Surgical volume and the mysterious 90th percentile

[kid Icarus 3]

I've noticed a lot of programs describe their surgical numbers as being in the "90th" percentile or above yet I sometimes scratch my head and wonder if they are sharing outdated information or if it is accurate.

I know that the minimum requirement for phacos is something like 86. As an example of what I've been reading West Virgina's website says they are 90th percentile at an average 140 cataracts, and then San Diego's website says they averaged over 400 cataracts in the 2014 graduating class but just a few years prior were ranked in the 80th percentile for primary surgeon cataracts. It might be true that UCSD ramped up their cataract numbers quickly over the last few years but still I don't feel like I know what 90th percentile really is these days.

I guess I'm curious if any of you out there who have done interviews have a good idea of what average cataract numbers are for most programs. Is 150+ really considered 90th percentile? I've rotated at some places that have very high surgical volume (300+ cataracts during training) so I feel my thought process here is definitely skewed. And yes, I recognize it is not all about just doing cataracts but I"m considering comprehensive and want to be as comfortable as possible with doing phacos. Thanks.

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[DrZeke]

I've noticed a lot of programs describe their surgical numbers as being in the "90th" percentile or above yet I sometimes scratch my head and wonder if they are sharing outdated information or if it is accurate.

I know that the minimum requirement for phacos is something like 86. As an example of what I've been reading West Virgina's website says they are 90th percentile at an average 140 cataracts, and then San Diego's website says they averaged over 400 cataracts in the 2014 graduating class but just a few years prior were ranked in the 80th percentile for primary surgeon cataracts. It might be true that UCSD ramped up their cataract numbers quickly over the last few years but still I don't feel like I know what 90th percentile really is these days.

I guess I'm curious if any of you out there who have done interviews have a good idea of what average cataract numbers are for most programs. Is 150+ really considered 90th percentile? I've rotated at some places that have very high surgical volume (300+ cataracts during training) so I feel my thought process here is definitely skewed. And yes, I recognize it is not all about just doing cataracts but I"m considering comprehensive and want to be as comfortable as possible with doing phacos. Thanks.

Quality of cataracts matters as well. 300 20/30 cataracts with no complications doesn't compare to 150 cataracts in complicated eyes. For example post vitrectomized eyes, dropping nucleus, pc tears requiring anterior vitrectomy or white cataracts. Also if you plan on taking call at a major hospital while in private practice, a program with exposure to open globe and trauma is vital for comfort exploring the orbit and the globe.

 

[LightBox]

If someone is doing >400 cataracts/year, then they are bound to run into some complicated cases! It's not always mutually exclusive to have "high volume" and "complicated cases". Conversely, if you only have 150 chances to do cataract surgery in residency, then you have a statistically lower chance of running into complicated situations.

In private practice, most moderate-volume surgeons are doing >1000 cataracts/year -- you are bound to run into complicated patients with 1000 exposures!

 

[kid Icarus 3]

These are good points... thanks to both comments. Curious, however, if anyone has a feel for what an average number of cataracts might be. Also what a true 90th percentile might be. I agree there are other important factors but I'm curious simply from a numbers standpoint.

 

[LightBox]

These are good points... thanks to both comments. Curious, however, if anyone has a feel for what an average number of cataracts might be. Also what a true 90th percentile might be. I agree there are other important factors but I'm curious simply from a numbers standpoint.

Probably 50th percentile is around 140 cataracts... 90th would be around 250... Anything over 200 is pretty decent imho.

 

[DrZeke]

If someone is doing >400 cataracts/year, then they are bound to run into some complicated cases! It's not always mutually exclusive to have "high volume" and "complicated cases". Conversely, if you only have 150 chances to do cataract surgery in residency, then you have a statistically lower chance of running into complicated situations.

In private practice, most moderate-volume surgeons are doing >1000 cataracts/year -- you are bound to run into complicated patients with 1000 exposures!

Good point however most programs in the country will not hit >200 cataracts. Realistically the match is pretty random at times. I think we all have to trust that one will still be prepared with around ~150 cataracts and that everyone gets through some growing pains in the first few years of practice.

 

[123ophtho]

https://www.acgme.org/acgmeweb/Portals/0/Opthalmology_National_Report_Program_Version.pdf

No residents average 400 primary phacos. They must be talking about assists as well.

 

[Pinkertinkle]

https://www.acgme.org/acgmeweb/Portals/0/Opthalmology_National_Report_Program_Version.pdf

No residents averages 400 primary phacos. They must be talking about assists as well.

"assists" haha

 

[Slide]

The only place I've heard having an extraordinary amount of phacos has been LSU-Shreveport, and they hit the 300s for cataracts. I would serious doubts about any program claiming more than 400 primary phacos; only doing half of the surgery like the I&A and lens insertion doesn't count.

On the numbers part, there's no magic number that will get you prepared for after residency. Some people only need 100-120, others need up to 250. 130-150 seems reasonable for most people; the first few years after practice is where you finally refine your technique because you'll be on your own and you can do it your way. The reason why numbers are such a big issue is because it's really the only measurable landmark we have easily available that determines how well you're trained surgically.

