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Survival With Excellence: Education and the Future of Ophthalmology: XLII Edward Jackson Memorial Lecture
AMERICAN
OF
OPHTHALMOLOGY®
NUMBER 6
DECEMBER, 1985
JOURNAL
VOLUME 100
Survival With Excellence: Education and the Future of Ophthalmology XLII Edward Jackson Memorial Lecture Bruce E. Spivey, M.D.
Health care and medicine are in tremendous flux. Survival of the specialty of ophthalmology in a traditional sense is in question. Positive adaptation to our new environment must occur. A central focus of ophthalmology has always been its commitment to excellence in education. Residency education in ophthalmology is at a high level. Far more random and non-individualized education characterizes continuing education in ophthalmology and all of medicine. The fundamental approach is to base our future on personal accountability and excellence in providing consummate care. I have proposed a more systematic, individually oriented approach to continuing education in ophthalmology. A combined effort by the American Academy of Ophthalmology with other ophthalmic organizations and the individual ophthalmologist would provide individual assessment and educational programs based on practice setting and clinical emphasis. FIFTEEN BRIEF YEARS away from the beginning of a new millennium, we find our proud spe-
Accepted for publication Oct. 10, 1985. From the Department of Ophthalmology, Pacific Medical Center, San Francisco, California. Presented before the 90th Annual Meeting of the American Academy of Ophthalmology, San Francisco, California, Sept. 3D, 1985. Reprint requests to Bruce E. Spivey, M.D., Pacific Medical Center, 2340 Clay, San Francisco, CA 94115.
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cialty and our profession at a crossroad. Extraordinary influences are challenging the familiar fabric of all of medicine. And as ophthalmologists, we are probably more, certainly no less vulnerable than the rest of medicine to this dramatically changing environment. Jackson and Our Heritage In facing the future we are inextricably connected to our heritage. People personify a profession and this lecture appropriately honors one of our most important past leaders, Edward Jackson. Only a handful of people active in ophthalmology today knew or even met Edward Jackson. Yet, every ophthalmologist knows his name, primarily because we use his cross-cylinder. Others may also know that he was the driving force behind the amalgamation of five ophthalmic publications into the present AMERICAN JOURNAL OF OPHTHALMOLOGY. and that he was the principal individual responsible for forming the American Board of Ophthalmology. Fewer still know that, while he spent his early years in Philadelphia, he practiced in Denver, Colorado, where he established the oldest continuing education course in all of medicine with the Colorado Ophthalmological Society meetings. Edward Jackson was a remarkable individual and the values he subscribed to with such determination are particularly germane to our present professional dilemma. Jackson was a clinician, a clinician who cared as deeply for the ethics of his specialty as he did for its DECEMBER,
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science. He was dedicated to excellence and professional growth, a commitment I would like to champion with zeal today. I would like to reflect on the environment, excellence, education, and the future survival of ophthalmology. These thoughts are motivated by my strong personal conviction that, while these are difficult times, they are also times during which we can purposefully and positively influence our future, both individually and collectively. To do so, we must assure excellence in the care of our patients. In large measure, our journey to excellence will be furthered by a systematic and restructured approach to our ongoing education. I will offer a proposal that I believe will help us carryon the proud tradition which distinguishes our specialty. The premise for this proposal follows: In medicine and in ophthalmology, we are experiencing a time of unprecedented and profound change. Our practices, the perception of the public toward us, our clinical and nonclinical educational needs, and, possibly most important, our perception of ourselves will be modified forever. Ophthalmology as a specialty and each ophthalmologist can meet the challenges by desiring and rigorously pursuing excellence as a common goal. The best means we have to ensure excellence in our individual and collective performance is through our own ongoing education and our personal accountability in applying what we know and are able to do. With this, we will survive and thrive. It is important to note that personal accountability is a backbone of this premise. When I use this term, I am referring to a certain type of trustworthiness and responsibility to perform at the full extent of our capabilities. An important aspect of this personal accountability is the knowledge that in today's world individual actions can have significant implications for the future and for society. Thus, our actions must always be guided by a consideration of their long-term consequences for the society as a whole. We will gain credibility in our own eyes and in the eyes of others. The significance of personal accountability for each of us as ophthalmologists will become clearer as we explore three separate areas: our changing environment, our conception of excellence, and our education and the new demands on it.
December, 1985
Our Changing Environment I believe we are in the midst of the greatest transition ever in American medicine. We are at the edge of a new society in which the structure and practice of medicine will be fundamentally altered. The Past There is no doubt that since the end of World War II until very recently we, as physicians and ophthalmologists, enjoyed a golden era. During this era, we were privileged to practice in a specialty with high standards, and to have access to highly respected educational programs. Our ability to help our patients increased dramatically as significant advances were made in the science of ophthalmology. Our practice opportunities were abundant, as were our incomes. During this era, the need for well-trained, qualified physicians, both generalists and specialists, continued to grow. Private practice opportunities or academic positions existed in every part of our country. Competition, although certainly present, was based on performance and personality. The relationship between patient and physician was direct and personal. Together, physicians and patients made decisions about the course of care without, or with little, interference and intervention from outside parties. Gimmicks and questionable indications for surgery existed but did not dominate. Of course, every specialty, including ophthalmology, had its self-serving opportunists, but these were the exception rather than the rule. Individual needs for continuing education seemed relatively easy to identify and meet. Discussions at meetings reflected the primary emphases and concerns of the day, namely clinical advances. This was truly a golden era, an era in which the high standards of excellence were easily understood and generally upheld. In retrospect, this time seems to have been a much simpler one. Our goals and roles as ophthalmologists were straightforward and what we needed to know was more easily defined and attained. The golden era did not end overnight nor did ophthalmology change in a vacuum. The moral and ethical standards of our entire society shifted dramatically in the 1960s. In the 1970s litigation for any unexpected outcome became commonplace. Specialization and subspecialization were expected. Training was at a high level.
