- Email: [email protected]
Shaping the future of ophthalmology in Canada
EDITORIAL
Shaping the Future of Ophthalmology in Canada There are more than 1200 ophthalmologists in Canada, making ophthalmology the fourth largest surgical specialty. In fact, more surgeons practice ophthalmologic surgery than cardiac, vascular, plastic, and neurosurgery combined. This concentration of surgeons is necessitated by the fact that more than 4 million Canadians live with a potentially blinding eye disease, and approximately 500 000 Canadians have already suffered permanent blindness or visual impairment.1 Moreover, the economic burden of eye disease, estimated in excess of $15 billion per year, represents a significant drain on the Canadian economy, making investment in eye care vitally important.2–4 To a greater extent than most specialties, the burden of eye disease is expected to grow significantly with an aging population because major eye diseases are age-related and ophthalmologic care is typically provided to older patients.5 As a result, careful attention is needed to sustainably match the training and distribution of eye surgeons to the needs of the population. While many factors have an impact on ophthalmologists and the care they provide, two of the most important themes are subspecialization and system resource limitations.
Subspecialization Recent evidence suggests that subspecialization is now established in many areas of ophthalmology.6,7 These developments have a number of important consequences. For instance, subspecialization may exacerbate geographic maldistribution of ophthalmologic services, which is already a major issue for the Canadian eye care system.8,9 Subspecialization also fragments patient care and increasingly leaves comprehensive ophthalmologists with a surgical practice consisting exclusively of cataract surgery. On the other hand, some evidence suggests that subspecialization and higher surgical volumes can improve outcomes.10,11 Many forces drive the increase in subspecialization. The rapid expansion of medical knowledge and the associated need for advanced training are key factors. Additionally, the need for sufficient surgical volume to maintain competence requires the concentration of rare procedures. In the current milieu, in which job opportunities for new ophthalmologists have become increasingly rare, many recent graduates see fellowships as a means to differentiate themselves in order to fill specific subspecialty postings. In some regions with growing fellowship training opportunities, general ophthalmologists have gained easier access to subspecialists, resulting in an increased likelihood of non-cataract surgical case referrals. In addition to clinical reasons for the trend toward subspecialization, educational factors also play an important
role. In particular, the emphasis on acquiring cataract surgical skills during residency and the limited exposure to subspecialty surgical learning opportunities partially underpin the trend for noncataract operations to be the purview of fellowship-trained subspecialists. Consequently, 94% of surgical ophthalmologists in Ontario now perform cataract surgery with 42% performing no other type of surgery (Campbell et al., publication pending). If operations other than cataract surgery are to be offered by a significant proportion of general ophthalmologists, residency programs will need to continue to look for innovative ways to increase learning opportunities. Simulation laboratories and curricula could help increase the volume of training residents receive.12 Without sustained efforts, surgical training in a number of areas of ophthalmology will increasingly become reserved for fellowship education.13 It is important to note that should residency programs relinquish responsibility for training to fellowship programs, significant regulatory changes would be required. Compared to residency training programs, fellowships are generally minimally regulated and much more variable. Narrowing the surgical competencies required to graduate from residency programs would require more intensive focus on accreditation standards for fellowships. Our education system also has additional, indirect influences because residents undertake most training in academic centres where subspecialization is common and noncataract surgical procedures are generally performed by subspecialists. As a result, residency programs will need to continue developing approaches to teach skills in ways that incorporate the perspective of comprehensive ophthalmology. With