New Technology and Training: A Resident's View

A rapidly changing field may collide with traditional priorities

By Nicholas Tosi, MD

I remember buying my first smartphone five years ago with excited fascination and anticipation of newfound convenience. Today, like most Americans, I admittedly confess that I remain at the behest of a dynamic consumer-driven technology industry, consciously (or subconsciously) obsessing over new products, advancements and even marginal iterations. Discerning what are truly life-changing products increasingly blurs with the more-faddish marketable substitutes (ie, the iPhone, other smartphones, or tablet PCs) we are inundated with on a daily basis. Futurist Ray Kurzweil has proposed “The Law of Accelerating Returns,” suggesting that technology systems tend to increase exponentially over time, which explains this ongoing cultural phenomenon of smaller, faster, better.

New Technology and Residency Training

As an ophthalmology resident currently undergoing training and being exposed on an everyday basis to both traditional and new technology-based procedures, I am well aware that our profession is evolving rapidly in numerous areas. I do see that as a good thing. Coming into practice in the 21st century, my contemporaries and I will undoubtedly be able to do more to help our patients than any generation of ophthalmologists that has previously been produced. All we need now is the experience and professional judgment that we must gain if we are to be successful physicians.

However, at this point in my excellent training at LSU-Ochsner, like many of my peers I am wondering how well we will be able to combine the traditional tenets of patient care with the rapidly growing array of advanced ophthalmic technology that is now available to us. Shouldn't my priorities first and foremost lie within mastering the basics of providing superior patient care?

As technology advances more rapidly than it can be adopted, it creates both a philosophical and practical conundrum. From a resident-training perspective, what constitutes an appropriate balance between teaching established surgical techniques and adequate exposure to newer methods that will eventually become integrated clinically? A didactic on residency educational objectives would be lengthy and undoubtedly encompass numerous goals and sub-goals. However, several considerations immediately come to mind.

The author points to advances such as the EYESI surgical simulator that brings virtual-reality technology into residency training but is also relevant in developing basic surgical skills.

The True Goals of Training

For the sake of brevity, I would begin by stating that the primary goal of an ophthalmology residency program ought to be to train independent, competent and comprehensive ophthalmologists. That is, when a trainee graduates he or she should feel comfortable and prepared to maximize patient care within accepted specialty standards. Whether or not a fellowship subspecialty is then pursued is irrelevant to the primary goals of residency training. Additional training is essentially an independent choice—and usually a wise one—but it is based on a specific interest and not bred solely out of the inexperience in performing ophthalmic procedures that characterizes almost all ophthalmology residents.

Although the basic objectives I have just set out for residency programs appear straightforward, ophthalmology is constantly pushing the envelope with regard to technological advances. Thus, we can easily fall prey to being sidetracked from achieving the basic goals of training if instructors and residents become too enamored of advanced technology.

Focusing on consistent and safe surgical outcomes is essential. However, will it help or hinder us in achieving these good outcomes if we are exposed too soon to too many different approaches, some of which require proficiency in advanced and more complicated technologies. Moreover, many of these technologies—even when employed perfectly—may yield only slightly incremental improvements in results.

The Tools We Have

Practically speaking, wet labs represent a cornerstone of ophthalmology training because they offer a risk-free practice environment for necessary techniques such as corneal suturing and instrument manipulation. The development of virtual reality training systems, such as the EYESI surgical simulator for cataract or retina surgery tasks, may help alleviate the aforementioned concern of safety. There is little doubt that as technology moves forward, simulation will become more and more realistic and provide an effective training arm, branching out to new procedures. While cost-prohibitive in some cases, these alternative methods of physical training will nonetheless become more commonplace in the very near future.

Only One Mentor May Be One Too Many

Even if surgical simulation can live up to its role of improving residents' proficiencies in a range of procedures, the ultimate depth and breadth of training depends on the perspectives of the attending physicians who direct the residency programs. For instance, if a primary teacher at an institution has ingrained tendencies and preferences in regard to surgery—such as not performing premium lens cataract surgery or always pursuing traditional glaucoma surgery—the residents' perspective and overall experience will suffer. As in every area of medicine, each ophthalmologist is trained in a particular way and this will trickle down into an individual physician's patient management comfort level. How ophthalmic training is planned and conducted will surely play an immense role in influencing how residents perform once they get into practice.

