Low clinical and surgical volume

[phacoforever]

I just started my ophthalmology residency and heard on orientation that the seniors only see five patients a day at their VA clinic. Honest souls they are, one also shared she is trying incredibly hard to get up to 150 cataracts by the time she leaves residency. This wasn't what I expected when I interviewed at the program, and I am very worried about the low clinical and surgical volume, and what it might mean for the quality of my training. What can I do to make sure I'm not underprepared coming out of residency?

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[cubsrule4e]

I just started my ophthalmology residency and heard on orientation that the seniors only see five patients a day at their VA clinic. Honest souls they are, one also shared she is trying incredibly hard to get up to 150 cataracts by the time she leaves residency. This wasn't what I expected when I interviewed at the program, and I am very worried about the low clinical and surgical volume, and what it might mean for the quality of my training. I'm worried that I'll receive inferior training. Is there anything I can do about this, and what can I do to make sure I'm not a poorly trained ophthalmologist coming out of residency?

What is the clinic volume for the first two years, and how many locations do you cover? As seniors, you should already have had the bulk of your clinical skills and knowledge built up, and at that point be concentrating on surgery. Honestly for much of my time in PGY4 outside of our 4 month off site rotation, all I was doing in clinic was pre-op/post ops and helping out the first years. As for surgery, you dont have to do 300+ phacos to be decently trained, even though the numbers are all the rage. I want to say I was just shy of 200 and was operating on my own on even the toughest cases, as well as scrubbing in to help teach PGY3s during the last month of training. 150 is still 50-something over the minimum. Its really about the quality of teaching over the quantity. I routinely do 20 phacos a week with an average of 5-6 minutes/case, because I had awesome teaching. If the teaching aspect isnt that strong (ask for their thoughts on that) then it certainly wouldnt hurt for the numbers to be higher, but I wouldnt be worried that youre not getting at least adequate training.

 

[MstaKing10]

5 patients a day in clinic is a waste of time. If that’s true, then this should be brought to the attention of the PD as they may not be aware of the problem. That seems very odd. Surgical numbers are highly variable but I think 150 is a solid number. More is always better. Not sure I would get too worked up as you are just beginning but certainly keep on the lookout for areas of improvement and use every patient encounter and time with attendings to absorb as much information as possible.

 

[ocularis]

How much of the training is at the VA clinic? How many patients are the first and second years seeing at the VA? (Maybe this is a seniority thing where seniors actively try to see less ...) Have there been some changes since you interviewed? You can only embelish things relatively at interview time, usually you get a pretty good feel during interviews and from word of mouth, and there is an expectation of honesty about numbers that cannot be hidden. Just some thing to think about it, it may not be as bad as you think.

150 sounds like a fair number for the majority of the country. As said above, quality not quantity is key.

As far as what you can do - be as proactive as you can, read a lot around what you do see to maximize learning from each experience, try to get some advice from seniors to see how they have managed it, considering speaking with your PD at a later point.

 

[Slide]

150 is a good number if the pathology and difficulty is wide in spectrum. Your numbers reflect partially on how aggressive you are in seeking out more phacos (ethically I would add); if you want more numbers you can probably find more I’d motivated. Some seniors start to run out of steam from residency and putter out on signing up more
Cataracts as the year ends.

 

[WhatNEyeTem]

It is always better to have more vokume in surgery. Some programs espouse "quality over quantity" because, well, their quantity stinks. I hear that adage being tossed around more at the super academic (but low volume) programs like Wilmer.

 

[DrZeke]

I just started my ophthalmology residency and heard on orientation that the seniors only see five patients a day at their VA clinic. Honest souls they are, one also shared she is trying incredibly hard to get up to 150 cataracts by the time she leaves residency. This wasn't what I expected when I interviewed at the program, and I am very worried about the low clinical and surgical volume, and what it might mean for the quality of my training. I'm worried that I'll receive inferior training. Is there anything I can do about this, and what can I do to make sure I'm not a poorly trained ophthalmologist coming out of residency?

If you want to do comprehensive, I recommend maximizing what you see by reading extensively and watching videos. If that is not enough for you, then if it's cataract surgery you are concerned about you can do a mission trip/course in India and add volume that way. It does not count towards your case logs, but still helps.

If you think you want to do subspecialty then it doesn't matter, you will do fellowship and you will supplement a low volume/limited pathology education. Another great option is to do cornea/refractive if you think you wanna do comprehensive. Many people will do glaucoma or cornea and still do a good amount of comprehensive.