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Group practice and use of assistants resulted in more patients being cared for per physician. A business mentality began to compete with the traditional professional mentality. Medical costs rose and thus became a target of the public and government. Advertising was legalized, even encouraged, and medicine was prevented from "policing" its own, a role it never handled well anyway. Our ability to decrease overproduction of physicians was prevented by the Federal Trade Commission and others. The "me generation" made itself felt in medicine along with a strong "anti-authority" inclination, contributing both to clinical advances and the destabilization of the traditional structure of academic medicine. The Present Today, as a specialty and as individuals, we are being bombarded with a multitude of problems; including an excess of health providers of all stripes, expensive technology and overhead; plus a profound restructuring of the health care payment system. We are being regarded by the public and by government more as a trade than as a profession. Competition for dividing the dollar within medicine is beginning to affect us in a very direct way. Arguments rage about restructuring payment for cognitive services at the expense of procedures. Competition within the specialty is becoming uglier, less motivated by noble goals. Now, either by ignorance or avarice, a number of our own are bringing discredit to our specialty and spoiling our reputation through a lack of personal responsibility or accountability for their actions. This is not going unnoticed by the government, our colleagues in medicine, the media, and the public. We are doing damage to ourselves at the same time that outside forces are impinging on us. Ethical standards are, today, the biggest single controversy within ophthalmology. I have the opportunity daily to hear the compliments and complaints about our specialty and the individuals in it. We have a problem, as does all of medicine. Competition from optometry is likewise becoming more fierce, more time-consuming, and emotionally enervating. In ophthalmology, private practice opportunities and academic positions are extremely limited. The responsibility for and, thus, control of decisions on physician selection and patient management are shifting to the insurance companies, to the government, to corporations, and to other outside parties. Gimmicks and overaggressive in-
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dications for surgery seem to abound. The need to know about economic issues in addition to scientific and clinical concerns is drastically intensifying. When physicians gather, they now seem to discuss Competitive Medical Plans, Health Maintenance Organizations, sites for outpatient surgery centers, and contracts along with how to do the latest remunerative procedure. The Future If these trends continue, what will our future be like? Traditional referral lines will be disrupted forever. Groups of physicians will be in even more tense competition with other groups of physicians. Ophthalmology as we have known it will not be the same. At the same time, however, the future will bring more advances in the science of ophthalmology and, as a result, improve our capability to treat our patients and even prevent problems (such as cataracts). Pressures to keep up with the latest advances as well as to understand unfamiliar socioeconomic areas will intensify. Implications To adapt to this changing environment and reverse a negative trend, it is my deeply held conviction that as a specialty and as individual ophthalmologists, we must examine our basic values, explore and build on our strengths, and focus on what represents the best in ophthalmology. I believe our most basic value as physicians and as ophthalmologists centers on providing the best possible care for our patientspreserving or restoring their sight. We are recognized by our physician colleagues as having the essential knowledge and skills to provide the best and most comprehensive care of the eye and its related structures. What we know and can do, and how we apply this knowledge and these skills set us apart from our nonophthalmologic physician colleagues and from others who may deal with the eye and visual system. We must also recognize that there are some things we can control and some that we cannot. We must spend most of our time and energy on those aspects we can control directly such as our education and our care of patients. We must recognize that when elements are outside our control, we do have power over how well we adapt to them. Although not speaking to this directly, Jackson in 1914 had what I believe to be the correct and realistic approach when he
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wrote: "Any remedy for the present state of affairs with regard to ophthalmology must be found entirely outside of legal requirements and inside the profession.... " 1 While we look to the future, we must also acknowledge that our generation is beginning to learn a profound lesson, that of personal accountability. The actions we take daily have long-term consequences, many of which are not fully understood. Each of us must ensure that we maintain the delicate balance between innovation and exploitation by accepting personal accountability for our behavior. It seems almost incomprehensible that there should be any question about our specialty surviving-let alone any question of its excellence. Yet in the minds of many, including myself, the changes in health care today and in the forseeable future legitimize the question of whether we can survive in some reasonable semblance of what ophthalmology has been until now. When you think about this even for a short time it becomes clear that the best way to survive as a profession is for each of us to commit to a goal of excellence.
Excellence Excellence is a frequently heard term these days and clearly has different meanings to different individuals. In thinking about excellence, I have been particularly influenced by John W. Gardner's book Excellence: Can We Be Equal and Excellent Too? 2 Gardner points out that there are different types of excellence: individual, societal, professional, intellectual, technical, managerial, and ethical. For each of these, there is a "need for high standards of performance." In defining these standards, there needs to be a balance between the needs of society and the goals of individuals. Gardner also emphasizes the close relationship of excellence, individual fulfillment, and education. He suggests that education, broadly conceived, is the "chief instrument we have devised to further the ideal of individual fulfillment." How does this apply to ophthalmology? As I noted earlier, I believe excellence is tied to ophthalmology's most fundamental and noble goal, the specialty's reason for being, which is the preservation or restoration of sight. How well we achieve this goal is the hallmark of our
excellence. It is the primary effort for which we must be personally accountable. As ophthalmologists, we must determine standards for all levels of our professional performance, both as individuals and as a group. This goal might include, for example, a definition of excellence in the physician-patient relationship in which each of us commits to having our patients leave each encounter with full knowledge of the diagnosis, delivering or planning appropriate care, and understanding of what the situation is now and for the future. The Academy's Code of Ethics is another example of a set of standards, one that only takes on meaning when it is supported by our profession as a whole. By explicitly considering and committing to lofty ideals at all levels and by establishing standards to guide our actions we will have a greater chance of improving the "tone and fiber" of our specialty. As Gardner states "We cannot have islands of excellence in a sea of slovenly indifference to standards." Excellence is not new to ophthalmology and has been demonstrated repeatedly throughout ophthalmology's history in the United States. Establishing the first specialty society in the United States of America helped expand the science of ophthalmology and infuse new discoveries and advances into ophthalmic practice. Over 120 years ago, ophthalmology (through the American Ophthalmological Society) began to set standards that helped distinguish the highly qualified from the less qualified practitioners of ophthalmology. As I mentioned previously, Edward Jackson and other leaders during the first part of this century vigorously pursued excellence in education. Requirements for residency training programs were set and standardized through the institution of the first certifying examination. Today, the Academy's Code of Ethics, the high standards of ophthalmic training programs, and even our National Eye Care Project, I believe, demonstrate our continued striving for excellence.
Education Today we are brought together and bound by our identity as ophthalmologists. Although many of us do very different things day to day, common terminology, educational experiences, problems, and opportunities link us today and in the future.
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We have acquired our unique relationship through education and practice. Education is the foundation upon which we have built our competence. Without competence, we cannot expect to join the rest of medicine and to be treated as vital and desirable colleagues. Does our education give us what we need to deliver the best possible eye care? If one looked only at the quality and level of ophthalmic education in this country, which is the highest in the world, the answer would be "yes." On average, we produce the best trained ophthalmologists in the world. Indeed, we train people to do things they rarely if ever will do after their training. Our residency education and training programs are superior. Our continuing education courses are plethoric. Our Academy educational programs and offerings are among the finest if not the finest in medicine. On the surface, then, it would seem that our educational system deserves commendation. But is this truly the case? I would say yes when it comes to basic and clinical education during our years of formal training, but would have to add that I have serious reservations about the adequacy of our current continuing education system. That is not to say that I would question the excellence of many current continuing education offerings. Fine programs of continuing education abound. What I am questioning here is the system of continuing education, and what I would maintain is that the system requires significant reshaping and new emphases before it will really serve our individual needs. I suspect many of you may have harbored similar unspoken feelings. This somewhat negative sentiment can be explained by examining how well our educational system educates us in the science and art of ophthalmology, from two perspectives: the goal of our educational system and the process of that education.
Education's Goal The goal of our medical educational system is to educate and train individuals so that they are qualified to practice both the science and the art of medicine. What do I mean by qualified? Qualified physicians are most often described as "competent." The concept of physician competence, however, is complex. It includes more than just the physician's mastery of knowledge and skills. The physician's attitude and the manner in which he or she applies knowledge and skills to patient care also are components of compe-
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tence. I expect most of us are technically competent. I do not believe, however, that technical competence is an adequate goal since it suggests only satisfactory, not consummate ability. As such, competence is uninspiring and unmotivating. For these reasons, I have chosen to use the phrase "consummate ability" to describe a higher level of achievement in both the science and the art of medicine. This achievement of "consummate ability" in the practice of the science and the art of medicine is education's goal. The distinction between science and art in medicine also is an important one, far too often overlooked in discussions of education. William C. Felch, Sr., M.D., Executive Director of Alliance for Continuing Medical Education, has explained this distinction in an especially enlightening way. Science, in Felch's words "deals with the advance of knowledge, especially with matters that are quantifiable with some precision." In my mind, science would include the translation of scientific advances into technical skills as well. Art, on the other hand, is equated with attitude and "refers to matters that are difficult to quantify. It deals with intangibles and imponderables, often the so-called 'human factors' that are part of the doctor/patient relationship-such things as trust, confidence, caring," to which I would add ethical considerations. Our educational system is far more successful in teaching the science of medical practice than it is at cultivating the art of medicine. We must put far greater emphasis on the selection process of those entering medicine and ophthalmology. Gradepoint averages and achievement tests do not relate directly to humanistic and ethical performance.
