Commentary: Questioning the status quo of residency training in India: Optimizing the learning course!

The goal of residency is to generate competent doctors who can provide clinical and surgical services independently to patients. By encouraging trainees to acquire and uphold the highest quality of patient care, the ultimate goal of training program is to pursue excellence in eye care.

Residents gain clinical knowledge and acquire surgical skills through inpatient department (IPD)/outpatient department (OPD) services, clinics, clinical case presentations, and operating under supervision. The trainers/faculties need to ensure that residents come out well trained as independent practicing clinicians after their period of metamorphosis.

The designed curriculum for 3 years duration expects a certain level of competency to be achieved by the end of each year of residency. The first year of residency focuses on basic examination techniques of the eye, including clinical duties, as the first point of contact in emergency patient eye care. It basically acts as an introduction to ophthalmology as a surgical branch, wherein residents are acclimatized to eye–hand coordination with initial and basic surgical steps. The second year encompasses additional training of both clinical and advanced surgical skills. By the final year, residents are expected to perform independent cataract and other basic surgeries.

Our country’s residency training programs have been questioned on multiple forums despite having a surplus clinical material, competent faculties, and supportive infrastructure.^[1] Ophthalmology as a speciality branch has come a long way having experienced numerous advancements and innovations in techniques and ophthalmic procedures. The same is not true for residency training, which seemingly has not kept pace with the times.^[2]

The learning curve of individual residents is variable depending on their aptitude, necessitating optimization to further their diagnostic and surgical skills. Greater the practical training in residency, the greater will be the competency of residents to deftly handle cases, exercise correct judgment, and minimize surgical complications. As the saying goes, sweat more in practice, so as to bleed less in battle. Simulation training by means of wet labs could help residents in practicing basic and advanced surgeries. According to Ramani et al.,^[3] residents who had undergone training in wet labs experienced less post-cataract surgery problems. Also, the incidence of aphakia, posterior capsular rent, and vitreous loss decreased and patients demonstrated better visual outcomes.

In a survey conducted to collect responses from final-year residents from South India, the residents felt the need for increased training in subspecialities of ophthalmology, apart from cataract surgery. They also felt a mismatch in the desired numbers of surgeries required for competency and the actual numbers performed by them.^[4] Also, more than half of the residents said they had not performed phacoemulsification and subspeciality surgeries like squint, dacryocystorhinostomy, trabeculectomy, and others. Another study by the All India Ophthalmological Society (AIOS) found that a quarter of residents finished residency from 2014 to 2016 felt that their teaching program was not adequate.^[5] Furthermore, coronavirus disease 2019 (COVID-19) has been attributed to impairment in residency training, particularly in nonemergency sectors. Residents had to respond to the national call for COVID-19 services, irrespective of their speciality. The pandemic situation affected the clinical teaching and training of ophthalmology residents greatly as only emergency cases were attended to. OPDs were restricted to a minimum and elective cases were postponed.

This study^[6] has been conducted to assess the quantum of cataract surgical training opportunities for ophthalmology residents in India as an online survey. It provides some insight into the present status of residency training. However, this data and consequent outcome cannot be extrapolated to all academic institutes across the country. The limitation of one institute does not necessarily apply for another one and vice versa. Hence, a multicenter study with representative academic institutes and a validated questionnaire in a prospective model can be undertaken in future.

Though surgical training is an integral part of residency curriculum, learning of all domains related to clinical care has to be stressed. Competence is a specific, measurable dimension of knowledge, skill, and behavior that a learner has to display at the end of a program. Apart from surgical skills, it integrates multiple components like knowledge, values, attitude, and communication skills. According to Dreyfus model of skill acquisition,^[7] the order of learning of skill for a learner proceeds from novice to advanced beginner to competent to proficient to an expert. A novice needs step by step instructions to reach the stage of competent, when he/she has experience with real complications and can handle them appropriately. As per Miller’s prism of clinical competence,^[8] during the period of metamorphosis from a novice to an expert, assessment of four aspects of knowledge, skills, and attitude can be done as follows: Knows, Knows how, Shows, Does. Thus, learning objectives during residency need to encompass a wider approach.

The mandate Of National Medical Commission (NMC) is to standardize ophthalmology teaching at a postgraduate level throughout the country, so as to achieve uniformity in postgraduate teaching and, as a result, create competent ophthalmic surgeons with appropriate expertise. The purpose of NMC document is to provide teachers and learners illustrative guidelines to achieve defined outcomes through learning and assessment. Hence, it is imperative for teaching and training institutes to follow and improvise, as the need be.

The surgical exposure to residents may vary among institutes and centers, depending on the patient input. It is thus important to train the residents both in theoretical and practical aspects, as the in-depth knowledge of basic anatomy, physiology, and other basic sciences is imperative for surgical training to mitigate complications.

The standardization of residency programs and the adoption of a standardized curriculum will go a long way in having a positive and a lasting impact.^[1] Recognizing the need for updating the curriculum for residency training in light of the numerous new developments in ophthalmology, the AIOS National Curriculum, which is a modification of the International Council of Ophthalmology (ICO) curriculum, has already been published in the Indian Journal of Ophthalmology.^[9] Once adopted and streamlined, rich dividends may surely be expected. It may take some time or more to effect real change – hoping that we will get there!