Refraction: are your program's residents good at it?

[mj844]

This sounds silly but I know residents from my program (& from friends in other programs) are not comfortable AT ALL with refraction. Yet this is essential... so I'd like hear from anyone involved in a residency where the majority of residents are not only proficient but are strong in refraction? If so, are they comfortable by the end of R1, R2 or R3? I know "you can get good at it if you try" but that's true for anything so I'd like to hear the rest. I'm interested to hear what these 'good' programs do in particular -- who teaches you to refract? Optom or ophthal? How often and in which years do you refract (besides pre- or post-op cataracts)? Are there particular attendings in your clinics that "pimp" you on the refraction repeatedly? Thank you.

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[CarpetWindow7]

We hit refraction hard on day 1. Most of my experience is VA with screening anf post op for cataract surgery. I would say my program as a whole makes us proficient within first month of residency.

 

[Bronze Medal]

We basically learn as we go and most commonly refract before and after cataract surgery. I became proficient during PGY-3. You could read, “The Fine Art of Prescribing Glasses Without Making a Spectacle of Yourself.” Then practice.

 

[TheLesPaul]

This sounds silly but I know residents from my program (& from friends in other programs) are not comfortable AT ALL with refraction. Yet this is essential... so I'd like hear from anyone involved in a residency where the majority of residents are not only proficient but are strong in refraction? If so, are they comfortable by the end of R1, R2 or R3? I know "you can get good at it if you try" but that's true for anything so I'd like to hear the rest. I'm interested to hear what these 'good' programs do in particular -- who teaches you to refract? Optom or ophthal? How often and in which years do you refract (besides pre- or post-op cataracts)? Are there particular attendings in your clinics that "pimp" you on the refraction repeatedly? Thank you.

How does anyone get through an ophthalmology residency without becoming adept at refraction? It's like an internist not knowing how to take a blood pressure. Seems like a deficiency in the residency. You should be able to do this within 1 month of starting your first year.

 

[increscence]

mj844, do those residents say they're not comfortable, or are they actually bad at it?

Residents from my program were comfortable with the basics at the level of an ophthalmic technician. They may not have been able to identify every single function on the phoropter, but they could provide a good refraction.

TheLesPaul, I would not expect any resident to be proficient within their first month. It's much more complicated than taking a BP and really takes experience, not just with knowing how to mess with the dials but also how to read a patient's nonverbal cues and know all the pitfalls. That takes experience that is probably fine-tuned by the end of the R2 year. But it's certainly not reasonable to expect an R1 to be super proficient at refraction by the end of the first month of residency.

 

[TheLesPaul]

mj844, do those residents say they're not comfortable, or are they actually bad at it?

Residents from my program were comfortable with the basics at the level of an ophthalmic technician. They may not have been able to identify every single function on the phoropter, but they could provide a good refraction.

TheLesPaul, I would not expect any resident to be proficient within their first month. It's much more complicated than taking a BP and really takes experience, not just with knowing how to mess with the dials but also how to read a patient's nonverbal cues and know all the pitfalls. That takes experience that is probably fine-tuned by the end of the R2 year. But it's certainly not reasonable to expect an R1 to be super proficient at refraction by the end of the first month of residency.

Perhaps they wouldn't be able to satisfy an engineer, but they should be pretty good at it! 10-20 refractions daily for 1 month = about 300 refractions, some programs don't even do as many cataracts in the whole residency...

 

[airplanes]

10-20 refractions daily? What if you start off on Retina or Plastics? Your experience sounds atypical. Some programs have pretty good technician support for residents. I maybe did 300 total refractions my entire residency.

OP if you want to get better at it, find the time to refract comprehensive patients, even if they don't want glasses. It's not rocket science and you'll get the hang of it eventually.

 

[TheLesPaul]

10-20 refractions daily? What if you start off on Retina or Plastics? Your experience sounds atypical. Some programs have pretty good technician support for residents. I maybe did 300 total refractions my entire residency.

