Refractive surgery experience for the ophthalmology resident: An update

The issue of practical resident experience in refractive surgery remains a complex challenge to ophthalmology training programs and trainees alike. Despite the large numbers of refractive surgery procedures being performed by ophthalmologists across the world, approximately half of United States ophthalmology programs graduate their residents without any primary surgeon experience in laser in situ keratomileusis (LASIK) or surface ablation procedures. Challenges to the enthusiastic adoption of resident refractive surgery programs have been pointed to in excellent articles by Aaron and Aaberg,1 Alió,2 and Randleman and Stulting.3 They include patient reluctance to accept a lower level of surgeon experience for an elective self-pay procedure, fear of training one's competition amidst a finite pool of refractive surgery candidates, concerns of patient risk, and a belief by some that refractive surgery should be the domain of subspecialty-trained cornea and refractive surgery specialists.1 At the same time, two thirds of recent U.S. ophthalmology residency graduates have expressed a need for additional training in subspecialty surgery, including refractive surgery,4 and most residents see the opportunity to gain exposure to and perform refractive surgery, regardless of their future practice patterns, as a positive (and, for some, a requisite) feature of a training program. In this issue (pages 1629–1632), Kwon et al. report the results of a 2005–2006 postal mail survey sent to residency directors, chairpersons, and refractive surgery directors of U.S. ophthalmology residency training programs that provides a snapshot of resident refractive surgery experience among residents training between 2003 and 2006. Consumers of survey data should consider a number of questions when interpreting results; among them, who was asked (faculty versus residents, subspecialty-trained cornea/refractive surgeons versus comprehensive ophthalmologists), how were the questions and answer choices phrased, and were programs that do not offer primary surgeon refractive surgery experience less likely to return a survey and thus lead to overestimation of the surgical experience across all programs? Even in light of the limitations, a comparison of the current survey and one performed by Aaron and Aaberg circa 20001 is irresistible and suggests some progress in the adoption of formal refractive surgery experience in U.S. ophthalmology residency programs. In the earlier survey, which achieved a 77% response rate, only 26% of programs claimed that residents were performing supervised LASIK cases as primary surgeon.1 The current study, with a 64% response rate, indicates that this number has effectively doubled. Another 3 years have passed since data collection for the most recent survey, and it is possible that today's numbers are higher yet. While 16% of respondents in the earlier study stated that formal LASIK training should not be a part of residency education,1 only 11% took a similar stance in the later study. Nine percent of programs in the current study indicated no resident exposure to any LASIK procedures, whether as primary surgeon or observer. The majority of programs offer marked discounts to patients undergoing surgery with a resident. The essential question underlying such surveys is this: Is refractive surgery experience fundamental to the education of the ophthalmologist? The answer, which has been reinforced by a multitude of educational initiatives by the American Academy of Ophthalmology, the International Society of Refractive Surgery, and the American Society of Cataract and Refractive Surgery, is an unequivocal “yes.” The goal of the residency-based refractive surgery experience should not be to produce technically skilled refractive surgeons, however. This is the aim of subspecialty training programs and concerted clinical practice after residency and could occur only at the expense of other important objectives during residency. Ophthalmology programs should offer residents significant exposure to and some practical surgical experience with refractive surgery but supported by strong didactic programs, significant clinical time devoted to the nuances of surgical decision-making and management of operative and postoperative complications, and thoughtful wet-lab experiences modeled to replicate critical procedural steps5 that allow residents to hone technical skills and confidence in advance of patient contact. Using survey results as a tool for establishing a residency review committee requirement for all ophthalmology programs seems a perilous proposition, and one that does not reflect the greater need for comprehensive refractive surgery education programs. The American Society of Cataract and Refractive Surgery and the Journal of Cataract & Refractive Surgery support the goal of comprehensive education by providing free subscriptions to ophthalmology residents, with the goal of providing ready access to the field's clinical and scientific dialogue and encouraging residents to participate. It is encouraging that residency programs are, without undue external pressure, responding in earnest to the expressed desire of residents to become more involved with this exciting field.