Dr. Parikshit Gogate, G06928, Dr. Quresh B Maskati, Dr. Partha Biswas
Abstract
Background: Residency training has evolved over decades
Purpose: To gauge the differences in ophthalmology residency training, academic, clinical and surgical, inthe last threedecades of the 20thcentury and the first decade of the 21st century
Methods: A survey was conducted by the Academic & Research Committee of the All India Ophthalmological Society, in 2014-16, using a pre-validated questionnaire, which was circulated to ophthalmologists to gauge the practicality of the teaching protocols of clinical and surgical skills during post-graduate residency program.
Statistical analysis: Statistical Package for Social Sciences Version 16
Results: Of the 1005 respondents, 320 Ophthalmologists who completed residency between 1967-2002 (20th century trained) and 531 who completed residency in 2003-12 (21st century trained) fulfilled the inclusion criteria. Average age was 49.2 years (SD 4) and 32.6years (SD 4) respectively.21st century trained ophthalmologists rated their training significantly better than the 20th century trained ophthalmologists for slit lamp examination (P=0.001), indirect ophthalmoscopy, gonioscopy, automated perimetry, optical coherence tomographyandfundus photography (all having P<0.001),while the20th century trained rated their teaching of refraction, synoptophore, diplopia charting better (all P<0.001).The range of grading was 0-10 in all categories. The median of surgeries performed independently by 20th century trained&21st century trained(during their training period )were: Intra-Capsular Cataract Extraction (ICCE)10, 0; Extra-Capsular Cataract Extraction (ECCE) 43,18; Small Incision Cataract Surgery (SICS)5, 55; phacoemulsification 0, 1;pterygium excision 20, 15; dacryocystectomy11, 4; dacryocystorhinostomy11, 2; chalazion 35, 30; trabeculectomies 5, 0; strabismus correction 0, 0; vitrectomy 0,0; keratoplasty 0, 0; eyelid surgery 6, 2 and ocular emergencies 18, 20.
Introduction
Residency training of post graduate medical students is the base for all medical specialty training. Ophthalmology, a surgical specialty, is no exception to this. The goal of a post-graduate educational programme in ophthalmology is training for practice. Practice involves being competent to diagnose, treat and manage the most common conditions encountered in clinical practice effectively and with minimal error.
Traditionally, this has meant acquisition of knowledge and skills for decision making and operative skills. In addition, the dissertation has been a part of the postgraduate courses in order to develop the residents’ research skills. Other competencies identified more recently as being an important part of the postgraduate curriculum includes professionalism and ethics, communication, leadership, social accountability and an understanding of systems – based practice.
Curriculum is dynamic and is expected to change in keeping with the scientific advancements of the particular speciality. While regulatory bodies and universities continue to update their curricula regularly (the ‘declared curriculum’) [1,2], the “taught curriculum” predominates in the residency program. Though congruence between declared and taught is the ideal, there is a variance in adherence.
In the past decades, ophthalmology practice has changed tremendously. Intra capsular cataract surgery (ICCE), the surgery of choice for cataract extraction till the 1970s has given way to phacoemulsification (Phaco) and small incision cataract surgery (SICS). Glaucoma management and treatment of retinal disorders have undergone a sea change.
However, there are few studies documenting if and how the residency training has changed or progressed with time. The Academic & Research Committee of the All India Ophthalomological Society had commissioned a survey to understand the functionality ofophthalmological residency training. There have been numerous studies from India, China, Canada and Unites States of America regarding the efficacy of residency training, but none comparing it across time. [3-13]This manuscript presents the feedback of residency training of those who were trained in the last decades of the 20th century and compares it with thefeedback on training imparted in the first decade of the 21st century. Clinical skills learnt, surgical training and demographic factors were compared between both the groups.
This study endeavours to capture the change over time in the trend related to the choice of ophthalmology as a speciality, the nature of educational experience during the residency and ways in which the graduates advance their careers and continue to develop professional skills. The research question that the study seeks to answer is: What is the changing trend of ophthalmology residency programmes from the last decades of the 20th century to the first decade of the 21st century.
Methods
This was a cross sectional study to explore the changes in teaching practice in ophthalmology residency programmes in India, using a pre-validated questionnaire. The survey was pre-validated by having it vetted by six researchers & educationists and then doing a pilot study on a sample of 15 ophthalmologists. The All India Ophthalmological Society (AIOS) through its Academic & Research Committeecommissioned a survey of residency training. The study population was ophthalmologists who were trained in India.
The “change” was studied between two cohorts that graduated at different points in time: Group A (20th century trained) who started training between 1967-2001 and graduated before 2002, and Group B (21st century trained) that enrolled between 2003-12 and graduated before 2014.The respondents were asked to grade clinical skills and surgeries learnt and performed during their residency. They had the choice of anonymity but were also asked certain demographic information and details of their academic program and research project during residency training. The details are in Appendix A.