the steadily growing importance of competencybased medical education in modern residency education, defining the skills and knowledge required of graduating ophthalmologists will become increasingly important.14 In making such decisions, we will need to be cognizant of the need to train flexible surgeons who are capable of providing care not only today but in the future as new techniques evolve. Training programs also need to consider that subspecialties occasionally disappear altogether as new interventions arise. For example, among general surgeons, subspecializing in the surgical treatment of peptic ulcer disease was once common but as a result of medical therapies, those specific skills are no longer needed. In ophthalmology, two recent papers describe the use of pharmacologic chaperones—chemicals in the sterol family—used either topically or intracamerally to reverse the misfolding and clumping of crystallins in mammalian cataracts and partially restore lens clarity.15,16 Such reports regarding the potential for medical reversal of cataracts are just a few of many potentially revolutionary possibilities within our specialty. While policies and educational approaches should sustain broadly trained, flexible surgeons, other areas of CAN J OPHTHALMOL — VOL. ], NO. ], ] 2016
1
Editorial care may also become subsets of ophthalmology. In such situations, devoting significant training to all residents for procedures performed only by a minority of ophthalmologists may be an inefficient use of finite educational resources. Hence, the creation of streams of training within residency programs has also been suggested as a compromise position, whereby only residents committed to providing comprehensive or subspecialist ophthalmologic procedures in a clinical practice learn the relevant procedures.6,7,17,18 However, the potential positive impact of such streaming would need to be carefully balanced against negative effects on access to care in regions with few surgeons and the potential detraction from the development of well-rounded surgeons. Moreover, this approach would require major policy changes and approval from the Royal College of Physicians and Surgeons of Canada, and is thus is not likely a practical solution in the short term. Planning for the future
There is evidence that many regions of Canada face a shortage of ophthalmologists.8,9 Furthermore, because ophthalmologists provide care to an older patient population compared to other specialties, the eye care needs of this population will are expected to rise more rapidly than the need for other medical and surgical care. Ophthalmologist-to-population ratios are a helpful starting point in health human resources planning but are not sufficient because access to specific services correlates poorly with these ratios.19 Instead, a global perspective of the mix and volume of services provided by clinicians in each region is needed. Policies should support surgeons in providing access to the complete spectrum of high quality ophthalmologic care in all areas of the country. For example, the provincial Vision Strategy Task Force in Ontario has mandated that each region develop a vision care plan detailing how access to all aspects of care, both medical and surgical, will be ensured.20
System Resource Limitations The combination of an aging population and the ongoing expansion of treatment options, including new therapies for previously untreatable conditions, has resulted in significant resource constraints within the healthcare system. With ophthalmologic operations being the most common surgical procedures performed in Canada, constraints in the system have had substantial effects on ophthalmology and will continue to shape the eye care system for the foreseeable future. Limitations in operating room access have already altered the practice of recent graduates. Indeed, despite the increasing medical needs of Canada’s aging population, graduates from a number of medical and surgical specialties have recently had difficulty in securing practice
2
CAN J OPHTHALMOL — VOL. ], NO. ], ] 2016
