- Email: [email protected]
More debate on underemployment of ophthalmologists needed
Letters to the Editor and afternoon, especially between 11:00 AM and 5:00 PM. It has been reported that IOP fluctuations range from 2 to 6 mm Hg over a 24-hour period, whereas in eyes with glaucoma the fluctuations can be more than 10 mm Hg.2,3 Therefore, measuring the IOP of each patient or different patients at different hours might have affected the results of the present study. The authors also reported that all patients had used topical corticosteroid medication during the study, but they did not state whether all patients used the same or different corticosteroid drop. It has been reported that different corticosteroid drops have different abilities in elevating IOP; for instance, dexamethasone 0.1% is 2 times more powerful than prednisolone 1.0% and 3 times more powerful than fluorometholone 0.1% in elevating IOP.4,5 Therefore, if patients used different types of steroids, this might have affected the results. Additionally, they reported that a preoperative diagnosis of glaucoma was noted in 27 patients overall: 15 in the PKP group and 12 in the DSEK group. The etiology of glaucoma was primary open-angle glaucoma (n ¼ 15), iridocorneal endothelial syndrome (n ¼ 3), pseudoexfoliation (n ¼ 2), and angle-closure glaucoma (n ¼ 2), but information about glaucoma etiology of 5 patients is not given.
More debate on underemployment of ophthalmologists needed As clinicians, we are trained to identify and treat the cause of a disease. In “The Underemployed Ophthalmologists— Results of a Survey of Recent Ophthalmology Graduates” by Manusow et al.,1 an opportunity presents itself to identify 2 underlying causes of underemployment. First, underemployment is an inherent problem of the health care system at a certain level and not independent of it. The lack of sustained expansion of the number of operating rooms is one facet of the problem. The lack of transparency and accountability to the common good that matches patients’ needs (i.e., “perceived local ophthalmologists resistance” [p.149] to employment of new ones), and the bureaucratic centralization of medical services in certain hospitals for the benefit of budgetary bottom line are 2 more. Second, the current ophthalmology residency programs have shifted away from the model of training general ophthalmologists who possess a full range of postresidency surgical skills. Manusow et al. have identified a scope of practice for newly graduating residents that highlights the sharp drop in surgical skills, with the exception of cataract surgery. Sadly, we are missing out on creating a true breed of general ophthalmologists who are comfortable surgically treating many diseases other than cataract. It appears that it is acceptable from a curriculum standpoint to graduate future ophthalmologists who are
Yakup Aksoy, MD Girne Military Hospital, Girne, Cyprus Correspondence to: Yakup Aksoy, MD: [email protected]
REFERENCES 1. Sharma RA, Bursztyn LL, Golesic E, et al. Comparison of intraocular pressure post penetrating keratoplasty vs Descemet’s stripping endothelial keratoplasty. Can J Ophthalmol. 2016;51:19-24. 2. Sit AJ. Intraocular pressure variations: causes and clinical significance. Can J Ophthalmol. 2014;49:484-8. 3. Agnifili L, Mastropasqua R, Frezzotti P, et al. Circadian intraocular pressure patterns in healthy subjects, primary open angle and normal tension glaucoma patients with a contact lens sensor. Acta Ophthalmol. 2015;93:e14-21. 4. Razeghinejad MR, Katz LJ. Steroid-induced iatrogenic glaucoma. Ophthalmic Res. 2012;47:66-80. 5. Yamamoto Y, Komatsu T, Koura Y. Intraocular pressure elevation after intravitreal or posterior sub-Tenon triamcinolone acetonide injection. Can J Ophthalmol. 2008;43:42-7. Can J Ophthalmol 2016;51:492–493 0008-4182/16/$-see front matter & 2016 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jcjo.2016.05.012