Though the survey aimed at getting feedback from 21st century trained Ophthalmologists, it was kept open for all ophthalmologists. The survey was circulated amongst all members of the AIOS, irrespective of their seniority and was open to all ophthalmologists (both members &non-members). There were repeated reminders through emails, text messages and later phone calls to participate in the study. Heads of institutions of excellence, retired and serving Professors were requested to send the survey link to their past students. Telephone, email and text message reminders were sent to potential respondents on 11 occasions between October 2014 to February 2016. Respondents had the choice of anonymity. Incomplete responses were not considered.
The collected data was organized into four categories – 1. Demographic data 2. Training Place characteristics 3. Curricular Aspects 4. Career advancement following the training.
The data was entered into Excel worksheets and statistical package for social sciences (SSPS version 16), IBM Corporation, Armonk, New York, USA was used for data analysis. Mean, standard deviation and median of the responses was considered.
Results
320 Ophthalmologists who did their residency in the last decades of the 20th century completed the questionnaire, 75(23.4%) were females. Their averageage was 49.2 years (SD 8.7, range 37-84), median 47 years. They had completed their residency between 1967 to 2002. 128(39.9%) were from metro cities, 93 (29%) from large towns, 70(21.8%) from district headquarters while 18(56%) from smaller towns or villages. 23(7.2%) were MD, 107(33.3%) were Master of Surgery in Ophthalmology (MS), 58(18.1%) were diplomate of the national board in ophthalmology (DNB) while 81(25.2%) were diploma in ophthalmology (DO).Only 15(4.7%) came from a family of ophthalmologists. 98(30.5%) chose ophthalmology as they believed it had good career prospects. 21(6.5%) chose ophthalmology forfinancial gains and 67(20.9%)chose ophthalmology forimprovement of knowledge. 18(5.6%) worked in a Government Hospital, 28(8.7%) in an NGO hospital, 49(15.3%) in a teaching institution, 66(20.6%) in private practice and 15(4.7%) in group practice. The rest did not give details about the type or nature of their practice.The data of 21st century trained ophthalmologists has been published in this journal earlier. [14,15]
Table 1 shows how the 20th century trainedophthalmologists rated their clinical skills and education while undergoing residency training. Refraction, slit lamp examination and direct ophthalmoscopy were taught well. But exposure to equipment oriented skills like perimetry, fundus photography, fluorescein angiography, OCT, B-scan and Ascan ultrasonography was not taught to their satisfaction. Contact lens evaluation was taught to 109(52.6%)of the survey respondents.
Table 3 compares the demographics between 20th century trained and 21st century trained ophthalmologists in this study. Table 4 compares the clinical skills learnt during residency training between 20th and 21st century trained ophthalmologists. Ophthalmologists trained in 21st century were better exposed to automated perimetry, fundus photography, fluorescein angiography, optical coherence tomography, +90/+78 D fundus evaluation, A and B-scanultrasonography, Indirect ophthalmoscopy and applanation tonometry. But exposure to paediatric visual acuity testing and orthoptic evaluationwere areas that were desired by the respondents. Clinical skills like refraction, diplopia charting and synoptophore use were perceived to be taught less by 21st century trained ophthalmologists compared to their 20th century trained counterparts. While Nd:YAG LASER capsulotomy and retinal LASER exposure has increased, the same did not feature for YAG iridotomies. While 52.6% 20th century trained reported being taught contact lenses during residency training, only 152/531 (28.6%) 21st century trained ophthalmologists reported the same.
Discussion
The type of ophthalmic surgeries have changed over the decades and the clinical skills have improved. However, there was a wide variation amongst residency programs and the range of responses weregraded from 0-10. Some aspects have had desirable changes. Demographically more women have entered ophthalmology. There were more second generation medical professionals and many of them chose ophthalmology as a career. Ophthalmology still remained a sought-after career option for medical graduates.
In the 21st century trained, many more come from a family of ophthalmologists as compared to the cohort trained in the last century. Medical graduates still remained the choice for spouse for both the groups.
Almost all the clinical skills, teaching and exposure to investigations had improved over the past decade. The 20th century trained cohort reported only refraction, diplopia charting and synoptophore being taught better than the 21-century trained cohort.Orthoptic evaluation, paediatric visual acuity testing and diplopia charting are skills imperative for general ophthalmologists, and this is a requirement which needs to be addressed in the teaching curriculum, even in the present day.
However, a wide range (actual reported range 0-10 for all clinical skills, investigations and surgeries) had remained the same with both the groups. Thus, while the median residency program has improved, uniformity in basic quality in residency training needs to be pursued energetically.
Cataract is still the commonest cause of avoidable blindness.[16,17, 18] Exposure to cataract surgery was adequate but not uniform. ICCE had become a surgery of the past and manual SICS was the commonest cataract surgery taught presently. Glaucoma surgeries in residency training programs showed a decline, even though it is a significant cause of blindness. [19] Better pharmacological agents and their easier availability may be a reason for the overall decrease in glaucoma surgeries.[20,21] However, learning the correct technique of filtration glaucoma surgery is essential in a residency program. [22] Pterygium excisions, sac surgeries and eyelid surgeries had declined in number in residency training. Less out-door work, use of protective spectacles and by and large, lesser number of patients being referred to the teaching hospitals could be possible causes. The median for strabismus surgeries, retinal detachment surgery, vitrectomy and keratoplasty was zero for both groups. Both independent surgeries and surgeries performed under supervision were less. Strabismus, corneal and retinal diseases are significant contributors to ocular morbidity and visual impairment.[23]
Eye bank training had improved to an extent. The Medical Council of India has made it mandatory for each medical college to have an eye bank.