150 is not that bad. I finished with less than that and felt ok with cataract surgery. I only barely hit my minimum for globes and glaucoma and cornea. Cataracts are not the only thing that matter depending what type of job you will take.

 

[TheLesPaul]

if it's cataract surgery you are concerned about you can do a mission trip/course in India and add volume that way

That's a really ****ty attitude that I hope dies with this generation of residents. International missions trips are just that -- missions. Not a way to add volume for trainees. There are plenty of cataract surgeons much better than you in India who can take care of these people, much more efficiently.

It is always better to have more vokume in surgery. Some programs espouse "quality over quantity" because, well, their quantity stinks. I hear that adage being tossed around more at the super academic (but low volume) programs like Wilmer.

110% agree. Quality over quantity is BS, especially in cataract surgery, where residents create their own "quality" by getting into various situations that are difficult to get out of...

 

[DrZeke]

That's a really ****ty attitude that I hope dies with this generation of residents. International missions trips are just that -- missions. Not a way to add volume for trainees. There are plenty of cataract surgeons much better than you in India who can take care of these people, much more efficiently.

Personally I wouldn’t do it, but I spoke with someone who did a course like this and found it very helpful. Since you think it’s so awful... What would you do if you came out of residency with 100 cases? And felt unprepared?

 

[MstaKing10]

Personally I wouldn’t do it, but I spoke with someone who did a course like this and found it very helpful. Since you think it’s so awful... What would you do if you came out of residency with 100 cases? And felt unprepared?

A fellowship maybe?

 

[DrZeke]

I agree with this, because I'm doing two fellowships. I basically am of the mind that if you want to sub specialize, you should do fellowship. Or if you feel like you were undertrained in residency you should do fellowship.

However, there are people who do not want to take an extra year to do fellowship. I have spoken to people who told me they did courses in India and felt it was a good way to expand their skillset or build on skills they already had. LesPaul implies there is something wrong/bad about those courses. Can anyone else comment on those 2-4 weeks courses that are advertised?

 

[TheLesPaul]

Those who don't want to take an extra year to do fellowship need to put on their big boy pants and learn on the job like everyone else. If 100 cataracts is inadequate (which I think it is), ACGME needs to revise their minimums.

Taking a course in something unique (MSICS) is different from practicing phaco under the guise of medical missions. There is something unethical about practicing surgery in a country where you have no way to deal with complications, and the patients have no idea that you are essentially a trainee.

Informed consent shouldn't disappear because you got on a plane, and the so-called "course directors" are equally culpable if they haven't told their patients who is operating on them (which they do in a reputable place like Aravind).


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[airplanes]

Nice prior discussion on resident cataract volume here: Surgical volume and the mysterious 90th percentile

Someone there also linked the 2014 numbers: http://www.acgme.org/Portals/0/Opthalmology_National_Report_Program_Version.pdf
Here are the numbers for the 2017 graduating class: http://www.acgme.org/Portals/0/PDFs/240_National_Report_Program_Version_2016-2017.pdf

Average went up from 161 to 186. Average anterior vitrectomies were 1.5, which is interesting because most studies have resident vitrectomy rates pegged between 3-6%! Hmm.

Phaco numbers are all based on self-reported data and prone to bias. Are there places where Attendings and Residents both keep separate logs so at least two people confirm the numbers? At our program, only the residents kept track and some residents are obviously better at that than others.

All that being said, to OP, 150 is a fine number. Someone with 300+ will likely be more comfortable out the gate, but you'll be fine.

 

[Equality]

There can be a big range of cataract numbers even within a single program because if a resident is "good" at surgery, they'll obviously get to do more than someone who keeps dropping lenses or cause other problems that take time to fix. And yes it's normal to work harder to get more cataracts (i.e. see more patients, keep track of who had one eye done and is ready for second eye, or keep track of people who cancelled due to weather, flu, etc).

Even if you end up with "only" 100 cataracts or so, ultimately you will be okay. I do find it a bit shocking that someone reported total primary cataract count of 372 in 2017...

 

[Fascia Lata]

I agree with this, because I'm doing two fellowships. I basically am of the mind that if you want to sub specialize, you should do fellowship. Or if you feel like you were undertrained in residency you should do fellowship.

However, there are people who do not want to take an extra year to do fellowship. I have spoken to people who told me they did courses in India and felt it was a good way to expand their skillset or build on skills they already had. LesPaul implies there is something wrong/bad about those courses. Can anyone else comment on those 2-4 weeks courses that are advertised?

