Ophthalmology is a subject where surgical techniques are continuously changing and advancing rapidly. Passing on the knowledge and skills of new techniques to succeeding generations of ophthalmological trainees is both a responsibility and necessity of teachers and trainers in the field. Trainers usually make sincere efforts to improve the skills of their students. In this context, obtaining frank feedback from students regarding present skills and future plans would be helpful to improve training programs.
Prior surveys of ophthalmology residents have discussed feedback and satisfaction of residents with their residency training as a whole. This article presents the results of a survey concentrating on surgical training in ophthalmology residency.
The survey was conducted on final-year residents in ophthalmology and had three purposes. Firstly, to solicit information from students about various methods used in their surgical training. Secondly, to obtain information about numbers and types of surgeries performed in the training centers, and by the residents. Thirdly, to know the future plans after finishing residency. From this information, our study intended to answer the question, “What is the present status of surgical training in ophthalmic training centers?”
Materials and Methods
The study was conducted at an intensive 4-day teaching program for final-year ophthalmology residents, held at Hubli, Karnataka state, South India, in January 2014. The questionnaire used in this survey was developed and validated in consultation with the division of research and patents of the parent institute of the chief author.
The questionnaire contained 21 questions (Appendix 1), eliciting information from the students about orientation and wet lab training received, operation theatre (OT) facilities for training, free surgical camps and detailed information about numbers and types of surgeries observed and performed; also, questions about what factors influenced the student to pursue ophthalmology residency, about future plans after finishing residency, and if considering fellowship training after residency, which sub-specialties were preferred.
Identity information like name was not solicited, and the students were free to not participate in the survey by simply not returning the form.
To ensure increased response rate, the students were counseled about the objectives and importance of the survey during the training program. Repeated announcements were made on each day of the training program requesting students to return completed forms.
Completed forms were collected on or before the last day of the teaching program.
One hundred and fifty-five ophthalmology residents participated in the teaching program. One hundred and thirteen residents participated in the survey by returning completed forms (72.9%). Six respondents were found to be 1st year postgraduates (number of completed months of residency being < 12) and were excluded from further analysis in the survey.
Forty-three of the 107 residents (40.18%) were male. The age range of the students was between 25 and 45 years. The state-wise break-up of students was 76 from Karnataka (71.02%), 16 Maharashtra (14.95%), 8 Tamil Nadu (7.47%), 5 Andhra Pradesh (4.67%) and 2 Kerala (1.86%). The results of this survey, therefore, present a picture mainly from Karnataka State and Southern India.
Twenty-four students were from a Government Medical College (22.42%), 38 from Private Medical Colleges (35.51%), 22 from Private Eye Hospitals (20.56%) and 23 from other hospitals (21.49%). Forty-two students were M.S. residents (39.25%), 35 were DNB (32.71%) and 30 were Diploma residents (28.03%).
Thirty-nine students (36.5%) chose “got seat in the subject through entrance examination” as the most important factor which influenced the decision to pursue ophthalmology residency. Thirty-six students (33.6%) mentioned “offers chance of combined medical and surgical practice” as the most important factor. Eleven students (10.3%) mentioned “workload predictability/flexibility,” while “positive undergraduate experience” made seven students (6.5%) choose ophthalmology. The two least important factors were “family influence” (5 students, 4.6%) and “earning potential” (2 students, 1.8%).
Forty-one students (38.31%) received orientation/training about ophthalmic surgery/OT. Sixteen of the 41 students (39.02%) had received such orientation from their senior postgraduate/resident, 11 students (26.82%) from senior faculty and 4 students (9.75%) from junior faculty. Four students had mentioned both senior postgraduates and faculty as orientation imparters.
Sixty-one students (57.00%) had undergone wet lab/simulation lab training. Fifty-six students (52.33%) had attended the wet lab training in their own college/hospital, and five had attended wet lab training in conferences.
Eighteen students (16.82%) mentioned that the OT in their center had no closed-circuit television facility for relaying surgical procedures while 37 students (34.57%) mentioned that their OT did not have a microscope with observer arm.