Diabetic retinopathy is increasing as a cause of blindness and visual impairment.[24, 25] The resident’s exposure to various modalities to manage this disease (OCT, fundus photography, LASERs) has improved over time; but the exposure was uneven across the different programs in the country.
The ‘declared curricula’ earlier and now were guidelines about the topics and subject matter to be covered. [1,2] They were not explicit about the details of the clinical, surgical and research skills that a resident should master during the training unlike the competency standards set in United States of America. [13] The system leaves a lot to the residents’ initiative. They are expected to learn by observing and following their teachers as it was in the ancient ‘Gurukul’ times. [26]
Mid-term assessments were rare. Exit exams are mainly theoretical and practical examinations are based on case presentations. A robust methodology to judge the surgical skills of a passing-out resident is needed. Practical and theoretical teaching of refractive errors, the commonest cause of visual impairment is of paramount importance. The residency curriculum should stress on comprehensive ophthalmology.
The teaching of certain diagnostic techniques hasgained importance in the past decade, but teaching of basic ophthalmic clinical skills has not shown a consistent growth. The emphasis of surgical training is mainly on cataract surgery. Some tried & tested academic techniques like journal clubs and wet labs need to be popularised.
The study is limited to the respondents’ responses. There may be a selection bias since respondents with extreme views (both positive & negative) about their residency training may have been more inclined to participate. The possibility of recall bias is relevant to the study. The other limitation of this study werethe absence of evaluation of other pertinent skills eg. professionalism and ethics, communication, leadership, social accountability. However, since the entire process was voluntary (and anonymous if needed), we have for the first time a picture across decades about how residency training was being imparted.
The lack of standardization indicates the role of a strong regulatory authority for the implementation of the curriculum. The curriculum should be such that it focuses on the infra-structure, human resources and the actuality of the residents’ learning. In addition, the curriculum should be ‘need-based’; it should establish standards, follow them.There should be a method to monitor these standards.
The role of residents as teachers and researchers needs to be emphasised during residency, since senior residents make excellent teachers.[27] These are part of competency-based residency curricula elsewhere.[13]
Indian ophthalmology is considered as one of the world leaders in blindness prevention and control. [28, 29] It is held as a model for delivering quality eye care with low cost innovations. [30, 31]Ophthalmology is still a sought-after medical sub-speciality attracting the best of talents for post-graduation. Residency training programs have evolved considerably in the past decades, but a significant variation still exists in the Indian subcontinent, which needs to be bridged at the earliest, through a uniform and robust residency program.
References
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Table 1 Teaching of clinical skills as rated by 20th century trained ophthalmologists.
| Range | Average(SD) | Median | |
| Refraction | 0-10 | 6.5(2.9) | 7 |
