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The weight of the basic and clinical science course
Ophthalmology Volume 110, Number 8, August 2003 intervals, was performed on the logarithms. The results were displayed in the antilog scale as geometric mean IL-10 to IL-6 ratios (Fig 1). The fractions of PIOL and uveitis patients with an IL-10 to IL-6 ratio greater than 1.0 were calculated to determine the benefit of this cutoff point in disease diagnosis. For the PIOL group, the geometric mean IL-10 to IL-6 ratio was 5.23, with a 95% confidence interval of 2.13– 12.86. The geometric mean ratio for the uveitis group was 0.23, with a 95% confidence interval of 0.15– 0.36. The means significantly differed. Correct classification by the ratio greater than 1.0 cutoff rule for these patients was accomplished 74.7% of the time. The sensitivity of the cutoff rule for PIOL diagnosis was 74.3%, and the specificity was 75.0%. Because the two disease groups are complementary, these rates are reversed for diagnosis of uveitis (i.e., the sensitivity for uveitis is 75.0% and the specificity for uveitis is 74.3%). The above rates of differentiation are consistent with previous data showing that inflammatory cells produce high levels of IL-6, as seen in uveitis, whereas malignant Blymphoid cells, such as PIOL B-cells, produce IL-10. Cytokine analysis alone cannot be used to make the diagnosis of PIOL. However, in difficult “uveitis” cases where the diagnostic vitrectomy specimen is inconclusive, a vitreal IL-10 to IL-6 ratio greater than 1.0 may prompt further evaluation to distinguish uveitis from PIOL. This may spare the patient unnecessary treatment or delays for additional diagnostic procedures. LESLEY A. WOLF, BS GEORGE F. REED, PH.D RONALD R. BUGGAGE, MD ROBERT B. NUSSENBLATT, MD CHI-CHAO CHAN, MD Bethesda, Maryland References 1. Cassoux N, Merle-Beral H, Lehoang P, et al. Interleukin-10 and intraocular-central nervous system lymphoma. Ophthalmology 2001;108:426 –7. 2. Velez G, Buggage R. Interleukin-10 and intraocular-central nervous system lymphoma [letter]. Ophthalmology 2001;108: 427– 8. 3. Akpek EK, Maca SM, Christen WG, Foster CS. Elevated vitreous interleukin-10 level is not diagnostic of intraocularcentral nervous system lymphoma. Ophthalmology 1999;106: 2291–5. 4. Chan CC, Buggage RR, Nussenblatt RB. Intraocular lymphoma. Curr Opin Ophthalmol 2002;13:411– 8. 5. Buggage RR, Chan CC, Nussenblatt RB. Ocular manifestations of central nervous system lymphoma [review]. Curr Opin Oncol 2001;13:137– 42. 6. Read RW, Zamir E, Rao NA. Neoplastic masquerade syndromes [review]. Surv Ophthalmol 2002;47:81–124. 7. Tuaillon N, Chan CC. Molecular analysis of primary central nervous system and primary intraocular lymphomas [review]. Curr Mol Med 2001;1:259 –72. 8. Benjamin D, Park CD, Sharma V. Human B cell interleukin 10 [review]. Leuk Lymphoma 1994;12:205–10.