opportunities or obtaining operating room time.21 Many of Canada’s well-known health human resources reports have emphasized the fundamental link between physician human resources and the overall design of the healthcare system, and the need for policies that reflect this link.22–24 As such, policies should reflect the need to continually renew the surgical workforce by ensuring that surgeons of all career stages have the opportunity to operate.20 Beyond recent graduate issues, numerous other opportunities for leadership exist in the face of difficult times. As a specialty, we will need to ensure that appropriate operating room access is maintained for ophthalmologic surgery as system changes occur. Additionally, within our specialty, we will need to continue to focus on necessary, high-value care and to do so efficiently. Thus, efforts should continue to refine indications for therapies, ensure appropriate criteria are applied when choosing interventions, and seek efficiencies without compromising safety. In the face of system constraints, the ongoing development of novel technologies requires methodical approaches to assessment and implementation. While the uptake of truly revolutionary therapies that increase the value of care should be broadly supported, the marginal costs of some innovations significantly exceed the marginal improvements in outcomes. Similarly, some technologies provide improved outcomes only for a small fraction of those patients for whom they are marketed. In addition to careful evaluation of new technologies, exploration of alternative models of healthcare delivery, in which high-quality care would be provided for all regardless of ability to pay, may be warranted while allowing alternative funding mechanisms to coexist. The 2016 Canadian eye care system bears little resemblance to that of 50 years ago, when the Canadian Journal of Ophthalmology came into existence. As ophthalmologists evolve in the types and breadth of care they provide, we will continue to become a much less homogenous specialty that faces many difficult decisions. The next 50 years will most certainly require significant efforts and strong leadership to find ways to collaboratively and efficiently provide the full spectrum of world-class eye care for all Canadians. Robert J. Campbell, MD, MSc, FRCSC,*,†,‡, Sherif R. El-Defrawy, MD, PhD, FRCSC§,‖ *
Department of Ophthalmology, Queen’s University, Kingston, Ont † Department of Ophthalmology, Hotel Dieu and Kingston General Hospitals, Kingston, Ont ‡ Institute for Clinical Evaluative Sciences, Toronto, Ont § Department of Ophthalmology, University of Toronto, Toronto, Ont ‖ Department of Ophthalmology, Kensington Eye Institute, Toronto, Ont. Correspondence to: Sherif R. El-Defrawy, MD, PhD, FRCSC: sherif.el.defrawy@ utoronto.ca
Editorial REFERENCES 1. Buhrmann R, Hodge W, Beardmore J. Foundations for a Canadian Vision Health Strategy. Toronto: The National Coalition for Vision Health; 2007. 2. Frick KD, Gower EW, Kempen JH, Wolff JL. Economic impact of visual impairment and blindness in the United States. Arch Ophthalmol. 2007;125:544. 3. Brown GC, Brown MM, Sharma S, et al. The burden of age-related macular degeneration: a value-based medicine analysis. Trans Am Ophthalmol Soc. 2005;103:173. 4. Cruess AF, Gordon KD, Bellan L, Mitchell S, Pezzullo ML. The cost of vision loss in Canada. 2. Results. Can J Ophthalmol. 2011;46:315-8. 5. Roos NP, Shanahan M, Fransoo R, Bradley JE. How many physicians does Canada need to care for our aging population? CMAJ. 1998;158:1275-84. 6. Campbell RJ, Gill S, Ten Hove M, et al. Strabismus surgical subspecialization: a population-based analysis JAMA Ophthalmol. 2015;133:555-9. 7. Campbell RJ, Bell CM, Gill SS, et al. Subspecialization in glaucoma surgery. Ophthalmology. 2012;119:2270-3. 8. Bellan L, Buske L, Wang S, Buys YM. The landscape of ophthalmologists in Canada: present and future. Can J Ophthalmol. 2013;48:160-6. 9. Bellan L, Buske L. Ophthalmology human resource projections: are we heading for a crisis in the next 15 years? Can J Ophthalmol. 2007;42:34-8. 10. Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: the relationship between clinical experience and quality of health care Ann Intern Med. 2005;142:260-73. 11. Bell CM, Hatch WV, Cernat G, Urbach DR. Surgeon volumes and selected patient outcomes in cataract surgery a population-based analysis. Ophthalmology. 2007;114:405-10. 12. Reznick RK, MacRae H. Teaching surgical skills–changes in the wind. N Eng J Med. 2006;355:2664-9. 13. O’Day DM, Wilkinson CP. Realities regarding subspecialty accreditation and certification in ophthalmology. Retina. 2010;30:537-41. 14. Competence by Design (CBD): Moving toward competency-based medical education. Ottawa, Canada: Royal College of Physicians and Surgeons of Canada; 2015 [cited 2015 Dec 14]. Available at 〈www.royalcollege.ca/portal/page/portal/rc/resources/cbme〉. 15. Zhao L, Chen XJ, Zhu J, et al. Lanosterol reverses protein aggregation in cataracts. Nature. 2015;523:607-11.