comfortable with performing one type of surgery. While bearing in mind that the bulk of future ophthalmologists will not work in tertiary centres or academic hospitals, ophthalmology residency programs emphasize the need for core competency procedures but fall short by producing only cataract surgeons. No wonder cataract surgery has been in the crosshairs for fee reduction by many provinces. This should be identified as a hidden curriculum agenda—one that accepts the notion that if graduates want to develop further surgical confidence in an even smaller field of ophthalmology, a fellowship should follow, as if the residency programs are no longer a place for the fine-tuning of a wide range of surgical skills. Although Manusow et al. identify the importance of fellowships as a tool for employability, this has the repercussion of creating what I call an “academic counterintuition,” in which future ophthalmologists view working in an academic centre as the only way to fully utilize a fellowship. If they work anywhere else, their surgical abilities are underutilized. The other more serious implication of this arrangement is that patients are given a subtle understanding of the 2tier service system wherein centrally located ophthalmologists are more capable than their peers in peripherally located hospitals. The intertwining of both problems is also creating, as a direct implication of the current structure of the health care system, frustrated and misinformed patients who must be driven to central/academic
CAN J OPHTHALMOL — VOL. 51, NO. 6, DECEMBER 2016
493
Letters to the Editor hospitals to have a certain ophthalmology procedure or surgery. The ophthalmology residency curriculum needs to be revised and established in a new frame that reflects the current employment market and yet remain true to itself.
REFERENCE 1. Manusow JS, Buys YM, Bellan L. The underemployed ophthalmologist—results of a survey of recent ophthalmology graduates. Can J Ophthalmol. 2016;51:147-53. Can J Ophthalmol 2016;51:493–494 0008-4182/16/$-see front matter & 2016 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jcjo.2016.09.007
Rani N. Al Karmi, MD, FRCSC, Master of Education Dalhousie University, Halifax, N.S. Correspondence to: Rani N. Al Karmi: [email protected]
Re: State-of-the-art: low vision rehabilitation, S. Markowitz, Vol. 51, No. 2, April 2016 I would like to commend Dr. Markowitz on his article.1 I very much support his presenting a state-of-the-art description of our field and would like to broaden the scope of some topics he addresses. As set forth in the American Academy of Ophthalmology’s Preferred Practice Pattern (PPP) in Vision Rehabilitation, a low-vision evaluation includes assessments of fall risk, falls and other safety issues, comorbidities that compromise function, the range of activities of daily living, isolation and community integration, depression, adjustment to vision loss, fear of blindness, hallucinations, and well-being. An evidence base is evolving, and there remains a wide variation of application in day-to-day practice; however, a comprehensive definition includes these elements. The PPP also describes rehabilitation training with an occupational therapist as an intrinsic part of comprehensive vision rehabilitation; the MD or OD and OT function as a team, with mutual feedback. The OT addresses the issues identified in the MD or OD’s low vision evaluation, develops strategies to optimize safety and function at home and in the community, confirms the effectiveness of devices as applied to desired tasks, and connects patients to local and national
resources. In other countries, other individuals may fulfill a similar role in the multidisciplinary team. Finally, Dr. Markowitz is correct that there are varied approaches to vision rehabilitation. As examples, many comprehensive vision rehabilitation practices do not find prisms the most effective first-line treatment or training for those with strokes or central field loss, do not prescribe neutral density filters routinely, and do not consider 25% of PRLs to be “unfavourable.” Such examples underscore the need for comparative effectiveness trials in vision rehabilitation, research that is a priority for our domain. I thank Dr. Markowitz for launching this discussion of vision rehabilitation. Lylas G. Mogk Henry Ford Health System, Grosse Pointe, Michigan. Correspondence to: Lylas G. Mogk, MD: [email protected] REFERENCE 1. Markowitz SN. State-of-the-art: low vision rehabilitation. Can J Ophthalmol. 2016;51:59-66.