An obvious way to counteract or reduce the results of too much influence coming from a single mentor is by making sure to expose all residents to a variety of situations, experiences and instructors. Dedicated interaction with sub-specialty, private-practice-associated and outside-trained faculty should lead to varying perspectives and foster a tendency towards greater skillset diversity. Furthermore, taking advantage of educational lectures and conferences that emphasize the latest industry developments provide a separate introductory avenue for the resident. From personal experience, I can attest that immersion into conference settings provides trainees with unique perspectives, simply through networking with people from various institutions and companies.

Avenues to New Technology

Regardless, the above suggestions have a better chance of becoming a reality if the issue of the role of new technologies in residency training is directly addressed. To me, the essential question is how much should I be learning about the new technologies without sacrificing any of the basic competencies that every resident should be learning. This is especially pertinent in today's healthcare cost-cutting environment and the accompanying economic pressures that naturally affect both residency training and real-world practices. For example, Alcon allows residents a small number of toric lenses and related instruction, while LASIK certification courses are often available at no charge for residents.

Though such examples of industry co-partnership with trainees may be of concern to educational purists who see this as a form of subtle indoctrination, they do illustrate a viable route to enriching the residency experience in a cost-effective manner. From a pragmatic standpoint, recognition and acceptance that industry's influence in innovation is directly tied to continuing education is a good first step in further exposing residents to new technologies.

Which Technologies Have a Future?

Many questions remain unanswered and the future is unpredictable for a variety of reasons. Even with a healthy skepticism of company-friendly procedure data and convincing testimonials for new products, how does one then accurately predict how and when novel technologies will be adopted on a widespread clinical basis? This process is multi-factorial, extending into both the politics of reimbursements and the economics of practice integration.

For example, imagine a device that makes a step in cataract surgery marginally more predictable but slightly increases the time and cost of surgery—all for a historically slashed reimbursement rate. It would make little financial sense for a surgeon to incorporate that product's slightly incremental result because the bottom line for cataract procedures would be significantly reduced. Ultimately, for these reasons, the future timeline of technology becomes difficult to anticipate, further muddying the waters of educational change. Accordingly, exposure for exposure's sake becomes increasingly debatable when little or no future clinical utility is expected, or the prospects are unknown.

More Questions Than Answers

Fellowships for graduating residents and practice environments that are conducive to advancement of skills currently help bridge the technology gap. This is reasonable on many levels, most notably because medicine is a continuing education profession. To what extent new technology and trends toward subspecialization act as drivers for residents to pursue fellowship is difficult to measure accurately at this time.

Will high-volume successful private practices start to take a more active role in training because they are more likely to invest in new technologies? It's a reasonable assumption because business-minded volume practices are more likely to be oriented toward a high return on their investments.

Will graduating residents entering small practices or starting their own feel comfortable making this magnitude of investment? Probably not, if exposure to new technologies is lacking during residency. Moreover, in speaking to my colleagues at many different institutions, it becomes apparent that many graduates are underprepared to make such decisions. Unless awareness of practice economics and the art of surviving in today's changing financial environment are aggressively emphasized during the formative years of training, conservatism and reluctance in practice integration will perpetuate.

As Albert Einstein articulated, “I never think of the future—it comes soon enough.” Ophthalmology in 2011 is already at a technology crossroads. Thinking about these issues surrounding the integration of traditional surgical training with new techniques and products is complicated, yet necessary. How many practices will adopt the various technological innovations is at this point anyone's guess and the landscape remains mostly uncharted. Like buying my first smartphone years ago and watching this life-altering market unfold, I similarly look forward to experiencing the development and impact of practice-altering technologies throughout my entire career. Starting now. OM

Nicholas Tosi, MD, is currently in residency training at Louisiana State University-Ochsner Hospitals. He has written previously for Ophthalmology Management on issues that could impact the future of the profession and the next generation of ophthalmologists.