Verifying Surgical Competence: Our Fiduciary Responsibility

Abstract

In this issue of Ophthalmology, Gedde et al1Gedde S.J. Volpe N.J. Feuer W.J. Binenbaum G. Ophthalmology resident surgical competence: a survey of program directors.Ophthalmology. 2020; 127: 1123-1125Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar (see page 1123) summarize the results of a survey of ophthalmology residency program directors about the surgical competence of their trainees. The study aimed to follow up on a similar questionnaire conducted approximately 20 years ago by Binenbaum and Volpe,2Binenbaum G. Volpe N.J. Ophthalmology resident surgical competency: a national survey.Ophthalmology. 2006; 113: 1237-1244Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar and published in this journal in 2006. The earlier survey estimated that 9% of ophthalmologists in training struggled to achieve surgical competence. Although 31% of those individuals were remediated before graduation, some residents were allowed to graduate and were endorsed by their program directors and department chairs to sit for the American Board of Ophthalmology (ABO) Written Qualifying Examination. The ABO, whose mission is to serve and protect the public by verifying the competencies of its diplomates, has grappled for many years with how best to address this quandary. In particular, the ABO’s Public Directors, nonphysicians whose role in part is to advocate for the safety and welfare of patients, have charged the Board to avoid “kicking the can down the road.”3Santen S.A. Christner J. Mejicano G. Hemphill R.R. Kicking the can down the road – when medical schools fail to self-regulate.N Engl J Med. 2019; 381: 2287-2289Crossref PubMed Scopus (2) Google Scholar So, where are we now and can we improve? Let’s start with the positives. Despite the known limitations of surveys and the difficulties of comparing data procured from 2 questionnaires administered distant in time, the study by Gedde et al1Gedde S.J. Volpe N.J. Feuer W.J. Binenbaum G. Ophthalmology resident surgical competence: a survey of program directors.Ophthalmology. 2020; 127: 1123-1125Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar contains reasons for optimism. First, responses were received from more than three-quarters of residency programs, a rate considerably higher than several other surveys of ophthalmology residency program directors,4Macaluso D.C. Andre M. Caroline P.J. et al.Assessment of ophthalmology residents’ contact lens training.CLAO J. 2000; 26: 221-224PubMed Google Scholar, 5Scott I.U. Smalley A.D. Kunselman A.R. Ophthalmology residency program leadership expectations of resident competency in retinal procedures and resident experience in retinal procedures.Retina. 2009; 29: 251-256Crossref PubMed Scopus (14) Google Scholar, 6Shah D.N. Volpe N.J. Abbuhl S.B. et al.Gender characteristics among academic ophthalmology leadership, faculty, and residents: results from a cross-sectional survey.Ophthalmic Epidemiol. 2010; 17: 1-6Crossref PubMed Scopus (32) Google Scholar, 7Chen A.J. Scott I.U. Greenberg P.B. Disclosure of resident involvement in ophthalmic surgery.Arch Ophthalmol. 2012; 130: 932-934Crossref PubMed Scopus (11) Google Scholar, 8Chen A.J. Chan J.J. Scott I.U. Greenberg P.B. Ophthalmic resident education on preventable surgical errors.JAMA Ophthalmol. 2013; 131: 1238-1240Crossref PubMed Scopus (4) Google Scholar, 9Coombs P.G. Feldman B.H. Lauer A.K. et al.Global health training in ophthalmology residency programs.J Surg Educ. 2015; 72: e52-e59Crossref PubMed Scopus (12) Google Scholar, 10Lotfipour M. Rolius R. Lehman E.B. et al.Trends in cataract surgery training curricula.J Cataract Refract Surg. 2017; 43: 49-53Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar, 11Tran E.M. Scott I.U. Clark M.A. Greenberg P.B. Assessing and promoting the wellness of United States ophthalmology residents: a survey of program directors.J Surg Educ. 2018; 75: 95-103Crossref PubMed Scopus (10) Google Scholar, 12Mishra A. Browning D. Haviland M.J. et al.Communication skills training in ophthalmology: results of a needs assessment and pilot training program.J Surg Educ. 2018; 75: 417-426Crossref PubMed Scopus (8) Google Scholar, 13Justin G.A. Custer B.L. Ward J.B. et al.Global health outreach by United States ophthalmology residency programs: understanding of host country systems-based practice.Mil Med. 2019; 184: e642-e646Crossref PubMed Scopus (1) Google Scholar, 14Zafar S. Chen X. Sikder S. et al.Outcomes of resident-performed small incision cataract surgery in a university-based practice in the USA.Clin Ophthalmol. 