16. Makley LN, McMenimen KA, DeVree BT, et al. Pharmacological chaperone for α-crystallin partially restores transparency in cataract models. Science. 2015;350:674-7. 17. Grantcharov TP, Reznick RK. Training tomorrow’s surgeons: what are we looking for and how can we achieve it? ANZ J Surg. 2009;79:104-7. 18. Gawande AA. Creating the educated surgeon in the 21st century Am J Surg. 2001;181:551-6. 19. Roos NP, Fransoo R. How many surgeons does a province need, and how do we determine appropriate numbers? Healthc Manage Forum. 2001;14:11-5. 20. The Provincial Vision Strategy Task Force. A vision for Ontario: strategic recommendations for ophthalmology in Ontario Toronto: Ontario Ministry of Health and Long Term Care; 2013 May [cited 2015 Dec 14]. Available at 〈www.health.gov.on.ca/en/common/ ministry/publications/reports/docs/ontario_vision_strategy_report. pdf〉. 21. Frechette D, Hollenberg D, Shrichand A, Jacob C, Datta I. What’s really behind Canada’s unemployed specialists? Too many, too few doctors? Findings from the Royal College’s employment study Ottawa, Ontario: The Royal College of Physicians and Surgeons of Canada; 2013 [cited 2015 Dec 14]. Available at 〈www.royalcollege.ca/portal/ page/portal/rc/common/documents/policy/employment_re port_2013_e.pdf〉. 22. Romanow RJ. Building on values: the future of health care in Canada final report. Ottawa, Canada: Commission on the Future of Health Care in Canada; 2002 Nov [cited 2015 Dec 14]. Available at 〈www. publications.gc.ca/collections/Collection/CP32-85-2002E.pdf〉. 23. Task Force Two. A physician human resource strategy for Canada: Final report. Ottawa, Canada: Government of Canada; March 2006 [cited 2015 Dec 14]. Available at 〈www.tools.hhr-rhs.ca/index.php? option=com_mtree&task=att_download&link_id=4673&cf_ id=68&lang=en〉. 24. McKendry R. Physicians for Ontario: Too many? Too few? For 2000 and beyond Ontario, Canada: report of the fact finder on physician resources in Ontario, Ontario Ministry of Health and Long-Term Care; 1999 Dec [cited 2015 Dec 14]. Available at 〈www.health.gov.on.ca/en/common/ ministry/publications/reports/mckendry/mckendry.pdf〉. Can J Ophthalmol 2016;]:]]]–]]] 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.2016.07.022
CAN J OPHTHALMOL — VOL. ], NO. ], ] 2016
3
Shaping the Future of Ophthalmology in Canada There are more than 1200 ophthalmologists in Canada, making ophthalmology the fourth largest surgical specialty. In fact, more surgeons practice ophthalmologic surgery than cardiac, vascular, plastic, and neurosurgery combined. This concentration of surgeons is necessitated by the fact that more than 4 million Canadians live with a potentially blinding eye disease, and approximately 500 000 Canadians have already suffered permanent blindness or visual impairment.1 Moreover, the economic burden of eye disease, estimated in excess of $15 billion per year, represents a significant drain on the Canadian economy, making investment in eye care vitally important.2–4 To a greater extent than most specialties, the burden of eye disease is expected to grow significantly with an aging population because major eye diseases are age-related and ophthalmologic care is typically provided to older patients.5 As a result, careful attention is needed to sustainably match the training and distribution of eye surgeons to the needs of the population. While many factors have an impact on ophthalmologists and the care they provide, two of the most important themes are subspecialization and system resource limitations.
