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Dear Editor, We read the article by Ozair et al.,[1] and we were extremely happy and overwhelmed to see the authors touching on the most sensitive and vital topics in ophthalmology training in our country. After reading this article in the current issue of IJO (October 2020), we could not resist our self to share our extremely satisfying experience of choosing ophthalmology as a career. We hope that this article will be immensely helpful for all the aspirants who have achieved top ranks in recent exams and are hesitant in choosing ophthalmology as a career. As correctly pointed out by the authors that top AIRs have continued to ignore ophthalmology since NEET 2017[2] and the same trend was seen in earlier years too. Me and my wife were AIR DNB 1981 and 2014 during NEET PG 2015, and we choose Aravind Eye Hospital, Pondicherry for our residency training. Most of the top institutes like Sankara Netralaya, Chennai, LVPEI Hyderabad, and Bhuvneshwar and Aravind Coimbatore were filled by that time. We took a bold step of choosing DNB over MS (comparing the pass rates and pattern of training), and we consider ourselves extremely lucky to be trained in one of the best Ophthalmology training institutes. Ophthalmology as a branch is a perfect mix of clinical and surgical exposure. In the top notch institutes like AIIMS Delhi, PGI Chandigarh, MAMC Delhi, KGMC Lucknow, Sankara Netralaya Chennai, LVPEI Hyderabad and Bhuvneshwar, and Aravind Eye Care System (seven tertiary eye care institutes), the training pattern is very rigorous with perfect orientation. These institutes offer regular academic lectures, surgical training from the beginning, research orientation, and perfect thesis guidance. This is very much evident by the quality of candidates passing out each year from these institutes.[3] The quality of incoming residents can further be enhanced by conducting regular Continuing Medical Education (CME's), Webinars, and Conferences under the preview of All India Ophthalmological Society (AIOS) and also the Youth Ophthalmic Society of India (YOSI). The All India Ophthalmic Conference can also have additional small sessions for undergraduates aspiring for Ophthalmology career in future. They should be given an insight into residency curriculum, opportunities for fellowship[4] in India and overseas the advantage of no entrance and exit exam for fellowship training, NEET SS exam and MCh opportunity at PGI, Chandigarh, futures prospects like ICO exams, the FAICO exam, FRCS, MRCS, MRCOphth exam, etc. The recent induction of AIOS exchange program with Singapore National Eye Centre in uvea, retina, and neuro-ophthalmology and also the travel grants opportunities by AIOS and YOSI will also encourage and motivate the incoming candidates and definitely improve the quality. The misconception of ophthalmology being a saturated speciality can be easily erased by targeting the focussed candidates and some extra coordinated efforts in near future. In a nutshell, ophthalmology is a perfect mix of clinical exposure, surgical hands on, research opportunities, balanced lifestyle, job satisfaction, and one of the most rewarding branches when it comes to patients care. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

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Residency training in India: Time for a course correction

Ashok Kumar Grover (2018)