| Slit lamp examination | 0-10 | 6.4(3.3) | 7 |
| Automated perimetry | 0-10 | 3.8(3.8) | 3 |
| Fundus Photography | 0-10 | 3.7(3.7) | 2 |
| Direct ophthalmoscopy | 0-10 | 7.5(2.7) | 8 |
| Pachymetry | 0-10 | 2.5(3.5) | 0 |
| OrthopticEvaluation | 0-10 | 4.7(3.1) | 5 |
| Fluorescein angiography | 0-10 | 3.7(3.6) | 3 |
| Applanation tonometry | 0-10 | 4.2(3.8) | 4 |
| Optical coherence tomography | 0-10 | 1.7(3.1) | 0 |
| Gonioscopy | 0-10 | 4.4(3.7) | 4 |
| A-scan biometry | 0-10 | 4.9(3.7) | 5 |
| +78/+90D | 0-10 | 3.8(3.8) | 3 |
| B-scan ultra-sonography | 0-10 | 3.9(3.7) | 3 |
| Indirect ophthalmoscopy | 0-10 | 4.6(3.4) | 4 |
| Synoptophore | 0-10 | 4.0(3.2) | 4 |
| Keratometry | 0-10 | 5.6(3.4) | 6 |
| Hess charting | 0-10 | 4.2(3.3) | 4 |
| Paediatric visual acuity testing | 0-10 | 3.0(3.0) | 2 |
| YAG LASER capsulotomy | 0-10 | 4.1(3.9) | 3 |
| Retinal LASERs | 0-10 | 2.3(3.3) | 0 |
| YAG iridotomy | 0-10 | 3.6(3.7) | 2 |
Table 2: Surgeries observed, assisted, performed under supervision and independently by 20th century trained ophthalmologists during their residency training
| Type of
Surgery |
Observed | Assisted | Done under supervision | Operated independently | ||||||||
| Range | Mean (SD) | Median | Range | Mean (SD) | Median | Range | Mean (SD) | Median | Range | Mean (SD) | Median | |
| ICCE | 0->25 | 15.8(10.9) | 25 | 0->25 | 14.8(11.2) | 25 | 0->25 | 11.2(11.1) | 25 | 0->150 | 52.6 (63.5) | 10 |
| ECCE | 0->25 | 20.4(8.5) | 25 | 0->25 | 19.3(9.2) | 25 | 0->25 | 16.4(10.4) | 25 | 0->150 | 63.9(63.7) | 43 |
| SICS | 0->25 | 13.1(11.6) | 10 | 0->25 | 12.0(12.0) | 9.5 | 0->25 | 10.1(12.0) | 3 | 0->100 | 44.9(62.5) | 5 |
| Phacoemulsification | 0->25 | 11.3(11.6) | 5 | 0->25 | 9.8(11.1) | 4 | 0->25 | 5.7(9.8) | 0 | 0->100 | 25.3(53.3) | 0 |
| Trabeculectomy | 0->25 | 16.7(9.5) | 25 | 0->25 | 14.5(10.1) | 11 | 0->25 | 8.1(9.8) | 3 | 0->100 | 25.5(45.9) | 5 |
| Strabismus | 0->25 | 14.0(10.3) | 12 | 0->25 | 11.8(10.4) | 10 | 0->25 | 5.8(8.8) | 0 | 0->100 | 13.4(31.2) | 0 |
| Pterygium | 0->25 | 19.6(8.9) | 25 | 0->25 | 17.6(9.5) | 25 | 0->25 | 13.7(10.2) | 10 | 0->100 | 41.2(50.8) | 20 |
| Dacrocystectomy | 0->25 | 15.4(9.5) | 15 | 0->25 | 13.8(9.6) | 10 | 0->25 | 10.8(9.7) | 8 | 0->100 | 35.2(49.9) | 11 |
| Dacrocystorhinostomy | 0->25 | 16.1(9.7) | 25 | 0->25 | 14.8(9.9) | 14 | 0->25 | 11.0(10.1) | 8 | 0->100 | 29.3(43.0) | 11 |
| Chalazion | 0->25 | 19.5(8.5) | 25 | 0->25 | 17.2(10.1) | 25 | 0->25 | 15.2(10.5) | 25 | 0->100 | 61.7(51.9) | 35 |
| LASIK & Refractive | 0->25 | 3.5(7.6) | 0 | 0->25 | 2.4(6.7) | 0 | 0->25 | 1.1(4.3) | 0 | 0->100 | 4.3(22.2) | 0 |
| Retinal detachment | 0->25 | 12.2(10.3) | 10 | 0->25 | 10.0(10.4) | 5 | 0->25 | 2.9(6.8) | 0 | 0->100 | 5.9(23.2) | 0 |
| Vitrectomy | 0->25 | 10.4(10.9) | 5 | 0->25 | 8.7(10.7) | 3 | 0->25 | 3.2(7.2) | 0 | 0->100 | 5.7(20.0) | 0 |
| Keratoplasty | 0->25 | 12.6(10.6) | 10 | 0->25 | 11.3(11.0) | 7.5 | 0->25 | 5.3(8.7) | 0 | 0->100 | 9.8(24.6) | 0 |
| Eyelid surgery | 0->25 | 14.9(9.7) | 15 | 0->25 | 14.2(10.1) | 12 | 0->25 | 8.1(9.5) | 5 | 0->100 | 24.7(41.9) | 6 |
| Ocular emergencies | 0->25 | 18.7(9.0) | 25 | 0->25 | 16.7(9.8) | 25 | 0->25 | 12.7(10.3) | 10 | 0->100 | 48.2(59.0) | 18 |
The range reported by the respondents for observed, assisted and operated under supervision for all the type of surgeries was 0->25.
The reported range for all the types of surgeries performed independently by the respondents was 0->100
Table 3: Comparing demographics between 20th and 21st century trained ophthalmologists in this study.
