Supervision and autonomy of ophthalmology residents in the outpatient Clinic in the United States: a survey of ACGME-accredited programs

Assessment of Ophthalmology Residency Training in Switzerland: A Trainee-Based Survey

BACKGROUND

This study aimed to evaluate the current status of ophthalmology residency training in Switzerland and provide insights for enhancing training programs.

MATERIALS AND METHODS

The survey covered demographic data such as gender, age, workplace, and year of residency, as well as working conditions, current practical and diagnostic skills, interest in scientific work, and future plans. It consisted of 16 multiple choice questions (MCQ), 5 multiple select questions (MSQ), 8 free-text, 6 Net Promoter Score (NPS), and 4 Likert scale questions. All Young Swiss Ophthalmologists (YSO) members received an invitation to participate in the survey using an online form. All collected data were anonymized, and participants provided their consent for data collection, analysis, and publication.

RESULTS

The survey assessed the perspectives of 63 Swiss ophthalmology residents on their training experiences. Respondents indicated the greatest interest in specializing in cataract and vitreoretinal surgery, followed by cornea, glaucoma, refractive surgery, and lid surgery. They also expressed a great need for improved supervision, structured curricula, and alignment of clinical and research duties. While pursuing additional surgical training and private practice autonomy, residents also expressed a preference for balanced workloads that emphasize patient care over full-time academic work.

CONCLUSION

The survey indicates a need to standardize ophthalmology residency training in Switzerland to ensure comprehensive and uniform education. It also highlights specific areas for improvement, such as the absence of surgical training. Ongoing assessments are necessary to evaluate future developments.

Association Between Teaching Clinic Structure and the Readiness of Ophthalmology Residents to Enter Independent Practice

OBJECTIVE

Our objective is to determine if the structure of Graduate Medical Education teaching clinics is associated with how well ophthalmology residents are prepared to meet the workload demands of independent clinical practice.

DESIGN

Resident preparedness to enter independent practice was measured by the Readiness Index. Part of the Department of Veterans Affairs' new Workload-based Resident Academic Performance measures (WRAP), resident readiness is computed from electronic health records for residents by clinic and service-date. The index compares resident productivity net of supervision and adjusted for care quality to the average productivity of non-supervising ophthalmologists. Readiness comprises a Workload component (ratio of resident gross productivity to the average productivity of non-supervising ophthalmologists) and Supervision component (ratio of resident net of supervision to gross productivity). Teaching clinic factors include resident postgraduate-year level, resident-to-physician staff ratios, patient care complexity, and program size. Covariates include time into the academic year, facility quality ranking and complexity rating, and attending physician productivity rate.

SETTING

Study setting is 109 ophthalmology outpatient clinics from the United States Department of Veterans Affairs and its 1,300 annual ophthalmology resident positions rotating on 84,600 ophthalmology clinic-days during academic years from July 1, 2015, through June 30, 2019.

PARTICIPANTS

An average 2.6 residents at a second-year or higher saw 25.0 patients requiring 93.6 relative value units (RVUs) of workload.

RESULTS

Senior ophthalmology residents from clinics with higher resident-to-physician ratios had greater practice readiness than their counterparts primarily from having greater progressive autonomy from supervision. Residents from larger programs treating more complex patients had only slightly greater practice readiness than their counterparts primarily from having greater workload productivity.

CONCLUSIONS

The readiness of ophthalmology residents to enter independent practice is associated with their academic level and resident-to-physician staff ratios, and to a lesser extent care complexity and program size.

Ophthalmology Residency in the United States: The Case for a National Curriculum

To identify strategies for effective curriculum development and implementation in United States (US) ophthalmology residency training programs. A literature review was conducted for all English-language PubMed/Medline articles relating to ophthalmology residency education or curriculum/curricula. Despite ACGME-defined program requirements outlining curricular goals for US ophthalmology residency training programs, there is no comprehensive, national curriculum with detailed plans for instruction of necessary topics within the 36-month residency training period. Several articles identify a need for detailed curricula on various topics, propose ideas on how residency programs could create curricula, and explore ways of assessing resident competence. There is a paucity of literature evaluating how ophthalmology residents best learn various ophthalmology topics. We need to develop an intentional, comprehensive, and timely national curriculum for ophthalmology residency programs in the US, with detailed plans on how to meet curricular objectives and consideration of the most effective teaching strategies for different ophthalmology concepts.

