years were you in the academic position? ____________years
8. If you answered yes to #6, what was the most important reason that you left the academic position?
[ ] Financial factors
[ ] Lifestyle or family factors
[ ] Lack of academic success or productivity
[ ] Geographical reasons
[ ] Other (please expand):_____
9. Did you obtain extramural funding prior to or during residency? Yes / No
10. Did you receive an MD-PhD degree? Yes / No
If “yes”, at the end of your PhD research time, were you more or less likely to choose academics, compared to your
goals prior to commencing the PhD research years? More / Less
81
11. Did you take time off (>=1 year) during medical school to pursue a research project? Yes / No
If yes, what was the main reason for which you chose to take a year off?
[ ] Increase training in research skills for a future research career
[ ] Enhance portfolio and increase chances of matching
[
] Lifestyle considerations (ie. Change of pace, extra year before residency, personal reasons/family
commitments)
[ ] Other (please expand):________________
12. How many articles did you publish prior to residency?
Peer-reviewed, first author________
Peer-reviewed, non-first author________
Non-peer reviewed, first author _______
Non-peer reviewed, non-first author ______
Book chapters, first author ________
Book chapters, non-first author ____________
13. How many articles did you publish during residency?
14. How many articles did you publish after residency?
15. Did you present at any national meetings?
Prior to residency? Yes / No
During residency? Yes / No
After residency? Yes / No
16. In your residency, did you do any laboratory research? Yes / No
17. During residency, approximately how many months did you spend doing elective time? ___________months
18. Did you enter medical school immediately after college? Yes / No
If “no”, what did you do prior to entering medical school?________
19. Did you receive an award for excellence in teaching, either during or after residency? Yes / No
20. Did you receive an award for clinical excellence?
Before residency? Yes / No
During residency? Yes / No
After residency? Yes / No
21. Did financial debt play a role in determining your career path after completing residency? Yes / No
22. If salaries were equivalent between private practice and academic jobs, would you have chosen an academic career?
Yes / No
23. How satisfied have you been with your post-residency career?
[ ] Extremely satisfied
[ ] Very satisfied
[ ] Satisfied
[ ] Not satisfied
82
24. What factors have contributed to your satisfaction (pick 2)?
[ ] Access to complicated patients
[ ] Available resources from other subspecialists
[ ] Access to cutting edge technology
[ ] Ease of practice
[ ] Level of intellectual stimulation
[ ] Financial gains
25. If you are not in an academic position, please list the primary aspect of academia that you miss most (if any).
___________________
26. Since completing residency, have you received NIH or other federal funding for research?
Yes / No
If yes,
K award (or equivalent career development award)
R01 (or equivalent independent investigator award)
Other
If yes, how many years after completing residency did you receive the funding? __________years
27. By the middle of your internship year, what were your career goals:
[ ] Leaning towards academics
[ ] Undecided
[ ] Leaning towards private practice
28. By the middle of your residency, what were your career goals:
[ ] Leaning towards academics
[ ] Undecided
[ ] Leaning towards private practice
29. If your answers to the previous 2 questions were different, please rank any of the following reasons for the change in your
career goals (1=most important):
[ ] Role models in academic medicine
[ ] Role models in private practice
[ ] Feeling that private practice is boring
[ ] Perceived difficulty of success in academics
[ ] Financial reasons
[ ] Geographical reasons
[ ] Family considerations, spouse, children
[ ] Perception that academic jobs are hard to find
[ ] Perception that private practice jobs are hard to find
[ ] Other (please expand):__________________
30. Did you pursue a fellowship after residency? Yes / No
31. In what field(s) was your fellowship?__________________
32. What subspecialty within ophthalmology (if any) did you plan to enter prior to, or during your first 6 months of
residency?_________________
33. What was your undergraduate major?___________________
34. What are your parents jobs? (if your parent is a physician, please state whether they are in private practice or academic
positions)________________
35. Were you married when you entered your residency?_______When you made your first job choice?___________________
36. When did you decide on ophthalmology as a career?
[ ] Before medical school
[ ] During medical school
[ ] After medical school
83
37. During medical school, what was the other residency/field that you considered (ie. ENT, medicine, neurology, dermatology, etc.)?__________________
38. How much did your perception of the career satisfaction of your role models during residency affect your career goals and
plans to enter an academic career?
[ ] More likely to enter academics
[ ] Less likely to enter academics
[ ] No effect
39. Were there aspects of your ophthalmology residency (ie. Isolation of ophthalmology from other medical subspecialties
within academic medicine, attendings focused on single procedures, isolation from systemic medicine) that contributed to
your decision whether or not to pursue academics? Yes / No
If yes, please expand:_________
40. Please briefly summarize the various factors that determined the position that you currently hold. _________________________
41. What residency program did you attend? (optional)_________
42. Why did you select your residency program (please rank, with 1=most important)
[ ] Location
[ ] Reputation
[ ] Surgical volume
[ ] Research resources
43. Did your residency have a research requirement? Yes / No
44. Did your residency cover academic meeting/travel expenses? Yes / No
45. What was your perception of the lifestyles of your academically-based attendings?
[ ] Good, lifestyle that I would have enjoyed
[ ] Bad, lifestyle that I would not have wanted for myself
[ ] Neutral
46. Who taught you most of your surgical procedures?
Full time faculty members: _____%
Volunteer/adjunct faculty:______%
Fellows:______%
84
Effect of Period of Academic Year on
Cataract Extraction Surgical Time
Kenneth J. Mortimer, M.H.A., M.S.W.1, T. Eugene Day, D.Sc.*2, Kristyn J.
Williams, M.H.A.3 , Nicole L. Mitchel, M.H.A.4, James Banks Shepherd III, M.D.5,
Nathan Ravi, M.Sc., Ph.D., M.D.6
VA Heartland Network, Kansas City, Missouri, 2Health Care Optimization Group, St. Louis Veterans Administration Medical Center, St. Louis, Missouri, 3Pathology & Laboratory Medicine Service, St. Louis Veterans Administration Medical Center, St. Louis, Missouri, 4Nursing Service, VA Gulf Coast Veterans Health Care System, Biloxi,
MS, 5Washington University in St. Louis, St. Louis, Missouri 63110, 6St. Louis John Cochran VA Medical Center,
St. Louis University, Institute of Public Health Washington University in St. Louis
1
Abstract
Purpose: To determine if cataract surgery cases performed earlier in the academic year will be associated with longer case times
Methods: All cataract removal surgeries with compete records performed between July 1, 2005 through June 30,
2008 at the St. Louis Veterans Affairs Medical Center (n=1476) were examined. Specific variables were preparatory
time, procedure length, and operating room time. Times for each variable were compared across the course of the
academic year.
Results: Mean times for cataract cases varied significantly based on period (P<0.001). Two-tailed, unpaired testing
revealed that operating room times during the first three months of the year were significantly longer than during the
middle of the year (P<0.0001) and late in the year (P<0.0001). Cases in the middle of the year were also found to
take significantly longer than cases late in the year (P=0.0012). Further, more time was spent preparing the patient
for surgery (P<0.0001) early in the year. More time was spent preparing the patient in cases early than during the
middle (P<0.0001) or end (P<0.0001) of the year. Additionally, procedure lengths were found to decrease significantly as the year progressed (P<0.0001).
Conclusion: Surgical schedulers should adjust anticipated block time for cataract surgery based on the relative experience of residents in order to allot optimal block time, particularly in the earlier parts of the academic year. Further
study will be required to determine if this pattern holds for other surgical specialties and procedures.
Keywords: Surgical Time, Cataract, Operating Room Scheduling, Learning Curve
Introduction
In 2007, the St. Louis Veterans Administration
Medical Center (VAMC) established the Health
Care Optimization Group to study and improve
health care delivery processes within the medical
center, and beyond. This multidisciplinary assembly is focused on applying systems engineering,
computer simulation, and statistical methods to examine health care delivery. Tasked with finding and
ameliorating the underlying causes of health delivery inefficiency, the authors examined the change
in surgical times as it related to the performance of
cataract surgeries at St. Louis VAMC. Determining
the nature of seasonal variation in surgical times
will allow for more efficient scheduling of Operating Rooms (ORs).