Educational Process From premedical and medical school through internship and residency training, and even in fellowship training, our lives are sheltered. Expectations are fairly well defined and the realities of practicing in a highly competitive, complicated environment have not yet been confronted. The knowledge and the skills we need are relatively prescribed and the educational programs well structured. Most training programs use the Academy's Basic and Clinical Science Course as an outline for the curriculum for residents. The Basic and Clinical Science Course, however, does not include in its curriculum the acquisition of technical skills, the
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other component of the "science" of ophthalmology. It also does not instruct in the art of ophthalmic practice. The faculty of the training programs, however, usually identify, in large measure, what technical skills the resident must acquire. Similarly, most faculty members serve as role models for the humanistic side of patient care. As role models, faculty members have the responsibility to practice the "art" of medicine ethically and to convey this by example. Evaluation of a resident's capability also is conducted by the faculty. Through its review and personal interchange, the faculty can generally assess whether the resident has acquired the skills and knowledge necessary to meet the expectations set by the faculty or training program. The faculty also can help residents identify and master knowledge and skills in areas in which they may be weak. In sum, in our training years, we are essentially forced to be accountable by virtue of the well defined goals and structure of our training programs. Expectations are clearly laid out and there are guideposts along the way through which we and others judge our progress. While each individual must have an internal commitment to carry out the hard work of residency education, it is really the training programs themselves that dictate the specifics of one's educational experience. We are never really taught to be self-reliant learners. Once in practice, huge changes occur. The ophthalmologist is faced with new demands and competition. The ophthalmologist must manage a practice and be a physician as well. Education and learning continue but in a far less structured, serendipitous way. Through active participation in continuing education activities, physicians in general and ophthalmologists in particular have demonstrated a strong desire to continue their education. However, most ophthalmologists, I expect, feel very uncertain, and even confused, about how to structure effectively the limited time they have available to devote to continuing education. During our practice years, we are faced with a fundamental issue-what do we need to know and be able to do? Those of us trained over 20 years ago do very little in the same manner and with the same instruments our teachers taught us to use. Ophthalmology and its subspecialty areas have experienced phenomenal and rapid advances. Therefore, it is
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difficult to know, for example, how much neuro-ophthalmology one should and does know. Certainly, courses could be taken in this and other areas where there have been recent advances. But, this seems to be a rather haphazard and, perhaps, ineffectual approach. Jackson, in 1912, expressed similar sentiments in discussions about teaching ophthalmology in medical schools: Ophthalmology is a field broad enough to claim all the time and energy that can be given to it by any trained mind. Proper preparation for ophthalmic practice requires long, systematic and thorough training as preparation for any other profession. Such professional training should be systematic and carried on by responsible institutions, working up to a recognized standard."
This raises the issue of standards. For the past 45 years or longer, a certificate from the American Board of Ophthalmology has been the basic standard of educational preparation for ophthalmologists in the United States. As formulated, the examination is not intended to evaluate "consummate ability." It is strongest at measuring knowledge, gives some limited sense of skills acquisition, and pays almost no attention to the art of medicine. Certification does not ensure ability, nor does it ensure continuing ability since it only samples cognitive areas soon after training. Nor does the lack of certification indicate a lack of ability. Nevertheless, I think it can be argued that board certification does, at the very least, begin to suggest a standard for practice. The examination ensures at least a minimal mastery of cognitive material pertinent to the practice of ophthalmology. But, for practicing clinicians, there is no objective mechanism for evaluating our performance. Once in practice, through close interaction with colleagues, each of us has a gauge of how we stand, especially in the area of surgical skills. Such interaction is informal, unstructured, and not based on agreed upon standards. In addition, neither solo practitioners nor the most academic subspecialists can comprehensively evaluate their skills and knowledge across the breadth of ophthalmology. From the time we enter our specialty, we also become further removed from the rest of medicine and begin to limit or reduce our educational needs in other areas of medicine. Likewise, if we subspecialize, we begin to limit our educa-
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tional needs in general and in other subspecialty areas in ophthalmology. Most of us decide what we will not know by failing to keep up in all areas. Yet, these areas continue to exist, and we have no satisfactory, systematic means of knowing and evaluating what we need to know in them. To add a personal note, I have never felt really satisfied by my own continuing education efforts, and I believe this is the case with most of us. Yes, I have attended wonderful meetings, and have learned something at nearly every turn-be it a journal, rounds, or just talking with colleagues. All the same, I cannot begin to equate the satisfaction of my four years of residency to my 20 plus years since. Some of that satisfaction during residency came from the excitement of exposure to a new field, the awe of new things, and the pleasure derived from learning rapidly with a group of close friends and colleagues. I also believe the learning experience found in residency was positive because of three things: I knew better what I needed to know; I was able to judge my progress and proficiency against others; and I was able to judge my efforts toward excellence in a far more tangible way than I have since entering practice. If this mirrors your beliefs, we should work hard as individuals and as an Academy to help ourselves pursue excellence. At this point I want to insert a disclaimer. I am not leading up to the issue of recertification! There was a time (and it may occur again) when heightened consumerism and societal demand were pushing for recertification. No good method, however, has been found for recertification and one may never be found. No single test or evaluation can adequately judge the tremendous diversity of practice that exists in each specialty of medicine and certainly in ours. That is not to say, however, that we are not in need of tools to help us maintain personal accountability for our ongoing education. Because we are so accustomed to being educated in a structured environment, becoming selfreliant for one's education is often far more difficult than might be expected.
Environment, Excellence, and Education The integration of the three areas-our changing environment, our concept of excel-
lence, and our individual continuing education -form the basis for the premise of this presentation. How do these three areas tie together and what do they imply for the future of ophthalmology? We cannot expect to practice ophthalmology in a near-vacuum, focusing only on the science of ophthalmology. Education is the only area where we can individually and collectively gain control over our actions and, thus, our fate. We must expand our definition of education, especially of continuing education. Our changing environment has made education in nonclinical and socioeconomic areas such as management, contracting and negotiating skills, prepaid health systems, business ethics, public relations, or advocacy crucial. Since our time for continuing education away from our offices will become even more limited, we must identify what it is we need to know based on our current practice situation, patient mix, subspecialty, and other factors that will affect our new needs for knowledge. We will have to choose educational experiences that will offer us the most effective means of acquiring the new knowledge or skills. We will have to have an effective mechanism for self-assessment so that we can identify deficits in our capabilities. Education is not now, nor will it ever be, a panacea for all our ills. It must be seen, however, as the primary mechanism through which we, as individuals and as a specialty, can respond positively to and even seize the initiative in our changing environment.