People may disagree with what I say below, but...
There's a post from a while back talking about how many numbers is necessary, but the gist of it (which I've found to be true) is that after a certain amount of "standard" normal phacos, you'll either get it or you won't. After the minimum amount, you either can do a normal one on your own or you can't. If you can't, having more phacos probably won't really help out at all. The good thing about having higher numbers are two things: 1) complicated cataracts, and 2) refining new techniques. Having more complicated cataracts obviously improves your ability to handle more cases and refines your technique. It also gives you a chance to figure out what to do if a bag breaks and how to salvage a case vs send it to retina. Being able to take on more complicated cataracts definitely helps out in private practice, but for some types, it may be safer and better just to send them out (e.g. traumatic cataracts or PXE that are almost bound to drop). The other thing is refining new techniques. In my training, we were all forced to do divide and conquer starting out. However, after my 40th cataract, I had the technique down for 20/40-20/60 cataracts without issue. I then "rebelled" and started using other techniques like stop and chop and horizontal chop. Once I had those techniques down, my efficiency increased and I was able to shave off at least a third off my total surgical time as well as use less energy (great for getting those POD #1 20/20 "aha!" moments for patients). As a resident, you're protected and you have a safety net when experimenting, but when you're out on your own, venturing out onto uncomfortable territory can scare you enough to staying static in your technique for a while. The extra numbers help you experiment and refine techniques so you can be efficient as possible. If you're in private practice, a 30-45 min phaco may not fly well for your ASC because that could be money lost or unrealized.

One more thing: after being through the interview process twice (2nd time for fellowship), just beware if a program touts that their phacos are "well-taught", especially if their numbers aren't stellar. You may be able to scrub in and see great surgeons operate, but nothing replaces doing the surgery yourself. In some places, I've realized "well-taught" is a term to disguise the fact that you aren't operating enough, and that you're banking on coaching of other attendings to give you enough training. Great coaching doesn't teach you the feel of how deep you are in a groove, and it doesn't teach you the feeling of being too aggressive or being too timid during surgery.

 

[DrZeke]

The only place I've heard having an extraordinary amount of phacos has been LSU-Shreveport, and they hit the 300s for cataracts. I would serious doubts about any program claiming more than 400 primary phacos; only doing half of the surgery like the I&A and lens insertion doesn't count.

On the numbers part, there's no magic number that will get you prepared for after residency. Some people only need 100-120, others need up to 250. 130-150 seems reasonable for most people; the first few years after practice is where you finally refine your technique because you'll be on your own and you can do it your way. The reason why numbers are such a big issue is because it's really the only measurable landmark we have easily available that determines how well you're trained surgically.

People may disagree with what I say below, but...
There's a post from a while back talking about how many numbers is necessary, but the gist of it (which I've found to be true) is that after a certain amount of "standard" normal phacos, you'll either get it or you won't. After the minimum amount, you either can do a normal one on your own or you can't. If you can't, having more phacos probably won't really help out at all. The good thing about having higher numbers are two things: 1) complicated cataracts, and 2) refining new techniques. Having more complicated cataracts obviously improves your ability to handle more cases and refines your technique. It also gives you a chance to figure out what to do if a bag breaks and how to salvage a case vs send it to retina. Being able to take on more complicated cataracts definitely helps out in private practice, but for some types, it may be safer and better just to send them out (e.g. traumatic cataracts or PXE that are almost bound to drop). The other thing is refining new techniques. In my training, we were all forced to do divide and conquer starting out. However, after my 40th cataract, I had the technique down for 20/40-20/60 cataracts without issue. I then "rebelled" and started using other techniques like stop and chop and horizontal chop. Once I had those techniques down, my efficiency increased and I was able to shave off at least a third off my total surgical time as well as use less energy (great for getting those POD #1 20/20 "aha!" moments for patients). As a resident, you're protected and you have a safety net when experimenting, but when you're out on your own, venturing out onto uncomfortable territory can scare you enough to staying static in your technique for a while. The extra numbers help you experiment and refine techniques so you can be efficient as possible. If you're in private practice, a 30-45 min phaco may not fly well for your ASC because that could be money lost or unrealized.

One more thing: after being through the interview process twice (2nd time for fellowship), just beware if a program touts that their phacos are "well-taught", especially if their numbers aren't stellar. You may be able to scrub in and see great surgeons operate, but nothing replaces doing the surgery yourself. In some places, I've realized "well-taught" is a term to disguise the fact that you aren't operating enough, and that you're banking on coaching of other attendings to give you enough training. Great coaching doesn't teach you the feel of how deep you are in a groove, and it doesn't teach you the feeling of being too aggressive or being too timid during surgery.

I'm still in residency but I agree with all the teaching stuff you said. I can't comment on years out in practice.

At my program we have very average numbers but our staff hardly ever take over. This is an issue at some other places. A lot of the time if the case is challenging at some programs staff take over. Some programs pride themselves on having no anterior vitrectomies because of their great "coaching", but I would not what to be doing my first ever ant vitrectomy out in practice with nobody around.

