Vanderbilt Eye Institute

When the Vision spoke with Dr. Laura Wayman in 2007, she had just been at her post as VEI’s Residency Education Program Director for two years. She had already led the redesign of the curriculum, beefed up formal lectures and seminars, and established an ethics roundtable. She had also added a microsurgical skills “wet lab,” where residents could get hands-on practice in surgical skills before heading into the operating room.

The Vision caught up with her again, along with newly named Associate Director of Residency Education Dr. Janice Law, to find out how what’s new, what’s changed and what’s on the horizon for residency training at VEI.

Surgical Skills

The Microsurgical Skills program – unique to the VEI – has undergone continual improvement. In their first year, residents spend a 10-week rotation in the microsurgical “wet” lab, where they receive hands-on experience with cataract surgery before they ever leave the classroom.

First-year residents meet in the lab with Dr. Wayman for ten weeks. When she feels a resident has mastered a surgical skill, the resident take that skill into surgery: performing the step on an actual patient, supervised by Dr. Wayman. This immediate immersion in hands-on surgery helps the resident gain confidence and allows Dr. Wayman to focus on the training needs of each resident.

During the three-year residency, approximately nine months are spent at the Veterans Administration Medical Center. This is a rare opportunity only a few residency programs in the United States can offer. The VA is equipped to allow residents to perform comprehensive ophthalmology procedures as well as subspecialty procedures, supervised by physicians from the VA and Vanderbilt Eye Institute, as well as clinical faculty from the community.

Fourth-year residents spend part of a 10-week rotation at the Warfighter Refractive Eye Surgery Center in Ft. Campbell, Kentucky. This arrangement allows them to perform upwards of 25 bilateral cases as the primary surgeon. To determine a patient’s candidacy and/or risk factors for refractive surgery, it’s important to learn about and perform preoperative evaluations. Each resident observes corneal laser refractive surgery – and then performs it as a primary surgeon. Finally, they become familiar with and provide postoperative care for patients. When the resident completes the rotation, he or she receives on-site certification in refractive surgery.

Clinical Skills

Office retinoscopy, refraction, keratometry, and biometry are all critical to diagnosis and to prescribing the correct prescription for glasses or intraocular lens implant during cataract surgery. While these skills are fundamental to a resident’s education, there is no current published metric to evaluate how well a resident can perform them. When Dr. Janice Law took the position last year as Associate Residency Education Director, she set out to ensure that VEI residents were getting the office exam skills training they needed.
“One of my passions in medical education is clinical skills development,” she says. “We know these skills are being taught, but how well do we teach it? We want to make sure residents are competent before they leave here. This is something that really can’t be tested through conventional medical knowledge testing such as the OKAPs (Ophthalmic Knowledge Assessment Program).”

Dr. Law has developed a new assessment tool – called the Ophthalmic Skills Competency Assessment Tool, or OSCAT –which she hopes one day may be implemented in other ophthalmology residency programs across the country.

This assessment tool is made up of clinical stations. The residents rotate through the timed stations and have to perform the correct steps of an office skill, in addition to deriving the correct measurement or prescription. A faculty expert in that skill evaluates each resident with a score sheet to determine his or her competency.

The assessment committee consists of Drs. Law and Wayman, as well as Drs. Amy Chomsky, Chasidy Singleton, Mark Ewald, Nancy Benegas, John Downing and Jennifer Lindsey. The program first implemented the OSCAT on June 18 to capture baseline data.

Dr. Law will correlate these findings along with a resident self-assessment survey and a survey to graduates of VEI to evaluate their perceived weaknesses and strengths in particular skills.

“Often residents can get to an answer, but the steps may not always be correct,” Dr. Law explains. “The scoresheet breaks down each step and helps us to target areas on which we need to work. We also need to be consistent in the way we teach these steps. Once the program has developed new teaching methodologies we will reassess the skill to evaluate the new curriculum.”

Law sits in on lectures and workshops to see how the skills are currently being taught. The residency program has also purchased a video indirect ophthalmoscope to teach residents indirect biomicroscopy, a very difficult skill. “We can also use it to assess the residents’ ability to identify peripheral retinal lesions,” explains Dr. Law, “because we can now see what they are seeing real time and can determine competency in this area.”

This Skills Assessment course is being funded by GIVME – Great Ideas in Vanderbilt Medical Education. This unique grant is sponsored by the School of Medicine, in conjunction with the Office of Undergraduate Medical Education and the Office for Teaching and Learning in Medicine, and provides start-up support for implementing a new curricular idea or researching an educational problem. Only one in three applications is accepted each year.

Mortality, Morbidity and Improvement

While the mortality and morbidity model has been used in medicine for many years, it’s only been fairly recently that the ‘I’ was added. Traditional M&M sessions examined what went wrong in cases with unsatisfactory outcomes, with the focus on medical knowledge, application or treatment. But recently, there has been a paradigm shift – away from a “blame” model and toward transformation to improvement.
The Vanderbilt Eye Institute uses MM&I not only as an assessment tool for faculty, but also as a teaching tool for residents. The MM&I team – Dr. Wayman, Dr. Law, Dr. Robert Estes (Risk Management Liaison), Dr. Uyen Tran (Quality Assurance Officer), and Brian Carlson (Administrator) seeks out cases from each division to use as examples. The team meets with the physician and uses the Healthcare Matrix, a tool developed at Vanderbilt, to organize thoughts and get to the answers. The Ichikawa Fishbone Diagram helps them develop action plans. The result is a patient-centered systems approach in which the faculty works together to find a solution for turning an M&M into an MM&I.

The cases are presented in front of the entire department – including residents. “Residents are humbled,” says Law, “because faculty members are willing to get up and show their mistakes. It also instills competencies that are required of them. They’re able to see where the breakdown occurs and take steps to make those changes themselves. It’s a great teaching tool.”

Use of the Healthcare Matrix and Fishbone Diagram has helped the VEI move from a format focused on discussion of adverse events to a cross-disciplinary conference that removes the focus from the provider and identifies system failures, develops action plans, and prevents recurrence of failures. This engaged participation of faculty, trainees and staff contributes to improved patient care and prevention of adverse effects.

A Culture of Support and Success

Recently, the Accreditation Council of Graduate Medical Education (ACGME) reviewed the VEI’s residency education program. The program passed the very stringent Residency Review Committee peer review process with flying colors and received the maximum length of time a program can be reaccredited without peer review.

“The biggest reason for this success is the culture change that has occurred in the department,” explains Dr. Wayman. “The mood, the atmosphere, the work ethic, the interest – the culture – has changed. It’s been a gradual evolution and we’ve had a lot to do. It’s a great accomplishment for all of us.”