| Senior | 21st century trained | |
| Age: Mean (Std. dev, range) | 49.2 (SD 8.7, range 37-84) | 32.6(SD 4, range 24-56) |
| Age (median) | 47 years | 32 years |
| Gender Male | 245 (76.6%) | 325(61.2%) |
| Degree | ||
| MS | 107 (66.6%) | 299(56.3%) |
| MD | 23 (7.2%) | 31(5.8%) |
| DO | 81 (25.3%) | 114(21.5%) |
| DNB | 58 (18.1%) | 162(30.5%) |
| 1st generation doctor | 97 (74.6%) | 62.3% |
| From family of ophthalmologist | 15 (11.4%) | 52 (14.4%) |
| Married to doctor | 67 (50.8%) | 43.5% |
| Number of Children (median) | 2 | 2 |
| Ophthalmology as choice of career | ||
| Top | 162 (50.6%) | 194(36.5%) |
| Amongst top 3 | 119 (37.2%) | 263(49.5%) |
| Not amongst top 3 | 27 (8.4%) | 74(13.9%) |
| Years in practice | 10-55 years | 2- 9 years |
Table 4: Comparing the clinical skills taught during residency between 20th and 21st century trained ophthalmologists
| Mean 20th century trained | Mean 21st century trained | Median 20th century trained | Median 21st century trained | P value | |
| Refraction | 6.5(2.9) | 5.2 (3.1) | 7 | 5 | < 0.001 |
| Slit lamp examination | 6.4(3.3) | 7.2 (2.8) | 7 | 8 | 0.001 |
| Automated perimetry | 3.8(3.8) | 6.2 (3.2) | 3 | 7 | < 0.001 |
| Fundus Photography | 3.7(3.7) | 6.0 (3.5) | 2 | 7 | < 0.001 |
| Direct ophthalmoscopy | 7.5(2.7) | 7.4 (2.8) | 8 | 8 | 0.829 |
| Pachymetry | 2.5(3.5) | 4.2 (3.9) | 0 | 4 | < 0.001 |
| Orthoptic Evaluation | 4.7(3.1) | 4.3 (3.1) | 5 | 4 | 0.074 |
| Fluorescein angiography | 3.7(3.6) | 5.4 (3.5) | 3 | 5 | < 0.001 |
| Applanation tonometry | 4.2(3.8) | 6.0 (3.7) | 4 | 7 | < 0.001 |
| Optical coherence tomography | 1.7(3.1) | 4.6 (4.0) | 0 | 5 | < 0.001 |
| Gonioscopy | 4.4(3.7) | 5.7 (3.4) | 4 | 6 | < 0.001 |
| A-scan biometry | 4.9(3.7) | 7.0 (2.9) | 5 | 8 | < 0.001 |
| +78/+90D | 3.8(3.8) | 6.8 (3.2) | 3 | 8 | < 0.001 |
| B-scan ultra-sonography | 3.9(3.7) | 5.4 (3.6) | 3 | 6 | < 0.001 |
| Indirect ophthalmoscopy | 4.6(3.4) | 6.2 (3.3) | 4 | 7 | < 0.001 |
| Synoptophore | 4.0(3.2) | 2.5 (2.9) | 4 | 1 | < 0.001 |
| Keratometry | 5.6(3.4) | 6.1 (3.2) | 6 | 6 | 0.039 |
| Hess charting | 4.2(3.3) | 3.2 (3.2) | 4 | 2 | < 0.001 |
| Paediatric visual acuity testing | 3.0(3.0) | 3.2 (2.9) | 2 | 2 | 0.094 |
| YAG LASER capsulotomy | 4.1(3.9) | 5.8 (3.6) | 3 | 6 | < 0.001 |
| Retinal LASERs | 2.3(3.3) | 3.1 (3.5) | 0 | 1 | < 0.001 |
| YAG iridotomy | 3.6(3.7) | 4.1 (3.7) | 2 | 3 | 0.013 |
| Exposure to eye banking | 4.4 (3.7) | 5.0 (3.5) | 5 | 5 | |
| Exposure to Community Ophthalmology | 6.4 (3.2) | 6.1 (3.1) | 7 | 6 |
Table 5: Comparing surgical skills taught during residency between 20th and 21st century trained ophthalmologists, by comparing the number of surgeries performed independently during the residency
| Type of
Surgery |
20th century trained | 21st century trained | ||
| Mean | Median | Mean | Median | |
| ICCE | 52.6 (63.5) | 10 | 3.0(14.9) | 0 |
| ECCE | 63.9(63.7) | 43 | 39.9(53.2) | 18 |
| SICS | 44.9(62.5) | 5 | 75.3(64.4) | 55 |
| Phacoemulsification | 25.3(53.3) | 0 | 30.0(52.6) | 1 |
| Trabeculectomy | 25.5(45.9) | 5 | 4.0(14.9) | 0 |
| Strabismus | 13.4(31.2) | 0 | 1.4(4.9) | 0 |
| Pterygium | 41.2(50.8) | 20 | 31.5(43.2) | 15 |
| DCT | 35.2(49.9) | 11 | 20.3(38.1) | 4 |
| DCR | 29.3(43.0) | 11 | 11.7(26.2) | 2 |
| Chalazion | 61.7(51.9) | 35 | 46.4(48.3) | 30 |
| LASIK & Refractive | 4.3(22.2) | 0 | 1.5(12.2) | 0 |
| Retinal detachment | 5.9(23.2) | 0 | 1.5(12.5) | 0 |
| Vitrectomy | 5.7(20.0) | 0 | 3.1(17) | 0 |
| Keratoplasty | 9.8(24.6) | 0 | 5.2(17.8) | 0 |
| Eyelid surgery | 24.7(41.9) | 6 | 8.6(18.9) | 2 |
| Ocular emergencies | 48.2(59.0) | 18 | 41.7(52.4) | 20 |
Table 6: Comparing the rating of academic schedule and types of teaching activities.