Survey of Ophthalmology Training Experiences Among Young Ophthalmologists in the Asia-Pacific

PURPOSE

To describe ophthalmology training experiences across the Asia-Pacific (APAC).

DESIGN

Survey study.

METHODS

We utilized an anonymous online survey, which was previously validated and conducted in Europe, through Young Ophthalmologist leaders from the national member societies of the Asia-Pacific Academy of Ophthalmology (APAO) from September 2019 to July 2021. Responses were based on a 5-point Likert scale (where applicable) and data were analyzed using Microsoft Excel. Our main outcome measures were differences between regions, that is, Southeast Asia (SEA) and Western Pacific (WP); and seniority, that is, trainees/junior ophthalmologists and senior ophthalmologists.

RESULTS

We collated 130 responses representing 20 regions in the APAC region. The year of completion of ophthalmic training ranged from 1999 to 2024. The mean duration of training was 3.7±1.0 years. Most (98/130, 75%) indicated an interest for a common training standard across the APAC. Comparing SEA and WP trainees, both regions had similar working environments, but those in SEA reported significantly lower remuneration than their counterparts in WP ($600 vs $3000, P <0.05). WP trainees performed more phacoemulsification surgeries (76 WP vs 19 SEA), while SEA trainees conducted more manual small incision cataract surgeries (157 WP vs 1.5 SEA per duration of training). Senior ophthalmologists performed more cataract surgeries (210.9 senior ophthalmologists vs 40.1 junior ophthalmologists). Trainees had less confidence in medical competency areas such as interpreting an electroretinogram/visual evoked potential/electrooculogram (SEA=1.8, WP=2.1) and conducting an angiography (SEA=2.8, WP=3.4).

CONCLUSIONS

Our study highlighted heterogeneity among ophthalmology training experiences in the APAC region, with the majority indicating an interest in a common training standard.

A Systematic Analysis of the Impact of an Ambulatory Ophthalmology Urgent Care Clinic

Importance A same-day ophthalmic urgent care clinic can provide efficient eye care, a rich educational environment, and can improve patient experience.

Objective The aim of this study was to systematically evaluate volume, financial impact, care metrics, and the breadth of pathology of urgent new patient encounters based on their site of initial presentation.

Design, Setting, and Participants A retrospective analysis was performed on consecutive urgent new patient evaluations in our same-day triage clinic at the Henkind Eye Institute at Montefiore Medical Center between February 2019 and January 2020. The cohort of patients who presented directly to this urgent care clinic were referred to as the “TRIAGE” group. Patients who initially presented to an emergency department (ED), and were subsequently referred to our triage clinic, are referred to as the “ED + TRIAGE” group.

Main Outcomes and Measures Visits were evaluated on a variety of metrics, including diagnosis, duration, charge, cost, and revenue. Furthermore, return to the ED or inpatient admission was documented.

Results Of 3,482 visits analyzed, 2,538 (72.9%) were in the “TRIAGE” group. Common presenting diagnoses were ocular surface disease (n = 486, 19.1%), trauma (n = 342, 13.5%; most commonly surface abrasion n = 195, 7.7%), and infectious conjunctivitis (n = 304, 12.0%). Patients in the “TRIAGE” group, on average, were seen 184.6% faster (158.2 vs. 450.2 minutes) than patients in the “ED + TRIAGE” group (p < 0.001). The “ED + TRIAGE” group were furthermore found to generate 442.1% higher charges ($870.20 vs. 4717.70) and were associated with 175.1% higher cost ($908.80 vs. 330.40) per patient. The hospital was found to save money when noncommercially insured patients with ophthalmic complaints presented to the triage clinic instead of the ED. Patients seen in the triage clinic had a low rate of readmission to the ED (n = 42, 1.2%).

Conclusions and Relevance A same-day ophthalmology triage clinic provides efficient care, while providing a rich learning environment for residents. Less wait time with direct access to subspecialist care can help improve quality, outcome, and satisfaction metrics.

The perceived impact of the Covid-19 pandemic on medical student education and training - an international survey

BACKGROUND

The Covid-19 pandemic led to significant changes and disruptions to medical education worldwide. We evaluated medical student perceived views on training, their experiences and changes to teaching methods during the pandemic.