Proposal I would like to offer the following proposal for your consideration as a mandate for action. I have divided this proposal into two interrelated sections: actions for the American Academy of Ophthalmology and other interested ophthalmic organizations and actions for the individual ophthalmologist. Before turning to the proposal, I would like to outline several key assumptions upon which it is based. Most of us: 1. Chose our profession because it would provide us with a sense of individual fulfillment through intellectual, humanitarian, and economic achievements;
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2. Share the same noble goal: to preserve or restore sight; 3. Strive to practice ophthalmology at a COnsummate level of ability; 4. Realize and experience the difficulty, even impossibility, of maintaining excellence across the breadth of ophthalmology, given the myriad of scientific, clinical, and socioeconomic knowledge that must be assimilated to become consummate in all areas. 5. Strive to be personally accountable for our education and. actions, but find it increasingly difficult to achieve. Only those who have accepted personal accountability for their own growth and actions will pursue it. As professionals, we need and deserve to be supported by organizations that foster a climate of excellence; excellence being a journey, not a destination. I speak as an individual ophthalmologist and Fellow of the American Academy of Ophthalmology. The following suggestions framed as actions are my personal desires at this time and do not reflect, in any way, Academy policy. Organizational Actions First, I propose that the American Academy of Ophthalmology, in conjunction with other interested ophthalmic organizations and in close consultation with practicing ophthalmologists, establish curriculum content for continuing education that will accommodate the individual needs of each ophthalmologist. Under the aegis of the Academy, I envision that curricula designed to assist the individual ophthalmologist in planning a systematic approach to his or her continuing education would be developed. The curricula would cover socioeconomic areas in addition to clinical knowledge and skills. The curricula would only guide the ophthalmologist, based on his or her unique needs, to identify what education in which area is needed to achieve consummate ability. Overall excellence based on acquiring or maintaining different levels of knowledge or skills can be reached based on individual practice needs and settings. Since it is impossible to keep up with all aspects of a specialty, the curricula also would help us decide what we will not do and thus what we will not learn. We must recognize our deficiencies in both specific and broad areas and act to correct them. We must be willing to refer clinical problems in our areas of deficien-
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cy to those who have these as strengths. Otherwise, we undermine our own excellence. This must be done despite the barriers to referral. For example, new payment mechanisms are barriers that will produce an economic incentive to keep rather than refer patients. Second, I propose that the Academy develop and make available for use on a periodic basis a mechanism for self-assessment so that each ophthalmologist can determine his or her level of ability depending on individual standards in various areas. The self-assessment mechanism would be sensitive to the variety of settings in which we practice (rural vs urban, solo vs group, salaried vs fee for service, generalist vs subspecialist) and our various clinical emphases in practice. Sound educational principles with immediate feedback mechanisms would serve as the basis for the self-assessment method. Third, I propose that the Academy, in conjunction with other interested ophthalmic organizations, provide formal educational mechanisms for helping ophthalmologists acquire new skills, such as new diagnostic and surgical techniques, as well as marketing, managerial, financial, contracting, and negotiating techniques. Self-assessment and individualized learning tools would also be provided. The Academy's traditional role in ophthalmic continuing education has focused on the acquisition of clinical knowledge needed for direct application to patient care. This role, however, has been changing as evidenced by the existence of and growing attendance at our Annual Meeting instruction courses on ethical, legislative, and practice management issues. Fourth, I propose that the Academy implement and make available educational programs using new learning modalities that optimize learning in the office or home. As direct and indirect costs of travel increase, the demand and the need for new technologies for learning at home or in the office will grow. Computers, interactive videodiscs, and other new modalities may not be attractive to everyone but their acceptance and desirability will undoubtedly increase as those more familiar with these technologies enter practice. Individual Actions Many of us have been doing in varying degrees for years what I am about to recommend as actions for each ophthalmologist to consider. Thus, they may seem to be apple-pie and
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motherhood suggestions. The difference, however, is in the intensity of commitment necessary and the comprehensive and systematic approach recommended. Each of us should spend time pondering two important questions before commiting to any action. First, what will be the effects of the dramatic changes in our environment on the standards and concepts of excellence held by our patients, by medicine, and by our specialty of ophthalmology? Change will always be present. The pace and magnitude of change in decades past was slow and more predictable. Today, changes are occurring with unprecedented speed and revolutionary ramifications. We must concentrate our energies on determining and pursuing our own standards of performance, our roles, and our concept of excellence. Second, what are our personal standards of excellence? When we decide what they are, we will be in a far better position to control and meet the challenges ahead of us. Our personal standards must be developed within the constraints and limits of the "greater good" and, therefore, must not be even marginally unethical. I propose, first, that each of us as ophthalmologists commit to strive for consummate ability (and behavior) in all aspects of our professional life. We can only consider the future in the light of our continuing commitment to excellence. Our tradition, our values, and our patients deserve and require nothing less. The opportunity to choose volume over quality or actively to undermine colleagues will be present as never before. The relationship each of us has with our specialty is critical. The naive or intentionally inappropriate behavior of one of us reflects on all of us. Second, I propose that each of us approach our continuing education in a planned, systematic, and committed way, aided by the Academy and other ophthalmic organizations. As I have stated, the Academy would provide a series of self-assessment and educational packages appropriate for each of us in our individual situations. The process of systematically reviewing our own needs and working in an organized, planned manner to address them will be contrary to most of our styles. Physicians seem to pick certain continuing educational offerings on the basis of real interest or need, and others on the basis of geography,
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advertising, or personal quirk. We can do better than we have. In a symbiotic activity, the Academy through its fellows and members can make individual learning more appropriate and even exciting. I am certain the self-fulfillment that is possible in enhancing our own education will have extremely positive results for our patients and ophthalmology. This proposal represents, I believe, another major evolutionary step in the continuum of our education and training, not dissimilar from that which evolved in our residency programs. The Academy and other ophthalmic societies must develop a continuously evolving, lifetime program of education, dedicated to our self-development and based on our individual needs and practice demands. With it, we will be better able to judge our ability and, in a systematic way, achieve consummate ability. Anything less is unacceptable. Our patients will be better for it. We will feel better about ourselves. And although not the only motivator, our competitive advantage will be dramatically improved. We can achieve this for ourselves by our own action. We will be perceived as the best, because we will be. Implementing this proposal will be a massive undertaking that will take years of strenuous effort. I expect there will be more active participation and sharing than has ever existed before. Knowing first hand the tremendous reservoir of talent and energy that exists in ophthalmology, I am confident we can develop the programs suggested in this proposal. I have learned and intuited the precepts contained in this paper from many teachers, especially Herman Burian, Alson Braley, Frederick Blodi, and George Miller. Two colleagues, Suzanne Quick and Lea Gamble, were extremely instrumental in its evolution and contributed significantly to its content and clarity. Finally, I would like to make several personal remarks. I am very proud and consider myself very fortunate to be an ophthalmologist. The only position I have ever actively sought in my professional career is that of the Executive Vice President of the American Academy of Ophthalmology. I am honored to serve ophthalmology in this capacity. In this and a variety of other positions, I have had the opportunity to meet and work with all of American medicine. There are superb people in each specialty. Given this, if we were to select a random group of ophthalmologists and a similar group from every other specialty of medicine, and then
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impartial judges were to compare intellect, compassion, dedication, personality, range of competence, and outside interests, I strongly believe that ophthalmologists would prove their excellence. Ours is the oldest specialty and, in my mind, the best. Although we have our problems from without and within, let us not lose sight of the wonderful profession we have. Let us not despair or question "is it all worth it?" Let us work together to maintain and enhance our positives and strive to reduce our negatives. We share a noble goal: to preserve or restore sight. We have a marvelous capability and with that a deep responsibility. We must survive with excellence.
References 1. Jackson, E.: Report of the Committee on Education in Ophthalmology. In Transactions of the Section on Ophthalmology. 65th Annual Session. Chicago, American Medical Association, 1914, pp. 395-406. 2. Gardner, J. W.: Excellence. Can We Be Equal and Excellent Too?New York, Harper and Row, 1961, pp. 127-157. 3. Jackson, E.: The proper provision for teaching ophthalmology in the medical schools. In Transactions of the Section on Ophthalmology. 63rd Annual Session. Chicago, American Medical Association, 1912, pp. 255-273.