2019; 13: 529-534Crossref PubMed Scopus (4) Google Scholar suggesting a sincere interest in the survey’s theme and that the findings should be reasonably descriptive of the current educational environment. Second, residents appear to have ample opportunities during their training to operate as the primary surgeon, performing an average of approximately 250 intraocular cases (range, 100–550). Third, there was no significant difference between smaller programs (defined as graduating <40 residents during the 10-year study period) and larger programs in regard to the percentage of residents who had difficulty learning and performing surgery (S. Gedde, unpublished data, February 2020). Finally, although the percentage of surgically challenged residents decreased only modestly since the earlier survey (from 9% to 7%, but a statistically significant change), 84% of those individuals were successfully remediated before graduation. According to the authors’ estimates, only 4 residents per year are endorsed by their programs for ABO certification while falling short of this required competence. On the other hand, achieving and assessing surgical competence can be challenging. A competent surgeon is able to make an accurate diagnosis, knows whether surgical intervention or nonoperative treatment is appropriate, executes the technical aspects of the proper procedure safely and efficiently, cares for the patient postoperatively, and interacts effectively and ethically with the patient and family throughout the entire episode. Some elements of this process, such as clinical knowledge and judgment, are assessable through the standardized written and oral examinations conducted by certifying boards. Other elements, specifically operative technique, do not lend themselves to point-in-time, high-stakes examinations but rather are more accurately assessed by multiple preceptors over the course of a resident’s training. However, the survey by Gedde et al1Gedde S.J. Volpe N.J. Feuer W.J. Binenbaum G. Ophthalmology resident surgical competence: a survey of program directors.Ophthalmology. 2020; 127: 1123-1125Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar confirmed that more than three-fourths of most residents’ surgical experience occurs during their final year, so a struggling resident once identified may have limited time to undergo remediation before the expected graduation date. What are the options to decrease the likelihood that an incompetent surgeon is set loose on an unsuspecting public? Approaching the problem chronologically, perhaps medical students applying for an ophthalmology residency can be screened to weed out those who lack the skills to become good surgeons. Unfortunately, tests of manual dexterity have not been shown to correlate with surgical performance and are unlikely to be useful predictors of surgical competence,15Graham K.S. Deary I.J. A role for aptitude testing in surgery?.J R Coll Surg Edinb. 1991; 36: 70-74PubMed Google Scholar and their validity and legality have been questioned.2Binenbaum G. Volpe N.J. Ophthalmology resident surgical competency: a national survey.Ophthalmology. 2006; 113: 1237-1244Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar Not surprisingly, the survey by Gedde et al1Gedde S.J. Volpe N.J. Feuer W.J. Binenbaum G. Ophthalmology resident surgical competence: a survey of program directors.Ophthalmology. 2020; 127: 1123-1125Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar found that few programs currently perform vision or dexterity testing of resident applicants or residents. How about the Accreditation Council for Graduate Medical Education (ACGME) and the Ophthalmology Review Committee that monitors residencies? Isn’t it their job to ensure resident competence? Well…no. The ACGME is responsible for accrediting residency programs in the United States, including ophthalmology, but does not evaluate individual residents. With input from the Association of University Professors of Ophthalmology, the ACGME and Review Committee set the required minimum number of procedures for graduating ophthalmology residents.16Lessell S. The Residency Review Committee for Ophthalmology.Arch Ophthalmol. 