Intelligent scheduling use of OR time is critical to
operating room efficiency, as well as cost control. If
case lengths are underestimated, there may be additional costs related to overtime staffing; if they
85
Cataract Surgical Time - Mortimer et al.
are overestimated, this may indicate excessive costs
for routine staffing[1,2]. Historical data on case
times has been cited as a useful tool for ensuring
that cases are scheduled for the appropriate amount
of time[3-5]. Reasons for inaccurate judgment of
surgical times may include equipment or power
failure, variations in staff, failure to account for
changes in surgical methods, and various forms of
observation bias on the part of the scheduler[6,7].
One question that receives little attention in the literature, however, is the question of seasonal variation in surgical case times, particularly among academic medical centers which may face the “July
Phenomenon.”
The July Phenomenon is the notion that quality of
care might be diminished at academic medical centers as house staff begin new assignments and take
on new responsibilities in July, the typical beginning
of the academic cycle[8-15]. While much attention
has been paid to the July Phenomenon effect on
morbidity/mortality[16,12,17,13,18,19], adverse
effects[9-11,20,14,15], and cost of care[8,17,13],
only one study known to the authors has specifically
examined whether the July Phenomenon influences
surgical case times, in which Bakeen et al. showed
that there was a small, but statistically significant,
drop in cardio-thoracic surgical times throughout
the course of the academic year[21].
Cataract surgery is a common procedure at the St.
Louis Veteran’s Affairs Medical Center (VAMC).
Between 1 July, 2005 and 30 June 2008, 1476 cases
of cataract extraction, either by phacoemulsification or by extra capsular cataract extraction[22,23],
were performed at St. Louis VAMC. This represented approximately 7% of all surgical cases[23] and
was the second most common surgical procedure at
the facility. The great majority of these surgeries
are performed by residents under the supervision
of the attending ophthalmologist. Ophthalmology
residents at St. Louis VAMC perform one or two
cataract extractions in their first year, as many as
fifteen in their second year, and 80-100 during their
third year of residency. There are five third year
residents each academic year. Thus, 86%-88% of
all cataract extractions are performed by third year
residents. Give the number of cases and the heavily
resident-dependent nature of this type of surgery,
cataract surgery was identified as an ideal procedure to use in studying the effect of resident experience on case length.
86
Methods
A data set of surgical procedures was generated
from the surgical package of the Veterans Integrated Service and Technology Architecture (VistA)
system; this was retrospective data, and the appropriate waivers of informed consent were filed. This
report included the case number, Operating Room
(OR) number, principal procedure code, time the
patient entered the holding area, time the patient
entered the OR, anesthesia start and end times,
time the surgery started and ended and the time the
patient left the OR. From this data, the dependent
variables of three different time spans were measured: Preparatory Time (from the start of anesthesia to the start of surgery), Procedure Length (from
start of surgery to end of surgery), and Operating
Room Time (from OR entry to OR exit). Operating Room start and stop time, as well as procedure
beginning and end time, were taken from the Nurse
Intraoperative Report.
The month of surgery was then used to separate the
cases into Early Academic (July through September), Mid-Academic (October through March) or
Late Academic (April through June) groups. Mean
Preparatory Time, Procedure Length, and Operating
Room Time were calculated, along with the Standard Deviation for each variable in each portion
of the academic year. Three periods were chosen
to best represent large trends in the data, in order
to maximize relatability for the quality assurance
project which was the genesis of the investigation.
ANOVA testing using the Microsoft Excel statistical add-in was used to determine the existence of a
statistically significant variation in the data. Post
hoc pairwise significance testing was performed
using the two-tailed unpaired Student’s t-test. A
threshold of P<0.05 was used to assess statistical
significance.
Results
Single Factor ANOVA testing on Preparatory Time,
Procedure Time, and OR Time over the three periods of the academic year, each give P values of
P<0.0001, indicating the existence of a strongly
statistically significant variation among the time
periods examined. Post hoc t-testing showed there
was a strongly statistically significant decrease in
time required for Preparation, Procedure, and Total OR Time between each period in the academic
year with the exception of preparation between the
middle period and late period. With the exception
of change in Preparatory Time between the middle
and late academic year periods, every difference
in time was found to be strongly statistically significant (P<0.001). For each time span, time required to complete tasks decreased over the course
of the academic calendar. Mean Preparatory Time
decreased by a total of 16.4% (4.5 min) over the
course of the academic year, with 98% of that decrease occurring during the period of training corresponding to the beginning of the academic year.
Similarly, Procedure Length decreased by 25.4%
(19.5 min) over the academic year, with nearly
two thirds of the difference occurring between the
early and middle periods. Finally, Operating Room
Time decreased by 22.4% (24.1 min) over the year,
with the same two thirds of the difference occurring
between the early and middle period. The small
discrepancy between Operating Room Time and its
component elements is due to small periods of interstitial time between the end of anesthesia and the
start of surgery, as well as after surgery has ended
but prior to exiting the OR. Complete results and P
values may be found in tables 1-3 for Preparatory
Time, Procedure Time, and Operating Room Time
respectively.
Discussion
The results of this study show a decrease in cataract surgical length over the course of the academic
year. It should be noted that the study makes no
conclusions about the outcome of surgery. Longer procedure lengths during the early part of the
year are likely due to a number of factors including
increased oversight by the attending physician, an
abundance of caution by resident surgeons, and familiarization with operating room protocols, in addition to the effect of improved surgical skill as the
academic year progresses. The July Phenomenon
is readily observable with respect to time required
for overall Operating Room Time for cataract surgery, as well as its component elements of Preparatory Time and Procedure Length respectively.
However, this study suggests that the so called July
Phenomenon is not a specific effect confined to the
beginning of a surgical resident’s instructional period, but rather a gradual reduction in mean surgical
time over the course of the academic year, albeit
concentrated in the first four months. This process
can be seen graphically in figure 1. Surgical times
jump suddenly in July when new residents begin
the surgical rotation, and drop significantly in the
first three months, followed by slower reduction in
the following nine months.
Figure 1 also appears to show a ‘bulge’ in the Procedure Time and OR Time during the month of December. This mean increase in times was not found
to be statistically significant in comparison to either
the month immediately preceding or following.
Table 1. Mean and Significance of Preparatory Time by
period of Academic Year.
Group
Jul-Sept
Prep Time
Oct-Mar
Prep Time
Apr-Jun
Prep Time
P
0.4564
0.2035
0.0117
303
<0.0001
0.3885
0.1361
0.0049
777
*
0.3815
0.1588
0.008
396
0.434
P
*
<0.0001
<0.0001
Mean
SD
SEM
N
Table 2. Mean and Significance of Procedure Time by
period of Academic Year.
Group
Mean
SD
SEM
N
P
P
Jul-Sept
Proc Time
1.2802
0.6003
0.0345
303
<0.0001
<0.0001
Oct-Mar
Proc Time
1.082
0.627
0.0225
777
*
0.0008
Apr-Jun
Proc Time
0.9548
0.5776
0.029
396
0.0008
*
Table 3. Mean and Significance of Operating Room
Time by period of Academic Year.
Group
Mean
SD
SEM
N
P
P
Jul-Sept
OR Time
1.7928
0.7046
0.0405
303
<0.0001
<0.0001
Oct-Mar
OR Time
1.5258
0.6832
0.0245
777
*
0.0012
Apr-Jun
OR Time
1.3918
0.6412
0.0322
396
0.0012
*
Mean: Mean of sample group in hours
SD: Standard Deviation of sample Group in hours
SEM: Standard Error of the Mean of sample group in
hours
N: Number of samples in group
P: Null Probability
*: comparison group
87
Table 4. Mean and Significance of Preparatory Time,
Procedure Length, and Operating Room Time for December in comparison with November and January
Group
Mean
SD
SEM
N
P
Group
Figure 1. Mean Preparatory, Procedure, and Operating Room Times by Month of Academic Year
Prep: Preparatory time for cataract extraction surgery
Proc: Procedure time for cataract extraction surgery
OR: Total Operating Room time for cataract extraction
surgery
Results and P values may be seen in table 4. Therefore, this is likely due to random variation in the
data, although it is plausible that there are seasonal
effects due to the holidays during the month of December.
While the literature is generally quiescent on specific
relationships between surgical time and outcomes,
reduced surgical time is frequently mentioned as a
benefit of new procedures[24]. Similarly, studies
which show reduced surgical time frequently also
report improved outcomes and reduced complications[25-27]. While the specific connection between reduced surgical time and outcomes may not
be conclusively established, there have been studies
associating surgeries with long surgical times with
increased complications[28].