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OPHTHALMOLOGY®
NUMBER 6
DECEMBER, 1985
JOURNAL
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Survival With Excellence: Education and the Future of Ophthalmology XLII Edward Jackson Memorial Lecture Bruce E. Spivey, M.D.
Health care and medicine are in tremendous flux. Survival of the specialty of ophthalmology in a traditional sense is in question. Positive adaptation to our new environment must occur. A central focus of ophthalmology has always been its commitment to excellence in education. Residency education in ophthalmology is at a high level. Far more random and non-individualized education characterizes continuing education in ophthalmology and all of medicine. The fundamental approach is to base our future on personal accountability and excellence in providing consummate care. I have proposed a more systematic, individually oriented approach to continuing education in ophthalmology. A combined effort by the American Academy of Ophthalmology with other ophthalmic organizations and the individual ophthalmologist would provide individual assessment and educational programs based on practice setting and clinical emphasis. FIFTEEN BRIEF YEARS away from the beginning of a new millennium, we find our proud spe-
Accepted for publication Oct. 10, 1985. From the Department of Ophthalmology, Pacific Medical Center, San Francisco, California. Presented before the 90th Annual Meeting of the American Academy of Ophthalmology, San Francisco, California, Sept. 3D, 1985. Reprint requests to Bruce E. Spivey, M.D., Pacific Medical Center, 2340 Clay, San Francisco, CA 94115.
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cialty and our profession at a crossroad. Extraordinary influences are challenging the familiar fabric of all of medicine. And as ophthalmologists, we are probably more, certainly no less vulnerable than the rest of medicine to this dramatically changing environment. Jackson and Our Heritage In facing the future we are inextricably connected to our heritage. People personify a profession and this lecture appropriately honors one of our most important past leaders, Edward Jackson. Only a handful of people active in ophthalmology today knew or even met Edward Jackson. Yet, every ophthalmologist knows his name, primarily because we use his cross-cylinder. Others may also know that he was the driving force behind the amalgamation of five ophthalmic publications into the present AMERICAN JOURNAL OF OPHTHALMOLOGY. and that he was the principal individual responsible for forming the American Board of Ophthalmology. Fewer still know that, while he spent his early years in Philadelphia, he practiced in Denver, Colorado, where he established the oldest continuing education course in all of medicine with the Colorado Ophthalmological Society meetings. Edward Jackson was a remarkable individual and the values he subscribed to with such determination are particularly germane to our present professional dilemma. Jackson was a clinician, a clinician who cared as deeply for the ethics of his specialty as he did for its DECEMBER,
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science. He was dedicated to excellence and professional growth, a commitment I would like to champion with zeal today. I would like to reflect on the environment, excellence, education, and the future survival of ophthalmology. These thoughts are motivated by my strong personal conviction that, while these are difficult times, they are also times during which we can purposefully and positively influence our future, both individually and collectively. To do so, we must assure excellence in the care of our patients. In large measure, our journey to excellence will be furthered by a systematic and restructured approach to our ongoing education. I will offer a proposal that I believe will help us carryon the proud tradition which distinguishes our specialty. The premise for this proposal follows: In medicine and in ophthalmology, we are experiencing a time of unprecedented and profound change. Our practices, the perception of the public toward us, our clinical and nonclinical educational needs, and, possibly most important, our perception of ourselves will be modified forever. Ophthalmology as a specialty and each ophthalmologist can meet the challenges by desiring and rigorously pursuing excellence as a common goal. The best means we have to ensure excellence in our individual and collective performance is through our own ongoing education and our personal accountability in applying what we know and are able to do. With this, we will survive and thrive. It is important to note that personal accountability is a backbone of this premise. When I use this term, I am referring to a certain type of trustworthiness and responsibility to perform at the full extent of our capabilities. An important aspect of this personal accountability is the knowledge that in today's world individual actions can have significant implications for the future and for society. Thus, our actions must always be guided by a consideration of their long-term consequences for the society as a whole. We will gain credibility in our own eyes and in the eyes of others. The significance of personal accountability for each of us as ophthalmologists will become clearer as we explore three separate areas: our changing environment, our conception of excellence, and our education and the new demands on it.
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Our Changing Environment I believe we are in the midst of the greatest transition ever in American medicine. We are at the edge of a new society in which the structure and practice of medicine will be fundamentally altered. The Past There is no doubt that since the end of World War II until very recently we, as physicians and ophthalmologists, enjoyed a golden era. During this era, we were privileged to practice in a specialty with high standards, and to have access to highly respected educational programs. Our ability to help our patients increased dramatically as significant advances were made in the science of ophthalmology. Our practice opportunities were abundant, as were our incomes. During this era, the need for well-trained, qualified physicians, both generalists and specialists, continued to grow. Private practice opportunities or academic positions existed in every part of our country. Competition, although certainly present, was based on performance and personality. The relationship between patient and physician was direct and personal. Together, physicians and patients made decisions about the course of care without, or with little, interference and intervention from outside parties. Gimmicks and questionable indications for surgery existed but did not dominate. Of course, every specialty, including ophthalmology, had its self-serving opportunists, but these were the exception rather than the rule. Individual needs for continuing education seemed relatively easy to identify and meet. Discussions at meetings reflected the primary emphases and concerns of the day, namely clinical advances. This was truly a golden era, an era in which the high standards of excellence were easily understood and generally upheld. In retrospect, this time seems to have been a much simpler one. Our goals and roles as ophthalmologists were straightforward and what we needed to know was more easily defined and attained. The golden era did not end overnight nor did ophthalmology change in a vacuum. The moral and ethical standards of our entire society shifted dramatically in the 1960s. In the 1970s litigation for any unexpected outcome became commonplace. Specialization and subspecialization were expected. Training was at a high level.