Re: State-of-the-art: low vision rehabilitation We thank Dr. Mogk for her valuable comments and enlarging the discussion on Low Vision Rehabilitation following the publication of our above-named paper. Samuel N. Markowitz, MD, FRCS(C) Professor of Ophthalmology and Vision Sciences, Faculty of Medicine, University of Toronto, 1225 Davenport Rd.,
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CAN J OPHTHALMOL — VOL. 51, NO. 6, DECEMBER 2016
Can J Ophthalmol 2016;51:494 0008-4182/16/$-see front matter & 2016 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jcjo.2016.09.006
Toronto, Ontario, Canada M6H 2H1, Phone: 416 531 5425 Correspondence to: Samuel N. Markowitz, MD, FRCS(C): [email protected] Can J Ophthalmol 2016;51:494 0008-4182/16/$-see front matter & 2016 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jcjo.2016.09.006
More debate on underemployment of ophthalmologists needed As clinicians, we are trained to identify and treat the cause of a disease. In “The Underemployed Ophthalmologists— Results of a Survey of Recent Ophthalmology Graduates” by Manusow et al.,1 an opportunity presents itself to identify 2 underlying causes of underemployment. First, underemployment is an inherent problem of the health care system at a certain level and not independent of it. The lack of sustained expansion of the number of operating rooms is one facet of the problem. The lack of transparency and accountability to the common good that matches patients’ needs (i.e., “perceived local ophthalmologists resistance” [p.149] to employment of new ones), and the bureaucratic centralization of medical services in certain hospitals for the benefit of budgetary bottom line are 2 more. Second, the current ophthalmology residency programs have shifted away from the model of training general ophthalmologists who possess a full range of postresidency surgical skills. Manusow et al. have identified a scope of practice for newly graduating residents that highlights the sharp drop in surgical skills, with the exception of cataract surgery. Sadly, we are missing out on creating a true breed of general ophthalmologists who are comfortable surgically treating many diseases other than cataract. It appears that it is acceptable from a curriculum standpoint to graduate future ophthalmologists who are
Yakup Aksoy, MD Girne Military Hospital, Girne, Cyprus Correspondence to: Yakup Aksoy, MD: [email protected]
REFERENCES 1. Sharma RA, Bursztyn LL, Golesic E, et al. Comparison of intraocular pressure post penetrating keratoplasty vs Descemet’s stripping endothelial keratoplasty. Can J Ophthalmol. 2016;51:19-24. 2. Sit AJ. Intraocular pressure variations: causes and clinical significance. Can J Ophthalmol. 2014;49:484-8. 3. Agnifili L, Mastropasqua R, Frezzotti P, et al. Circadian intraocular pressure patterns in healthy subjects, primary open angle and normal tension glaucoma patients with a contact lens sensor. Acta Ophthalmol. 2015;93:e14-21. 4. Razeghinejad MR, Katz LJ. Steroid-induced iatrogenic glaucoma. Ophthalmic Res. 2012;47:66-80. 5. Yamamoto Y, Komatsu T, Koura Y. Intraocular pressure elevation after intravitreal or posterior sub-Tenon triamcinolone acetonide injection. Can J Ophthalmol. 2008;43:42-7. Can J Ophthalmol 2016;51:492–493 0008-4182/16/$-see front matter & 2016 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jcjo.2016.05.012
comfortable with performing one type of surgery. While bearing in mind that the bulk of future ophthalmologists will not work in tertiary centres or academic hospitals, ophthalmology residency programs emphasize the need for core competency procedures but fall short by producing only cataract surgeons. No wonder cataract surgery has been in the crosshairs for fee reduction by many provinces. This should be identified as a hidden curriculum agenda—one that accepts the notion that if graduates want to develop further surgical confidence in an even smaller field of ophthalmology, a fellowship should follow, as if the residency programs are no longer a place for the fine-tuning of a wide range of surgical skills. Although Manusow et al. identify the importance of fellowships as a tool for employability, this has the repercussion of creating what I call an “academic counterintuition,” in which future ophthalmologists view working in an academic centre as the only way to fully utilize a fellowship. If they work anywhere else, their surgical abilities are underutilized. The other more serious implication of this arrangement is that patients are given a subtle understanding of the 2tier service system wherein centrally located ophthalmologists are more capable than their peers in peripherally located hospitals. The intertwining of both problems is also creating, as a direct implication of the current structure of the health care system, frustrated and misinformed patients who must be driven to central/academic
CAN J OPHTHALMOL — VOL. 51, NO. 6, DECEMBER 2016
493
Letters to the Editor hospitals to have a certain ophthalmology procedure or surgery. The ophthalmology residency curriculum needs to be revised and established in a new frame that reflects the current employment market and yet remain true to itself.