Conclusion
Our study suggests that the period of the academic
year should be considered as a factor when determining how long to block an OR for cataract surgery. Annual mean case time will tend to underestimate time required for cataract surgery during
the beginning of the academic year, resulting in OR
overtime or postponed surgeries, and overestimate
time required during the latter part of the year, resulting in excess OR availability. By accounting
for variations in operative times related to the July
Phenomenon, staffing needs may be more accurately determined, thus likely reducing costs related to
operative care.
88
Mean
SD
SEM
N
P
Group
Mean
SD
SEM
N
P
Nov Prep
Time
0.3709
0.117
0.011
113
0.1471
Nov Proc
Time
1.1047
0.7184
0.0676
113
0.3497
Nov OR
Time
1.5242
0.7385
0.0695
113
0.1615
Dec Prep
Time
0.396
0.1442
0.0132
120
*
Dec Proc
Time
1.186
0.604
0.0551
120
*
Dec OR
Time
1.654
0.6724
0.0614
120
*
Jan Prep
Time
0.3991
0.1451
0.0124
137
0.863 Jan Proc
Time
1.0534
0.5332
0.0456
137
0.0626 Jan OR
Time
1.5072
0.5701
0.0487
137
0.0593
Mean: Mean of sample group in hours
SD: Standard Deviation of sample Group in hours
SEM: Standard Error of the Mean of sample group in
hours
Acknowledgements
Dr. Day’s work was supported by 2009 VHA Innovations Award #123. Dr. Ravi and Dr. Day were
supported by a St. Louis VA Medical Center Grant.
This study was approved by the St. Louis VA Medical Center Institutional Review Board.
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17. Huckman RS, Barro J. Cohort turnover and produc-
89
Primary Carcinoid Tumor of the Inferior
Rectus Muscle
Jamison R. Ridgeley, M.D.* and Daniel P. Schaefer, M.D.
Dr. Schaefer is an Oculoplastic surgeon and volunteer faculty for the University at Buffalo Department of Ophthalmology. Dr. Ridgeley is a comprehensive ophthalmologist with University Eye Specialists, P.C.,Warsaw, New York;
this article originated when he was an ophthalmology resident at the University of Buffalo
Carcinoid tumors are insidious, slow growing tumors of neuroendocrine cell origin, specifically the
enterochromaffin cells, that mostly originate from
a gastrointestinal origin[1]. Accordingly, the most
common sites include the appendix (40%), jejunoileum (27%), rectum (13%), and bronchial tract
(11.5%)[2]. Furthermore, these low-grade malignant tumors may rarely originate from the thyroid,
pancreas, biliary system, thymus, and ovaries. The
most common metastases are to lymph nodes and
the liver[2]. Metastases to the orbit and extra-ocular
tissues are relatively rare. Moreover, primary orbital carcinoid has only been documented in a rare
case[3]. We present one patient with focal involvement of the left inferior rectus muscle with no apparent additional systemic involvement.
Figure 1. Initial Scanning Sagittal CT Scan
Report of a Case
A 62 year old male initially presented to his primary
care physician in December 2007 complaining that
his left eye was bulging. The patient had noticed
the abnormality for the past couple of years, but
had not experienced any pain or change in vision.
The patient underwent an initial CT ordered by his
primary care physician. The computed tomography
(CT) scan of the head and orbits revealed an orbital
mass involving the inferior rectus muscle measuring 1.54 cm transversely, 1.48 cm anteriorly-posteriorly, ~1.19 cm in craniocaudal dimension. The
Available via open-access on the web at http://www.academicophthalmology.com
90
Figure 2. MRI - T1 Coronal Image of Left Inferior
Rectus Mass
Carcinoid Tumor - Ridgeley & Schaefer
well-circumscribed mass appeared to engulf the left
inferior rectus muscle and extended posteriorly toward the orbital apex. The left optic nerve appeared
to be spared. There was no bony erosion or intracranial extension noted. MRI was performed to further
characterize the mass (Figs. 1 and 2). Partial biopsy
revealed a neuroendocrine carcinoid tumor, which
stained positively for a gastrointestinal derived tumor CDX2 (Fig. 3).
Table 1. Differential Diagnosis of Orbital Masses[4]
Vascular
Inflammatory
Cavernous Hemangioma
Diffuse Idiopathic Orbital
Inflammation
Hemangiopericytoma
Lymphangioma
Orbital Varices
Myositis
Thyroid Orbitopathy
(Grave’s Disease)
Wegner’s Granulomatosis
Neoplastic
Metastatic origin
Sphenoid Wing Meningioma
Breast
Optic Nerve Glioma
Gastrointestinal
Neurofibroma
Schwannoma
Optic Sheath Meningioma
Prostate
Lung
Sarcoma
Rhabdomyosarcoma
Figure 3. H & E stain of Carcinoid Tumour
An extensive workup was performed including serotonin and chromogranin blood levels, octreotide
scintigraphic scanning, and positron emission tomography. Serotonin blood levels measured 334 ng/
ml, 13 ng/mL above the normal range (21-321 ng/
mL). Chromogranin levels (5 nmol/L) were within
normal limits (0-5nmol/L). Octreotide Scanning
(Fig. 4) did not reveal a potential source. positron
emission tomography also did not identify a poten-
Figure 4. Octreotide Scan after 4 hours. Normal Uptake
in the Liver, Kidneys, Spleen, and Bladder. Right Inguinal Contamination. Left Orbit Uptake noted. tial source. The patient is currently undergoing external beam radiation therapy to left orbit dispersed
over 30 visits (180 cGy) for a total of 5500 cGy.
A colonoscopy was offered to the patient, but he
deferred until after external beam radiation therapy
was completed.
Discussion
Carcinoid tumor is a low-grade malignant neoplasm that most commonly originates in the gastrointestinal and respiratory tracts. Predominant metastatic sites include the liver and surrounding lymph
nodes[2]. The enterochromaffin cells of carcinoid
tumor have the ability to produce serotonin, which
is metabolized by the liver to 5-hydroxy-indoleacetic acid (5-HIAA). Carcinoid syndrome, caused by
an excess of peptides (such as serotonin, histamine,
tachykinins and bradykinins) in the circulation, includes symptoms of flushing, diarrhea, abdominal
pain, and edema of the lower extremities[5]. The
clinical nature and presentation of carcinoid tumors
can be variable, ranging from undetectable, solitary
tumors found incidentally during autopsy to widely
metastatic lesions with gastrointestinal obstructive
symptoms, and a debilitating carcinoid syndrome.
Size of the primary carcinoid tumor may predict
metastatic potential as carcinoid tumors of < 1 cm in
size have a ~2% chance of metastasis as compared
to ~80% of carcinoid tumors > 2 cm[6]. Metastatic
orbital carcinoid tumors are a relatively rare occurrence. The diagnosis of metastatic involvement of
the intraocular structures or the orbit is made about
91
5 years after the diagnosis of the primary carcinoid
tumor[1]. When the ocular signs are noted first, the
search for a primary tumor can be more directed to
the most common sites of the primary tumor[2]. In
a handful of cases in which eye involvement was
the first sign noted, there was an average period of
18 months before systemic signs were observed[1].
Orbital metastases generally involve the choroid
rather than orbital structures, the most likely explanation being the highly oxygenated choroidal
tissue[1]. Previous studies indicate the majority of
uveal metastases originate from a primary bronchial carcinoid, whereas the majority of extraocular
orbital metastases arise from primary tumors of the
ileum[2].
Primary carcinoid tumor and metastatic foci can
be diagnosed utilizing multiple imaging modalities and serological testing. Computed tomography
(CT) is useful in detecting gastrointestinal carcinoid tumors, especially with the use of intraluminal contrast, and widespread metastatic lesions[7].
However, smaller tumors (< 1cm) are difficult to
visualize. Octreotide scanning, commonly known
as somatostatin receptor scintigraphy (SRS), has
90% sensitivity for detection of primary carcinoid
tumors and metastatic lesions[8]. This imaging modality employs octreotide to bind somatostatin receptors that are expressed in 80-85% of carcinoid
tumors[8]. Positron emission tomography (FDGPET, 18F-dopa PET) has been used to image primary gastrointestinal carcinoid tumors, lymph nodes,
and organ metastases with early promising results.