| 20th century trained | 21st century trained | ||||||
| Academic schedule: | Possible range | Reported range | Mean (SD) | Median | Reported range | Mean (SD) | Median |
| Academic schedule: Expert faculty | 0-10 | 0-10 | 6.5(2.8) | 7 | 0-10 | 6.4 (2.7) | 7 |
| Academic schedule: Residents | 0-10 | 0-10 | 6.2(3.7) | 7 | 0-10 | 5.9 (3.1) | 6 |
| Academic schedule’s management | 0-10 | 0-10 | 4.3(3.7) | 4 | 0-10 | 4.6 (3.5) | 4 |
| Types of academic activities: | |||||||
| Academic schedule: Didactic lectures | 0-4 | 0-4 | 2.2(1.4) | 2 | 0-4 | 2.2 (1.4) | 2 |
| Academic schedule: Seminar | 0-4 | 0-4 | 2.7(1.1) | 3 | 0-4 | 3.2 (1.1) | 3 |
| Academic schedule: case presentation | 0-4 | 0-4 | 3.1(1.0) | 3 | 0-4 | 3.2 (1.0) | 3 |
| Academic schedule: Journal club | 0-4 | 0-4 | 2.1(1.4) | 2 | 0-4 | 2.2(1.1) | 2 |
| Academic schedule: Wet lab | 0-4 | 0-4 | 1.0(1.3) | 0 | 0-4 | 1.3 (1.4) | 1 |
| Academic schedule: all of the above (Overall) | 0-4 | 0-4 | 2.4(1.1) | 2 | 0-4 | 2.5 (1.1) | 3 |
| Dissertation | |||||||
| Level of supervision | 0-10 | 0-10 | 5.7(3.1) | 6 | 0-10 | 5.9(3.1) | 6 |
| Infrastructure for dissertation | 0-10 | 0-10 | 6.1(3.0) | 6 | 0-10 | 6.4(3.1) | 7 |
| Value added by dissertation | 0-10 | 0-10 | 6.1(3.1) | 7 | 0-10 | 6.2(3.7) | 7 |
Table 7: Comparing the clinical skills taught to 20th and 21st century trained ophthalmologists depending on the type of institution in which residency raining was completed. The possible range for each response was 0-10.
Table 7A: 20th century trained
| Government Medical College | Non-Government Institute | Private Hospital | Private Medical College | ||||||||||
| Min | Max | Median | Min | Max | Median | Min | Max | Median | Min | Max | Median | p-value | |
| Refraction | 0 | 10 | 7 | 1 | 10 | 8 | 4 | 10 | 9 | 2 | 10 | 5 | 0.172 |
| Slit-lamp examination | 0 | 10 | 7 | 2 | 10 | 9.5 | 2 | 10 | 10 | 0 | 10 | 5 | 0.012 |
| Direct Ophthalmoscopy | 0 | 10 | 8.5 | 0 | 10 | 8 | 5 | 10 | 8 | 3 | 10 | 7 | 0.683 |
| Orthoptic evaluation | 0 | 10 | 5 | 0 | 10 | 5 | 1 | 9 | 8 | 0 | 9 | 3 | 0.029 |
| Applanation tonometry | 0 | 10 | 3 | 0 | 10 | 9 | 1 | 10 | 10 | 0 | 10 | 3.5 | < 0.001 |
| Gonioscopy | 0 | 10 | 3 | 0 | 10 | 8.5 | 2 | 10 | 10 | 0 | 10 | 3 | 0.002 |
| +78 / +90 D fundus evaluation | 0 | 10 | 2 | 0 | 10 | 8 | 0 | 10 | 10 | 0 | 10 | 2.5 | < 0.001 |
| Indirect ophthalmoscopy | 0 | 10 | 4 | 1 | 10 | 9 | 3 | 10 | 10 | 0 | 10 | 3 | < 0.001 |
| Keratometry | 0 | 10 | 5 | 0 | 10 | 7 | 8 | 10 | 9.5 | 0 | 10 | 6 | 0.049 |
| Pediatric visual acuity testing | 0 | 10 | 2 | 0 | 10 | 4.5 | 0 | 10 | 8 | 0 | 9 | 2 | 0.012 |
| Automated Perimetry | 0 | 10 | 2 | 0 | 10 | 8 | 0 | 10 | 9 | 0 | 10 | 5 | < 0.001 |
| Fundus photography | 0 | 10 | 2 | 0 | 10 | 7 | 0 | 10 | 10 | 0 | 10 | 3 | 0.001 |
| Pachymetry | 0 | 10 | 0 | 0 | 10 | 6 | 0 | 10 | 10 | 0 | 10 | 0.5 | < 0.001 |
| Fluorescein angiography | 0 | 10 | 2 | 0 | 10 | 7 | 0 | 10 | 10 | 0 | 10 | 3 | 0.001 |