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The Weight of the Basic and Clinical Science Course Dear Editor: As clinician– educators, we have lately felt the strain of imparting a rapidly expanding clinical and surgical curriculum to ophthalmology residents. We have further felt the stress of trying to do this within the unchanging confines of a traditional 3-year residency program. We sought to analyze this issue objectively by (1) identifying an accessible and ongoing proxy for the minimum amount of ophthalmic knowledge residents are expected to absorb and (2) using this proxy to determine the rate of increase in this “required” or “core” professional knowledge base over the past decade. The American Academy of Ophthalmology produces annually a written Basic and Clinical Sciences Course (BCSC) in multiple subspecialty sections. The BCSC has been available for over 60 years. Each section is updated approximately every 3 years on a rolling schedule. We decided that an analysis of the BCSC over time could be a reasonable proxy for the rate of increase of core knowledge. Because the BCSC has maintained an identical physical format over the past decade, we used the weight of the books as the measured variable. Figure 1 graphs weight versus academic year. A nearly perfect linear relationship is observed (R ⫽ 0.974). Over the past decade, the rate of increase in essential ophthalmic basic science and clinical knowledge according to our proxy measure is in excess of 345 g/year. If we assume a linear rate of increase (slope) for all previous decades, we reach the amusing hypothetical conclusion that ophthalmic knowledge was zero in 1974. If the current trend continues, a complete set of the BCSC would weigh 16 kg (35 lb) by the year 2020, and residents may have to resort to the use of pack animals to carry their reference books to clinic. Our analysis objectively confirms our intuitive sense that the fund of knowledge that must be transmitted from teacher to student during an ophthalmology residency is relentlessly increasing. Of course, ophthalmic knowledge was not zero before 1974, which suggests that the rate of increase in the BCSC series is nonlinear and has been significantly greater in the past 10 years than in previous decades. We think that we can speak for many training program directors when we say that it is becoming increasingly difficult to compress the curriculum into a 3-year residency1,2 especially with the need now to train residents in advanced cataract and refractive surgery3 techniques. Even if the goal of the graduate is to become a general or comprehensive ophthalmologist, the basics for practice can no longer be truly mastered without supreme effort in the traditional 3 years. In his prophetic editorial, Keltner1 stated that the profession had held a “lively discussion” on the merits of a 4-year ophthalmology residency “for the last 6 years,” due to the rapid expansion of ophthalmic knowledge in “the last decade.” He is referring to the 1980s. In 1989 –1990, the BCSC weighed a mere 5440 g. Despite the continued accrual of knowledge and advances in surgical technique from
Letters to the Editor
Figure 1. Weight of the entire Basic and Clinical Sciences Course plus the master index versus time. The 1989 –1990 series was published without a master index. It is included in the figure but was not used in the calculation of the linear regression coefficient.
1990 to the present, widespread debate has lapsed and the profession has fallen into a “consensus of inertia” on the 3-year residency for several reasons. First, there is no federal funding for the adoption of 4-year programs. Second, until recently, training programs at all levels of prominence could be nearly assured of filling their ranks with the brightest medical students, who were motivated and efficient learners. Third, a substantial proportion of residents proceeded to a voluntary fourth year via a fellowship.1 The relatively recent creation of the “comprehensive” ophthalmology fellowship provides a de facto fourth year of general training. In response to the ever-enlarging BCSC, we propose the use of web-based learning to expand backwards into the internship year and possibly even into the fourth year of medical school for particularly eager future residents. Ophthalmology programs can individually or collectively develop web-based learning modules on topics that lend themselves well to independent learning and self-testing, such as optics and refraction, ocular anatomy, and ophthalmic pharmacology. Given the increasing access to high-speed internet connections and thus to streaming video, it is theoretically possible to provide some instruction in examination techniques as well. Although we feel this preresidency education should be optional, we foresee significant utiliza-
tion of well-designed materials during, for example, ophthalmology elective rotations. Although the manner in which we presented our analysis may seem lighthearted, we do not want to detract from our message that a coordinated overhaul in ophthalmic education seems urgently necessary and requires action on the part of those who lead our profession. Until then, teaching physicians should be sensitive to the increase in this socalled core or basic knowledge burden; their greatest educational service may be to prune away the accumulated years of fact from their fields so as to reveal to residents the true clinical essentials of ophthalmic practice. SANDRA M. BROWN, MD KENN A. FREEDMAN, MD Lubbock, Texas References 1. Keltner JL. Four years of ophthalmology training. Has its time come? Arch Ophthalmol 1990;108:35–7. 2. Sadun AA. The challenge of teaching ophthalmology: a Residency Review Committee perspective. Ophthalmology 2000; 107:1971–2. 3. Aaron MM, Aaberg TM. Ophthalmology resident training in refractive surgery. Am J Ophthalmol 2001;131:241–3.