In general, it is advised that FDG-PET should not
be used as a first-line imaging agent, but is primarily useful when the results of SRS are negative[6].
Biochemical evaluation for carcinoid presence includes measurement of serum serotonin, serum
chromogranin (CgA)(precursor to peptides released
from neuroendocrine cells), and urinary excretion
of 5-HIAA. However, patients that have relatively
small or occult tumors may exhibit normal serology
and urinary testing.
Histologically, carcinoid tumors have several characteristic patterns and stains, which aid in diagnosis. Well-circumscribed tumors, with nest and cords
of cells, with or without atypia, and possible necrosis can be observed in primary tumors as well
as metastatic foci (liver, orbital, etc.). Immunohistochemical stains, such as synaptophysin and
chromogranin, specifically stains cells of neuroendocrine origin. Additionally, CDX2 stain helps
92
to determine tissue type and localize origin. This
can be extremely helpful in rare cases, in which the
manifestations of orbital carcinoid precede the diagnosis of the primary tumor.
Treatment modalities of orbital carcinoid tumors
are highly variable due to limited documented data,
but mainly include local surgical excision, radiation
methods, chemotherapeutic agents, and palliative
agents. Local excision may be utilized for small,
focal tumors whose removal may not interfere with
normal anatomic function. External beam irradiation and plaque radiation have been employed in
a number of cases with mixed results, and may be
used in tumors that are deemed unresectable. Chemotherapeutic agents, such as 5-FU and streptomycin, have been attempted, however, very little
published data about the use of these agents exists.
Somatostatin analogues can improve symptoms in
50-80% of patients suffering from the carcinoid
syndrome.
Upon review of the literature, there appears to be
only 9 documented cases of carcinoid involvement
of the extraocular muscles. Furthermore, only 2
cases isolated to the inferior rectus muscle are documented[2]. Few cases first present with metastatic
orbital manifestations, however,those cases mostly
yield a primary source upon systemic investigation
by the previously stated methods. Only 1 case of
primary orbital carcinoid has been documented, as
the patient was followed for 15 years without systemic evidence of carcinoid[3].
The interdisciplinary approach for this case was
absolutely essential for proper diagnosis and instituting the optimal treatment plan. The patient initially presented to his primary care physician with
subsequent referral to the ophthalmology service.
Upon biopsy by the ophthalmology service, pathology relayed a final tissue diagnosis by use of immunohistochemical stains. Furthermore, the internal
medicine and nuclear medicine departments were
vital in ensuring a thorough medical evaluation of
this patient.
This case report illustrates the sixth ACGME core
competency, systems based practice. In systems
based practice, physicians demonstrate an awareness of and responsiveness to the larger context and
system of health care, as well as the ability to call
on other resources in the system to provide optimal
health care[9].
References
1. Couch DA, O’Halloran HS, Hainsworth KM, et
al. Carcinoid metastasis to extraocular muscles:
case reports and review of the literature. Orbit
2000;19(4):263-269.
2. Borota OC, Kloster R, Lindal S. Carcinoid tumour
metastatic to the orbit with infiltration to the extraocular orbital muscle. APMIS 2005;113(2):135139.
3. Zimmerman LE, Stangl R, Riddle PJ. Primary carcinoid tumor of the orbit. A clinicopathologic study
with histochemical and electron microscopic observations. Arch Ophthalmol 1983;101(9):1395-1398.
4. Yanoff M, Duker JS. Ophthalmology. 2nd ed. St.
Louis: Mosby, 2004:729-743.
5. de Herder WW. Tumours of the midgut (jejunum,
ileum and ascending colon, including carcinoid
syndrome). Best Pract Res Clin Gastroenterol
2005;19(5):705-715.
6. Wallace S, Ajani JA, Charnsangavej C, et al. Carcinoid tumors: imaging procedures and interventional
radiology. World J Surg 1996;20(2):147-156.
7. Horton KM, Fishman EK. Multidetector-row computed tomography and 3-dimensional computed tomography imaging of small bowel neoplasms: current concept in diagnosis. J Comput Assist Tomogr
2004;28(1):106-116.
8. Jensen RT, Norton JA. Carcinoid tumours and the
carcinoid syndrome. Cancer Principles and Practice
of Oncology. 5th ed. Philadelphia: Lippincott-Raven, 1997:1704-1723.
9. ACGME Board. Common Program Requirements:
General Competencies. www.acgme.org/outcome/
comp/GeneralCompetenciesStandards21307.pdf.
Posted February 13,2007.[Accessed on February
2010].
93
Corneal Ulceration Due to Xerophthalmia
Following Biliopancreatic Diversion
Bariatric Surgery
Brian O. Haugen, M.D.1, David C. Gritz, M.D., M.P.H.*2, Jean Hausheer, M.D.,
F.A.C.S.1,3
Department of Ophthalmology, University of Missouri, Kansas City (UMKC) School of Medicine, Truman Medical
Center; the Eye Foundation of Kansas City and Vision Research Center, Kansas City, Missouri; 2Department of Ophthalmology and Visual Science, Department of Epidemiology and Population Health, Montefiore Medical Center,
Albert Einstein College of Medicine, Bronx, New York; 3Sabates Eye Centers, Leawood, Kansas.
1
Abstract
Purpose: To describe the clinical presentation of ocular complications due to malnutrition, five years post biliopancreatic diversion bariatric surgery
Methods: Case presentation
Results: A 23-year-old Caucasian female presented with severe bilateral corneal ulceration and xerophthalmia.
Although the patient was morbidly obese, history revealed that she had undergone biliopancreatic diversion bariatric
surgery five years prior to presentation. Slit-lamp biomicroscopy showed areas of keratinized conjunctival epithelium in both eyes in addition to the bilateral corneal ulcers, the left corneal ulcer showing signs of previous perforation. Laboratory evaluation showed severe vitamin A deficiency with a serum level of <0.06 mg/L (normal range
0.38-1.06 mg/L), in addition to other vitamin and metabolic abnormalities. Oral vitamin A and topical antibiotic
therapy resulted in healing of corneal ulcers in both eyes along with improved ocular surface health, vision, and
comfort.
Conclusion: Corneal and conjunctival findings consistent with vitamin A deficiency should heighten the ophthalmologist’s suspicion of the diagnosis, even though the patient may not clinically appear malnourished. Specific
questioning is sometimes required to elicit the pertinent medical history. Some types of bariatric surgery, such as
biliopancreatic diversion, carry higher risks of postoperative malabsorption, especially in patients who are noncompliant on recommended postoperative nutritional supplements.
Keywords: corneal ulcer, hypovitaminosis A, xerophthalmia, bariatric surgery, malnutrition.
Introduction
Various bariatric surgeries have become increasingly common to address epidemic levels of obesity in
the USA. Potential postoperative complications include malabsorption with subsequent malnutrition
and the incidence of these complications is dependent on the type of bariatric procedure[1]. When
94
malabsorption complications occur, a patient may
not appear malnourished because post-bariatric
surgery patients may still be overweight. In these
patients, the fat soluble vitamins, such as vitamins
A, D, E, and K, are at highest risk for malabsorption and subsequent deficiency[1]. When vitamin
deficiencies occur after bariatric surgery, xerophthalmia can be the presenting symptom[2]. Thus,
when a patient has ocular findings compatible with
xerophthalmia, this diagnosis must be kept in mind.
Case Report
A 23-year-old Caucasian female was referred from
an outside cornea specialist for bilateral loss of vision and red eyes. Bilateral photophobia, tearing,
Corneal ulceration following bariatric surgery - Haugen et al.
and foreign body sensation began six weeks before
presentation. Two weeks after the symptoms began,
the patient was rubbing her left eye when she felt
a gush of fluid and lost vision in that eye. She ignored the ongoing soreness and poor vision in the
left eye until she began to lose vision in her right
eye. She had not noted nyctalopia. She wore glasses, but had not been to any eye care professionals
for at least five years. Regarding social history, the
patient smoked ¾ packs of cigarettes per day. She
denied alcohol or illicit drug use. Her past medical history included a biliopancreatic diversion five
years prior to presentation. She lost approximately
125 pounds, but had inconsistent follow up postoperatively. She only revealed the bariatric surgery
upon direct questioning by the attending ophthalmologist. Past medical history was positive for hypertension and depression. Review of systems was
positive for fever, frequent diarrhea, fatty stools,
fatigue and poor appetite, bilateral lower extremity
edema, and eczema.