1996; 114: 1002-1004Crossref PubMed Scopus (5) Google Scholar Minima have been established in multiple categories of ophthalmic procedures as indicators of adequate experience, but are not considered as indicators of technical competence or requirements for resident graduation. A poor correlation between case volume in training and surgical ability has been reported in general surgery,17Mattar S.G. Alsidi A.A. Jones D.B. et al.General surgery residency inadequately prepares trainees for fellowship: results of a survey of fellowship program directors.Ann Surg. 2013; 258: 440-449Crossref PubMed Scopus (135) Google Scholar and the volume of procedures performed may be less important than the quality of teaching during such operations.18Hall J.C. Imagery practice and the development of surgical skills.Am J Surg. 2002; 184: 465-470Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar A major shift occurred in graduate medical education approximately 20 years ago when the ACGME required that each program not only demonstrate adequate experience for its trainees, but also competence in clinical and surgical practice. The ACGME, in collaboration with the American Board of Medical Specialties, identified 6 core competencies as educational outcomes (namely, patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice). Each competency is composed of different “milestones” that residents are expected to attain at key stages of their training. Surgical ability traditionally has been subsumed under the patient care competency. Milestones are observable developmental steps that describe a trajectory from novice to master. Faculty members report resident progress to a departmental Clinical Competency Committee, and a formal milestones assessment is provided to the ACGME semiannually. Milestones were established for ophthalmic surgery as a product of the Ophthalmology Milestones Project, a collaborative effort between the ACGME and the ABO.19Gedde S.J. Day S.H. Bartley G.B. How will the next accreditation system affect ophthalmology residency training?.Ophthalmology. 2013; 120: 2364-2365Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar Ideally, milestones can be used to determine if a resident is progressing as expected or falling behind. Unfortunately, despite this initiative, 79% of program directors in the survey by Gedde et al1Gedde S.J. Volpe N.J. Feuer W.J. Binenbaum G. Ophthalmology resident surgical competence: a survey of program directors.Ophthalmology. 2020; 127: 1123-1125Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar thought that the ACGME milestones did not facilitate earlier recognition of residents who struggled with the acquisition of surgical skills. After residents graduate, approximately two-thirds pursue fellowship training and the remaining third enter practice. Don’t the academic institutions and healthcare facilities to which these newly minted ophthalmologists go confirm that they are competent? As most who will read this essay know, credentialing committees rely on attestation from former supervisors or colleagues about a candidate’s qualifications for a portfolio of clinical scenarios and surgical procedures but typically do not review outcomes data. At present, institutional credentialing is necessary but not sufficient to ensure the public’s safety. Should certifying boards such as the ABO, then, be expected to be the “last line of defense?” Theoretically, the ABO could assume the responsibility of conducting annual site visits to all 123 allopathic ophthalmology residency training programs in the United States to directly observe and assess the clinical and surgical performance of approximately 500 senior residents. Doing so, however, would be logistically nightmarish; intrusive and immensely stressful, and redundant to what teaching faculty already do; and would carry an enormous price tag for increased personnel, infrastructure, and other expenses. Such costs ultimately would be borne by young physicians who often shoulder heavy educational debt loads. Such an approach is untenable. The ABO could follow the example of some surgical certifying boards that have elected to define their credential in terms of the knowledge and judgment required to practice competently but remain silent about a diplomate’s technical skills. Although being unambiguous about what a certificate does and does not imply is admirable for its honesty, the Directors of the ABO, both ophthalmologists and its lay members, aspire to provide more comprehensive information, if feasible, to patients who seek eye care. Other surgical boards have opted to delay certification after residency graduation until candidates are able to accrue an operative case log that serves as the