METHODS

An online survey of medical students was conducted in the Autumn of 2020. An international network of collaborators facilitated participant recruitment. Students were surveyed on their perceived overall impact of Covid-19 on their training and several exposure variables. Univariate analyses and adjusted multivariable analysis were performed to determine strengths in associations.

RESULTS

A total of 1604 eligible participants from 45 countries took part in this survey and 56.3% (n = 860) of these were female. The median age was 21 (Inter Quartile Range:21-23). Nearly half (49.6%, n = 796) of medical students were in their clinical years. The majority (n = 1356, 84.5%) were residents of a low or middle income country. A total of 1305 (81.4%) participants reported that the Covid-19 pandemic had an overall negative impact on their training. On adjusted analysis, being 21 or younger, females, those reporting a decline in conventional lectures and ward based teaching were more likely to report an overall negative impact on their training (p ≤ 0.001). However, an increase in clinical responsibilities was associated with lower odds of participants reporting a negative impact on training (p < 0.001). The participant's resident nation economy and stage of training were associated with some of the participant training experiences surveyed (p < 0.05).

CONCLUSION

An international cohort of medical students reported an overall significant negative impact of the Covid-19 pandemic on their undergraduate training. The efficacy of novel virtual methods of teaching to supplement traditional teaching methods warrants further research.

A Qualitative Study of the Barriers and Benefits to Resident Education in Ambulatory Surgical Centers

OBJECTIVE

As Ambulatory Surgical Centers (ASCs) become more common in academic medical centers, large hospital systems must determine how to shift resident education from inpatient to outpatient surgical centers. This study aims to define stakeholders' views regarding the integration of surgical residents into ASCs.

DESIGN

Long-form interviews lasting 30 to 60 minutes were conducted. Interviews were hand-transcribed and analyzed by qualitative analysis to determine benefits of learning in ASCs for residents, challenges that arise from integrating residents, and recommendations to improve resident incorporation.

SETTING

Interviews were conducted using a video conferencing platform.

PARTICIPANTS

Residency program directors, attending surgeons, graduate medical learners, and a nursing manager were interviewed. Twenty-one total interviews were conducted, representing ten different departments.

RESULTS

Stakeholders agreed that residents benefit from being placed in ASCs because the fast, surgical pace allows the residents to engage in more cases. However, different stakeholders highlighted different challenges, all centered around the notion of inter-stakeholder conflict due to conflicting priorities among residents, attending physicians, and administration. Likewise, recommendations differed by stakeholder group-faculty members sought more defined learning objectives and enhanced communication, whereas residents desired that ambulatory surgical time be more structured.

CONCLUSIONS

Despite the pressures of rapid case turnover, stakeholders agreed that there are many benefits to resident education in ASCs. Findings related to challenges and recommendations support the need to strengthen communication between stakeholder groups and better plan for resident integration into ASCs.

Cost and Visit Duration of Same-Day Access at an Academic Ophthalmology Department vs Emergency Department

Importance

Convenient outpatient access for ophthalmology patients seeking urgent care could offer savings compared with an emergency department (ED) visit.

Objective

To evaluate the costs and visit durations of same-day access (SDA) in an ophthalmology department at an academic medical center vs ED care.

Design, Setting, and Participants

This single-center study was a retrospective quality improvement analysis of an institutional electronic medical record system at the Wilmer Eye Institute clinics and the Johns Hopkins Hospital ED. On June 1, 2015, the Wilmer Eye Institute and Johns Hopkins Hospital initiated an official policy of providing SDA to patients calling for appointments (ie, the same-day project). All ophthalmology clinic locations created same-day appointment slots for at least 1 practitioner. In recognition of seasonal variations in patient visit volumes, the 10 months before implementation (August 1, 2014, to May 31, 2015) were compared with complementary periods in 2015 to 2016 and 2016 to 2017.

Main Outcomes and Measures

The study tabulated encounters, charges, and visit length for outpatients seen on the same day or by previously scheduled appointments. For the ED patients, volume, diagnoses, charges, and length of stay data were collected. The numbers of SDA patients who indicated urgency were tabulated.