Subspecialization Recent evidence suggests that subspecialization is now established in many areas of ophthalmology.6,7 These developments have a number of important consequences. For instance, subspecialization may exacerbate geographic maldistribution of ophthalmologic services, which is already a major issue for the Canadian eye care system.8,9 Subspecialization also fragments patient care and increasingly leaves comprehensive ophthalmologists with a surgical practice consisting exclusively of cataract surgery. On the other hand, some evidence suggests that subspecialization and higher surgical volumes can improve outcomes.10,11 Many forces drive the increase in subspecialization. The rapid expansion of medical knowledge and the associated need for advanced training are key factors. Additionally, the need for sufficient surgical volume to maintain competence requires the concentration of rare procedures. In the current milieu, in which job opportunities for new ophthalmologists have become increasingly rare, many recent graduates see fellowships as a means to differentiate themselves in order to fill specific subspecialty postings. In some regions with growing fellowship training opportunities, general ophthalmologists have gained easier access to subspecialists, resulting in an increased likelihood of non-cataract surgical case referrals. In addition to clinical reasons for the trend toward subspecialization, educational factors also play an important
role. In particular, the emphasis on acquiring cataract surgical skills during residency and the limited exposure to subspecialty surgical learning opportunities partially underpin the trend for noncataract operations to be the purview of fellowship-trained subspecialists. Consequently, 94% of surgical ophthalmologists in Ontario now perform cataract surgery with 42% performing no other type of surgery (Campbell et al., publication pending). If operations other than cataract surgery are to be offered by a significant proportion of general ophthalmologists, residency programs will need to continue to look for innovative ways to increase learning opportunities. Simulation laboratories and curricula could help increase the volume of training residents receive.12 Without sustained efforts, surgical training in a number of areas of ophthalmology will increasingly become reserved for fellowship education.13 It is important to note that should residency programs relinquish responsibility for training to fellowship programs, significant regulatory changes would be required. Compared to residency training programs, fellowships are generally minimally regulated and much more variable. Narrowing the surgical competencies required to graduate from residency programs would require more intensive focus on accreditation standards for fellowships. Our education system also has additional, indirect influences because residents undertake most training in academic centres where subspecialization is common and noncataract surgical procedures are generally performed by subspecialists. As a result, residency programs will need to continue developing approaches to teach skills in ways that incorporate the perspective of comprehensive ophthalmology. With the steadily growing importance of competencybased medical education in modern residency education, defining the skills and knowledge required of graduating ophthalmologists will become increasingly important.14 In making such decisions, we will need to be cognizant of the need to train flexible surgeons who are capable of providing care not only today but in the future as new techniques evolve. Training programs also need to consider that subspecialties occasionally disappear altogether as new interventions arise. For example, among general surgeons, subspecializing in the surgical treatment of peptic ulcer disease was once common but as a result of medical therapies, those specific skills are no longer needed. In ophthalmology, two recent papers describe the use of pharmacologic chaperones—chemicals in the sterol family—used either topically or intracamerally to reverse the misfolding and clumping of crystallins in mammalian cataracts and partially restore lens clarity.15,16 Such reports regarding the potential for medical reversal of cataracts are just a few of many potentially revolutionary possibilities within our specialty. While policies and educational approaches should sustain broadly trained, flexible surgeons, other areas of CAN J OPHTHALMOL — VOL. ], NO. ], ] 2016
1