OP if you want to get better at it, find the time to refract comprehensive patients, even if they don't want glasses. It's not rocket science and you'll get the hang of it eventually.

Most of our first year was at county hospitals. But forget the first month -- in 6 months you should certainly have racked up 300 refractions. What are you doing if you didn't accomplish that in your entire residency? Are you not refracting your postops?

 

[airplanes]

I rarely refracted in any of my attending clinics the first two years of residency, at County/VA we had technicians so I would only refract on top if something looked unusual or the vision didn't add up to BSCVA. We also had technicians refracting our post-ops, so I would only over-refract if there was an issue. Many of the patients had adequate VAsc and didn't want glasses anyways.

I am comfortable with refraction but I'm not going to lie and say I was refracting a few dozen times a week. Most of the residents at my fellowship and my current institution rarely refract. Again... good technician support.

What are you doing if you didn't accomplish that in your entire residency?

Sounds like my experience at 3 different institutions are all at the other end of the spectrum from you. Are you trying to imply graduates at all of these places aren't "accomplishing" anything because we don't perform some arbitrary number of refractions?

 

[TheLesPaul]

Sounds like my experience at 3 different institutions are all at the other end of the spectrum from you. Are you trying to imply graduates at all of these places aren't "accomplishing" anything because we don't perform some arbitrary number of refractions?

Getting an accurate BCVA is like knowing how to get an accurate bp or heart rate. Any internal medicine resident would be adept at that by a few weeks into their first year despite the fact that technicians and nurses do this routinely.

If an ophthalmology resident is not comfortable with refraction, I would absolutely say the training is inadequate. It's a fundamental skill, residents should be competent at this within weeks of starting the residency (though the skill should obviously be refined as training goes on).

Also, what is an "adequate" VAsc? Anyone worse than 20/20-25 should be refracted in the clinic to determine BCVA. Otherwise you are potentially missing disease.

 

[airplanes]

Getting an accurate BCVA is like knowing how to get an accurate bp or heart rate. Any internal medicine resident would be adept at that by a few weeks into their first year despite the fact that technicians and nurses do this routinely.

If an ophthalmology resident is not comfortable with refraction, I would absolutely say the training is inadequate. It's a fundamental skill, residents should be competent at this within weeks of starting the residency (though the skill should obviously be refined as training goes on).

Also, what is an "adequate" VAsc? Anyone worse than 20/20-25 should be refracted in the clinic to determine BCVA. Otherwise you are potentially missing disease.

You think too little of me. Adequate post op is 20/20 in my book.

Who said we’re not comfortable refracting? I’m not arguing refraction isn’t an important skill, don’t pin that strawman argument on me. I’m simply saying many residents don’t refract hundreds of times a month and end up just fine.

Also don’t quite get your point about missing disease when not doing your own refractions. Isn’t a BSCVA 20/30 or 20/40 a red flag to look for pathology? If anything I’m on higher alert.

 

[TheLesPaul]

You think too little of me. Adequate post op is 20/20 in my book.

Who said we’re not comfortable refracting? I’m not arguing refraction isn’t an important skill, don’t pin that strawman argument on me. I’m simply saying many residents don’t refract hundreds of times a month and end up just fine.

Also don’t quite get your point about missing disease when not doing your own refractions. Isn’t a BSCVA 20/30 or 20/40 a red flag to look for pathology? If anything I’m on higher alert.

If you're comfortable, that's fantastic, clearly you put your time in somewhere along the way. I was mainly thinking of the original poster who said his residents were NOT comfortable. It's absurd to imagine an ophthalmology resident not knowing how to refract at the end of their first year, let alone first few months


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[hurdlepup]

I agree with sentiment of not knowing how to refract being inadequate for practice Ophthalmology. I learned as a medical student doing Ophthalmology rotations so clearly not too hard. And should be able to fine tune. Would change structure of residency to require refraction if it doesn’t currently require refraction because of too much tech support.