A number of communications in the recent months have brought into sharp focus the many deficiencies that afflict the Ophthalmology residency training in India.[1 2] The difficulties and the limitations pertain to ophthalmic and teaching infrastructure, human resources, and the teaching programs. Wide variability in the quality of academic programs was a glaring problem. A study of medical colleges by the Academic and Research Committee of the All India Ophthalmological Society (AIOS) in 2000 provided evidence of huge gaps in ophthalmic infrastructure and the lack of subspecialty services.[3] Another survey of the medical colleges in India in 2005 pointed to the deficiencies in academics and research. It showed that 20% of the institutions had no ophthalmic journals, 60% had two or less international journals, and only 8.6% had > 5 international publications in the last 3 years.[4] A study from the state of Andhra Pradesh revealed that there was no significant change in the residency training in eight medical colleges in two evaluations 8 years apart (1998 and 2006) after provision of modern instrumentation and training. The intervention did not make a difference to the quality of postgraduate training or help to make the residents confident of setting up their practice.[5] The studies which sought the perception and experience of residents and young ophthalmologists corroborate these observations. A survey from Maharashtra (2008) pointed to dissatisfaction of residents with their residency programs. There was poor emphasis on surgeries other than cataract.[6] In another recent survey, the final-year residents from South India (2014) expressed the need for improved training across all aspects of ophthalmology. There was a big difference between the numbers of surgeries they performed and the numbers they felt would have been ideal.[7] Another study from the same region showed that nearly half of the final-year residents had not experienced wet lab/simulation lab training. More than 50% of the residents had not performed any extracapsular cataract extraction, phacoemulsification, squint, trabeculectomy and dacryocystorhinostomy or any other oculoplastic surgery. Forty percent of the residents expressed their lack of satisfaction with their surgical training.[8] A study of young ophthalmologists completing their residency from 2014 to 2016 by the AIOS revealed that nearly a quarter (24.5%) felt that their teaching program was not adequate. It also showed a wide variation in the support for academics and research in the medical colleges.[9] Has the residency training shown a measurable progress in the recent years? Six years ago the AIOS introduced postgraduate teaching programmes in all five zones of the country during my tenure as president, which have been running successfully. Many other PG teaching programmes have also been initiated in this period. Have the programmes shown any impact? The communication by Biswas et al.[10] in this issue is an attempt to look at the changes over the years. This article[10] brings out persistent shortcomings in the present state of residency training even though there has been some improvement. The 21st-century-trained ophthalmologists perceived training such as refraction, orthoptic evaluation, pediatric visual acuity testing, fluorescein angiography, optical coherence tomography, and use of retinal LASERs to be inadequate (median perception rating ≤ 5). Fifty percent had performed 1 or less phacoemulsification, no trabeculectomy, no strabismus surgery and 2 or less eyelid surgeries. The continuing wide variability in standards of residency training across the country points to the need for a major rethinking and a course correction. A basic need for the course correction would be the creation of a fresh curriculum for residency as stressed by Gupta and Honavar in their recent editorials in the journal.[1 2] The other important element would be ensuring a strong enforcement of the curriculum which would require a more robust system for accreditation of residency programs and a uniform nationwide exit examination. This issue carries salient features of a proposed National Curriculum of Ophthalmology, which is based on a workshop by the AIOS in 2011 that adapted the International Council of Ophthalmology residency curriculum in the context of the needs of the country.[11 12] The curriculum is based on the premise that a well-structured curriculum should lay down all the ingredients including the minimum requirements of infrastructure, medical as well as teaching, tools and resources of education, human resources (numbers, qualifications, experience), and the course content. The curriculum includes research methodology and community ophthalmology. It incorporates the aspects of communication skills, professionalism, ethics and management which includes financial as well as practice and hospital management. The course content outlines the cognitive and technical skills that are necessary for a modern comprehensive ophthalmologist. It lays down the minimum acceptable diagnostic and therapeutic (including surgical) procedures that a resident should perform in his/her period of training. It outlines a well-defined mechanism for formative and summative assessment. It incorporates rubrics for evaluation of surgical skills and clinical examination, assessment of the affective domain, internal assessment which includes maintenance of log books and the outlines for an exit examination. The National Curriculum of Ophthalmology by AIOS formed an important input for the recommendations made by the curriculum committees of the National Board of Examination and Medical Council of India (MCI) (The author was a member of both committees). Laying down a curriculum however can only be a step for moving in the right direction. The real test lies in how well it is implemented. There are huge obstacles to implementation of a residency curriculum in the country in the current scenario. These include deficiencies in infrastructure (medical/ophthalmic equipment and teaching), human resources (numbers, training, and motivation) as well as the structure and mechanism for enforcing the curriculum. A new National Medical Commission Act which proposes replacement of the MCI and constitution of a new postgraduate medical board is in the offing. Does this portend a better future for residency training? This is still an unanswered question and only the future holds the Key ! About the author Dr. A.K. Grover is the recipient of Padmashri Award by the President of India for his services to Ophthalmology. He is the Chairman, Department of Ophthalmology at Sir Ganga Ram Hospital and Vision Eye Centres, New Delhi, India. Dr. Grover is Chairman of Subspecialty Education Committee, International Council of Ophthalmology, Councilor at large of the Asia Pacific Academy of Ophthalmology and Vice President of the Ocular Trauma Society of India. He is a past President of the Asia Pacific Society of Ophthalmic Plastic and Reconstructive Surgery, Oculoplastics Association of India and the All India Ophthalmological Society (AIOS). He is an impeccable clinician, a gifted surgeon, an academician of repute, a dedicated teacher and a visionary leader. Indian Journal of Ophthalmology is proud to have him on the Editorial Board and represent the speciality of Ophthalmic Plastic Surgery. Ophthalmic education has been a passion for Dr. Grover. As chairman, Academic and Research Committee and as president of the AIOS, he took several initiatives including a nationwide survey on residency training, development of residency and subspecialty curricula and annual post graduate teaching programmes in each zone of the country.