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The Weight of the Basic and Clinical Science Course Dear Editor: As clinician– educators, we have lately felt the strain of imparting a rapidly expanding clinical and surgical curriculum to ophthalmology residents. We have further felt the stress of trying to do this within the unchanging confines of a traditional 3-year residency program. We sought to analyze this issue objectively by (1) identifying an accessible and ongoing proxy for the minimum amount of ophthalmic knowledge residents are expected to absorb and (2) using this proxy to determine the rate of increase in this “required” or “core” professional knowledge base over the past decade. The American Academy of Ophthalmology produces annually a written Basic and Clinical Sciences Course (BCSC) in multiple subspecialty sections. The BCSC has been available for over 60 years. Each section is updated approximately every 3 years on a rolling schedule. We decided that an analysis of the BCSC over time could be a reasonable proxy for the rate of increase of core knowledge. Because the BCSC has maintained an identical physical format over the past decade, we used the weight of the books as the measured variable. Figure 1 graphs weight versus academic year. A nearly perfect linear relationship is observed (R ⫽ 0.974). Over the past decade, the rate of increase in essential ophthalmic basic science and clinical knowledge according to our proxy measure is in excess of 345 g/year. If we assume a linear rate of increase (slope) for all previous decades, we reach the amusing hypothetical conclusion that ophthalmic knowledge was zero in 1974. If the current trend continues, a complete set of the BCSC would weigh 16 kg (35 lb) by the year 2020, and residents may have to resort to the use of pack animals to carry their reference books to clinic. Our analysis objectively confirms our intuitive sense that the fund of knowledge that must be transmitted from teacher to student during an ophthalmology residency is relentlessly increasing. Of course, ophthalmic knowledge was not zero before 1974, which suggests that the rate of increase in the BCSC series is nonlinear and has been significantly greater in the past 10 years than in previous decades. We think that we can speak for many training program directors when we say that it is becoming increasingly difficult to compress the curriculum into a 3-year residency1,2 especially with the need now to train residents in advanced cataract and refractive surgery3 techniques. Even if the goal of the graduate is to become a general or comprehensive ophthalmologist, the basics for practice can no longer be truly mastered without supreme effort in the traditional 3 years. In his prophetic editorial, Keltner1 stated that the profession had held a “lively discussion” on the merits of a 4-year ophthalmology residency “for the last 6 years,” due to the rapid expansion of ophthalmic knowledge in “the last decade.” He is referring to the 1980s. In 1989 –1990, the BCSC weighed a mere 5440 g. Despite the continued accrual of knowledge and advances in surgical technique from
Letters to the Editor
Figure 1. Weight of the entire Basic and Clinical Sciences Course plus the master index versus time. The 1989 –1990 series was published without a master index. It is included in the figure but was not used in the calculation of the linear regression coefficient.
1990 to the present, widespread debate has lapsed and the profession has fallen into a “consensus of inertia” on the 3-year residency for several reasons. First, there is no federal funding for the adoption of 4-year programs. Second, until recently, training programs at all levels of prominence could be nearly assured of filling their ranks with the brightest medical students, who were motivated and efficient learners. Third, a substantial proportion of residents proceeded to a voluntary fourth year via a fellowship.1 The relatively recent creation of the “comprehensive” ophthalmology fellowship provides a de facto fourth year of general training. In response to the ever-enlarging BCSC, we propose the use of web-based learning to expand backwards into the internship year and possibly even into the fourth year of medical school for particularly eager future residents. Ophthalmology programs can individually or collectively develop web-based learning modules on topics that lend themselves well to independent learning and self-testing, such as optics and refraction, ocular anatomy, and ophthalmic pharmacology. Given the increasing access to high-speed internet connections and thus to streaming video, it is theoretically possible to provide some instruction in examination techniques as well. Although we feel this preresidency education should be optional, we foresee significant utiliza-
tion of well-designed materials during, for example, ophthalmology elective rotations. Although the manner in which we presented our analysis may seem lighthearted, we do not want to detract from our message that a coordinated overhaul in ophthalmic education seems urgently necessary and requires action on the part of those who lead our profession. Until then, teaching physicians should be sensitive to the increase in this socalled core or basic knowledge burden; their greatest educational service may be to prune away the accumulated years of fact from their fields so as to reveal to residents the true clinical essentials of ophthalmic practice. SANDRA M. BROWN, MD KENN A. FREEDMAN, MD Lubbock, Texas References 1. Keltner JL. Four years of ophthalmology training. Has its time come? Arch Ophthalmol 1990;108:35–7. 2. Sadun AA. The challenge of teaching ophthalmology: a Residency Review Committee perspective. Ophthalmology 2000; 107:1971–2. 3. Aaron MM, Aaberg TM. Ophthalmology resident training in refractive surgery. Am J Ophthalmol 2001;131:241–3.
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