Current medications were duloxetine hydrochloride, clonazepam, triazolam, and naproxen. She
was not taking any vitamin or herbal supplements.
She had stopped the recommended postoperative
vitamin supplements several years prior to her presentation in the eye clinic. The referring physician
had started hourly fortified cephazolin (50mg/ml),
fortified gentamicin (14mg/ml), levofloxacin 0.5%,
and twice daily dosing of 5% homatropine eye
drops in both eyes, in addition to oral doxycycline.
General examination revealed an overweight woman, appearing older than her chronological age
(Figure 1). She had a flattened affect and generally
seemed depressed.
Ophthalmic examination showed best corrected visual acuity of 20/100 in the right eye, and count
fingers at 2 feet in the left eye. The right pupil was
round and dilated at 8 mm. The left pupil was irregular.
On slit-lamp biomicroscopy, there was bilateral
conjunctival hyperemia with areas of bilateral limbal keratinized conjunctival epithelium (Figure 2).
In the right eye, the cornea had a 3.0 mm by 1.0 mm
cornea ulcer with 20% thinning (Figure 3). Superior to the ulcer, there was an endothelial plaque.
There was diffuse moderate stromal edema and
diffuse stromal infiltration with white blood cells.
The anterior chamber of the right eye was deep and
appeared quiet, with poor view due to the corneal
Figure 1. Patient’s overall appearance
opacity. In the left eye, there was conjunctival ulceration. Also in the left eye, the cornea had multiple small ulcerations with underlying infiltrates.
The left cornea had an area of slightly bulging, vascularized granulation tissue involving two thirds
of the superior cornea (Figure 4). Inferiorly, there
were iridocorneal adhesions suggesting prior perforation. The left anterior chamber contained fibrin
with posterior synechiae of the iris to the lens. Patient was phakic in both eyes.
Indirect fundus exam of the right eye was limited
due to extensive central corneal opacity. The optic
nerve, macula, and vessels appeared normal. There
was no view of the left fundus. Ultrasound of the
left eye revealed a normal posterior pole. Dark adaptation studies were not performed.
The history and exam findings, including the history of gastric bypass surgery with inadequate vitamin supplementation, strongly suggested vitamin A
deficiency. Corneal cultures and laboratory studies
were performed (Table 1).
Topical antibiotics were continued hourly in both
95
eyes by the patient. She was started on oral vitamin
A supplementation 200,000 IU once daily for two
days. This was repeated two weeks later for two
days. The patient declined intramuscular preparation of vitamin A. She was also started on a multivitamin supplementation. Aggressive lubrication
with preservative-free artificial tears and carboxylmethylcellulose sodium 1.0% was started. The patient was counseled multiple times regarding lifelong compliance on multivitamin supplementation,
and immediate compliance on usage of fortified
antibiotic drops in each eye.
Corneal cultures grew Staphylococcus aureus and
coagulase-negative Staphylococcus species. Both
isolates were sensitive to cephazolin. Fortified
gentamicin (14mg/ml) and levofloxacin (0.5%)
were discontinued and fortified cephazolin (50mg/
ml) was continued. The result of serum vitamin A
level was less than 0.06 mg/L (normal range: 0.381.06 mg/L), indicating depleted liver stores due to
chronic severe vitamin A deficiency.
One week after starting the vitamin A therapy, the
patient’s symptoms of dryness and photophobia improved and she felt more energetic and alert overall.
Her visual acuity improved to 20/25 in the right eye
and 20/400 in the left eye. Her left eye intraocular pressure was elevated at 40 mm Hg. There was
almost complete resolution of limbal conjunctival
keratinization in the both eyes. The right corneal
ulcer progressively healed. The anterior chamber
inflammation also progressively improved. Topical
combination brimonidine 0.2% /timolol 0.5% agent
was started to lower intraocular pressure in the left
eye. She continued hourly fortified cephazolin eye
drops (50mg/ml). Oral doxycycline was discontinued because of progressive improvement.
Figure 2. The right eye had keratinization of limbal conjunctiva, involving almost 360 degrees of the limbus.
Figure 3. The patient’s right eye, which had an epithelial
defect with underlying infiltrate. The corneal ulcer has
an associated endothelial plaque.
The patient was referred to a gastroenterologist for
monitoring of post-bypass nutrition levels. She was
also referred for evaluation and treatment of ongoing depression.
Four months after initial presentation, the patient
reported compliance with vitamin supplements.
Best corrected visual acuity was 20/25 and 20/200,
in the right and left eyes, respectively. Inflammation in both eyes had resolved. A significant corneal
scar associated with vascularization was responsible for the poor vision in the left eye. A penetrating
keratoplasty is planned for that eye. The intraocular
pressure was stable at 20 mm Hg on brimonidine
0.2% /timolol 0.5% twice daily in the left eye.
96
Figure 4. The patient’s left eye, which had a superior
area of inflamed adherent leukoma. The prominent opacity had intense vascularization, suggestive of granulation
tissue. The underlying iris was adherent to the cornea,
indicating a healed prior corneal perforation. The anterior chamber remained shallow with iridocorneal adhesions. Multifocal corneal infiltrates with overlying epithelial defects are also seen in this photo.
Discussion
Table 1. Results from initial laboratory evaluation
The World Health Organization in 1976 accepted
the term xerophthalmia to encompass all ocular
manifestations of vitamin A deficiency[3]. Xerophthalmia is one of the most common causes of vision
loss and death worldwide[2,4].
Test
Calcium
Albumin
Total Protein
Alk Phos
Amylase
Lipase
Cholesterol
LDL
HDL
Triglyceride
Vit A (Retinol)
Retinyl Palmitate
Thiamine
Vit B12
WBC
Hemoglobin
Hematocrit
MCV
MCH
Result
7.0 mg/dL
2.9 g/dL
6.3 g/dL
165 U/L
19 U/L
31 U/L
81 mg/dL
41 mg/dL
28 mg/dL
62 mg/dL
<0.06 mg/L
0 mg/L
0.2 ug/dL
753 pg/mL
10.9 x103 /uL
10.4 g/dL
33.7 %
86.2 fL
26.6 pg/cell
Normal Range
8.4-10.2 mg/dL
3.5-5.5 g/dL
6.1-7.9 g/dL
70-230 U/L
25-125 U/L
10-140 U/L
0-200 mg/dL
65-175 mg/dL
40-60 mg/dL
0-150 mg/dL
0.38-1.06 mg/L
0-0.10 mg/L
0.2 - 2.0 ug/dL
180-914 pg/mL
4.5-11.0 x103 /uL
12-16 g/dL
35-45 %
80-100 fL
26-34 pg/cell
Platelets
285 x103 /uL
150-450x103/uL
Protime
ESR
HLA-B27
ANA
Rh factor
SLE Anticoagulant
15.5 seconds
60 mm/hr
Neg
Neg
Negative
Undetected
11-15 seconds
0-25 mm/hr
HSV IgG
22
1.1 or greater
= positive
HSV IgM
0.41
<0.89=Negative
C-ANCA
< 1:20
Vitamin A is a fat-soluble vitamin that has three
forms: retinoic acid, retinol, and retinaldehyde.
Most people get their vitamin A through carotenoids, vitamin A precursors found in leafy green
and yellow vegetables. Other sources are synthetic
analogs (retinoids) and animal products. Vitamin A
plays significant role in maintenance of epithelial
surfaces of the conjunctiva and cornea as well as
phototransduction and retinal pigment epithelium
(RPE) viability[5,6,7].
One study of 170 patients found the prevalence of
vitamin A deficiency to be 52% and 69% of patients
one and four years after bariatric surgery, respectively[1].
Biliopancreatic diversion (BPD) is a malabsorptive
bariatric technique that involves a distal gastrectomy with subsequent shortening of the small intestine. The ileum is cut 200 cm proximal to the ileocecal valve and anastamosed to the gastric pouch. The
distal end of the proximal bowel is anastomosed to
the ileum 50 cm proximal to the ileocecal valve,
leaving only the last 50 cm of the small intestine
available for digestion and absorption[8].