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Fellowship training in India: How to produce leaders?

Raja Narayanan, Shashank Gupta, Santosh Honavar (2018)

“If a person masters the fundamentals of his subject, and has learned to think and work independently, he will surely find his way,” is what Einstein once said. The quality and structure of the various Retina fellowship programs in our country is quite varied with the result that some of the programs produce “specialists,” but sadly, inadequately trained to manage common retinal conditions in patients. The Vitreo-Retinal Society of India (VRSI) recently conducted a survey of young retina surgeons to get a sense of the prevailing mood among them about fellowship programs in India. Invariably, across all programs, the emphasis is on technical aspects of diagnostics and surgeries. Approximately 20% of fellows had performed 30% had performed > 100 vitrectomies. More than 25% of them had not done any case of diabetic vitrectomy, internal limiting membrane (ILM) peeling, or epiretinal membrane peeling during their fellowship. More than a third of those who responded were not confident of doing surgeries independently immediately after their fellowship, and felt that their programs needed re-structuring. There is hardly any time allocated for research, critical thinking, and communication with patients. Interestingly, the survey showed unusually high variations among faculty within a single institution. However, compliance with minimum standards is what should be expected from fellowships. It was satisfying to note that all fellows had presented a minimum of five cases or journal articles during their fellowship. However, many of them did not get a chance to attend CMEs or major conferences during their fellowship. Not surprisingly, many of the doctors surveyed wanted to have additional knowledge on trade and industry, which could help them choose the appropriate equipment and consumables when they start their practice. The All India Ophthalmological Society (AIOS) has formed a draft curriculum, which needs further description and has to be shared with all program directors for implementation. AIOS and VRSI should take the lead in ensuring compliance among fellowship programs with these guidelines. The list of compliant programs should be made available on the society websites, so that applicants to these fellowships would be aware of the standards in their programs. This could be used to implement minimum standards among Retina fellows trained in India for clinical, research, and presentation skills. While it may not be possible to ensure strict compliance as the societies are not statutory bodies, voluntary compliance of programs should be encouraged and highlighted. Recently, India has seen a spurt in the number of publications, research presentations, surgical videos, and attendance in general at various national and international meetings. While this is a positive sign, we need to improve the standard of research, for which adequate training has to be imparted. Independent thinking should be encouraged by way of research fellowships and interactive fellow's forum, especially designed for fellows across the country should be initiated. India also has a large pool of patient population, and there is a great scope of conducting network trials. The next step is to have a talent pool of doctors with knowledge of clinical trials and provide a platform for large-scale randomized controlled trials. More importantly, programs also need to think beyond technical training and impart the value of critical thinking and imagination. To quote Einstein again, “Imagination is more important than knowledge,” and we must enable the next generation of Retinologists for the challenges ahead. About the author Dr. Raja Narayanan is the Honorary Secretary of the Vitreo-retinal Society of India. He is also the Head of Operations and Systems, and Director of Clinical Research at L.V. Prasad Eye Institute. He is an adjunct Professor at the University of Rochester, New York, USA. He completed his medical degree and residency in Ophthalmology from Maulana Azad Medical College, and Retina training at the University of California Irvine, CA, USA, with Dr. Barry Kuppermann in 2005. He did his MBA in 2011. Dr. Narayanan is a member of the Macula Society and American Society of Retina Specialists. He is an Editorial Board Member of PLOSOne and Indian Journal of Ophthalmology. He has more than 100 publications to his credit. Dr Narayanan is the Guest Editor for this Retina Special Issue of Indian Journal of Ophthalmology.