I did a couple of those (I currently am an attending at a US institution). There are 2 points here. First thing, quality varies. There are really good training opportunities where they give you many cases of different difficulty levels: soft, hard, intumescent, small pupils, loose zonules, malyugins, CTRs, hooks, management of intraop complications, and others that would take over the case if the rhexis runs out and all 2+NS single technique (prolapse nucleus). So you need to do your homework and find out which ones are really good (typically NOT the better known places). Second thing, it is best to delay this experience as much as possible when you are better trained. It is a waste of time and money to go when you are still novice. PM me if you need recommendations.

 

[hello lady!]

It is always better to have more vokume in surgery. Some programs espouse "quality over quantity" because, well, their quantity stinks. I hear that adage being tossed around more at the super academic (but low volume) programs like Wilmer.

I think it also depends on how programs count the numbers. I've talked to colleagues where their program had them count part of a cataract (like just injecting the lens) as a full case. That will inflate the numbers.

 

[dantt]

I think inadequate training and subsequent discomfort with patients and surgery is a serious concern. Can and should additional skills be obtained internationally? I think it can be done legitimately with adequate consent and under supervision. I don't think it's appropriate for US physicians to go overseas and "practice" surgery on their own when they are not competent and there are no subsequent follow-up plans.
I would strongly suggest anybody who doesn't feel comfortable to either pursue a fellowship or additional training elsewhere. Everybody knows the first year out is the hardest. It is important to seek mentor-ship whenever possible. You want to minimize "learning on the job" as there is a strong potential of both harming your local reputation and doing a disservice to patients.

Regardless of whatever programs advertise, programs that graduate a significant percentage of residents who do not feel prepare need to do some serious introspection.

 

[hello lady!]

I think inadequate training and subsequent discomfort with patients and surgery is a serious concern. Can and should additional skills be obtained internationally? I think it can be done legitimately with adequate consent and under supervision. I don't think it's appropriate for US physicians to go overseas and "practice" surgery on their own when they are not competent and there are no subsequent follow-up plans.
I would strongly suggest anybody who doesn't feel comfortable to either pursue a fellowship or additional training elsewhere. Everybody knows the first year out is the hardest. It is important to seek mentor-ship whenever possible. You want to minimize "learning on the job" as there is a strong potential of both harming your local reputation and doing a disservice to patients.

Regardless of whatever programs advertise, programs that graduate a significant percentage of residents who do not feel prepare need to do some serious introspection.

What are you going to do when a new procedure comes out? At some point you're always "learning on the job." I don't think it matters if you do 100 or 200 phacos in residency; your first cases on your own are going to be stressful - you're always going to wish you had more experience.

 

[dantt]

Great question. Cataract surgery is bread and butter. The first year out will be stressful. That's okay. However, if you're not a competent surgeon, you need to acquire additional training whether it's through a fellowship or course or international experience. Patients and referring doctors expect great outcomes and are not so forgiving if you have a 10% complication rate.

New procedures are a different story as patients know it's a new procedure. You should educate and properly inform your patients that it's a new procedure and they benefit from this new procedure because x y and z despite it being new. Surgeons in general who have been out in practice for awhile are more confident to tackle new procedures. Many will take wetlabs or travel to visit other surgeons and observe live surgery. If it involves new devices, medical device manufacturers are more than happy to send reps whenever requested. You can even pay to travel to a practice at an international location to do your first cases under supervision.

 

[Brathmore]

I did a couple of those (I currently am an attending at a US institution). There are 2 points here. First thing, quality varies. There are really good training opportunities where they give you many cases of different difficulty levels: soft, hard, intumescent, small pupils, loose zonules, malyugins, CTRs, hooks, management of intraop complications, and others that would take over the case if the rhexis runs out and all 2+NS single technique (prolapse nucleus). So you need to do your homework and find out which ones are really good (typically NOT the better known places). Second thing, it is best to delay this experience as much as possible when you are better trained. It is a waste of time and money to go when you are still novice. PM me if you need recommendations.

What places would you recommend? Feel free to PM if so desired.

 

[Fascia Lata]

What places would you recommend? Feel free to PM if so desired.

Sent PM

 

[Dusn]

I honestly don’t think you need more than 100 cases. Maybe if there’s an attending who can teach you different tricks like suturing an iol or something more cases might be useful.