Treatment of vitamin A deficiency involves replacement of vitamin A through either oral or intramuscular routes of administration, 200,000 IU daily for
two days. The same dose is repeated two weeks
later and then once every four to six months[9]. Intramuscular administration can be more efficacious
for patients with malabsorption. This patient was
given oral vitamin A supplements due to patient’s
reluctance to have injections.
<20 = Negative
Vitamin A can be toxic to the liver when given in
high dosages. Liver function tests should be ordered
when the vitamin A level is retested and patients
should be warned about the signs and symptoms
of liver failure when initiating such therapy. Topical retinoids may promote faster healing of corneal
ulcers but no significant improvement in final outcome has been noted[10].
to be caused by a combination of the metabolic
effects of vitamin A and protein deficiency. With
bacterial infection, bacterial toxins and enzymes,
in addition to the host inflammatory response, lead
to tissue destruction and perforation[11]. This case
could have been either a sterile corneal melt with
culture contamination or bacterial infection. Based
on the corneal infiltrates which cleared with antimicrobial treatment, it appears there was a bacterial
infection in addition to xerophthalmia.
In xerophthalmia, corneal ulceration and perforation
may occur as a sterile melt or by bacterial infection.
In sterile melts, progression and perforation seems
This case of xerophthalmia with keratomalacia and
corneal perforation was caused by chronic vitamin
A deficiency following bariatric surgery without
97
proper postsurgical nutritional supplements. Given
the increasing frequency of bariatric surgery seen
today, vitamin A deficiency needs to be on the differential diagnosis in any patient with corneal ulceration, with or without perforation. Careful examination for conjunctival keratinization should be
performed in all patients with corneal ulceration,
since this finding was the clue to this patient’s underlying etiology. Empiric vitamin A therapy should
be started immediately on any patient with a history
of bariatric surgery who demonstrates conjunctival
keratinization and corneal ulceration. One should
not wait for vitamin A level results[12]. Patients often report a dramatic change in energy levels and
ocular symptoms within days of starting vitamin A.
A multidisciplinary approach is important in bariatric surgery patients who develop hypovitaminosis
A with subsequent ocular involvement.
References
1. Slater GH, Ren CJ, Siegel N et al. Serum fat-soluble
vitamin deficiency and abnormal calcium metabolism after malabsorptive bariatric surgery. J Gastrointest Surg. 2004; 8: 48-55.
2. Lee BW, Hamilton SM, Harris, JP et al. Ocular complications of hypovitaminosis A after bariatric surgery. Ophthalmology 2005; 112: 1031-1034.
3. Vitamin A deficiency and xerophthalmia. Report of
a Joint WHO/USAID Meeting. World Health Organ
Tech Rep Ser. 1976; 590: 1-88.
4. Congdon NG, Friedman DS, Lietman T. Important
causes of visual impairment in the world today.
JAMA 2003; 290: 2057-2060.
5. Sommer A. Xerophthalmia, keratomalacia, and nutritional blindness. Int Ophthalmol. 1990; 14: 195199.
6. Powel SR, Schwab IR. Nutritional disorders affecting the peripheral cornea. Int Ophthalmol Clin.
1986; 26: 137-146.
7. Piric A. Xerophalmia. Invest Ophthalmol. 1976; 15:
417-422.
8. Scopinaro N, Gianetta E, Civalleri D, et al. Biliopancreatic bypass for obesity II. Initial experience
in man. Br J Surg. 1979; 66: 618-620.
9. Kunimoto D, Kanitkar K, Makar M. The Wills Eye
Manual Office and Emergency Room Diagnosis and
Treatment of Eye Disease Fourth Edition. Philadelphia: Lippincott Williams & Wilkins, 2004. p. 345346.
98
10. Smets KJ, Barlow T, Vanhaesebrouck P. Maternal
Vitamin A deficiency and neonatal microphthalmia:
complications of biliopancreatic diversion? Eur J
Pediatr 2006; 165: 502-504.
11. Cooney TM, Johnson CS, Elner VM. Keratomalacia
caused by psychiatric-induced dietary restrictions.
Cornea 2007; 26: 995-997.
12. Suan EP, Bedrossian EH Jr, Eagle RC Jr, Laibson
PR. Corneal perforation in patients with Vitamin A
deficiency in the United States. Arch Ophthalmol
1990; 108: 350-353.
Iris Vascular Malformations in Evaluation of
Spontaneous Hyphema
Virginia M. Utz, M.D.1, Daniel J. Pierre, M.D.1, John J. Weiter, M.D., Ph.D.2,
Johnny Tang, M.D.*1,3
University Hospitals Eye Institute, University Hospitals Case Medical Center, Cleveland, Ohio, 2Retina Specialists of Boston, Schepens Eye Research Institute, Harvard Medical School, Boston, Massachusetts, 3Retina Service,
Surgical Services, Research Service, Louis Stokes Cleveland Department of Veterans Affairs, Cleveland, Ohio
1
*Corresponding Author and email: [email protected]
Iris angiomas or microhemangiomas are small
vascular tufts present at the pupillary margin. In
some cases, recurrent hyphema or microhyphaema
leads to transient increased intraocular pressure and
secondary glaucoma[1-3]. Iris angiomas are distinguished from other vascular etiologies by their
unique fluorescein angiographic features[4]. Unlike
other vascular lesions of the iris of predominantly
congenital origin, these lesions are likely acquired,
and are predominantly found in patients over the
age of 50 years. Several systemic disease associations including hypertension, diabetes mellitus and
myotonic dystrophy have been described[1]. Thus,
iris hemangiomas should be considered in the differential diagnosis of spontaneous hyphema.
Report of a Case
A 61 year old woman who denied any significant
past medical history resented to the emergency
room with sudden onset painless blurred vision and
found to have a spontaneous hyphema OD. The
ophthalmology service was subsequently consulted. (Figure 1A). Her visual acuity OD was 20/400
and 20/20 OS. Intraocular pressure was within
normal limits. B-scan was completed at that time
None of the authors have any significant financial interests
related to the contents of this mansucript to disclose.
and was within normal limits. She was observed
closely without treatment. One month later, the hyphema resolved, however, small masses at the pupillary margin had become apparent in both eyes
(Figure 1B).
Anterior segment fluorescein angiography (FA)
revealed multiple hyperfluorescent foci at the pupillary margin with discrete feeder vessels (Figure
1C), consistent with a diagnosis of iris angioma.
Leakage of fluorescein was also present, but this
may be a normal finding with increasing age[5].
Working collaboratively with the patient’s internist,
the patient was evaluated for systemic causes such
as blood dyscrasias, diabetes and hypertension. The
patient was subsequently found to be hypertensive
and was placed on appropriate therapy.
The differential diagnosis of spontaneous hyphema
in the adult age group includes congenital and acquired vascular anomalies[2] and ischemia-related
neovascularization, acquired blood dyscrasias[6, 7],
iris nevi[8], as well as more ominous diagnoses
including malignant melanoma of the iris or ciliary body[9,10]. Vascular anomalies that may lead
to spontaneous hyphema include iris cavernous
hemangioma, iris microhemangioma, iris arteriovenous malformation, iris varix, and ischemia-related
neovascularization (Table 1). The specific disease
etiologies can be distinguished primarily by fluorescein angiographic findings, as well as by ancillary optical coherence tomography(OCT) and ultrasound biomicroscopy.
Our patient was managed with close observation.
Her intraocular pressure remained normal within
the observation period and so no treatment with
topical ocular anti-hypertensive agents was neces99
Iris Vascular Malformation - Utz et al
Figure 1A. Exterior photography, right eye. A thin trickle of blood (ARROW) is seen along the anterior lens
capsule, a hemorrhagic spot is seen on the lens (BLACK ARROW HEAD), and inferior faint microhyphema
(WHITE ARROWHEAD). Figure 1B. Exterior photography, right eye. One month after photo taken in A.
Microhyphema is resolved with a small mass on the pupillary border at site of prior bleeding (ARROW).
Figure 1C. Anterior segment fluorescein angiogram, right eye, film negative. Iris angiomas studding the
pupillary margin (BLACK ARROW HEADS) with individual feeder vessels (ARROW).
sary. Further treatment options described in the literature include laser photocoagulation or surgical
excision[11,12]. However, patients with multiple
episodes of spontaneous hyphema may describe
rapid, spontaneous resolution within days, which
suggests observation may be sufficient[12]. The
risks, benefits and alternatives of treatment of the
vascular tufts to prevent future recurrences of spontaneous hyphema were discussed thoroughly with
the patient, but the patient deferred intervention.
