American Academy of Ophthalmology Web Site: www.aao.org
Clinical Update: Eye on Eye Medicine, Part Two
A Place to Call Home: Eye Surgeons in the House of Medicine
Our patients don’t get undressed, we don’t lay our hands on them, and now our surgeries aren’t done in hospitals anymore. Our patients are treated almost exclusively in ambulatory settings, and we don’t even need preop labs on them.” Those are some of the incremental ways, according to Gary S. Schwartz, MD, in which ophthalmology is drifting away from mainstream medicine. And that drift, he added, begins in the formative years of medical training. Dr. Schwartz is an adjunct assistant professor of ophthalmology at the University of Minnesota in St. Paul, and was the author of a guest opinion, “The Eye Is Part of the Body,” in last September’s EyeNet addressing this development.
In recent years, medical education in general has been arraigned on a number of issues, both in academia and the news media. The glum working conditions of residents, the staggering weight of student loans and the jockeying over program curricula have inspired a host of public discussions. In fact, both Archives of Ophthalmology and the Journal of the American Medical Association plan to devote much of their upcoming September issues to articles on the state of medical education.1
On top of those discussions are issues unique to ophthalmic education:
Wanted: Well-Rounded Eye Physicians
Medicine for a Whole Patient
Ophthalmology clerkships—even ophthalmic rotations for the transitional year—are not mandatory components for medical schools or physician training programs to maintain their accreditation. In fact, the number of schools requiring a formal eye rotation has dropped by more than half since the year 2000. An opinion in Ophthalmology by David A. Quillen, MD, and colleagues pointedly regretted that development. “How can it be that the specialty we love so much receives so little attention in the overall scheme of medical education?”2
Even where it survives, ophthalmology education is often minimized by program neglect or chronic underfunding, according to Stuart R. Seiff, MD, chief of ophthalmology at San Francisco General Hospital, and professor of ophthalmology at the University of California, San Francisco.
S.F. General maintains robust ophthalmology and primary care rotations, among others, Dr. Seiff said, but that’s not the case everywhere. “Ophthalmology is just not a priority for most schools. It could disappear from the map without affecting their accreditation whatsoever.” He described a pattern in which many medical students fail to gain basic ophthalmic skills, and ophthalmology residents don’t always acquire core medical skills.
Curricular constraints. Curricula are so multipurposed in some schools, said Dr. Seiff, that both medical and ophthalmic teaching lack depth. Some institutions produce medical graduates, for example, who were introduced to fundus exams only as a very minor part of a primary care curriculum. And, as Dr. Quillen writes, “They have an insufficient understanding of ocular anatomy, fundamental eye examination skills, common causes of vision loss, and the relationship between the eye and systemic disease.”2
Conversely, Dr. Seiff noted, everyday medical skills may not intrigue students who choose to pursue ophthalmology, partly because they do not plan to deal with inpatient care. In either case, the result is not good for patients, he said, whose bodies don’t always cooperate with that compartmentalization.
“If you call for an ophthalmology consult on a patient with vision problems after, say, a hip replacement, you want someone with excellent medical skills, someone who can sort out hemodynamic fluxes and how they affect perfusion of the optic nerve and possible ischemia,” he said. But the consulting physician may not have that discursive skill.
Taking the pulse of new physicians. Dr. Seiff’s concerns were supported in part by a survey of ophthalmology residents conducted by James P. Dunn Jr., MD, who is director of the division of ocular immunology and director of residency education at Johns Hopkins University, as well as chairman of the Program Director’s Council of the Association of University Professors of Ophthalmology (AUPO). Dr. Dunn presented some results from his survey at the annual AUPO meeting in February.
The first survey question asked, “Was ophthalmology part of your required medical school curriculum?” Over 90 percent of the residents said no, supporting the charge of the marginalization of eye medicine. For another question, “What was/were the most important factor(s) in your choosing ophthalmology as a career?” the highest ranking answer, by far, was “Opportunity for surgery,” which would imply a strong interest in serious medicine on the part of these residents. But, paradoxically, the next highest ranking answer was “Lifestyle,” suggesting that these doctors imagined a more relaxed future than what might face their friends who chose obstetrics, oncology or pulmonology.
Like Dr. Seiff, Dr. Dunn believes a lot of medical school graduates have no idea how to use an ophthalmoscope, and many of those with an interest in ophthalmology have not pursued electives that would broaden their skills. He encounters such discrepancies in his work on the admissions committee at Johns Hopkins. “My personal bias is the ‘liberal arts’ approach to medical school. I’m looking for the graduate who is very well-rounded. I want an eye resident who’s done an elective in infectious disease, or cardiology or rheumatology, and understands other parts of the body. I’d much prefer that to someone who spends their fourth year of medical school doing three months of clinical ophthalmology and another three months of an ophthalmic elective.”
Dr. Dunn added that medical skills shouldn’t lurch to a halt after medical school. “I think the transitional year should be spent in a good internal medicine program. Instead, a lot of grads head into programs that aren’t very rigorous, taking more electives in ophthalmology without a lot of responsibility for direct patient care. So they’re not seeing the patient with metastatic cancer that may go to the eye, the patient with a bone fracture in whom you could look for fat globules in the retina. A lot of them will never learn how to run a code. If they worked in other services, they would become better all-around physicians. There’s a certain gestalt you create by managing patients medically, and dealing with their family members. The skill of treating someone’s cardiac disease or end-stage renal disease will translate well into telling future patients that they’ve got glaucoma or a retinal detachment that requires surgery. Having experience being the caregiver enriches the way you present yourself as an ophthalmologist: ‘I’m the doctor taking care of you now, for your eye problems.’”