Editorial care may also become subsets of ophthalmology. In such situations, devoting significant training to all residents for procedures performed only by a minority of ophthalmologists may be an inefficient use of finite educational resources. Hence, the creation of streams of training within residency programs has also been suggested as a compromise position, whereby only residents committed to providing comprehensive or subspecialist ophthalmologic procedures in a clinical practice learn the relevant procedures.6,7,17,18 However, the potential positive impact of such streaming would need to be carefully balanced against negative effects on access to care in regions with few surgeons and the potential detraction from the development of well-rounded surgeons. Moreover, this approach would require major policy changes and approval from the Royal College of Physicians and Surgeons of Canada, and is thus is not likely a practical solution in the short term. Planning for the future
There is evidence that many regions of Canada face a shortage of ophthalmologists.8,9 Furthermore, because ophthalmologists provide care to an older patient population compared to other specialties, the eye care needs of this population will are expected to rise more rapidly than the need for other medical and surgical care. Ophthalmologist-to-population ratios are a helpful starting point in health human resources planning but are not sufficient because access to specific services correlates poorly with these ratios.19 Instead, a global perspective of the mix and volume of services provided by clinicians in each region is needed. Policies should support surgeons in providing access to the complete spectrum of high quality ophthalmologic care in all areas of the country. For example, the provincial Vision Strategy Task Force in Ontario has mandated that each region develop a vision care plan detailing how access to all aspects of care, both medical and surgical, will be ensured.20
System Resource Limitations The combination of an aging population and the ongoing expansion of treatment options, including new therapies for previously untreatable conditions, has resulted in significant resource constraints within the healthcare system. With ophthalmologic operations being the most common surgical procedures performed in Canada, constraints in the system have had substantial effects on ophthalmology and will continue to shape the eye care system for the foreseeable future. Limitations in operating room access have already altered the practice of recent graduates. Indeed, despite the increasing medical needs of Canada’s aging population, graduates from a number of medical and surgical specialties have recently had difficulty in securing practice
2
CAN J OPHTHALMOL — VOL. ], NO. ], ] 2016
opportunities or obtaining operating room time.21 Many of Canada’s well-known health human resources reports have emphasized the fundamental link between physician human resources and the overall design of the healthcare system, and the need for policies that reflect this link.22–24 As such, policies should reflect the need to continually renew the surgical workforce by ensuring that surgeons of all career stages have the opportunity to operate.20 Beyond recent graduate issues, numerous other opportunities for leadership exist in the face of difficult times. As a specialty, we will need to ensure that appropriate operating room access is maintained for ophthalmologic surgery as system changes occur. Additionally, within our specialty, we will need to continue to focus on necessary, high-value care and to do so efficiently. Thus, efforts should continue to refine indications for therapies, ensure appropriate criteria are applied when choosing interventions, and seek efficiencies without compromising safety. In the face of system constraints, the ongoing development of novel technologies requires methodical approaches to assessment and implementation. While the uptake of truly revolutionary therapies that increase the value of care should be broadly supported, the marginal costs of some innovations significantly exceed the marginal improvements in outcomes. Similarly, some technologies provide improved outcomes only for a small fraction of those patients for whom they are marketed. In addition to careful evaluation of new technologies, exploration of alternative models of healthcare delivery, in which high-quality care would be provided for all regardless of ability to pay, may be warranted while allowing alternative funding mechanisms to coexist. The 2016 Canadian eye care system bears little resemblance to that of 50 years ago, when the Canadian Journal of Ophthalmology came into existence. As ophthalmologists evolve in the types and breadth of care they provide, we will continue to become a much less homogenous specialty that faces many difficult decisions. The next 50 years will most certainly require significant efforts and strong leadership to find ways to collaboratively and efficiently provide the full spectrum of world-class eye care for all Canadians. Robert J. Campbell, MD, MSc, FRCSC,*,†,‡, Sherif R. El-Defrawy, MD, PhD, FRCSC§,‖ *