basis for their oral examinations. Such a pathway has the advantage of demonstrating proficiency with actual outcomes rather than using structured, but hypothetical, case vignettes. However, by 2 or 3 years after residency graduation, many ophthalmologists have already narrowed their practices to a subspecialty. Customizing myriad oral examinations across the broad spectrum of our field would be daunting, especially because the ABO is 1 of only 4 member boards of the American Board of Medical Specialties that does not issue subspecialty certificates (the history for which could be the theme of another editorial). Yet another option, favored by 59% of the program directors surveyed by Gedde et al,1Gedde S.J. Volpe N.J. Feuer W.J. Binenbaum G. Ophthalmology resident surgical competence: a survey of program directors.Ophthalmology. 2020; 127: 1123-1125Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar would be for the ABO to issue a certificate that limits the diplomate to practicing nonsurgical ophthalmology. After all, some of our colleagues choose subspecialties, such as medical retina or neuro-ophthalmology, that do not require handling a scalpel. However, designating some ophthalmologists as nonsurgeons risks confusion in the public arena at a time when other health care practitioners seek to obtain the right to operate on the eye and ocular adnexa through legislative means. Ophthalmology is historically and in practice a surgical discipline, a fundamental principle that was reaffirmed by the ABO at its meeting on June 7, 2019. Fortunately, several improvements have been made in recent years to enhance ophthalmic surgical education. Many programs have successfully implemented a structured curriculum to transition residents into ophthalmic surgery.20Lee A.G. Greenlee E. Oetting T.A. et al.The Iowa ophthalmology wet laboratory curriculum for teaching and assessing cataract surgical competency.Ophthalmology. 2007; 114: e21-e26Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar,21Gedde S.J. Vinod K. Resident surgical training in glaucoma.Curr Opin Ophthalmol. 2016; 27: 151-157Crossref PubMed Scopus (13) Google Scholar Virtual reality surgical simulators have the potential to improve patient safety and resident comfort before operating on a live patient,22Khalifa Y.M. Bogorad D. Gibson V. et al.Virtual reality in ophthalmology training.Surv Ophthalmol. 2006; 51: 259-273Abstract Full Text Full Text PDF PubMed Scopus (75) Google Scholar although evidence to demonstrate their validity, efficacy, and cost-effectiveness is limited.23Thomsen A.S. Subhi Y. Kiilgaard J.F. et al.Update on simulation-based surgical training and assessment in ophthalmology: a systematic review.Ophthalmology. 2015; 122: 1111-1130Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar Several surgical skills assessment tools have been developed to allow an objective and standardized evaluation of the surgical skills of residents, such as the Objective Assessment of Skills in Intraocular Surgery,24Cremers S.L. Ciolino J.B. Ferrufino-Ponce Z.K. Henderson B.A. Objective Assessment of Skills in Intraocular Surgery (OASIS).Ophthalmology. 2005; 112: 1236-1241Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar Global Rating Assessment of Skills in Intraocular Surgery,25Cremers S.L. Lora A.N. Ferrufino-Ponce Z.K. Global Rating Assessment of Skills in Intraocular Surgery (GRASIS).Ophthalmology. 2005; 112: 1655-1660Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar and Eye Surgical Skills Assessment Test.26Fisher J.B. Binenbaum G. Tapino P. Volpe N.J. Development and face and content validity of an Eye Surgical Skills Assessment Test (ESSAT) for ophthalmology.Ophthalmology. 2006; 113: 2364-2370Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar Microsurgical instructional courses for ophthalmology residents are increasingly available locally and nationally. A recent initiative of the Association of University Professors of Ophthalmology seeks to ensure the surgical competence of graduating ophthalmology residents through the establishment of surgical training courses for all residents, faculty development to enhance their teaching abilities, and implementation of a national standardized assessment of surgical skills. Despite these advances, teaching surgery to residents is not for the faint of heart, especially contemporary intraocular surgery in which a smoothly proceeding procedure can degenerate into an operative misadventure in milliseconds and by fractions of a millimeter. Legal concerns add to this stress; approximately one-quarter of program directors surveyed by Gedde et al1Gedde S.J. Volpe N.J. Feuer W.J. Binenbaum G. Ophthalmology resident surgical competence: a survey of program directors.Ophthalmology. 