But honestly there’s also a big world of Ophtho out there outside of cataracts. In many locations you’ll be scrounging for cataracts and begging optoms to send you them your whole life if that’s all you can do.

Do you learn other skills well -med retina, glaucoma?

 

[Pink Eye]

150 is a solid number. I also agree that “quality over quantity” is BS. I think that is just an excuse that programs with low surgical numbers use. I do know of a program where the attending is not in the room for the majority of a resident’s cases. I would say in that situation quality is better than quantity but that is an extreme.

If you are at all concerned about your training and you want to do comprehensive, then do a cornea or glaucoma fellowship. At one of those fellowships, you will do more cataracts and be better trained. In private practice, a large majority of glaucoma and cornea doctors function as comprehensive docs anyways.

I completely disagree that you only need 100 cases.

My progression was this.. 0-20 cases I was just getting my feet wet. I had no idea what I was doing. I was nervous before each case and exhausted after it. 20-50 cases, I became more comfortable but still was completely clueless on how close I was to major complications. 50-85 I could get through completely uncomplicated cataracts. If anything deviated from normal (if I bowled out a lens or left a dense posterior plate), then I was screwed. I was probably averaging 30 minutes per case.
90-120 I could do most cataracts, but I still ran into trouble. I was comfortable using hooks (this was before rings were invented). 121-200 I become more polished and had less complications. After 200, I felt completely comfortable. I graduated with 270 something phacos. I did a cornea fellowship afterwards and my cofellow only had 150 under his belt. There was a noticeable difference between our phaco skills and complication rate.

Numbers do matter. Again, if you are concerned about yours then I would plan on doing some type of anterior seg fellowship (cornea or glaucoma).

After 90 phacos, I remember thinking that I was not ready for private practice. I personally think that the cataract minimum should be raised. The minimum for DO programs is 50 something (or it was 50 something last time I checked). 50 is way too low and there should not be a lower standard for DO programs. In the end, MDs and DOs are both ophthalmologists. They perform the same surgeries on the same patient population. And they should have the same standards. If a DO program can’t meet the minimum then they should be closed down. If an MD program cannot meet the minimum then they are closed down.

This is just from my personal opinion and from my own observation. I think I went on a few tangents there.


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[EyeGuy15]

I highly recommend the fellowship at the Massachusetts Eye Research and Surgery Institution (MERSI) run by Dr. Stephen Foster if you want to solidify your skills. Medical management of uveitis patients is only about half the daily clinic load. It is surgically heavy and you'll do a lot of "bread and butter" cataracts as well as "complex" cataracts (Hypermature cataracts, eyes with iris synechiae, poor dilation, hazy/scarred corneas, s/p PPV, s/p glaucoma surgery, s/p PKP, s/p trauma etc). Dr. Foster does not staff surgeries anymore, but Dr Anesi is a ridiculously good teacher of anterior segment surgery. The average fellow graduates with around 100 cataract surgeries, 30 glaucoma tubes, and 15 PKPs. These are real primary cases too, despite this being a private practice. You will also get the chance to learn how to perform scleral-fixated IOLs and have the opportunity to be certified on the Catalys Femtosecond Laser System. In addition, they have two full time retina surgeons now, so you'll get to see a fair amount retina pathology on that end as well. For someone who wants to do primarily anterior segment surgery, I think it's the best fellowship in the country.

 

[DrZeke]

I highly recommend the fellowship at the Massachusetts Eye Research and Surgery Institution (MERSI) run by Dr. Stephen Foster if you want to solidify your skills. Medical management of uveitis patients is only about half the daily clinic load. It is surgically heavy and you'll do a lot of "bread and butter" cataracts as well as "complex" cataracts (Hypermature cataracts, eyes with iris synechiae, poor dilation, hazy/scarred corneas, s/p PPV, s/p glaucoma surgery, s/p PKP, s/p trauma etc). Dr. Foster does not staff surgeries anymore, but Dr Anesi is a ridiculously good teacher of anterior segment surgery. The average fellow graduates with around 100 cataract surgeries, 30 glaucoma tubes, and 15 PKPs. These are real primary cases too, despite this being a private practice. You will also get the chance to learn how to perform scleral-fixated IOLs and have the opportunity to be certified on the Catalys Femtosecond Laser System. In addition, they have two full time retina surgeons now, so you'll get to see a fair amount retina pathology on that end as well. For someone who wants to do primarily anterior segment surgery, I think it's the best fellowship in the country.

I agree this is a surgically heavy fellowship, but isn't the focus uveitis as well?