Results

The number of SDA patients increased from 22 781 to 26 579 for the first year after SDA implementation. The mean charge was $258 (95% CI, $250-$266; median, $184; interquartile range [IQR], $175-$320), and the mean clinic transit time was 1.55 hours (95% CI, 1.54-1.57 hours; median, 1.28 hours). For patients seeking eye care in the ED, the mean professional fee was $401 (95% CI, $390-$411; median, $360; IQR, $255-$500), the mean (SD) total hospital charge was $1040 ($999) (95% CI, $729-$1079; median, $1002; IQR, $334-$1429), and the mean length of stay was 7.30 hours (95% CI, 7.01-7.57 hours; median, 7.20 hours). The top 4 ophthalmic diagnoses for ED patients were conjunctivitis, cornea abrasion, iritis, and visual loss, which were unchanged after SDA implementation. In calendar year 2017, a total of 4062 SDA patients reported urgency; their estimated savings in charges compared with an ED visit were $580 866 in professional fees and $3 176 484 in hospital charges.

Conclusions and Relevance

Same-day access appears to be less expensive and to require less time in the health care system than a visit to the ED for an ophthalmic diagnosis. Substantial savings in time and money might be achieved if urgent eye care is delivered in the clinic rather than the ED.

Supervision and autonomy of ophthalmology residents in the outpatient clinic in the United States II: a survey of senior residents

BACKGROUND

A balance between autonomy and supervision can be difficult to obtain in medical education. In this study, we sought to determine whether the presence and level of supervision of ophthalmology resident outpatient clinic correlates with metrics of resident success, professionalism and stress.

METHODS

A survey was emailed to all US ophthalmology program directors requesting it be forwarded to PGY4 residents. Questions included whether their program provided a resident-hosted outpatient clinic, and if so, whether residents were mandated to discuss every patient with faculty. Residents were assigned to three categories based on this question (0: no clinic, 1: mandated faculty input, 2: discretionary faculty input). Success metrics included numbers of manuscripts submitted, OKAP scores and success in obtaining fellowships. Professionalism metrics included rating comfort obtaining informed consent, breaking bad news, managing time in clinic, and confidence in providing care in various settings. Residents affirming participation in a continuity clinic also provided perceptions of the level of supervision and how the clinic affected stress.

RESULTS

Category 1 residents perceived somewhat too much supervision, while category 2 residents felt that they had somewhat insufficient supervision. The majority of residents in either category did not feel that the continuity clinic affected their overall stress, although those who reported a change in stress usually indicated that the presence of the clinic increased stress. There were no other statistically significant differences between the responses from any category.

CONCLUSIONS

The presence of a resident-hosted continuity clinic neither adds nor detracts from the success or sense of professionalism of ophthalmology residents. However, when such a clinic is present, the degree of supervision appears to correlate inversely with resident perception of autonomy. These results suggest that the decision of a training program to offer a clinic hosted by residents offering comprehensive continuity care can be informed primarily by faculty and trainee philosophy and personal preferences without comprising education quality, clinical efficiency, residents' perception of stress or their success in fellowship matching.

Implementation of an Orthopedic Trauma Program to Safely Promote Resident Autonomy

BACKGROUND

There is ongoing tension in graduate medical education between progressive resident autonomy with entrustable professional activities and the need for supervision to ensure patient safety.

OBJECTIVE

We implemented a pediatric orthopedic surgical trauma safety program that utilized a postcall review conference to provide residents graduated responsibility learning opportunities during overnight trauma call without compromising patient safety.

METHODS

In the program, all orthopedic trauma cases seen in our main tertiary hospital emergency department by the overnight orthopedic resident were reviewed in a case conference. For 1 year, we performed an analysis of all fracture patients who were treated in the emergency department by our orthopedic surgery residents. From June 1, 2016, through June 30, 2017, all care delivery encounters were reviewed for decision-making errors, technical errors, and complication rates. Two resident groups rotated through our institution over the course of the study.

RESULTS

During the year of analysis, all 1298 fracture patients seen overnight in the main tertiary hospital emergency department were reviewed. From the first to the second halves of their rotations, the rate of resident decision-making errors (3.1% [12 of 385] to 2.3% [9 of 399]) and technical errors (9.1% [35 of 395] to 7.3% [29 of 399]) decreased. Excluding decision-making and technical errors, the complication rate for patients discharged home was 3.4% (27 of 784).

CONCLUSIONS

Residents demonstrated decreased decision-making and technical error rates on overnight call while maintaining low complication rates.