| Optical Coherence Tomography | 0 | 10 | 0 | 0 | 10 | 1 | 0 | 10 | 7 | 0 | 10 | 0 | 0.005 |
| A-scan biometry | 0 | 10 | 5 | 0 | 10 | 7 | 0 | 10 | 10 | 0 | 10 | 5 | 0.011 |
| B-scan ultrasonography | 0 | 10 | 3 | 0 | 10 | 8 | 0 | 10 | 10 | 0 | 10 | 2 | < 0.001 |
| Synoptophore | 0 | 10 | 4 | 0 | 10 | 4 | 0 | 10 | 4 | 0 | 8 | 2 | 0.288 |
| Hess diplopia charting | 0 | 10 | 4 | 0 | 10 | 5 | 0 | 10 | 5 | 0 | 9 | 2 | 0.475 |
| YAG LASER capsulotomy | 0 | 10 | 3 | 0 | 10 | 7 | 0 | 10 | 10 | 0 | 10 | 1 | 0.001 |
| LASER retinal procedures | 0 | 10 | 0 | 0 | 10 | 6 | 0 | 10 | 9.5 | 0 | 10 | 0 | < 0.001 |
| YAG LASER Iridotomies | 0 | 10 | 2 | 0 | 10 | 5.5 | 0 | 10 | 10 | 0 | 10 | 1 | 0.003 |
Table 7 B: 21st century trained ophthalmologists
| Government Medical College | Non-Government Institute | Private Hospital | Private Medical College | ||||||||||
| Min | Max | Median | Min | Max | Median | Min | max | Median | Min | max | Median | p-value | |
| Refraction | 0 | 10 | 5 | 0 | 10 | 4 | 0 | 10 | 5 | 0 | 10 | 5 | 0.033 |
| Slit-lamp examination | 0 | 10 | 7 | 1 | 10 | 9 | 1 | 10 | 10 | 1 | 10 | 7 | < 0.001 |
| Direct Ophthalmoscopy | 0 | 10 | 9 | 0 | 10 | 7 | 0 | 10 | 8 | 1 | 10 | 8 | 0.189 |
| Orthoptic evaluation | 0 | 10 | 4 | 0 | 10 | 4 | 0 | 10 | 7 | 0 | 10 | 2.5 | < 0.001 |
| Applanation tonometry | 0 | 10 | 5 | 1 | 10 | 9 | 0 | 10 | 10 | 0 | 10 | 5 | < 0.001 |
| Gonioscopy | 0 | 10 | 5 | 0 | 10 | 9 | 0 | 10 | 9 | 0 | 10 | 4 | < 0.001 |
| +78 / +90 D fundus evaluation | 0 | 10 | 7 | 1 | 10 | 10 | 0 | 10 | 10 | 0 | 10 | 6 | < 0.001 |
| Indirect ophthalmolscopy | 0 | 10 | 6 | 1 | 10 | 9 | 0 | 10 | 10 | 0 | 10 | 5 | < 0.001 |
| Keratometry | 0 | 10 | 6 | 0 | 10 | 6 | 0 | 10 | 7 | 0 | 10 | 6.5 | 0.887 |
| Pediatric visual acuity testing | 0 | 10 | 2 | 0 | 10 | 3.5 | 0 | 10 | 4 | 0 | 10 | 2 | < 0.001 |
| Automated Perimetry | 0 | 10 | 7 | 0 | 10 | 7 | 1 | 10 | 8 | 0 | 10 | 5 | 0.003 |
| Fundus photography | 0 | 10 | 6 | 0 | 10 | 8 | 0 | 10 | 9 | 0 | 10 | 5 | < 0.001 |
| Pachymetry | 0 | 10 | 3 | 0 | 10 | 7 | 0 | 10 | 8 | 0 | 10 | 2 | < 0.001 |
| Fluorescein angiography | 0 | 10 | 5 | 0 | 10 | 6 | 0 | 10 | 8 | 0 | 10 | 4 | < 0.001 |
| Optical Coherence Tomography | 0 | 10 | 3 | 0 | 10 | 5 | 0 | 10 | 9 | 0 | 10 | 0 | < 0.001 |
| A-scan biometry | 0 | 10 | 8 | 0 | 10 | 7 | 1 | 10 | 8 | 0 | 10 | 8 | 0.487 |
| B-scan ultrasonography | 0 | 10 | 5 | 0 | 10 | 5.5 | 0 | 10 | 9 | 0 | 10 | 4 | < 0.001 |
| Synoptophore | 0 | 10 | 1 | 0 | 10 | 1 | 0 | 10 | 2 | 0 | 10 | 1 | 0.086 |
| Hess diplopia charting | 0 | 10 | 2 | 0 | 10 | 4 | 0 | 10 | 5 | 0 | 10 | 1 | < 0.001 |
| YAG LASER capsulotomy | 0 | 10 | 6 | 0 | 10 | 7 | 0 | 10 | 9 | 0 | 10 | 3.5 | < 0.001 |
| LASER retinal procedures | 0 | 10 | 1 | 0 | 10 | 2 | 0 | 10 | 3 | 0 | 10 | 0 | 0.001 |
| YAG LASER Iridotomies | 0 | 10 | 3 | 0 | 10 | 5 | 0 | 10 | 5 | 0 | 10 | 1 | < 0.001 |
Table 8: Comparison of surgical training imparted depending on the type of institute where residency was done.
