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Up Front | May 2008

Help Ophthalmology Residents Achieve Success

How to develop a comprehensive plan for evaluating surgical competency.

A paradigm shift is underway regarding the evaluation of competency in medical residency programs. Several years ago, various organizations—including insurers, patient advocacy groups, and hospitals—convinced the Accreditation Council for Graduate Medical Education (ACGME) that resident education must change.1 These groups argued that the traditional model of residency programs left physicians with an unreliable skill set that did not meet the demands of the healthcare market. As a result, ophthalmology residency programs have been working over the past several years toward a new model of competency, as discussed in Lee and Carter's now classic article of 2004.2

This article outlines the program that my colleagues and I set forth at the University of Iowa in Iowa City to set stages and expectations for each of them, to identify resources for growth, and to use formative feedback to assess and document residents' progress on a path toward surgical competency.3

The first step in creating a residency program based on the new model of competency is to determine the stages of competency. Andrew Lee, MD, introduced me to the Dreyfus model's stages of professional skill acquisition. According to this model, people learn professional skills in distinct stages by which they progress from novice to beginner, advanced beginner, proficient, and (rarely) expert.2,3 Advancement through these levels is expected, can be measured, and can be influenced by education and practice. Table 1 shows how we defined our stages.

It is necessary to set expectations for each stage of competency that are measurable, meaningful, and realistic. They should be established at the start of residency and should not be a moving target. It is important for a program to weave in all six of the ACGME's competencies, including medical knowledge, patient care, system-based care, practice-based learning, communication, and professionalism.1 Table 2 shows a few examples of expectations by stage and by competency that we use at the University of Iowa.

Video instruction, simulators, and wet labs can assist students' preparation for their first real surgery.3,4 Additionally, the most experienced faculty surgeons should help to guide the more junior surgeons through early surgical cases. I recommend having residents start live surgery by doing part of a case, because I find it is better for them to perform a small portion of a perfect case than all of a bad case.

At the University of Iowa, we use a "backing in" technique developed by Mark Wolken, MD, wherein the attending or senior resident starts the case, and the training surgeon takes over toward the end. The resident gradually undertakes more and more of the surgical steps until he performs the case from start to finish.

A similar strategy toward surgical competency is for the junior surgeon to use only the main wound, while the attending surgeon directs instruments through the paracentesis (eg, for difficult parts of the case such as the removal of nuclear fragments). This approach allows the training surgeon a comfortable transition from one hand to two.

Most residents and faculty consider the capsulorhexis to be the most difficult part of the case to master. A. Tim Johnson, MD, PhD,5 has developed a strategy for the capsulorhexis based on the idea of K. Anders Ericsson, PhD,6 in which the purposeful practice of difficult parts of a skill leads to ultimate mastery. First, Dr. Johnson creates a paracentesis and wound. Next, the resident performs the capsulorhexis but is quickly relieved if necessary. Dr. Johnson records all of the cases so that he may postoperatively review each capsulorhexis in detail with the resident.

The availability of learning resources is important, but the timing of these resources' presentation is crucial. The world's greatest wet lab held 9 months before a resident's first case is less useful than an OK wet lab just prior to his initial surgery. I therefore suggest making resources available when residents need them, rather than when it is convenient for faculty or the program.7 Placing key lectures on a Web site or local server, for instance, makes them available to residents 24 hours a day.4

A lack of resources may exist for certain expectations within a stage. For example, we expect our beginning surgeons to know the names of and typical use for the instruments on the phaco tray, but finding even a simple list proved difficult. To answer this need, we made a video that named all of the instruments on the tray. Our residents helped to refine this resource via flashcards and a Web-based resource.8

Medical education typically employs summative feedback. This format does little to help improve residents' competence, because the commentary occurs after a task is complete, often when the trainees have moved on to the next task. At the University of Iowa, we provide formative feedback throughout the rotation to promote directed growth. Essentially, we establish our expectations, tell residents what they did well and what needs work, and, most importantly, indicate resources for improvement.

Our feedback (Figure 1) is closely tied to the Dreyfus stages, which may help to reduce the inflation of grades and closely ties performance to expectations.3 Sondra Lora Cremers, MD, and colleagues at Massachusetts Eye and Ear Infirmary have developed more detailed systems to document surgical competence.9,10

The University of Iowa's plan for residents' competency incorporates stages, expectations, and resources (Table 3).3 Although training programs' plans may vary slightly, the ACGME has clearly mandated that competency-based resident education is the new standard. Although any paradigm shift is painful at first, this one has brought us new insight into our training program. Developing tools and resources gave our faculty renewed purpose, and our residents seem to appreciate the clarity of defined expectations.

The author wishes to thank Andrew Lee, MD; Keith Carter, MD; A. Tim Johnson, MD, PhD; Hilary Beaver, MD; Emily Greenlee, MD; Culver Boldt, MD; Richard Olson, MD; Michael Abramoff, MD; Mary Daly, MD; Bonnie Henderson, MD; Alan Flach, MD; Steven Sauer, MD; Robin Vann, MD; and the University of Iowa's residents.

Thomas A. Oetting, MS, MD, is a professor at the University of Iowa in Iowa City. He acknowledged no financial interest in the product or company mentioned herein. Dr. Oetting may be reached at (319) 384-9958; thomas-oetting@uiowa.edu.

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