Lack of standardization, insufficient surgical training take toll on development of European young ophthalmologists

Uncoordinated and poorly structured residency programs, lack of standardization in the curricula, and insufficient exposure to surgery are serious limitations to the professional growth and careers of young ophthalmologists in Europe.

“Most of us choose ophthalmology because we are made to believe that half of the curriculum is surgery and then we end up doing no surgery at all,” Marie Louise Roed Rasmussen, MD, PhD, president-elect of the European Society of Ophthalmology Young Ophthalmologists group (SOE YO), said.

With the exception of the United Kingdom and some other countries, where a fixed number of surgical cases in different subspecialties is required to be licensed as an ophthalmologist, the type and number of surgical procedures performed by trainees under supervision are extremely variable in Europe, and equally variable are the chances to be exposed to surgery after residency.

“First of all, you have to get a position, and there aren’t many, and then it depends on whether your seniors are willing to involve you in the surgical team and spend time training you. It all depends on where you are, whom you meet and, eventually, on how lucky you are,” Roed Rasmussen said.

Despite a PhD and 16 years of clinical experience, she feels “grounded” due to the lack of surgical training in her country, Denmark.

Image: Roed Rasmussen ML

“Most YOs cannot apply for post-residential jobs in Holland, Sweden, anywhere, because they don’t have the requirements. I have colleagues who are not able to get a fellowship because the requirement is 200 cataracts, and they have not been trained to do cataract at all,” she said.

“Quite a few go to India, spend a huge amount of money to be trained there and come back, hoping that their experience will be acknowledged here,” she said.

A survey across Europe

According to the results of a Surgical Skills questionnaire issued by the European Board of Ophthalmology (EBO), surgical training is perceived as the weakest point of curricula across Europe. On average, European ophthalmology trainees perform 10 to 50 cataract surgeries during residency, while the minimum required number of their U.S. colleagues is 86.

“The U.K. is at the top of the list, with a high number and a wide range of surgical operations mandatorily required during residency. On the opposite side, there are countries like Switzerland where intraocular surgery is not a part of the core curriculum and is only learned during additional 2 years of fellowship,” Marko Hawlina, MD, PhD, FEBO, chair of the SOE Education Committee, said.

Phacoemulsification is mandatory in only 13 European states, trabeculectomy in 10, entropion and ectropion repair in 12, and oculoplasty, blepharoplasty and basic extraocular muscle surgery in 11. Scleral buckling is included in the curriculum of only four countries.

“Not surprisingly, a survey launched by the SOE YO unveiled a dramatic 22% of responders who never had the opportunity to do surgery during their residency,” Hawlina said.

Most EU states agreed that basic surgery techniques should be learned during residency, that a realistic minimum number should be defined and accomplished, and that there is a need for surgical fellowships for additional training.

The role of EBO

Peter J. Ringens, MD, PhD, FEBO, president of the EBO, said he is well aware of the enormous discrepancy in training programs in Europe, particularly in terms of preparing residents for surgery.

“The U.K. is in the forefront, and there are countries that are almost comparable, like Portugal and the Netherlands, where we train residents to do cataract surgery, extraocular procedures and some glaucoma surgery. In Belgium there is no surgery in the residency curriculum, and Flemish-speaking Belgian students often move to the Netherlands,” he said.

The aim of the EBO and the EBO exam is to set harmonized standards in the training of ophthalmologists, but there is very little the board itself can do in regard to surgery.

“Candidates are tested in written and viva voce exams, but we have no ability to test surgical skills. The best we can do at this moment is question them about surgical approaches, and that is based on either them having done it hands-on or having been exposed to it while assisting someone else. But we would very much like to see that there is a similar training throughout Europe; that would be one of our greatest wishes,” he said.

Strong European ophthalmology goes hand in hand with harmonization of study curricula, which should not be exactly the same among countries, but similar and comparable, Ringens said.

“Then we have an issue, that we have to comply at the moment with local regulations, and that is really the biggest hurdle toward achieving a similar exposure to surgery,” he said.

The need for a learning contract

“I spent some time in the United States, and there I saw how professional the residency programs and fellowships can be,” Ivo Kocur, MD, MA, MSc, MBA, WHO medical officer who also oversees activities of the Lions Ophthalmology Educational Center in Prague, said.

In his view, what substantially differentiates the well-established U.S. training programs from continental Europe is that they are based on a learning contract between students and teachers.

“Getting residency in ophthalmology is a highly competitive process there, and in many cases only a small percentage of annual applicants are accepted. Trainees know what level of performance the institutions expect from them but also know exactly what they should expect from the institution. Everything is clearly defined and planned, with daily schedules, yearly programs and exams. Both parties are bound by a kind of contract, and if students don’t get what was agreed upon, there is space for complaint,” Kocur said.