2020; 127: 1123-1125Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar had reservations about departmental liability for signing off on surgical privileges for an incompetent resident, and a similar number of program directors worried that a surgically challenged resident would respond with legal action. Residency programs and their sponsoring institutions must provide residents with due process in cases of remediation, probation, and dismissal.27Irby D.M. Milam S. The legal context for evaluating and dismissing medical students and residents.Acad Med. 1989; 64: 639-643Crossref PubMed Scopus (44) Google Scholar, 28Schenarts P.J. Langenfeld S. The fundamentals of resident dismissal.Am Surg. 2017; 83: 119-126PubMed Google Scholar, 29Lefebvre C. Williamson K. Moffett P. et al.Legal considerations in the remediation and dismissal of graduate medical trainees.J Grad Med Educ. 2018; 10: 253-257Crossref PubMed Scopus (2) Google Scholar Multiple court decisions have affirmed that faculty members are uniquely qualified to judge all aspects of academic performance.27Irby D.M. Milam S. The legal context for evaluating and dismissing medical students and residents.Acad Med. 1989; 64: 639-643Crossref PubMed Scopus (44) Google Scholar,28Schenarts P.J. Langenfeld S. The fundamentals of resident dismissal.Am Surg. 2017; 83: 119-126PubMed Google Scholar When due process has been followed, the program can expect the courts to support the importance of upholding professional and academic standards.27Irby D.M. Milam S. The legal context for evaluating and dismissing medical students and residents.Acad Med. 1989; 64: 639-643Crossref PubMed Scopus (44) Google Scholar Unless and until a superior means of assessment becomes available, the ABO must rely on the attestation of program directors and department chairs, whose faculty are in the best position to fairly determine the surgical skills of their graduating residents. Patients and the public put their faith in educational institutions, specialty organizations, and certifying boards to execute their fiduciary responsibilities with integrity. We must not fail to honor such trust. Ophthalmology Resident Surgical Competence: A Survey of Program DirectorsOphthalmologyVol. 127Issue 8PreviewStudies have raised concern that some graduating ophthalmology residents are not prepared to operate safely and independently.1-5 Approximately two-thirds of newly practicing ophthalmologists indicated that they would have benefited from additional surgical training during residency.1 A survey of residency program directors in 2001 found that 9.1% of ophthalmology residents struggled with the acquisition of surgical skills, and only 31% were successfully remediated before graduation.2 The purpose of this study is to describe the prevalence, characteristics, management, and career outcomes of recent ophthalmology resident graduates who reportedly struggled with surgical competence and to evaluate differences that have occurred since a similar survey was conducted approximately 2 decades ago. Full-Text PDF Re: Bartley: Verifying surgical competence: our fiduciary responsibility (Ophthalmology. 2020;127:997–999)OphthalmologyVol. 127Issue 12PreviewThe Ethics Committee of the American Academy of Ophthalmology read the editorial by Dr George Bartley.1 We applaud Dr Bartley’s cogent discussion of the challenges faced by those who monitor and improve the outcomes, both medical and surgical, in our profession. Indeed, the tremendous responsibility of those who teach and mentor our residents through the difficult task of building surgical competence in 3 short years is both daunting and admirable. Dr Bartley notes that a “competent surgeon is able to make an accurate diagnosis, knows whether surgical intervention or nonoperative treatment is appropriate, executes the technical aspects of the proper procedure safely and efficiently, cares for the patient postoperatively, and interacts effectively and ethically with the patient and family throughout the entire episode.” He later points out that the “ACGME, in collaboration with the American Board of Medical Specialties, identified 6 core competencies as educational outcomes (namely, patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice).” Full-Text PDF