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Nonclinical Education for Residents Revisited 

Dr. Jennifer Hasenyager Smith wrote an outstanding letter, “Nonclinical Education for Residents” (Letters, April), based upon her study of ophthalmologists newly in practice, in which she advocated for resident training in nonclinical subjects such as practice management, finance, coding and political advocacy. We would like to go even one step further and suggest these subjects are clinical quality issues in that mastery of them allows us to deliver better care to our patients.

Two years ago, we conducted a poll assessing the health care financial level of knowledge of residents and medical students. On the five-part, multiple-choice question concerning the total national health expenditure in 2005 of $1.9 trillion, only 10 percent answered correctly! This begs the question, how can physicians expect to have a shred of credibility, much less influence, on health care economic policy issues vital to the well-being of their patients if they don’t even know the most basic facts?

Residents in ophthalmology and other specialties primarily study what they have to know to pass their board exams. And residency programs in virtually all specialties justifiably orient their teaching largely toward what their respective boards expect. Hopefully, these respective specialty boards will recognize that the matters Dr. Smith addresses enhance practice of the highest quality medicine and advocacy for our patients. Until then, resident education will still be deficient in regard to these vital real-world issues.

Melissa M. Brown, MD, RN, MN, MBA
Gary C. Brown, MD, MBA
Flourtown, Penn.


The Value of Ophthalmic Health Care 

The New England Journal of Medicine recently published an article reviewing 10 years of experience with the resource-based relative-value scale payment system.1 The authors said that relative value units (RVUs) per beneficiary rose significantly and that “an understanding of these sources of growth can inform policies to control Medicare spending.”

What I found interesting was that the greatest growth in the volume of RVUs according to specialty was in dermatology, cardiology and orthopedics, the volume of imaging services grew the most, and the introduction of new codes accounted for most of the growth among physician services. It would appear that, over the past 10 years, an aging population requires more care per person with the introduction of new therapies, uses more diagnostic imaging services and is experiencing more skin diseases.

There is a great deal of discussion about the cost of health care but little attention appears to be paid to the value and appropriateness. We need to be concerned about the cost, but the latter is an important consideration in a nation of considerable wealth and an aging population that is experiencing debilitating illnesses. Many of my acquaintances are alive because of improvements in diagnostics, medications and surgical procedures available to treat heart disease. They are also active and enjoying relatively pain-free lives because of hip and knee replacements.

Owing to improvements in cataract surgery, many of them are also enjoying safe, rapid, comfortable and useful visual rehabilitation compared with the extracapsular cataract extraction (ECCE) of a few decades ago. In today’s dollars, the cost of ECCE was much higher, and this doesn’t take into account phaco’s increase in safety and reduction in lost income for those patients who are still employed.

The success in preventing blindness due to diabetic retinopathy and macular degeneration are other examples of significant increased value for ophthalmic health care. While we can’t ignore the cost of health care individually and nationally, the value of that care to individuals and society needs to be considered also. We must educate our legislators and, more important, our patients—the voters—of these considerations.

By the way, ophthalmology and general surgery were the only specialties that experienced a reduction in overall RVUs per beneficiary!

George E. Garcia, MD
Glenview, Ill.


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1 Maxwell, S. et al. N Engl J Med 2007;356:1853–1861.
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