REFERENCE 1. Manusow JS, Buys YM, Bellan L. The underemployed ophthalmologist—results of a survey of recent ophthalmology graduates. Can J Ophthalmol. 2016;51:147-53. Can J Ophthalmol 2016;51:493–494 0008-4182/16/$-see front matter & 2016 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jcjo.2016.09.007
Rani N. Al Karmi, MD, FRCSC, Master of Education Dalhousie University, Halifax, N.S. Correspondence to: Rani N. Al Karmi: [email protected]
Re: State-of-the-art: low vision rehabilitation, S. Markowitz, Vol. 51, No. 2, April 2016 I would like to commend Dr. Markowitz on his article.1 I very much support his presenting a state-of-the-art description of our field and would like to broaden the scope of some topics he addresses. As set forth in the American Academy of Ophthalmology’s Preferred Practice Pattern (PPP) in Vision Rehabilitation, a low-vision evaluation includes assessments of fall risk, falls and other safety issues, comorbidities that compromise function, the range of activities of daily living, isolation and community integration, depression, adjustment to vision loss, fear of blindness, hallucinations, and well-being. An evidence base is evolving, and there remains a wide variation of application in day-to-day practice; however, a comprehensive definition includes these elements. The PPP also describes rehabilitation training with an occupational therapist as an intrinsic part of comprehensive vision rehabilitation; the MD or OD and OT function as a team, with mutual feedback. The OT addresses the issues identified in the MD or OD’s low vision evaluation, develops strategies to optimize safety and function at home and in the community, confirms the effectiveness of devices as applied to desired tasks, and connects patients to local and national
resources. In other countries, other individuals may fulfill a similar role in the multidisciplinary team. Finally, Dr. Markowitz is correct that there are varied approaches to vision rehabilitation. As examples, many comprehensive vision rehabilitation practices do not find prisms the most effective first-line treatment or training for those with strokes or central field loss, do not prescribe neutral density filters routinely, and do not consider 25% of PRLs to be “unfavourable.” Such examples underscore the need for comparative effectiveness trials in vision rehabilitation, research that is a priority for our domain. I thank Dr. Markowitz for launching this discussion of vision rehabilitation. Lylas G. Mogk Henry Ford Health System, Grosse Pointe, Michigan. Correspondence to: Lylas G. Mogk, MD: [email protected] REFERENCE 1. Markowitz SN. State-of-the-art: low vision rehabilitation. Can J Ophthalmol. 2016;51:59-66.
Re: State-of-the-art: low vision rehabilitation We thank Dr. Mogk for her valuable comments and enlarging the discussion on Low Vision Rehabilitation following the publication of our above-named paper. Samuel N. Markowitz, MD, FRCS(C) Professor of Ophthalmology and Vision Sciences, Faculty of Medicine, University of Toronto, 1225 Davenport Rd.,
494
CAN J OPHTHALMOL — VOL. 51, NO. 6, DECEMBER 2016
Can J Ophthalmol 2016;51:494 0008-4182/16/$-see front matter & 2016 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jcjo.2016.09.006
Toronto, Ontario, Canada M6H 2H1, Phone: 416 531 5425 Correspondence to: Samuel N. Markowitz, MD, FRCS(C): [email protected] Can J Ophthalmol 2016;51:494 0008-4182/16/$-see front matter & 2016 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jcjo.2016.09.006