How to remedy the situation. Dr. Seiff suggested several ideas that could help boost both medical and ophthalmic competency among resident physicians. They begin with ophthalmology departments actively advocating for eye medicine, and ensuring that eye residents learn medicine beyond the eye. “Internships could be more rigorous. Interns who assume they’re heading into ophthalmology should perhaps have to do a general surgery rotation. As academicians we need to aggressively insert ourselves into the general resources of a school. We need to do consults gleefully, and insist that our residents do consults. Eye residents need to go to ERs. Ophthalmology must be seen as a diagnostic and therapeutic tool for dealing with systemic disease, and these attitudes have to start in medical schools.”
How Many Eye M.D.s Are Enough?
Shadowing the current state of ophthalmology training is the fact that the number of ophthalmic residency slots around the country has not appreciably increased in many years. Ten years ago, in 1997, a total of 435 medical school graduates were matched with ophthalmology training programs. Five years later that number was 438. This year it was 450.
Those relatively steady numbers do not seem to reflect anticipation of what some observers are calling an eye physician shortage looming over the next several decades. Dr. Seiff predicts that the aging Baby Boomers will clearly tax the current capacity of ophthalmologists to provide care, but he said that planners are not motivated to change the numbers. “The government, for one, is not particularly worried because it sees a huge cadre of optometrists to fill the gap. It’s pretty clear they don’t want to get in the middle of our scope of practice battles. The government would be happy to pay optometrists to do eye exams.”
Supply and demand: vagaries rule the medical marketplace. Meanwhile, interestingly, the number of applicants to ophthalmology training programs every year is generally double the number of openings, suggesting that young physicians are interested in eye medicine even if many teaching institutions are not. But during residency that apparent enthusiasm soon becomes lopsided: some subspecialties, like cataract and refractive surgery, are heavily favored after residency, while others, such as pediatric and neuro-ophthalmology, are often left with unfilled fellowships.
Are some areas of eye medicine inherently more attractive than others? Carl Ware, MPH, who manages SF Match, the national program for ophthalmology resident placement, and who often speaks with applicants personally, surmised that ophthalmology is governed by the same social and economic dynamics that pervade all of medicine: The surgery-rich disciplines tend to be compensation-friendly, while patient-intensive ones pay much more modestly. “That would be one explanation why pediatric and neuro-ophthalmology are some of the most difficult fellowships to fill.”
But the full answer may be more nuanced. “Although surgical professions tend to be more lucrative, research on applicants to residency training programs indicates that compensation is not a big consideration when selecting a medical specialty,” Mr. Ware said.
Remember Your Roots
Finally, once in practice, many ophthalmologists may unintentionally isolate themselves from the rest of medicine by settling into private, stand-alone, ambulatory surgery centers and avoiding primary care or acute care settings. This may serve to reinforce the original neglect of ophthalmology in education.
Dr. Schwartz said that the relative isolation of ophthalmologists from other MDs can start as early as medical school. “At first, in med school, we’re all in ‘medicine’ together. Future ophthalmologists are in the same classes and labs as future nephrologists and cardiologists,” Dr. Schwartz said. But then in internship, “About half the class starts thinking about going into general medicine, and the other half starts thinking about radiology, cardiology, ophthalmology, anesthesiology. And for ophthalmologists, on day one of your residency you shift your whole focus of education away from an inpatient setting to an outpatient setting. And during a busy ophthalmology clinic, inpatient consults are often looked at by residents as inconveniences, rather than opportunities.”
Outpatients only need apply? Few other specialties take physicians so easily away from the mainstream of medicine like that, said Dr. Schwartz.
Dr. Seiff agreed with that assessment and said it actually fosters a dearth of ophthalmologists needed for emergent situations. “There are horrible shortages of ophthalmologists willing to work on-call in ERs. University and county hospitals end up being the last resort for private hospitals. We get calls like, ‘We have a ruptured-globe patient and we don’t have an on-call ophthalmologist, so we need to transfer this patient.’” Dr. Seiff noted that some private hospitals end up paying ophthalmologists a stipend for being on-call, something they wouldn’t do for a primary care MD.
Institutional speed bumps. While Dr. Schwartz advocates the fostering of ties with medicine, he also appreciates the various factors working against that. At one time, he himself tried to maintain admitting privileges at four separate hospitals. “But now, realistically, one MD can’t keep up with so many institutions’ regulations, and the work and time involved in learning different EMR systems may not seem worth the trouble of being available to see inpatient and emergency room consults. So the question comes up: ‘Do we need the hospitals as much the hospitals need us?’ And the answer, really, is no. I may need other physicians to refer certain patients to, but I don’t particularly need a hospital for my patient care.”
Eye, heart and soul M.D.s. “But there is a greater good to consider,” Dr. Schwartz added. “You have to think of the community of patients, and of the staff MDs in the ER who don’t want to mess with an eye injury. Part of the allure and the mystery of the wonder-ful organ called the eye is also what makes it intimidating for nonophthalmologists to approach. And it’s what gives us our work. How much better,” he said, “to look at a consult as an opportunity rather than an inconvenience: an opportunity to help another doctor formulate a diagnosis, to interact with the nursing staff, to help a patient. Sure, you could ignore acute and primary care medicine without hurting your career. But you could end up hurting patient care.”
Dr. Schwartz believes the solution will come from the concern of individual ophthalmologists. “We went to medical school and we took the Hippocratic oath, and not everything we do should be chalked up to a smart business decision. Ophthalmologists are still members of the house of medicine. We have the privilege of having the best job in the world, and part of that job is a sense of responsibility to the community.”
1 Arch Ophthalmol 2007;125(2):230.