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Group practice and use of assistants resulted in more patients being cared for per physician. A business mentality began to compete with the traditional professional mentality. Medical costs rose and thus became a target of the public and government. Advertising was legalized, even encouraged, and medicine was prevented from "policing" its own, a role it never handled well anyway. Our ability to decrease overproduction of physicians was prevented by the Federal Trade Commission and others. The "me generation" made itself felt in medicine along with a strong "anti-authority" inclination, contributing both to clinical advances and the destabilization of the traditional structure of academic medicine. The Present Today, as a specialty and as individuals, we are being bombarded with a multitude of problems; including an excess of health providers of all stripes, expensive technology and overhead; plus a profound restructuring of the health care payment system. We are being regarded by the public and by government more as a trade than as a profession. Competition for dividing the dollar within medicine is beginning to affect us in a very direct way. Arguments rage about restructuring payment for cognitive services at the expense of procedures. Competition within the specialty is becoming uglier, less motivated by noble goals. Now, either by ignorance or avarice, a number of our own are bringing discredit to our specialty and spoiling our reputation through a lack of personal responsibility or accountability for their actions. This is not going unnoticed by the government, our colleagues in medicine, the media, and the public. We are doing damage to ourselves at the same time that outside forces are impinging on us. Ethical standards are, today, the biggest single controversy within ophthalmology. I have the opportunity daily to hear the compliments and complaints about our specialty and the individuals in it. We have a problem, as does all of medicine. Competition from optometry is likewise becoming more fierce, more time-consuming, and emotionally enervating. In ophthalmology, private practice opportunities and academic positions are extremely limited. The responsibility for and, thus, control of decisions on physician selection and patient management are shifting to the insurance companies, to the government, to corporations, and to other outside parties. Gimmicks and overaggressive in-
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dications for surgery seem to abound. The need to know about economic issues in addition to scientific and clinical concerns is drastically intensifying. When physicians gather, they now seem to discuss Competitive Medical Plans, Health Maintenance Organizations, sites for outpatient surgery centers, and contracts along with how to do the latest remunerative procedure. The Future If these trends continue, what will our future be like? Traditional referral lines will be disrupted forever. Groups of physicians will be in even more tense competition with other groups of physicians. Ophthalmology as we have known it will not be the same. At the same time, however, the future will bring more advances in the science of ophthalmology and, as a result, improve our capability to treat our patients and even prevent problems (such as cataracts). Pressures to keep up with the latest advances as well as to understand unfamiliar socioeconomic areas will intensify. Implications To adapt to this changing environment and reverse a negative trend, it is my deeply held conviction that as a specialty and as individual ophthalmologists, we must examine our basic values, explore and build on our strengths, and focus on what represents the best in ophthalmology. I believe our most basic value as physicians and as ophthalmologists centers on providing the best possible care for our patientspreserving or restoring their sight. We are recognized by our physician colleagues as having the essential knowledge and skills to provide the best and most comprehensive care of the eye and its related structures. What we know and can do, and how we apply this knowledge and these skills set us apart from our nonophthalmologic physician colleagues and from others who may deal with the eye and visual system. We must also recognize that there are some things we can control and some that we cannot. We must spend most of our time and energy on those aspects we can control directly such as our education and our care of patients. We must recognize that when elements are outside our control, we do have power over how well we adapt to them. Although not speaking to this directly, Jackson in 1914 had what I believe to be the correct and realistic approach when he
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wrote: "Any remedy for the present state of affairs with regard to ophthalmology must be found entirely outside of legal requirements and inside the profession.... " 1 While we look to the future, we must also acknowledge that our generation is beginning to learn a profound lesson, that of personal accountability. The actions we take daily have long-term consequences, many of which are not fully understood. Each of us must ensure that we maintain the delicate balance between innovation and exploitation by accepting personal accountability for our behavior. It seems almost incomprehensible that there should be any question about our specialty surviving-let alone any question of its excellence. Yet in the minds of many, including myself, the changes in health care today and in the forseeable future legitimize the question of whether we can survive in some reasonable semblance of what ophthalmology has been until now. When you think about this even for a short time it becomes clear that the best way to survive as a profession is for each of us to commit to a goal of excellence.
Excellence Excellence is a frequently heard term these days and clearly has different meanings to different individuals. In thinking about excellence, I have been particularly influenced by John W. Gardner's book Excellence: Can We Be Equal and Excellent Too? 2 Gardner points out that there are different types of excellence: individual, societal, professional, intellectual, technical, managerial, and ethical. For each of these, there is a "need for high standards of performance." In defining these standards, there needs to be a balance between the needs of society and the goals of individuals. Gardner also emphasizes the close relationship of excellence, individual fulfillment, and education. He suggests that education, broadly conceived, is the "chief instrument we have devised to further the ideal of individual fulfillment." How does this apply to ophthalmology? As I noted earlier, I believe excellence is tied to ophthalmology's most fundamental and noble goal, the specialty's reason for being, which is the preservation or restoration of sight. How well we achieve this goal is the hallmark of our
excellence. It is the primary effort for which we must be personally accountable. As ophthalmologists, we must determine standards for all levels of our professional performance, both as individuals and as a group. This goal might include, for example, a definition of excellence in the physician-patient relationship in which each of us commits to having our patients leave each encounter with full knowledge of the diagnosis, delivering or planning appropriate care, and understanding of what the situation is now and for the future. The Academy's Code of Ethics is another example of a set of standards, one that only takes on meaning when it is supported by our profession as a whole. By explicitly considering and committing to lofty ideals at all levels and by establishing standards to guide our actions we will have a greater chance of improving the "tone and fiber" of our specialty. As Gardner states "We cannot have islands of excellence in a sea of slovenly indifference to standards." Excellence is not new to ophthalmology and has been demonstrated repeatedly throughout ophthalmology's history in the United States. Establishing the first specialty society in the United States of America helped expand the science of ophthalmology and infuse new discoveries and advances into ophthalmic practice. Over 120 years ago, ophthalmology (through the American Ophthalmological Society) began to set standards that helped distinguish the highly qualified from the less qualified practitioners of ophthalmology. As I mentioned previously, Edward Jackson and other leaders during the first part of this century vigorously pursued excellence in education. Requirements for residency training programs were set and standardized through the institution of the first certifying examination. Today, the Academy's Code of Ethics, the high standards of ophthalmic training programs, and even our National Eye Care Project, I believe, demonstrate our continued striving for excellence.
Education Today we are brought together and bound by our identity as ophthalmologists. Although many of us do very different things day to day, common terminology, educational experiences, problems, and opportunities link us today and in the future.
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We have acquired our unique relationship through education and practice. Education is the foundation upon which we have built our competence. Without competence, we cannot expect to join the rest of medicine and to be treated as vital and desirable colleagues. Does our education give us what we need to deliver the best possible eye care? If one looked only at the quality and level of ophthalmic education in this country, which is the highest in the world, the answer would be "yes." On average, we produce the best trained ophthalmologists in the world. Indeed, we train people to do things they rarely if ever will do after their training. Our residency education and training programs are superior. Our continuing education courses are plethoric. Our Academy educational programs and offerings are among the finest if not the finest in medicine. On the surface, then, it would seem that our educational system deserves commendation. But is this truly the case? I would say yes when it comes to basic and clinical education during our years of formal training, but would have to add that I have serious reservations about the adequacy of our current continuing education system. That is not to say that I would question the excellence of many current continuing education offerings. Fine programs of continuing education abound. What I am questioning here is the system of continuing education, and what I would maintain is that the system requires significant reshaping and new emphases before it will really serve our individual needs. I suspect many of you may have harbored similar unspoken feelings. This somewhat negative sentiment can be explained by examining how well our educational system educates us in the science and art of ophthalmology, from two perspectives: the goal of our educational system and the process of that education.
Education's Goal The goal of our medical educational system is to educate and train individuals so that they are qualified to practice both the science and the art of medicine. What do I mean by qualified? Qualified physicians are most often described as "competent." The concept of physician competence, however, is complex. It includes more than just the physician's mastery of knowledge and skills. The physician's attitude and the manner in which he or she applies knowledge and skills to patient care also are components of compe-
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tence. I expect most of us are technically competent. I do not believe, however, that technical competence is an adequate goal since it suggests only satisfactory, not consummate ability. As such, competence is uninspiring and unmotivating. For these reasons, I have chosen to use the phrase "consummate ability" to describe a higher level of achievement in both the science and the art of medicine. This achievement of "consummate ability" in the practice of the science and the art of medicine is education's goal. The distinction between science and art in medicine also is an important one, far too often overlooked in discussions of education. William C. Felch, Sr., M.D., Executive Director of Alliance for Continuing Medical Education, has explained this distinction in an especially enlightening way. Science, in Felch's words "deals with the advance of knowledge, especially with matters that are quantifiable with some precision." In my mind, science would include the translation of scientific advances into technical skills as well. Art, on the other hand, is equated with attitude and "refers to matters that are difficult to quantify. It deals with intangibles and imponderables, often the so-called 'human factors' that are part of the doctor/patient relationship-such things as trust, confidence, caring," to which I would add ethical considerations. Our educational system is far more successful in teaching the science of medical practice than it is at cultivating the art of medicine. We must put far greater emphasis on the selection process of those entering medicine and ophthalmology. Gradepoint averages and achievement tests do not relate directly to humanistic and ethical performance.