Seventy students (65.42%) did their first surgery in ophthalmic residency within the first 6 months, and 34 (31.77%) students did so before the end of the 1st year. Twenty-six students (24.29%) mentioned that free ophthalmic surgical camps were not held in their center.
On an average, 45 students (42.05%) went to the OT 2 times a week and 43 students (40.18%) went 3 times a week. Fifteen students (14.01%) went to OT once a week on average.
The details of number of different types of surgeries done per week in the training center of the student, and median and range of number of surgeries done by the student so far are given in Tables 1 and 2.
Eighty-eight students (82.2%) mentioned “join fellowship (or further training)” as the future plan after finishing residency. Six students (5.6%) wanted to join government service and 3 (2.8%) students wanted to join private service after finishing residency. “Joining medical college in the teaching profession” and “start own practice” was chosen as the next step after residency by two students (1.8%) each.
Of the 88 students considering fellowship/further training, 37 students (42.5%) mentioned Cataract surgery as the most preferred subject and 17 students (19.5%) mentioned Cornea/anterior segment. Thirteen students (14.9%) preferred vitreoretina/posterior segment and seven students (8.0%) were considering further training in general ophthalmology. Glaucoma and orbit/oculoplasty were being considered by 6 (6.9%) and five students (5.7%) respectively. Strabismus/pediatric ophthalmology was the first choice for two students (2.2%) while none mentioned uveitis as the preferred subject for further training.
The final question of the survey regarded satisfaction of the student with the surgical training during residency. Six students (5.6%) were “very satisfied” and 20 students (18.7%) were “satisfied” with their surgical training while 37 students (34.6%) found their surgical training during residency to be “fair/average.” Totally, 29 students (27.1%) were “not satisfied” with their surgical training and 15 students (14.0%) rated their surgical training as “poor.”
This survey with completed responses from 107 final-year residents provides us with a wealth of knowledge on the present status of surgical training in residency, especially in Karnataka state and Southern India, and on the immediate future plans of these residents. The residents surveyed in this study were from all types of training institutes in the region, including government and private medical colleges, and private eye hospitals and general hospitals.
Less than a quarter of the students had received formal orientation training about ophthalmic surgery from their faculty. Teachers, in their personal capacity, may be teaching students and explaining surgical principles while in the OT, but a formal orientation/training before the student enters the OT will be of benefit and is also desired by the student, as documented by a survey published in Indian Journal of Ophthalmology.
Nearly half the students had not experienced wet lab/simulation lab training. The value of these entities has already been established. Ophthalmic conferences across India have been providing wet lab training for residents, but only a few students in this survey had attended one such. More students can be encouraged to undergo such training and training institutes can help improve ophthalmic surgical training by establishing wet labs in their centers.
More than a third of the students were training in centers, where the OT did not have a microscope with observer arm (beam-splitter and assistant scope). The value of such equipment in the OT of a training institute would be immensely beneficial.
The vast majority of training centers conducted free ophthalmic surgical camps for patients, as per this survey. Most of the residents surveyed in this study went to the OT more than once a week. These can be termed as desirable statistics. Another statistic which could be termed desirable would be that nearly every student performed his/her first ophthalmic surgery before the end of the 1st year of residency. This compares favorably with the results of a survey of 129 ophthalmology residency directors in the United States, which had reported that 40% of residents gained experience as primary surgeons during their 1st year and 43% performed only part of the surgery.
When exactly a resident starts his first surgery is dependent on many factors, including personality, temperament and natural, surgical aptitude of the resident, as well as the trainer's considered judgment about the resident's readiness to operate. In this regard, both residents and trainers will find extremely informative Kirby's excellent treatise on surgical technique for residents in ophthalmology, published in 1983, but still relevant in this era for its sheer wisdom and understanding of teaching and learning methods of ophthalmic surgical techniques.
Approximately a third of the respondents indicated that the total number of surgeries done per week in their center is < 20. Increasing the number of operations per week is as much an administrative and logistic issue as a medical issue and lies under the purview of the respective training institutions, but higher numbers would obviously be desirable for the broader experience and exposure that would be provided. In our country, conducting free ophthalmic camps for the needy can be a win-win situation for ophthalmic care-givers and patients. Needy patients receive quality medical care at the hands of the teachers, which they may not otherwise be able to access, and they act as the providers of exposure and experience to the resident training under the teacher. Conducting such camps will also help increase number of operations done per week in the training center.
