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  • Goals for Harmonizing Ophthalmic Residency Training in Europe

    When the European Union (EU) was created, it enabled health care providers to practice in any one of the member states once they have attained the qualification in their home country. This free movement of workers is a challenge in ophthalmology, where there is enormous heterogeneity in postgraduate training. 

    There is no consensus on the medical and surgical competencies that a trainee should acquire during residency in order to obtain certification to practice as an ophthalmologist in different European countries. 

    To benchmark ophthalmology residency training in European countries and explore the degree of heterogeneity, we conducted a survey targeting young ophthalmologists to assess the differences, possible deficiencies and trainees’ satisfaction with residency training. 

    In our survey, we asked those in training to respond based on their training experience up to the time of the survey. If the respondents had completed residency training, we asked them to respond according to the overall experience of their residency. 214 participants representing 36 countries — all of which offer ophthalmology residency training — were included in data analysis. 

    The results revealed astonishing disparities even in the duration in years of ophthalmology training of the survey participants. The median was four years, which is close to the standard established by the European Union of Medical Specialists that claimed three years as a minimum residency time. This fact may explain the observation that mainly non-EU countries had less than three years (Ukraine and Russia: two years; Belarus: 1.5 years). On the opposite side, Ireland and the United Kingdom had seven years.

    The survey also showed discrepancies among countries regarding the need of a mandatory examination prior to practicing as an independent ophthalmologist. 55% reported the presence of a mandatory certification process, either in the form of a specific national examination or a national board for ophthalmology, while 20% did not have this requirement (Belarus, Denmark, Finland, France, Italy, Norway, Spain, Sweden and Turkey). The remainder were required to sit for regional examinations with the European Board of Ophthalmology or the International Council of Ophthalmology examinations. 

    Most participants reported a good level of confidence in the clinical competencies achieved during their training period. Although many were either completely satisfied (6%) or very satisfied (40%) with their medical competencies, only 16% were completely or very satisfied with the acquired surgical competences; 42% indicated that they were completely unsatisfied with their surgical competencies. 

    In some countries, residents do not perform any surgical procedures. If we consider the fourth-year residents as a reference, since they correspond to the median duration of residency in our study and therefore should reflect the representative final surgical volume for a given resident in Europe, more than 34% would have graduated without performing a single phacoemulsification surgery, 47% without ever excising a pterygium, and 31% never repaired any eyelid lacerations.

    These values are staggering, especially since these are common procedures considered essential for any ophthalmologist. Focusing on cataract surgery, the median of surgeons performing phacoemulsification surgeries during residency were 50%, and 47 % of the respondents performed fewer than 25 cases. Only two countries showed a median of more than 300 phacoemulsification surgeries: Portugal and the United Kingdom. 

    This causes enormous discrepancies in training experience among residents in different countries. Additionally, the lack of standardization in terms of ophthalmic training does not facilitate globalization, labor/skills interchange, clinical and scientific collaboration. The training of professionals should include minimum standards regardless of the country in which they have been trained in order to guarantee optimum patient care. 

    For this to happen, most participants were committed to standardizing residency training in Europe: 69% were in favor of an official program common to all European countries, and most participants agreed (40%) or completely agreed (24%) with the need to complete an exam in order to be eligible to practice as an ophthalmology specialist.

    It is evident from our results that there is a great heterogeneity in the different residency training programs and competencies achieved by ophthalmologists in training according to their country of residency, especially in terms of surgical skills. In recognition of this challenge for standardization, the European Union of Medical Specialists (UEMS) should create the European Training Requirements, including surgical requirements. 

    Through the harmonization of theoretical knowledge as well as surgical skills, the European ophthalmic community will improve the basic training, producing better-trained ophthalmologists and ensuring that patients across the continent benefit from safer and improved ophthalmic care in the future.

    About the Authors

    About the authors: Miguel González Andrades, MD, PhD, is an assistant professor in the University of Córdoba, Córdoba, Spain’s Department of Ophthalmology. He also serves as a consultant ophthalmologist at Reina Sofia University Hospital, Córdoba; research scientist at Maimónides Biomedical Research Institute of Córdoba; adjunct scientist in the Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School; chair of the European Society of Ophthalmology Young Ophthalmologists; and member of the Academy’s YO International subcommittee.
    Marie Louise Rasmussen, MD, PhD, is a senior consultant and associate professor in the Department of Ophthalmology, Rigshospitalet, Copenhagen, Denmark; past chair of European Society of Ophthalmology Young Ophthalmologists; past member of the Academy’s YO International subcommittee; and a member of the ophthalmic foundation's accreditation and mentoring/CPD subcommittees.