Educational Process From premedical and medical school through internship and residency training, and even in fellowship training, our lives are sheltered. Expectations are fairly well defined and the realities of practicing in a highly competitive, complicated environment have not yet been confronted. The knowledge and the skills we need are relatively prescribed and the educational programs well structured. Most training programs use the Academy's Basic and Clinical Science Course as an outline for the curriculum for residents. The Basic and Clinical Science Course, however, does not include in its curriculum the acquisition of technical skills, the
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other component of the "science" of ophthalmology. It also does not instruct in the art of ophthalmic practice. The faculty of the training programs, however, usually identify, in large measure, what technical skills the resident must acquire. Similarly, most faculty members serve as role models for the humanistic side of patient care. As role models, faculty members have the responsibility to practice the "art" of medicine ethically and to convey this by example. Evaluation of a resident's capability also is conducted by the faculty. Through its review and personal interchange, the faculty can generally assess whether the resident has acquired the skills and knowledge necessary to meet the expectations set by the faculty or training program. The faculty also can help residents identify and master knowledge and skills in areas in which they may be weak. In sum, in our training years, we are essentially forced to be accountable by virtue of the well defined goals and structure of our training programs. Expectations are clearly laid out and there are guideposts along the way through which we and others judge our progress. While each individual must have an internal commitment to carry out the hard work of residency education, it is really the training programs themselves that dictate the specifics of one's educational experience. We are never really taught to be self-reliant learners. Once in practice, huge changes occur. The ophthalmologist is faced with new demands and competition. The ophthalmologist must manage a practice and be a physician as well. Education and learning continue but in a far less structured, serendipitous way. Through active participation in continuing education activities, physicians in general and ophthalmologists in particular have demonstrated a strong desire to continue their education. However, most ophthalmologists, I expect, feel very uncertain, and even confused, about how to structure effectively the limited time they have available to devote to continuing education. During our practice years, we are faced with a fundamental issue-what do we need to know and be able to do? Those of us trained over 20 years ago do very little in the same manner and with the same instruments our teachers taught us to use. Ophthalmology and its subspecialty areas have experienced phenomenal and rapid advances. Therefore, it is
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difficult to know, for example, how much neuro-ophthalmology one should and does know. Certainly, courses could be taken in this and other areas where there have been recent advances. But, this seems to be a rather haphazard and, perhaps, ineffectual approach. Jackson, in 1912, expressed similar sentiments in discussions about teaching ophthalmology in medical schools: Ophthalmology is a field broad enough to claim all the time and energy that can be given to it by any trained mind. Proper preparation for ophthalmic practice requires long, systematic and thorough training as preparation for any other profession. Such professional training should be systematic and carried on by responsible institutions, working up to a recognized standard."
This raises the issue of standards. For the past 45 years or longer, a certificate from the American Board of Ophthalmology has been the basic standard of educational preparation for ophthalmologists in the United States. As formulated, the examination is not intended to evaluate "consummate ability." It is strongest at measuring knowledge, gives some limited sense of skills acquisition, and pays almost no attention to the art of medicine. Certification does not ensure ability, nor does it ensure continuing ability since it only samples cognitive areas soon after training. Nor does the lack of certification indicate a lack of ability. Nevertheless, I think it can be argued that board certification does, at the very least, begin to suggest a standard for practice. The examination ensures at least a minimal mastery of cognitive material pertinent to the practice of ophthalmology. But, for practicing clinicians, there is no objective mechanism for evaluating our performance. Once in practice, through close interaction with colleagues, each of us has a gauge of how we stand, especially in the area of surgical skills. Such interaction is informal, unstructured, and not based on agreed upon standards. In addition, neither solo practitioners nor the most academic subspecialists can comprehensively evaluate their skills and knowledge across the breadth of ophthalmology. From the time we enter our specialty, we also become further removed from the rest of medicine and begin to limit or reduce our educational needs in other areas of medicine. Likewise, if we subspecialize, we begin to limit our educa-
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tional needs in general and in other subspecialty areas in ophthalmology. Most of us decide what we will not know by failing to keep up in all areas. Yet, these areas continue to exist, and we have no satisfactory, systematic means of knowing and evaluating what we need to know in them. To add a personal note, I have never felt really satisfied by my own continuing education efforts, and I believe this is the case with most of us. Yes, I have attended wonderful meetings, and have learned something at nearly every turn-be it a journal, rounds, or just talking with colleagues. All the same, I cannot begin to equate the satisfaction of my four years of residency to my 20 plus years since. Some of that satisfaction during residency came from the excitement of exposure to a new field, the awe of new things, and the pleasure derived from learning rapidly with a group of close friends and colleagues. I also believe the learning experience found in residency was positive because of three things: I knew better what I needed to know; I was able to judge my progress and proficiency against others; and I was able to judge my efforts toward excellence in a far more tangible way than I have since entering practice. If this mirrors your beliefs, we should work hard as individuals and as an Academy to help ourselves pursue excellence. At this point I want to insert a disclaimer. I am not leading up to the issue of recertification! There was a time (and it may occur again) when heightened consumerism and societal demand were pushing for recertification. No good method, however, has been found for recertification and one may never be found. No single test or evaluation can adequately judge the tremendous diversity of practice that exists in each specialty of medicine and certainly in ours. That is not to say, however, that we are not in need of tools to help us maintain personal accountability for our ongoing education. Because we are so accustomed to being educated in a structured environment, becoming selfreliant for one's education is often far more difficult than might be expected.
Environment, Excellence, and Education The integration of the three areas-our changing environment, our concept of excel-
lence, and our individual continuing education -form the basis for the premise of this presentation. How do these three areas tie together and what do they imply for the future of ophthalmology? We cannot expect to practice ophthalmology in a near-vacuum, focusing only on the science of ophthalmology. Education is the only area where we can individually and collectively gain control over our actions and, thus, our fate. We must expand our definition of education, especially of continuing education. Our changing environment has made education in nonclinical and socioeconomic areas such as management, contracting and negotiating skills, prepaid health systems, business ethics, public relations, or advocacy crucial. Since our time for continuing education away from our offices will become even more limited, we must identify what it is we need to know based on our current practice situation, patient mix, subspecialty, and other factors that will affect our new needs for knowledge. We will have to choose educational experiences that will offer us the most effective means of acquiring the new knowledge or skills. We will have to have an effective mechanism for self-assessment so that we can identify deficits in our capabilities. Education is not now, nor will it ever be, a panacea for all our ills. It must be seen, however, as the primary mechanism through which we, as individuals and as a specialty, can respond positively to and even seize the initiative in our changing environment.
