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  • Ophthalmology Residency Training in Danger: Why the Department of Veterans Affairs Matters

    Soldier with doctor

     “You know, I’ve met a lot of residents over the years, and they’ve all been wonderful. I feel so grateful for the amazing care I’ve received here.” 

    The patient sitting in my exam chair was a veteran of the Korean War. Due to severe glaucoma, he was a frequent visitor to the ophthalmology department at his local Veterans Affairs (VA) clinic where I was rotating. He had undergone laser procedures, glaucoma surgeries and most recently cataract surgery, all performed by ophthalmology residents under the supervision of VA staff ophthalmologists. He could now see better than he had in years and could not contain his gratitude.

    Rotating at the VA is a formative experience for many ophthalmology residents in the United States. For many trainees, the VA is the site where we achieve the bulk of our surgical and procedural training. In my own program, each PGY-4 resident spends three months of the year at the VA.

    As a senior resident, I had the opportunity to leave the quaternary-care academic medical center where I primarily train to serve a population of patients who also deserve the best care. I performed challenging cataract surgeries with excellent teachers who improved my surgical skills, participated in laser clinics performing numerous SLTs, LPIs, YAG capsulotomies and PRPs, and formed connections with patients. These patients are extremely grateful for the care they received, most of whom were eager to share how much they value the VA and the ophthalmology residents who helped provide their care. My time there allowed me to grow tremendously as a clinician and surgeon. 

    Changes in VA National Standards

    Why is it important to think about the essential role of the VA in ophthalmology training now? In 2021, the VA launched an effort to revamp its national standards of practice for health professionals. With minimal transparency or stakeholder engagement, internal VA working groups are developing these new standards. 

    For instance, it is conceivable that a working group of VA-employed nonphysician providers, such as optometrists, would be able to define their own scope of practice without input from ophthalmologists. There is significant concern in the Academy and the American Medical Association that these changes may overturn state laws defining scope of practice for nonphysician providers, leading to widespread scope of practice expansion in the VA system and on a nationwide level. Of particular concern to ophthalmologists is the push among optometrists to gain the ability to perform laser eye surgery, which is a common target for scope battles.

    The VA is the largest integrated health care system in the United States, and its policies have a far-reaching impact. In 2004, the VA published a policy stating that only ophthalmologists and ophthalmology residents are authorized to perform laser eye procedures at VA facilities. This statement has been renewed three times and holds true even in states where optometrists have been successful in expanding their scope of practice on a state-wide level (Alaska, Arkansas, Kentucky, Louisiana, Missouri, Oklahoma, Wyoming and Virginia). However, if VA-employed optometrists gain the ability to perform laser procedures, future state scope battles could be eroded beyond repair. 

    Learning the technical and decision-making skills necessary to safely perform surgery on the eye takes years and surgical training. There are no shortcuts. The VA offers an opportunity for many ophthalmologists-in-training to practice a high volume of procedures in a safe, supervised environment. It is a mutually beneficial arrangement for the surgeon and the patient: the surgeon gains experience, and the patient receives excellent care from a trained physician who is equipped to identify and manage the complications of the procedures performed. If the VA's national standards project grants the ability to perform lasers and other surgical procedures to nonphysicians, as many fear it may, a formative surgical training experience will be irrevocably changed. More importantly, the impact on the quality of patient care will be profound. 

    Our veterans deserve the best care we can provide. They are entitled to a health care provider who has completed at least four years of medical school and four years of rigorous surgical residency, rather than one who has completed four years of optometry school and a weekend-long seminar on laser eye surgery. It is crucial for ophthalmologists to stay informed about the national standards project and to be prepared to write letters to representatives as the process moves forward. The quality of training for future ophthalmologists and the safety of our patients depends on it.     

    Marybeth C.K. Farazdaghi About the author: Marybeth C.K. Farazdaghi, MD, is a PGY-4 ophthalmology resident at the Mayo Clinic in Rochester, Minn. and a graduate of the Perelman School of Medicine at the University of Pennsylvania. Her interests include pediatric ophthalmology and spending time outside with her husband and daughter.