“Conversely, in some parts of Europe, starting physicians mostly learn by observing and asking. You may find someone who is nice and keen to teach, but you may not. There may be quite a lot of hanging around, and this is how you make it through those initial years. Making it a success very much depends on the young doctor’s stamina, dedication and understanding the challenge rather than being selected to get a residency post where you know you will work hard and they will work hard on you and together you will make a success story out of that,” he said.

Reasons behind the current situation

There may be several reasons behind the dysfunctionalities of an educational system that persists in not meeting the needs of the younger generations. According to Roed Rasmussen, Europe as a whole and some individual countries lack a central regulatory body to harmonize curricula, set the minimum requirements and perform quality assessment of training institutions.

“In the U.K. they have the deanery that supervises standards and ensures that doctors are given the right opportunities and experience. Nothing similar exists in other countries,” she said.

In addition, in the United Kingdom, many of the tasks that are performed by ophthalmologists in continental Europe are delegated to optometrists, and this allows shifting the emphasis on developing surgical skills in young trainees.

“In most European countries there are no optometrists, and a lot of ophthalmologists take care of the optometrists’ work. That tips the balance away from surgery,” Rasmussen said.

Cost might be a further reason. Training in the OR slows down the patients’ flow, causing case-related extra time and therefore higher costs, as proved by several studies. In addition, trainees may have more complications, leading to a longer hospital stay and higher costs.

“The SOE Education Committee survey found that lack of funds, and not language, is currently the main obstacle to the setting of fellowships across Europe. Most training centers stated they would not be able to accept financial obligations for fellowships, could not offer a salary, and some would in fact require payment from fellows. However, with the new fellowship database published by the SOE (http://soevision.org/fellowship-platform), all fellowship and observership opportunities in Europe will be advertised at one place, to start with. This database resulted from joint efforts of SOE Education YO Committee,” Hawlina said.

Fear of competition might also make specialists and consultants reluctant to share knowledge with younger fellows.

“In larger territories such as the U.S., seniors have fewer reasons to fear that their students might draw patients away from them. In smaller countries this may be an issue, and people don’t share knowledge because they are afraid of losing patients. In the EU the free market allows and encourages free circulation, but most ophthalmologists don’t move around a lot, also because of language barriers. Additionally, in many parts of continental Europe there are higher numbers of ophthalmologists per population compared to the U.S. and U.K. ratios. Therefore, the competition may be quite high at a local level,” Kocur said.

“In some countries, surgeons are a closed circle. For instance, in Germany there is only a small number of them, while the majority of ophthalmologists don’t do any surgery at all,” Ringens said.

According to Kocur, a lot of it has to do with the old pedagogical debate: Who educates the educators?

“More opportunities for training on teaching methods for those who should teach would certainly be beneficial for both teachers and students,” he said.

The role of simulators

Béatrice Cochener, MD, PhD, president of the French Academy of Ophthalmology, is part of a commission that redesigned residency training in France. In the new curriculum, the first foundation year will be followed by three specialty years in which cataract, pterygium and lid surgery will be taught. Two additional years will provide subspecialty training.

“Surgical training in the new system includes officially and mandatorily the use of simulators for training. Students will enter in a personal logbook all the surgeries they individually perform during their residency, and there will be an official list and minimum number of procedures they have to perform,” Cochener said.

Simulators will help rebalance the discrepancies that currently exist in France between centers that put residents in the surgical theater during their first year and centers that are not equipped or prepared to do so.

“Simulators will allow trainees to go through their learning curve away from the patients and therefore gain access to the OR earlier, more confidently and with much reduced risk for the patients,” Cochener said.

“There are studies now evaluating whether simulators can predict how skillful a trainee will be as a surgeon in real life,” Roed Rasmussen said.

However, to avoid simulators become “nothing more than a video game,” she suggested they should be used as preparation for, and not as a substitute to, real-life surgery.

“Their use should be planned to be sequentially combined with wet lab and OR surgery, as it is in the U.S.,” Roed Rasmussen said.

Young ophthalmologists are currently fighting a hard battle to change the current status of training in Europe.

“I am personally doing a lot, voicing our complaints and advocating changes through the SOE YO, the YO society in my country and also in my hospital. Others are doing so and we are trying to gain some political influence, but it is difficult,” Roed Rasmussen said. “We are 28 nationalities fighting our own case because there is no deanery and no supranational authority to talk to.” – by Michela Cimberle

• References:
• Chadha N, et al. Clin Ophthalmol. 2016;doi:10.2147/OPTH.S106293.
• Fahim AT, et al. Can J Ophthalmol. 2016;doi:10.1016/j.jcjo.2016.04.018.
• Lam CK, et al. BMC Ophthalmol. 2016;doi:10.1186/s12886-016-0269-2.
• Muttuvelu DV, et al. Can J Ophthalmol. 2016;doi:10.1016/j.jcjo.2016.04.006.
• Thomsen AS, et al. Ophthalmology. 2015;doi:10.1016/j.ophtha.2015.02.028.
• Tzamalis A, et al. J Ophthalmol. 2015;doi:10.1155/2015/932043.
• The Database for European Ophthalmology Fellowships. European Society of Ophthalmology website. http://soevision.org/fellowship-platform.