Table 8A: Surgeries performed independently by 20th century trained ophthalmologists during their residency
| Government Medical College | Non-Government Institute | Private Hospital | Private Medical College | ||||||
| Mean | SD | Mean | SD | Mean | SD | Mean | SD | p-value | |
| ICCE – | 59.0 | 64.9 | 34.7 | 61.0 | 52.5 | 68.5 | 17.2 | 37.9 | 0.007 |
| Manual SICS | 39.9 | 60.2 | 104.3 | 61.2 | 80.0 | 81.2 | 18.7 | 43.0 | 0.000 |
| Conventional ECCE – | 69.8 | 64.2 | 93.5 | 61.8 | 94.0 | 77.0 | 39.2 | 47.6 | 0.139 |
| Phacoemulsification – | 20.5 | 48.4 | 55.5 | 70.1 | 75.0 | 86.6 | 20.8 | 52.5 | 0.041 |
| Trabeculectomy – | 26.0 | 46.3 | 32.1 | 49.5 | 10.5 | 11.0 | 17.8 | 45.8 | 0.010 |
| Strabismus correction – | 15.6 | 34.1 | 11.5 | 22.4 | 2.0 | 4.5 | 0.8 | 2.7 | 0.024 |
| Pterygium excision – | 42.7 | 50.6 | 52.5 | 60.1 | 65.0 | 77.9 | 12.5 | 15.4 | 0.024 |
| Dacrocystectomy – | 33.3 | 47.0 | 63.8 | 69.6 | 72.8 | 72.7 | 9.9 | 12.7 | 0.033 |
| Dacrocystorhinostomy – | 27.5 | 40.1 | 50.9 | 55.4 | 81.3 | 80.0 | 7.8 | 14.7 | 0.002 |
| Chalazion incision and drainage – | 61.8 | 57.8 | 74.5 | 59.6 | 64.2 | 78.4 | 48.0 | 52.9 | 0.593 |
| LASIK, refractive surgery – | 4.1 | 21.0 | 10.3 | 38.7 | 0.0 | 0.0 | 0.2 | 0.8 | 0.836 |
| Retinal detachment surgery – | 7.0 | 25.9 | 4.0 | 13.6 | 2.0 | 4.5 | 0.3 | 1.1 | 0.303 |
| Vitrectomy – | 6.4 | 21.9 | 6.3 | 14.8 | 2.0 | 4.5 | 1.0 | 2.8 | 0.836 |
| Keratoplasty – | 10.4 | 23.8 | 4.8 | 8.8 | 37.5 | 75.0 | 0.1 | 0.3 | 0.054 |
| Lid surgeries – | 26.5 | 43.0 | 35.3 | 50.1 | 5.0 | 10.0 | 2.2 | 3.9 | 0.001 |
| Managing ocular emergencies – | 50.0 | 58.7 | 57.8 | 65.5 | 44.0 | 71.7 | 24.9 | 51.1 | 0.065 |
Table 8B: Surgeries performed independently by 21st century trained ophthalmologists during their residency
| Operated Independently | Government Medical College | Non-Government Institute | Private Hospital | Private Medical College | |||||
| Mean | SD | Mean | SD | Mean | SD | Mean | SD | p-value | |
| ICCE – | 3.9 | 18.9 | 4.4 | 12.2 | 1.2 | 3.4 | 0.8 | 2.2 | 0.048 |
| Manual SICS | 61.7 | 62.0 | 117.2 | 55.1 | 107.6 | 58.1 | 64.3 | 62.5 | < 0.001 |
| Conventional ECCE – | 32.9 | 46.6 | 64.4 | 63.3 | 62.4 | 63.6 | 27.1 | 46.2 | < 0.001 |
| Phacoemulsification – | 31.1 | 53.3 | 40.0 | 58.4 | 38.1 | 57.6 | 13.0 | 36.9 | < 0.001 |
| Trabeculectomy – | 4.5 | 16.0 | 6.7 | 23.5 | 2.8 | 7.4 | 1.4 | 4.0 | 0.001 |
| Strabismus correction – | 1.8 | 5.5 | 0.5 | 1.6 | 1.6 | 5.2 | 0.6 | 3.2 | 0.012 |
| Pterygium excision – | 29.6 | 38.4 | 50.2 | 58.0 | 29.0 | 50.3 | 27.0 | 37.0 | 0.014 |
| Dacrocystectomy – | 17.7 | 34.0 | 42.0 | 54.3 | 26.6 | 50.5 | 9.9 | 15.3 | 0.045 |
| Dacrocystorhinostomy – | 12.4 | 26.1 | 14.9 | 34.3 | 12.9 | 30.7 | 6.8 | 14.0 | 0.019 |
| Chalazion incision and drainage – | 45.8 | 45.5 | 57.2 | 57.8 | 41.1 | 50.5 | 46.0 | 48.2 | 0.238 |
| LASIK, refractive surgery – | 0.6 | 4.2 | 0.6 | 2.5 | 3.8 | 21.5 | 3.1 | 19.5 | 0.325 |
| Retinal detachment surgery – | 2.6 | 16.4 | 0.3 | 1.3 | 0.1 | 0.6 | 0.0 | 0.1 | 0.029 |
| Vitrectomy – | 4.0 | 19.5 | 5.0 | 24.4 | 1.3 | 3.7 | 0.2 | 0.8 | 0.036 |
| Keratoplasty – | 5.6 | 15.3 | 5.2 | 14.8 | 4.0 | 22.1 | 4.8 | 23.3 | < 0.001 |
| Lid surgeries – | 9.8 | 18.4 | 8.6 | 25.5 | 6.5 | 22.6 | 6.1 | 10.9 | 0.001 |
| Managing ocular emergencies – | 41.9 | 49.5 | 44.0 | 59.1 | 45.9 | 59.7 | 36.6 | 52.3 | 0.101 |
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