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Cataract Surgery | Jun 2011

Fostering Dynamic Resident Training

Programs must create symmetry between didactics and skills transfers.

Nearly 2 decades have passed since I (KGS) finished my residency at Tulane University. I may forget what it feels like to be in training, but I still remember many of the lessons I learned in those impressionable years. I was chosen as chief resident in 1990, and in the following year I began my fellowship in cornea and external disease. This made me an integral part of the residency training at the Dean A. McGee Eye Institute. The challenges that I faced in these positions continue to act as a reminder to always treat residents with respect and gratitude.

Today I am on the periphery of resident training at the University of North Carolina, but I never lose sight of the following principles:

No. 1: Even though I may be doing a procedure for the ten-thousandth time, the resident may be seeing it for the first time. Therefore, when facilitating skills transfers or performing surgery with an audience, I remember to speak on the residents' level, whether that is a first-year or a third-year level.

No. 2: Skills transfer is probably the biggest challenge and the scariest element of residency. Didactics come naturally, as these young doctors have been learning through books, the Internet, and videos for the past 8 to 10 years of their lives. But at some point, every resident has to perform his or her first case. Support from the staff goes a long way in the early stages of surgery.

No. 3: I try to remember that I was once a resident. Putting myself in their shoes creates a better learning environment and heightens the resident's overall experience. It is important to recall your own resident training days, but it is not advisable to compare your experience to theirs. Let each resident develop at his or her own pace.


I enjoy the time I spend interacting with residents. These fresh faces are motivated learners who typically ask enough questions to keep me on my toes. It is easy to get caught up in the daily grind of surgery, but a resident's pointed question or fresh perspective on a standard case is a welcome reminder of why I chose this profession. Unfortunately, there are roadblocks that we surgeons sometimes have to deal with when training residents. These include access to adequate training time, access to patients, and access to technologies. Successful resident training programs overcome these barriers by balancing didactics with skills transfers.

It has often been the latter—skills transfers—that has been the challenge in ophthalmology resident training programs. One large reason for this is lack of access to adequate training time. In many programs with high-profile instructors who are juggling their own practices, speaking engagements, and resident training, there is little time for one-on-one interaction, and skills transfers are limited to third-year residents who already have a surgical foundation. The consequence is that first- and second-year residents may be able to give an impressive differential diagnosis, but they might not have enough operating experience to fix what is wrong with the patient. However, there are other ways for universities to ensure the transfer of surgical skills to residents. For instance, the program may send residents outside the United States to missionary practices or to underserved facilities such as Veterans Affairs hospitals.

Ophthalmology residents do well with didactics; they can learn through lectures, through pictures, and through surgical videos, but their true education begins when they are invited into the operating room. Here we encounter the second roadblock, access to patients. Where do the patients for resident surgeries come from? The staff must negotiate who they want to operate on and which patients can be safely assigned to the residents. Additionally, some patients will not be comfortable undergoing surgery in the hands of someone with limited experience.

Somewhere along the line, everybody must do his or her first case. When does that first case come, and what can we as surgeons do to bring those residents to the forefront for that first case? Unlike when I was a resident, today’s robotics, training tools, wet labs, and simulators are good tools to initiate the surgical experience. By providing residents with plentiful access to such technologies, we are able to bypass the roadblock to technology in many cases. Mock cases in cadaver and animal eyes are also good for practice, but are not the same as the case itself.


It all comes back to skills transfers. We must better balance residents’ didactic training with the transfer of surgical skills. At the University of North Carolina, for instance, the staff members have started to incorporate wet labs during first-year residency so that we can foster residents’ surgical skills earlier in the program. First-year residents are also invited to observe cases in the operating room, and by the second year they typically are performing their first cases. During the third year, residents take charge of teaching first- and second-year residents and perform more surgeries themselves, allowing them to improve their skill set.

We must figure out ways to increase surgical skills across all boundaries. Retina cases are notoriously not transferred to residents because they are typically complicated. There are simple skills transfers, for example laser surgery for diabetic retinopathy, but residents should also be performing challenging cases to develop a preference for one subspecialty over another. That is the big push of today.


Didactics and skills transfers are the mainstays of residency programs, and striking the perfect balance between the two separates good programs from great programs. Whenever possible, consider incorporating residents into the surgical process, whether that is through observing surgery or scrubbing in to participate in parts of the procedure. When this is not possible, consider other educational avenues such as wet labs, surgical simulators, and even surgical videos.

Ophthalmic residency training is extremely visual and hands-on. In earlier years, surgeons could share their videos only through professional meetings and the Video Journal of Ophthalmology. Now, with the Internet readily accessible, surgeons can share their surgical cases, their complicated cases, and their new techniques and technologies more frequently through video transfers such as Eyetube.net. The visual experience through Eyetube.net cannot be understated. Residents should also be using these resources to better prepare themselves for that first crack at live surgery. A surgeon who feels comfortable with every part of the procedure is less likely to run into complications and will know what to do if complications arise. That is the goal of training.

Karl G. Stonecipher, MD, is Director of Refractive Surgery at The Laser Center in Greensboro, North Carolina. Dr. Stonecipher is a member of the CRST Europe Global Advisory Board. He states that he has consulted, served on the speakers' board, or received travel or research funding from these companies: Abbott Medical Optics Inc.; Alcon Laboratories, Inc.; Allergan, Inc.; Ista Pharmaceuticals; Inspire; Nidek; Oasis; Vistakon; and WaveLight. He may be reached at tel: +1 336 288 8823; e-mail: stonenc@aol.com.

Matej Polomsky, MD, is an Ophthalmology Resident at University of North Carolina in Chapel Hill, North Carolina.