• For more information:
• Béatrice Cochener, MD, PhD, is an OSN Europe Edition Board Member. She can be reached at University Brest Hospital CHU Morvan, Ophthalmology Department, 5 avenue FOCH-29605 Brest – Brest Cedex, France; email: beatrice.cochener-lamard@chu-brest.fr.
• Marko Hawlina, MD, PhD, FEBO, is an OSN Europe Edition Board Member. He can be reached at Eye Hospital, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia; email: marko.hawlina@gmail.com.
• Ivo Kocur, MD, MA, MSc, MBA, is an OSN Europe Edition Board Member. He can be reached at World Health Organization, Avenue Appia 20, 1211 Geneva 27, Switzerland; email: kocuri@who.int.
• Marie Louise Roed Rasmussen, MD, PhD, is an OSN Europe Edition Board Member. She can be reached at email: marie.louise.roed.rasmussen@regionh.dk.
• Peter J. Ringens, MD, PhD, FEBO, can be reached at Department of Ophthalmology, Maastricht University, Maastricht, The Netherlands; email: p.ringens@mumc.nl.

Disclosures: Cochener, Hawlina, Kocur, Roed Rasmussen and Ringens report no relevant financial disclosures.

Could the private sector contribute to surgical training for ophthalmology residents?

Too many risks and too many costs are involved

Although sharing knowledge should be a part of our profession and is indeed rewarding for a senior surgeon, I do not think that the private centers will ever be able to offer surgical training to junior surgeons. The only exception I know is when a close relative, usually a son or a daughter, is gradually being integrated in the clinic. In these cases, however, the ABCs of surgery are preferably learned somewhere else. Teaching is time-demanding and therefore hardly compatible with the tight schedule of a private practice or day clinics. It is also costly because of the additional time invested, the need to involve the rest of your staff and the expenses related to the use of surgical materials, such as viscoelastics, Malyugin rings and medication. Furthermore, serious complications such as a dropped nucleus, fragments in the vitreous or dislocation of the IOL could occur, as well as the costs for additional operations. University clinics and teaching hospitals are the institutes that have to educate the ophthalmologist. Last but not least, there are reputational risks to consider. More complications have to be expected as part of the learning curve, which would damage the reputation of your clinic and expose you to the risk of being sued. In my region and my town, which are relatively small and conservative, reputation is slowly gained and very difficult to rebuild when it is lost.

When patients choose private centers, ultimately they come because they want to be operated by a surgeon of their choice, and especially when they pay out of pocket for a procedure, they expect exclusive and personal attention from her or him, as well as top quality and best results. Very few, if any, would accept to be operated on by a junior and sign for it in the informed consent, even if the cost is covered by private insurance. Patients have to be informed about who will operate on them.

Magda Rau, MD, an OSN Europe Edition Associate Editor, is medical director of Augenklinik Cham, Cham, Germany. Disclosure: Rau reports no relevant financial disclosures.

Wet labs are an excellent form of private training centers

Although letting junior surgeons operate directly on patients might not be feasible for many good reasons, there are other ways private centers can contribute to developing surgical skills. Wet labs, for instance, are a very good option if you have the instruments, the space and the competencies for setting them up. Trainees can effectively learn how to perform surgical maneuvers, how to use the instruments, the machines, the pedals and the surgical microscope, and how to coordinate with an assistant. They are followed closely by a supervisor, can ask questions and learn from their own mistakes. Wet labs are also a good test for selecting those who have the talent to become good surgeons.

Back in the mid-90s, I organized courses for junior surgeons. We had 10 wet lab posts, each for two trainees, 10 phaco machines, 10 microscopes and 10 sets of surgical instruments. Each lab table was equipped with audio and video recording systems, and every procedure was watched by a senior surgeon. Eight to 10 colleagues collaborated in this project, and we had more than 1,000 trainees in 2 years. I can say, without fear of overstating things, that we contributed to an epochal change in Italian ophthalmology. We created a new generation of ophthalmic surgeons, and it was a major turn because no one in those days, with the exception of a few isolated cases, used to teach surgery in our universities. Those years also coincided with major steps forward in ophthalmology: Phaco was introduced, as well as IOLs, rigid and then foldable, and the use of surgical microscopes. These were the advancements we were able to teach our students in the wet lab. It was a rewarding, exciting experience that I have never forgotten, and it is in my plans to start organizing these courses again, hopefully already in 2017.

Lucio Buratto, MD, an OSN Europe Edition Board Member, is director of Centro Ambrosiano Oftalmico, Milan, Italy. Disclosure: Buratto reports no relevant financial disclosures.