Sometimes we can be sitting in the midst of what seems like incremental change and suddenly discover we are swept away in a revolution. Paradigm shifts are like that. They sneak up on you like tsunami. They seem to come suddenly, but actually have been brewing for some time, deep under the surface where they have been submerged by skepticism among the establishment. Phacoemulsification is an example to which most ophthalmologists over age 50 can relate (those under age 35 can’t understand why it took so long to become mainstream).

There’s a paradigm shift under way in medical education. It’s the explicit recognition that there’s more to being a competent physician than knowing a lot and having a quiver full of diagnostic and therapeutic arrows. Patients have long sought compassion, communication skills, ethics, professional behavior and their sister attributes in a physician; in fact, they have been telling us so for years. What, then, has caused the sudden realization among educators?

The lightning rod that has channeled all this academic energy is the development of the six general competencies. Yes, these are the same competencies you’ve been hearing about in the context of maintenance of certification: medical knowledge, patient care, communication, practice-based learning, professionalism and systems-based practice. Remarkably, these competencies have been adopted by the major accrediting and certifying organizations across medicine as a structure around which to organize teaching and evaluation of physicians in the pipeline and beyond.

The Residency Review Committee for Ophthalmology is beginning to require residency programs to provide training and evaluation in each of the six competencies, and to certify satisfactory completion in all of them, including a seventh, surgery. But not so fast—we’ve got a problem. The teachers have no time left to teach! In order to earn enough to fund their salaries, departmental faculty are forced to spend more and more time in the clinic or the lab.

Residents are in no position to complain. They don’t have the perspective of the “good old days”; they sympathize with the overstressed faculty, who have precious little time available; and besides, they are grateful to be in an ophthalmology residency at all. So with each passing year, there is further erosion of the teaching mission. In this environment, how can we commit to a new teaching paradigm?

I maintain that a lot of the solution is attitude. First, the teachers and their employers and the ophthalmic community need to honor teaching, even if it is not financially rewarded. Second, the crucial importance of mentoring needs more attention. One careless comment by a senior physician can undo hours of didactics in professionalism. An episode involving one of my former faculty members comes to mind. With a resident in tow, this attending entered an examining room containing the patient, her mother and her grandmother, declaring, “Somebody in this room will be needing surgery!” The inappropriate message for the resident was that surgery was the desired outcome of a patient (or even an accompanying person) encounter.

Finally, we need to stop thinking of reasons why we can’t implement this educational paradigm shift. It is, after all, the right thing to do.