Proposal I would like to offer the following proposal for your consideration as a mandate for action. I have divided this proposal into two interrelated sections: actions for the American Academy of Ophthalmology and other interested ophthalmic organizations and actions for the individual ophthalmologist. Before turning to the proposal, I would like to outline several key assumptions upon which it is based. Most of us: 1. Chose our profession because it would provide us with a sense of individual fulfillment through intellectual, humanitarian, and economic achievements;
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2. Share the same noble goal: to preserve or restore sight; 3. Strive to practice ophthalmology at a COnsummate level of ability; 4. Realize and experience the difficulty, even impossibility, of maintaining excellence across the breadth of ophthalmology, given the myriad of scientific, clinical, and socioeconomic knowledge that must be assimilated to become consummate in all areas. 5. Strive to be personally accountable for our education and. actions, but find it increasingly difficult to achieve. Only those who have accepted personal accountability for their own growth and actions will pursue it. As professionals, we need and deserve to be supported by organizations that foster a climate of excellence; excellence being a journey, not a destination. I speak as an individual ophthalmologist and Fellow of the American Academy of Ophthalmology. The following suggestions framed as actions are my personal desires at this time and do not reflect, in any way, Academy policy. Organizational Actions First, I propose that the American Academy of Ophthalmology, in conjunction with other interested ophthalmic organizations and in close consultation with practicing ophthalmologists, establish curriculum content for continuing education that will accommodate the individual needs of each ophthalmologist. Under the aegis of the Academy, I envision that curricula designed to assist the individual ophthalmologist in planning a systematic approach to his or her continuing education would be developed. The curricula would cover socioeconomic areas in addition to clinical knowledge and skills. The curricula would only guide the ophthalmologist, based on his or her unique needs, to identify what education in which area is needed to achieve consummate ability. Overall excellence based on acquiring or maintaining different levels of knowledge or skills can be reached based on individual practice needs and settings. Since it is impossible to keep up with all aspects of a specialty, the curricula also would help us decide what we will not do and thus what we will not learn. We must recognize our deficiencies in both specific and broad areas and act to correct them. We must be willing to refer clinical problems in our areas of deficien-
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cy to those who have these as strengths. Otherwise, we undermine our own excellence. This must be done despite the barriers to referral. For example, new payment mechanisms are barriers that will produce an economic incentive to keep rather than refer patients. Second, I propose that the Academy develop and make available for use on a periodic basis a mechanism for self-assessment so that each ophthalmologist can determine his or her level of ability depending on individual standards in various areas. The self-assessment mechanism would be sensitive to the variety of settings in which we practice (rural vs urban, solo vs group, salaried vs fee for service, generalist vs subspecialist) and our various clinical emphases in practice. Sound educational principles with immediate feedback mechanisms would serve as the basis for the self-assessment method. Third, I propose that the Academy, in conjunction with other interested ophthalmic organizations, provide formal educational mechanisms for helping ophthalmologists acquire new skills, such as new diagnostic and surgical techniques, as well as marketing, managerial, financial, contracting, and negotiating techniques. Self-assessment and individualized learning tools would also be provided. The Academy's traditional role in ophthalmic continuing education has focused on the acquisition of clinical knowledge needed for direct application to patient care. This role, however, has been changing as evidenced by the existence of and growing attendance at our Annual Meeting instruction courses on ethical, legislative, and practice management issues. Fourth, I propose that the Academy implement and make available educational programs using new learning modalities that optimize learning in the office or home. As direct and indirect costs of travel increase, the demand and the need for new technologies for learning at home or in the office will grow. Computers, interactive videodiscs, and other new modalities may not be attractive to everyone but their acceptance and desirability will undoubtedly increase as those more familiar with these technologies enter practice. Individual Actions Many of us have been doing in varying degrees for years what I am about to recommend as actions for each ophthalmologist to consider. Thus, they may seem to be apple-pie and
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motherhood suggestions. The difference, however, is in the intensity of commitment necessary and the comprehensive and systematic approach recommended. Each of us should spend time pondering two important questions before commiting to any action. First, what will be the effects of the dramatic changes in our environment on the standards and concepts of excellence held by our patients, by medicine, and by our specialty of ophthalmology? Change will always be present. The pace and magnitude of change in decades past was slow and more predictable. Today, changes are occurring with unprecedented speed and revolutionary ramifications. We must concentrate our energies on determining and pursuing our own standards of performance, our roles, and our concept of excellence. Second, what are our personal standards of excellence? When we decide what they are, we will be in a far better position to control and meet the challenges ahead of us. Our personal standards must be developed within the constraints and limits of the "greater good" and, therefore, must not be even marginally unethical. I propose, first, that each of us as ophthalmologists commit to strive for consummate ability (and behavior) in all aspects of our professional life. We can only consider the future in the light of our continuing commitment to excellence. Our tradition, our values, and our patients deserve and require nothing less. The opportunity to choose volume over quality or actively to undermine colleagues will be present as never before. The relationship each of us has with our specialty is critical. The naive or intentionally inappropriate behavior of one of us reflects on all of us. Second, I propose that each of us approach our continuing education in a planned, systematic, and committed way, aided by the Academy and other ophthalmic organizations. As I have stated, the Academy would provide a series of self-assessment and educational packages appropriate for each of us in our individual situations. The process of systematically reviewing our own needs and working in an organized, planned manner to address them will be contrary to most of our styles. Physicians seem to pick certain continuing educational offerings on the basis of real interest or need, and others on the basis of geography,
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advertising, or personal quirk. We can do better than we have. In a symbiotic activity, the Academy through its fellows and members can make individual learning more appropriate and even exciting. I am certain the self-fulfillment that is possible in enhancing our own education will have extremely positive results for our patients and ophthalmology. This proposal represents, I believe, another major evolutionary step in the continuum of our education and training, not dissimilar from that which evolved in our residency programs. The Academy and other ophthalmic societies must develop a continuously evolving, lifetime program of education, dedicated to our self-development and based on our individual needs and practice demands. With it, we will be better able to judge our ability and, in a systematic way, achieve consummate ability. Anything less is unacceptable. Our patients will be better for it. We will feel better about ourselves. And although not the only motivator, our competitive advantage will be dramatically improved. We can achieve this for ourselves by our own action. We will be perceived as the best, because we will be. Implementing this proposal will be a massive undertaking that will take years of strenuous effort. I expect there will be more active participation and sharing than has ever existed before. Knowing first hand the tremendous reservoir of talent and energy that exists in ophthalmology, I am confident we can develop the programs suggested in this proposal. I have learned and intuited the precepts contained in this paper from many teachers, especially Herman Burian, Alson Braley, Frederick Blodi, and George Miller. Two colleagues, Suzanne Quick and Lea Gamble, were extremely instrumental in its evolution and contributed significantly to its content and clarity. Finally, I would like to make several personal remarks. I am very proud and consider myself very fortunate to be an ophthalmologist. The only position I have ever actively sought in my professional career is that of the Executive Vice President of the American Academy of Ophthalmology. I am honored to serve ophthalmology in this capacity. In this and a variety of other positions, I have had the opportunity to meet and work with all of American medicine. There are superb people in each specialty. Given this, if we were to select a random group of ophthalmologists and a similar group from every other specialty of medicine, and then
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impartial judges were to compare intellect, compassion, dedication, personality, range of competence, and outside interests, I strongly believe that ophthalmologists would prove their excellence. Ours is the oldest specialty and, in my mind, the best. Although we have our problems from without and within, let us not lose sight of the wonderful profession we have. Let us not despair or question "is it all worth it?" Let us work together to maintain and enhance our positives and strive to reduce our negatives. We share a noble goal: to preserve or restore sight. We have a marvelous capability and with that a deep responsibility. We must survive with excellence.
References 1. Jackson, E.: Report of the Committee on Education in Ophthalmology. In Transactions of the Section on Ophthalmology. 65th Annual Session. Chicago, American Medical Association, 1914, pp. 395-406. 2. Gardner, J. W.: Excellence. Can We Be Equal and Excellent Too?New York, Harper and Row, 1961, pp. 127-157. 3. Jackson, E.: The proper provision for teaching ophthalmology in the medical schools. In Transactions of the Section on Ophthalmology. 63rd Annual Session. Chicago, American Medical Association, 1912, pp. 255-273.