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Academic quality of incoming ophthalmology residents in India: Concerns for the future

Ahmad Ozair, Kaushal K. Singh, Siddharth Agrawal (2020)

Dear Editor: We note with concern, for ophthalmology, the results of round-1 seat allotment for National Eligibility-cum-Entrance Test—Post-Graduation (NEET-PG) 2020, declared in April 2020.[1] Except for a few institutions, all-India ranks (AIRs) on the NEET-PG perform as the sole admission criterion to the majority of residency positions in India, and thereby to a career as specialist. Top rankers here represent the finest candidates offered by our medical education system. Currently, India has 1616 MD/MS, 103 Diploma, and 292 DNB (post-MBBS) positions for ophthalmology training.[2] Unfortunately, top AIRs have continued to ignore ophthalmology, as per last available data since NEET-PG 2017, when the exam began. In 2020, not a single examinee under-100 AIR chose ophthalmology, while seven of top-10 AIRs picked general medicine.[1] Similarly, no more than 2 in top-500 AIR and 10 in top-1000 AIR in each year have chosen ophthalmology. This year also saw the least number of candidates in both top-2500 and top-5000 AIRs choosing ophthalmology [Fig. 1]. Figure 1 The graphs provide data of the number of candidates preferring ophthalmology residency via the NEET-PG, from its introduction as NEET-PG 2017, till the year 2020, amongst (a) the top-500 all-India ranks (AIRs); (b) the top-1000 AIRs; (c) the top-2500 AIRS; and (d) the top-5000 AIRs Regarding the academic quality of incoming ophthalmology residents in India, these observations are perturbing, considering the speciality's extremely competitive nature in developed nations. In the USA, where US Medical Licensing Examination Step-1 scores serve as a critical surrogate of competitiveness, average score for applicants accepted to ophthalmology usually hovers amongst the highest of all specialities.[3 4] Similarly, in the UK, as per “competition ratios”, i.e., number of applicants per training position, ophthalmology is highly preferred as a speciality.[5] Urgent action on multiple fronts, led by All India Ophthalmological Society, is warranted to encourage the best candidates to choose ophthalmology. While we have been addressing ways to improve our residency and fellowship programmes, time and again, this important aspect has been largely ignored.[6 7] These unfortunate findings and ignorance of non-preference for speciality training have been true for otorhinolaryngology (ENT) as well, a field that is taught to MBBS students in the same year as ophthalmology.[8] Good quality seeds grow into the greatest trees; and the time has come to actively work towards acquiring them. Highlighting the obvious advantages of our field to the undergraduates, encouraging greater participation in clinical work, and having online career counselling prior to NEET-PG seat selection are some of the suggestions. We also need to widely promote the virtues of our profession through greater engagement on social media. By viewing third-year students as future trainees and treating them so, we shall go a long way. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

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Journal

Journal ID (nlm-ta): Indian J Ophthalmol

Journal ID (iso-abbrev): Indian J Ophthalmol

Journal ID (publisher-id): IJO

Title: Indian Journal of Ophthalmology

Publisher: Wolters Kluwer - Medknow (India )

ISSN (Print): 0301-4738

ISSN (Electronic): 1998-3689

Publication date (Print): February 2021

Volume: 69

Issue: 2

Page: 457

Affiliations

[1]Consultant Cornea and Refractive Services, Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, Pondicherry, India

[1 ]Pediatric and Squint Fellow, Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, Pondicherry, India

Author notes

Correspondence to: Dr. Kirandeep Kaur, Fellow Pediatric Ophthalmology and Strabismus Services, Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, Pondicherry - 605 007, India. E-mail: beingkirandeep@ 123456gmail.com

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Publisher ID: IJO-69-457

DOI: 10.4103/ijo.IJO_3090_20

PMC ID: 7933833

PubMed ID: 33463613

SO-VID: 8a8d1a02-c03e-4cd9-bf69-2fe14a5a64ed

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This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

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Residency training in India: Time for a course correction

Fellowship training in India: How to produce leaders?

Academic quality of incoming ophthalmology residents in India: Concerns for the future

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