Discussion
To our knowledge, iris angiomas were first described in the literature by Paez Allende and colleagues in 1965[13]. A PubMed search of “iris
angioma” revealed 2 other articles with similar
findings[4,14]. Iris angiomas belong to the subgroup of iris microhemangiomas (IMH), which was
reviewed by Bakke and colleagues, with 32 total
reports including their own[1].
Clinically, iris angiomas consist of vascular tufts at
Table 1. Differential Diagnosis of Iris Lesions Causing Spontaneous Hyphema
Vascular Anomaly
Extent / Associations
Onset
Appearance
Pathology
Capillary hemangioma
Regional: periorbital capil- Infancy
lary hemangiomas
Multiple Iris hemangiomas
Packed
Infancy –
Adulthood
Multilobulated
Large cavernous
vascular spaces
Adulthood
Vascular tufts at
papillary margin
Systemic: Diffuse Neonatal Hemangiomatosis
Cavernous hemangioma
Local or Systemic:
Microhemangioma
Diabetes Mellitus
CNS, cuteneous
hemangiomas or DNH
Myotonic Dystrophy
Arteriovenous malformation
Local
Varix
Local
Blood-filled
Coiled capillaries
Hyphema
Adulthood
Tortuous, dilated
Telangiectactic vessels
Loops from iris root
to papillary margin
Adulthood
Circumscribed
Dilated vascular channel
Multilobulated
Central Thrombus
Blood-filled
Hyphema
100
Thin walled capillaries
the pupillary margin of tightly coiled with capillary
walls, which may be overlooked on clinical exam.
They tend to be bilateral, single or multiple, occur
in older patients (>60 years), but not in children,
in contrast to congenital iris capillary or cavernous hemangioma[2]. Importantly, anterior segment
fluorescein angiography (FA) may highlight the
extent and location of the lesions, and differentiate
among other vascular etiologies (Table 1). Pathologically, according to electron microscopic studies
by Meades et al.[12], the vessels in the lesion are
normal thick walled iris vessels consisting of the
normal bilayer of endothelial cells and pericytes
surrounded by loose connective tissue, an arrangement that remains patent despite iris movements.
Several associations have been suggested: diabetes, myotonic dystrophy, and hypertension, but no
etiology has yet been identified[1]. Concomitant
ocular manifestations include hypertension-related
vascular sclerosis and the presence of juxtafoveal
telangiectasia has been described[1]. In evaluating
patients with a spontaneous hyphema, careful evaluation at the slit lamp and anterior segment fluorescein angiography should be strongly considered.
The ophthalmologist may consider referral for further systemic evaluation for hypertension and diabetes in patients presenting with acquired vascular
anomalies such as iris angiomas.
This case demonstrates four out of the six ACGME
core competencies including medical knowledge,
interpersonal and communication skills, professionalism, and system-based practice[15]. Medical
knowledge is exemplified by the development of a
differential diagnosis, followed by systematic investigation to arrive at a probable diagnosis, and treatment plan. Iris hemangiomas are often overlooked
on examination, and this article raises awareness
of these lesions and their potential complications.
Interpersonal skills and patient communication are
exemplified in the informed consent process, which
also represents the physician’s ethical obligation to
the patient, thus exemplifying professionalism. The
patient is educated on the alternatives to treatment
which includes observation in which this patient
elects. Finally, system-based practice is demonstrated with the initial coordination of care between
the emergency department and ophthalmology service as well as by the consultation with the internist
to evaluate for potential systemic morbidities.
In summary, vascular anomalies such as iris an-
giomas should be considered in the differential diagnosis of spontaneous hyphema and can be distinguished by other vascular lesions by their FA
characteristics. Treatment may be indicated for recurrent hyphema or the development of secondary
glaucoma. Review of systems and careful evaluation of the retina should be completed for findings
associated with hypertension or diabetes and appropriate referral made.
Acknowledgements
This work was funded by research grants from the
Veteran Affairs Career Development Award and
Veteran Affairs Research Foundation Award.
References
1. Bakke EF, Drolsum L. Iris microhaemangiomas and
idiopathic juxtafoveolar retinal telangiectasis. Acta
Ophthalmol Scand 2006; 84: 818-822.
2. Broaddus E, Lystad LD, Schonfield L, Singh AD.
Iris varix: report of a case and review of iris vascular
anomalies. Surv Ophthalmol 2009; 54: 118-127.
3. Akram I, Reck AC, Sheldrick J. Iris microhaemangioma presenting with total hyphaema and elevated
intraocular pressure. Eye (Lond) 2003; 17: 784-785.
4. Amasio E, Brovarone FV, Musso M. Angioma of
the iris. Ophthalmologica 1980; 180: 15-18.
5. Brancato R, Bandello F, Lattanzio R. Iris fluorescein
angiography in clinical practice. Surv Ophthalmol
1997; 42: 41-70.
6. Koehler MP, Sholiton DB. Spontaneous hyphema
resulting from warfarin. Ann Ophthalmol 1983; 15:
858-859.
7. Kageler WV, Moake JL, Garcia CA. Spontaneous
hyphema associated with ingestion of aspirin and
ethanol. Am J Ophthalmol 1976; 82: 631-634.
8. Song WK, Yang WI, Lee SC. Iris naevus with recurrent spontaneous hyphema simulating an iris melanoma. Eye (Lond) 2009; 23: 1486-1488.
9. Beck BL, Notz RG. Spontaneous hyphema--initial
presentation for malignant melanoma of the iris ciliary body. Trans Pa Acad Ophthalmol Otolaryngol
1986; 38: 289-293.
10. Abi-Ayad N, Grange JD, Watkin E, De Bats M,
Fleury J, Kodjikian L, Gambrelle J.[Ring melanoma
revealed by spontaneous hyphema]. J Fr Ophtalmol
2007; 30: 729-732.
101
11. Strauss EC, Aldave AJ, Spencer WH, Branco BC,
Barsness DA, Calman AF, Margolis TP. Management of prominent iris vascular tufts causing recurrent spontaneous hyphema. Cornea 2005; 24: 224226.
12. Meades KV, Francis IC, Kappagoda MB, Filipic M.
Light microscopic and electron microscopic histopathology of an iris microhaemangioma. Br J Ophthalmol 1986; 70: 290-294.
13. Paez Allende F.[Angioma of the iris. (A case)]. Arch
Oftalmol B Aires 1965; 40: 138-139.
14. Cashell GT. Angioma of the iris. Br J Ophthalmol
1967; 51: 633-635.
15. ACGME Board. Common Program Requirements:
General Competencies In; February 14, 2007.
102
Correspondence
U.S. Citizens Attending Caribbean Medical
Schools and the Ophthalmology Residency
Selection Criteria
Jimmy Nguyen, B.S., M.S.III
St George’s University, Granada, West Indies
e-mail: [email protected]
Ophthalmology is a highly competitive residency in the U.S., and especially so for U.S. citizens
who graduate from Caribbean medical schools. Of
the 456 positions filled in the 2010 San Francisco
match, 415 (91%) were obtained by U.S. seniors
and only 28 (6%) positions were obtained by international medical graduates (IMGs)[1]. Further,
only 630 rank lists were submitted, so U.S. seniors
probably also comprised a vast majority of the
applicant pool. According to an analysis of U.S.
Graduate Medical Education (GME) in 2009, IMGs
constituted only 7% of all ophthalmology resident
physicians[2]. IMGs include both U.S. citizens who
attended Caribbean medical schools as well as foreign graduates, both recent graduates and senior
physicians from other countries. It is apparent from
the data that non-U.S. seniors are not only less successful at obtaining ophthalmology residencies but
fewer also attempt the match.
Looking at residency placements of the last 5 years
at St. George’s University School of Medicine and
Ross University School of Medicine, two of the better known and longer established medical schools
in the Caribbean where a majority of students enter
U.S. residencies, one or 2 graduates per year have
been able to match into ophthalmology[3,4]; however, this is a very small proportion of both schools’
large annual match lists, even after considering that
some ophthalmology matches may have gone unreported.