 

[LightBox]

I agree that you should gain experience learning how to properly manage prolapsed vitreous, impending dropped nucleus/pieces, etc during residency or fellowship. You definitely don't want to feel like you don't know what you are doing during a "real" case as an attending. There won't be anyone to save you typically.

I remember proctoring certain residents during cataract surgery, and anytime the sh** hit the fan, they would immediately freak out and say "please take over!" Instead, those who just calmly followed my instructions gained a lot more from those complicated cases than the ones who immediately turned over the reins. It sucks for the patients, because despite what all of these "published" studies say, resident cataract surgery is DEFINITELY more risky than surgery performed by a seasoned attending You have to learn somewhere, and it is better to learn under the umbrella of the University's large malpractice policy!

I'm not saying you should be happy if you are dropping lenses 1/3 of the time. But hopefully after every complicated case, you are reviewing the recorded video to see what went wrong... reading up on how to prevent complications in the future... and genuinely caring that the patient you effed up recovers their vision. The thing that pissed me off the most when precepting residents were those residents who effed up a case, and then ignored the patient afterwards in terms of talking about what happened and also their post-op care. Don't be one of those douchebags

 

[ophthapp1]

During a powerpoint presentation at an interview last week a PD quoted 174 as national resident average for cataracts. His program has approximately 230s avg which he stated was around the 80th percentile.

 

[DrZeke]

During a powerpoint presentation at an interview last week a PD quoted 174 as national resident average for cataracts. His program has approximately 230s avg which he stated was around the 80th percentile.

174? That's not what I saw on acgme but perhaps I'm mistaken.

 

[ophthapp1]

174? That's not what I saw on acgme but perhaps I'm mistaken.

It's also on a handout they gave us that is "acgme reviewed" for 2015 graduates. No clue if it's accurate.

 

[Dusn]

I remember everyone on the interview trail was obsessed about cataract numbers which led me to believe it was the most important thing as well. As an attending I realize that my residency cataract number was not nearly as important as I thought it was.

1) You should expect to be pretty proficient at your basic cataract once you get past 100 cases -- if you're not maybe you're not reviewing your cases and the cases of others as much as you should be. We all know attendings who've done tens of thousands of cases and still somehow break bag commonly. They do tons of cases and don't pay attention to what they're actually doing. Doing more cases won't help you improve if you're doing them wrong to begin with. You need to be watching your videos over and over again to figure out how you can improve. After a year of being an attending you should be feeling pretty comfortable no matter how many cases you did as a resident. If you still can't fix that subluxed cataract in that marfans patient, who cares? Send it elsewhere.

2) Cataract reimbursement keeps dropping every year. Some people use multifocal lenses to make up for the decreased income. Personally I would never want a multifocal in my eye so I don't use them for my patients. I just do cataracts because I enjoy them. You can make as much or more in the clinic.

3) Pretty much every ophthalmologist knows how to do cataracts. It's not that valuable of a skill. If you join a practice and all you can do is cataracts the senior partners can easily fire you and take over your cataract practice or hire anyone else to do it. If you're the only one who can help them if they have a difficult neuro, orbit, uveitis or retina emergency they'll need you around. I just saw a case where a cavernous sinus fistula was mistaken for thyroid eye disease and another case where a retina surgeon sent home a patient with new onset blurry vision who was in the middle of having an occipital lobe stroke saying her "retina looked fine" -- that's how you're going to get into a major lawsuit. Most of the work we do is in the clinic not the OR.

4) Technology is making cataracts easier to do every year. Just switched to the Centurion -- it's great; my patients all have 20/25 or better vision POD1. But as technology makes doing cataract surgery easier it correspondingly makes cataract surgery a less valuable skill. If it takes half as much time to do a surgery with new technology, that's the equivalent of doubling the number of surgeons out there.

5) Most of the "bad outcomes" I've seen after cataract surgery were because the surgeon missed the wet macular degeneration in pre-op (or something similar). The surgery itself was excellent but pointless.... and the multifocal IOL perfectly centered.

 

[Ilovewater]

In addition to all the thoughtful comments before this, it's also important to look at other surgical numbers and not just cataracts. For instance, our program's number may be average (140-150s) with most as primary, but we have a lot of autonomy in peds, plastics, retina (a little less than other subspecialties), and glaucoma surgeries as well. This is especially important if you plan to do comp. As someone else already mentioned, you need to be great at more than just cataracts to be valuable to a private practice. You'll refer out complicated cases, but you should feel comfortable handling straightforward cases or know when to refer out.

Also, some places may tout insane cataract numbers, but their programs didn't have neuro-ophtho or plastics at all. I'd prefer average cataract numbers but not have deficiency in any subspecialties.

 

[redfish99]

I totally agree with the above comment about non-phaco volume. Lots of bases have lousy numbers for most surgeries/lasers and then they pride themselves in having high 100s in phacos. Its much better to have 20-40 less phacos and 10--15 more glaucoma surgeries. Cataract surgery isn't all that complicated in the grand scheme of things, after doing 100 you are basically just getting more efficient and learning your way out of tight jams but super high numbers aren't as critical there is however a big difference between doing 5 glaucoma surgeries and doing 20, the learning curve is much steeper early on obviously.