Comparison Between the State of Ophthalmology Resident Training in the U.S. with International Standards Nizar Abdelfattah, MD Doheny Stein Eye Institute, Los Angeles, CA Department of Ophthalmology, University of California – Los Angeles

Background The International Council of Ophthalmology (ICO) set a series of rules and regulations regarding the competencies & skills every ophthalmology resident should achieve before graduation. Before these regulations, residency programs provided residents with variable skill levels in each subspecialty. In the US, the ACGME sets the guidelines and follows up residency programs’ performance. However, US programs have never been studied in comparison to international standards.

Purpose The purpose of this study is: To evaluate the performance of American ophthalmology residency programs in achieving the competencies outlined by the International Council of Ophthalmology (ICO) and to assess residents’ satisfaction with their training programs

Design and Participants Cross-sectional web-based survey: United States ophthalmology residents enrolled in the final 2 years of their residency program as well as recent graduates within 1-4 years of graduation.

Survey A previously published survey that was extracted from the guidelines of the ICO was used in this study. In these guidelines, the basic level corresponds to the U.S. Post-graduate year (PGY)-2, standard level corresponds to the U.S. PGY-3, and the advanced level corresponds to the U.S. PGY-4. The guidelines were listed as educational points and areas which every ophthalmology specialist should be able to master.

Methods The survey was sent to 88 ACGME-accredited ophthalmology residency program directors and chairmen across the US: Contact information for program directors and chairmen was accessed through the American Medical Association, or Fellowship and Residency Electronic Interactive Database (FREIDA Online).

Methods Program directors were requested to forward the survey to their senior residents in PGY-3 & PGY-4, and recent graduates of 2014, 2013, 2012, and 2011: It was made very clear to all surveyed individuals that the data was being kept confidential, and the residency programs would not be able to see the individual respondents answers.

Methods Graduates and eligible residents were invited to participate in the 23-item survey during the winter of 2014: Data were categorized by demographic variables, and basic statistics were performed regarding satisfaction, teaching quality, surgical volumes, clinical and nonclinical skills and in-service exam performance.

Results Overview and Demographics: Of the 88 programs surveyed, responses were received from 34 (38.6%) with a total of 87 individuals responding (61 current residents, 26 graduates). Residents in PGY-3 composed 29.9% of the cohorts (26), with residents in PGY-4 represented 40.2% (35). Graduates were mostly within one year of graduation (15), with fewer graduates within two years (7), within three years (3), and within four years of graduation (1).

Results Overview and Demographics: Most graduates were currently working in a community private practice (53.9%). Those having current academic appointments comprised fewer than 16%. All the remainder were current fellows receiving their fellowships in the US, except for one respondent receiving their fellowship internationally.

Results Overall Residency Satisfaction Most respondents reported satisfaction with their programs, with 48.7% rating as very satisfied, and 44.8% rating satisfied. When we stratified the cohort, satisfaction levels were around similar regardless of the training level (92.3% for PGY-3, 94.3 for PGY-4, and 92.3% for graduates, rating as satisfactory or better).

Results Overall Residency Satisfaction Most respondents felt very satisfied with the case volume, case complexity, and case variety in their programs (83.5, 87.3, and 86.1% being satisfied or very satisfied). When stratified, residents in PGY-3and PGY-4 revealed lower satisfaction level with case volume and complexity (77.8, 77.8% respectively).

Results Quality of Teaching Most respondents rated the satisfaction with the teaching curriculum as satisfied or higher. The elements of the curriculum included didactic courses (77.2%), operating room (88.6%), outpatient clinic (84.8%), grand rounds (84.8%), wet labs (77.2%), conferences (83.5%), and journal clubs (73.4). The only elements that received lower levels of satisfaction were hospital rounds (49.4%), and among residents in PGY-3, journal clubs (68.8%).

Results Surgical Volumes Among all participants, 43% of respondents performed <50 cataract phacoemulsification surgeries, 77% performed <10 trabeculectomy or tube shunts, and 58% performed <20 strabismus surgeries. During their entire residency, 38% of graduates performed 150 – 200 cataract surgeries. Around 43% of PGY-4 residents performed 50 – 99 cataract surgeries, while all PGY-3 residents performed < 50 cataract.

Results Surgical Volumes None of PGY-3 residents performed any trabeculectomy or tube shunt surgeries, and 43% of PGY-4 performed 1 – 10 of these surgeries. Graduates reported that 27% of them performed 10 – 20 trabeculectomy surgeries during their residencies. Both PGY-3 and PGY-4 residents had performed 10 – 20 strabismus surgeries (41% and 43%), while 27% of graduates performed a similar number.

Results Ophthalmology Skills – general General skills such as prescribing glasses, contact lenses, phacoemulsification, extracapsular cataract surgery, toric IOL implantation, refractive surgery, and cornea surgery revealed variable levels of comfort to residents and graduates. Largest percent of residents and graduates were feeling comfortable prescribing glasses (100% of PGY-4 residents), phacoemulsification (100% of graduates), and toric IOL implantation (96% of graduates).

Results Ophthalmology Skills – general surgeries However, lowest percent of residents and graduates were feeling comfortable performing refractive surgery (0% of PGY-3 residents), extracapsular cataract extraction (18% of PGY-4 residents), and contact lens prescription (23.5% of PGY-4 residents).

Results Ophthalmology Skills – glaucoma Performing glaucoma ALT, AST, and managing glaucoma complications seemed to be a point of strength for residents and graduates in the US. More than 90% of PGY-4 residents reported comfort in performing glaucoma procedures, and 68% of them reported comfort in managing glaucoma complications. Graduates reported even a higher level of comfort, with 85% reporting comfort in managing glaucoma complications.

Results Ophthalmology Skills – posterior segment Most (82.3%) PGY-4 residents also reported comfort in management of posterior segment diseases, though only 8% reported comfort in performing vitreoretinal surgical procedures.

Results Ophthalmology Skills – oculoplastic Most respondents commented favorably on oculoplastic procedures. More than 60% felt comfortable managing lid trauma, orbital trauma, lid surgery, enucleation, and conjunctival tumors. However, only 44% of PGY-4 residents and 31% of graduates felt comfortable performing lacrimal surgeries.

Results Ophthalmology Skills – pediatrics Pediatric ophthalmology skills were variable in comfort levels between residents and graduates. Most respondents felt comfortable in clinical pediatric encounters (81.6%). Less than 65% of PGY-4 felt comfortable managing strabismus in children, and 54% of graduates felt the same. Retinopathy of prematurity management and low vision rehabilitation were skills that only 38% expressed comfort with..

Results Non clinical areas In these areas, respondents were asked if their programs provided them with sufficient exposure to areas such as professionalism, practice management, administrative skills, ethics, practice settings, and information technology. Most respondents commented favorably on professionalism and ethics (81.5% and 82.8%), while few confirmed that they had exposure to practice management (42.1%) or administrative skills (23.6%)

Results In Service Exam Performance Most respondents stated that they were given adequate and timely feedback regarding clinic and outpatient performance (81%), operating room performance (89%), and had time and opportunities to discuss progress with program director (93%). Also, the majority of respondents commented favorably that their programs prepared them adequately to perform well on their OKAP examinations (72% of graduates, 70% of PGY-4 residents).

Conclusions Take Home Message U.S ophthalmology residents express high levels of satisfaction with their residency training programs. Although most programs appear to adequately address most ICO core objectives, certain curriculum modifications should be considered.