Department of Ophthalmology, Queen’s University, Kingston, Ont † Department of Ophthalmology, Hotel Dieu and Kingston General Hospitals, Kingston, Ont ‡ Institute for Clinical Evaluative Sciences, Toronto, Ont § Department of Ophthalmology, University of Toronto, Toronto, Ont ‖ Department of Ophthalmology, Kensington Eye Institute, Toronto, Ont. Correspondence to: Sherif R. El-Defrawy, MD, PhD, FRCSC: sherif.el.defrawy@ utoronto.ca
Editorial REFERENCES 1. Buhrmann R, Hodge W, Beardmore J. Foundations for a Canadian Vision Health Strategy. Toronto: The National Coalition for Vision Health; 2007. 2. Frick KD, Gower EW, Kempen JH, Wolff JL. Economic impact of visual impairment and blindness in the United States. Arch Ophthalmol. 2007;125:544. 3. Brown GC, Brown MM, Sharma S, et al. The burden of age-related macular degeneration: a value-based medicine analysis. Trans Am Ophthalmol Soc. 2005;103:173. 4. Cruess AF, Gordon KD, Bellan L, Mitchell S, Pezzullo ML. The cost of vision loss in Canada. 2. Results. Can J Ophthalmol. 2011;46:315-8. 5. Roos NP, Shanahan M, Fransoo R, Bradley JE. How many physicians does Canada need to care for our aging population? CMAJ. 1998;158:1275-84. 6. Campbell RJ, Gill S, Ten Hove M, et al. Strabismus surgical subspecialization: a population-based analysis JAMA Ophthalmol. 2015;133:555-9. 7. Campbell RJ, Bell CM, Gill SS, et al. Subspecialization in glaucoma surgery. Ophthalmology. 2012;119:2270-3. 8. Bellan L, Buske L, Wang S, Buys YM. The landscape of ophthalmologists in Canada: present and future. Can J Ophthalmol. 2013;48:160-6. 9. Bellan L, Buske L. Ophthalmology human resource projections: are we heading for a crisis in the next 15 years? Can J Ophthalmol. 2007;42:34-8. 10. Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: the relationship between clinical experience and quality of health care Ann Intern Med. 2005;142:260-73. 11. Bell CM, Hatch WV, Cernat G, Urbach DR. Surgeon volumes and selected patient outcomes in cataract surgery a population-based analysis. Ophthalmology. 2007;114:405-10. 12. Reznick RK, MacRae H. Teaching surgical skills–changes in the wind. N Eng J Med. 2006;355:2664-9. 13. O’Day DM, Wilkinson CP. Realities regarding subspecialty accreditation and certification in ophthalmology. Retina. 2010;30:537-41. 14. Competence by Design (CBD): Moving toward competency-based medical education. Ottawa, Canada: Royal College of Physicians and Surgeons of Canada; 2015 [cited 2015 Dec 14]. Available at 〈www.royalcollege.ca/portal/page/portal/rc/resources/cbme〉. 15. Zhao L, Chen XJ, Zhu J, et al. Lanosterol reverses protein aggregation in cataracts. Nature. 2015;523:607-11.
16. Makley LN, McMenimen KA, DeVree BT, et al. Pharmacological chaperone for α-crystallin partially restores transparency in cataract models. Science. 2015;350:674-7. 17. Grantcharov TP, Reznick RK. Training tomorrow’s surgeons: what are we looking for and how can we achieve it? ANZ J Surg. 2009;79:104-7. 18. Gawande AA. Creating the educated surgeon in the 21st century Am J Surg. 2001;181:551-6. 19. Roos NP, Fransoo R. How many surgeons does a province need, and how do we determine appropriate numbers? Healthc Manage Forum. 2001;14:11-5. 20. The Provincial Vision Strategy Task Force. A vision for Ontario: strategic recommendations for ophthalmology in Ontario Toronto: Ontario Ministry of Health and Long Term Care; 2013 May [cited 2015 Dec 14]. Available at 〈www.health.gov.on.ca/en/common/ ministry/publications/reports/docs/ontario_vision_strategy_report. pdf〉. 21. Frechette D, Hollenberg D, Shrichand A, Jacob C, Datta I. What’s really behind Canada’s unemployed specialists? Too many, too few doctors? Findings from the Royal College’s employment study Ottawa, Ontario: The Royal College of Physicians and Surgeons of Canada; 2013 [cited 2015 Dec 14]. Available at 〈www.royalcollege.ca/portal/ page/portal/rc/common/documents/policy/employment_re port_2013_e.pdf〉. 22. Romanow RJ. Building on values: the future of health care in Canada final report. Ottawa, Canada: Commission on the Future of Health Care in Canada; 2002 Nov [cited 2015 Dec 14]. Available at 〈www. publications.gc.ca/collections/Collection/CP32-85-2002E.pdf〉. 23. Task Force Two. A physician human resource strategy for Canada: Final report. Ottawa, Canada: Government of Canada; March 2006 [cited 2015 Dec 14]. Available at 〈www.tools.hhr-rhs.ca/index.php? option=com_mtree&task=att_download&link_id=4673&cf_ id=68&lang=en〉. 24. McKendry R. Physicians for Ontario: Too many? Too few? For 2000 and beyond Ontario, Canada: report of the fact finder on physician resources in Ontario, Ontario Ministry of Health and Long-Term Care; 1999 Dec [cited 2015 Dec 14]. Available at 〈www.health.gov.on.ca/en/common/ ministry/publications/reports/mckendry/mckendry.pdf〉. Can J Ophthalmol 2016;]:]]]–]]] 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.2016.07.022
CAN J OPHTHALMOL — VOL. ], NO. ], ] 2016
3