Most of the students had performed manual small incision cataract surgery (MSICS), and this was also the surgery performed most commonly by the students Table 2.
An analysis of Table 2 shows that the median value of students’ responses to performance of surgeries other than MSICS was zero for all surgeries excluding pterygium (5), dacryocystectomy (2) and trauma repair (5). Increasing the number of noncataract surgeries done by residents should be taken up in more earnest by postgraduate trainers.
Questions 19 and 20 of the survey attempted to read the mind of the student regarding his/her immediate future. A huge majority planned to undergo further training, with cataract surgery and cornea/anterior segment being the most sought after subjects. It appears that most of the students would prefer to delay further the decision on practice till they are confident of their surgical skills.
A quarter of the respondents in this survey were satisfied with their surgical training while a significant number, more than 40%, were not satisfied with the surgical training during their residency. A Brazilian study published in 2013 on recent ophthalmology graduates reported 93.4% satisfaction with the acquisition of surgical skills during residency. Our survey demonstrates an unfavorable comparison. Improving satisfaction of residents with their surgical training should become an important goal of trainers.
More than a third of the students in this survey indicated that the most important factor influencing their decision to pursue ophthalmology residency was that they were allotted to the subject through the entrance examination. A survey of junior residents in Saudi Arabia had found that the main factor influencing the decision to pursue ophthalmology training (97% of the respondents) was the ability to combine medicine and surgery. This meant that in our survey, a significant chunk of the students were doing residency in ophthalmology but had not come in desiring the subject specifically.
If a student has come in because he had no perceived better choice, and subsequently, if he also feels that training being received is unsatisfactory, he may then find it difficult to involve himself in the subject, understand the subject and develop a liking for it. This can prevent the student from reaching his full potential, as he simply does not like what he is doing.
Training accomplished with modern standards with an aim to also satisfy the students’ expectations, should help such students develop more interest in and understand ophthalmology better.
The least important factors influencing the choice of ophthalmology residency were “positive under-graduate experience,” “family influence” and “earning potential.” Improving the experience of under-graduate medical students in their ophthalmology training may motivate more students to take up the field; such motivated students are also likely to strive to improve their own personal learning and satisfaction.
Finally, though the study achieved a fairly good response rate (72.9%), the nonresponse fraction may have an influence on the inferences and conclusions. The limitations of this study include selection bias owing to purposive sampling, which might influence the results and subsequent conclusions.
Ophthalmology residents in the region of Karnataka and Southern India are performing surgeries on a live human eye within the 1st year of residency and are entering the OT for surgery multiple times a week. The number of noncataract surgeries performed by residents is minimal. Most of the residents plan to undergo further training after residency. A large number of respondents believe that their training is unsatisfactory.
Further efforts from trainers can concentrate on adding to the quality of surgical training along with the quantity, by establishing more wet labs/simulation training programs, conducting formal orientation programs for residents before they start surgery and by promoting microscopes with observer arms and closed-circuit television facility. Increasing the numbers of noncataract surgeries performed by residents and enhancing satisfaction levels of residents with their surgical training can be taken up as important goals by postgraduate trainers.
We are extremely grateful to Dr. Nanda Kumar, Head, Division of Research and Patents and Associate Professor, Department of Community Medicine, M. S. Ramaiah Medical College, for providing valuable guidance on development and validation of the questionnaire for this study. We thank all the postgraduate students who filled up the feedback forms and participated in the study. We are grateful to staff and students of Dr. M M Joshi Eye Hospital, Hubli, for help and support provided in the logistics of conducting the study. We thank Mrs. Arati Kshirasagar, English language proof-reader and transcriptionist, and Mrs. Shailaja Balakrishnan, English language teacher and reading program facilitator, Bethany High School, Bangalore for assistance rendered in editing and proof-reading of article.
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Source of Support: Nil.
Conflict of Interest: None declared.