These statistics may give the impression IMGs are
simply weaker applicants; indeed, reports have
observed a high variability in the performance of
Caribbean medical students on the United States
Medical Licensing Examination (USMLE)[5,6].
However, in consideration of only the U.S. citizens IMGs who mostly attend Caribbean medical
schools, of which language and cultural barriers are
almost always non-issues, these students encounter
additional challenges that may at least contribute to
the disparity in application and match success between U.S. seniors and non-U.S. seniors in regards
to ophthalmology residency.
Perhaps the most obvious frustration facing a Caribbean medical student is the lack of access to
mentors within the field of ophthalmology. Lessell
notes how ophthalmic faculty members can be influential in advising medical students, such as what
electives to take and where, and how to evaluate
perspective residency programs[7]. However, because most Caribbean medical students only have
access to smaller community hospitals for their junior and senior year electives, most will have a hard
time finding such guidance. Instead, their information may come from peer-to-peer word of mouth,
web-sites such as Student Doctor Network and
ValueMD, and senior graduates. Especially since
exposure to ophthalmology is usually low relative
103
Caribbean Medical Schools - Nguyen
to other medical and surgical specialties, the lack of
support and mentor-ship may make the career decision extremely difficult.
According to Lessell, even most U.S. medical students have limited exposure to ophthalmology even
by their senior year. For undecided students, a clinical elective in ophthalmology would help formulate
their decision; further, since ophthalmology is an
early match, this elective should be taken as early
as possible to obtain the necessary recommendation letters[7]. This presents a two-fold problem for
Caribbean medical students. Besides the relatively
few ophthalmology programs and therefore few audition sites available, most institutions do not allow
foreign medical students to rotate through. Certainly the state that seems the most “foreign friendly”
is New York, with SUNY Upstate, SUNY Downstate, and SUNY Stony Brook among several that,
at least on paper, allow foreign medical students to
schedule audition electives in ophthalmology. In
other states, the process of audition could be expensive and oftentimes impossible without a personal
connection within the particular institution. However, institutions understandably preference elective spots for their own students, and opportunities
may not be available for the Caribbean student to
do an elective early enough to secure recommendation letters for ophthalmology’s early match. In
a recent survey of residency program directors on
the relative importance of selection criteria, recommendation letters were the most important criteria
pertaining to the ophthalmology specialty; audition
electives were ranked 12th in importance[8].
Lessell suggests that even ophthalmology residency
programs that are not research-oriented seem to appreciate research in assessing applicants[7]; however, many participants in research, especially at the
undergraduate and graduate levels, will agree that
in addition to hard work, perseverance, and dedication, some component of good chance is involved
in finding relevant research with a convenient publication timeline. Caribbean medical students have
the added obstacle of limited access, especially in
the basic science years where they are usually at
institutions with limited research resources. This
usually leaves the opportunity for clinical research
to mostly the hectic junior and early senior years, a
rather limited window for publications. Further, because community hospitals may not staff many researchers who successfully publish, students must
be especially cautious regarding which projects to
104
offer their participation; a poor choice could mean
months of effort without any concrete gain.
The literature on ophthalmology residency selection
has not discussed the relative importance of criteria
in respect to U.S. citizen graduates from Caribbean
medical schools, who may lack access to Alpha
Omega Alpha, academic awards, and research opportunities. Without some personal interaction, the
ability of a residency program to confidently assess
the caliber of a foreign medical student both academically and clinically may be relatively limited.
It is understandable that programs may choose to
avoid such risks when the applicant pool contains
numerous equally and better qualified U.S. seniors,
whom can be assessed with more confidence via
traditional criteria.
Especially pertaining to U.S. citizens attending foreign schools and even non-U.S. citizens well accustomed to the English language and American
culture, the principle issue is that even academically high achieving students are discouraged from
pursuing ophthalmology. The lack of support and
guidance personnel, difficulty in attaining audition
electives, early recommendation letters, and the
low match rate deter even competitive IMGs from
the ophthalmology specialty.
For Caribbean medical students interested in ophthalmology as a career, perhaps the best advice is
to stay motivated. Especially for offshore students
who have done well in basic sciences and on the
USMLE Step 1, an ophthalmology match is not impossible as indicated by the few Caribbean students
who do match year after year.
Early planning and application for audition electives are critical. This may require sending numerous emails and phone calls to program directors,
registrars, and visiting student coordinators across
the country to find programs with elective opportunities for their particular Caribbean medical school.
Because such early planning is needed, the decision
to pursue an ophthalmology career may oftentimes
precede sufficient exposure to the field; extensive
self-inquiry of the ophthalmology lifestyle and future research directions before committing to a decision may help prevent future disappointment.
Audition electives are probably the best opportunities for Caribbean students to prove they have the
personality and skills necessary to become successful in an ophthalmology career. These elective
usually allow for direct interaction with attendings
Caribbean Medical Schools - Nguyen
and staff involved in the residency selection at the
particular institution. Thus, the primary goal during these electives is to be especially impressive
through professionalism, sincere personal interactions, and academic diligence. During this time,
the astute student may also want to evaluate how
good of a “fit” they are and can be to the program,
and to consider how they can contribute to the programs’ direction and goals as a potential resident.
These assessments can improve their interactions
with supervisors, as well as, with the assumption
they will be invited for a residency interview, offer thoughtful answers to common interview questions. Overall, a successful audition elective may
give credibility to a Caribbean student’s application
at that particular institution even if they lack some
traditional U.S. senior selection criteria.
As opportunities for research within the field of
ophthalmology may be limited, Caribbean medical students will most likely decide to participate
in clinical research in other medical and surgical
specialties during their clerkship years to augment
their curriculum vitae. However, participation and
project selection should be very carefully considered. Caribbean students may want to learn more
about the researcher’s propensity to publish, how
far toward completion the project is, and the time
commitment necessary for authorship. If relevant
and timely research opportunities cannot be found,
students may find their time better invested in concentrating on USMLE Step 2 and preparing ahead
of their audition electives.
Perhaps shifts in the emphasis of certain criteria in
the ophthalmology residency selection process may
increase IMG applications. Recommendations have
suggested a re-evaluation of selection criteria as
well as a focus on selection of traits specific to ophthalmology that might predict success[9]. Foreign
medical students, especially U.S. citizens attending
foreign schools, may gradually feel more hopefully
in their chances and develop their interest and pursuit of ophthalmology. Residency programs may
find benefit from a larger applicant pool that should
conceivably increase the chances of matching and
producing competent ophthalmology physicians.
Till then, the advice to “stay motivated and have
a backup plan” remains a pearl of wisdom to the
relatively few Caribbean medical students trying to
enter this highly competitive specialty.
References
1. San Francisco Match. Ophthalmology Residency
Match Report- January 2010. (available at www.
sfmatch.org/residency/ophthalmology/about_
match/match_report.pdf). Accessed April 14, 2010.
2. Brotherton SE, Etzel SI. Graduate Medical Education, 2008-2009. JAMA. 2009; 302:1357-1372.
3. St. George’s University Alumni- SGU Alumni and
SGU Alumni Academic Accomplishments. Residency Appointments. (available at: www.sgu.edu/
alumni/student-profile-alumni-residency-appointments.html#residency). Accessed April 14, 2010.
4. Ross University School of Medicine. Ross Graduates- A Record of Achievement. (available at:
www.rossu.edu/medical-school/graduates.cfm). Accessed April 14, 2010.
5. van Zanten M, Boulet JR. Medical education in the
Caribbean: variability in medical school programs
and performance of students. Acad Med. 2008;83(10
Suppl):S33-6.
6. van Zanten M, Boulet JR. Medical education in the
Caribbean: variability in educational commission
for foreign medical graduate certification rates and
United States medical licensing examination attempts. Acad Med. 2009;84(10 Suppl):S13-6.
7. Lessell S. Advising Medical Students about Ophthalmology Electives and Residencies. J Acad Ophthalmol 2009;2(1):19-22.
8. Greene M, Jones P, Thomas JX. Selection Criteria
for Residency: results of a National Program Directors Survey . Academic Medicine. 2009; 84:362.
9. Lee AG, Golnik KC, Oetting TA, Beaver HA, Boldt
HC et al. Re-engineering the resident selection process: a literature review and recommendations for
improvement. Surv Ophthalmol 2008; 53:164-176.
105
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