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Residents & Fellows Corner | May/June '15

Teaching Residents to Fish

Although there are positive aspects of residency, there are also areas in which improvements could be made.

Recently, I traveled to Tampa, Florida, to take part in a Surgical Resident Mentor Program, chaired by Rob Weinstock, MD. Residents from all over the country gathered to hear experts in ophthalmology discuss the intricacies of cataract surgery, from the initial consultation to postoperative care. The first day of the program we spent touring a lens manufacturing facility and discovering the incredible attention to detail required to make an IOL. Did you know that a human being actually single-handedly places polypropylene haptics on a silicone optic? Can you believe that this is done at a microscope? This is such a tedious task that I always assumed was done by machines.

We then went to the Eye Institute of West Florida, where we learned about the latest technologies being used in refractive cataract surgery. We observed Neel Desai, MD, and Dr. Weinstock perform femtosecond laser cataract surgery. The entire procedure was moderated, and pearls were provided throughout the case. We were able to ask questions while observing world-class cataract surgeons handle complex situations—what a great learning experience for trainees who do not see this side of ophthalmology too often.

Next, we met our surgical mentors for the weekend. I was introduced to Parag Majmudar, MD, from Chicago, whose mission it was to ensure that my Program Director, Bethany Markowitz, MD; my co-resident, Stacy Story, MD; and I were taught anything and everything we wanted to know about refractive cataract surgery. Dr. Majmudar spent hours with us discussing different scenarios encountered during surgery and his approach to handling them.

The second day of the program included 5 hours of jam-packed lectures on traditional and refractive cataract surgery. It was refreshing to hear a variety of opinions from the many experts in the room. We finished the lectures with videos from each faculty member, in which he or she showed either pearls or mistakes encountered in the OR. Witnessing surgeons’ humility when they showed scenarios in which they tried to do everything perfectly but failed made for valuable learning opportunities. The videos helped me realize that even the experts are not always perfect, and a tremendous amount can be learned from watching them operate under stressful conditions.

That afternoon, we went into a large exhibit hall with about 20 phaco machines. Whether we had operated before or not, we were guided through the case by our surgical mentors. My mentor sat beside me and offered cutting-edge tips on my techniques from the teaching microscopes. I spent around 4 hours performing cataract surgery and learning to perform bimanual phacoemulsifcation, pars plana vitrectomy, and limbal relaxing incisions.

The weekend concluded with a dinner where we talked with the faculty casually about everyday life as an ophthalmologist. Far too often, residents feel like they exist at the bottom of the totem pole, but on this trip, the faculty treated us as if we were peers. Overall, I cannot imagine a more open, fun, and educational way for residents to interact with experts who came together for the sake of our education. I would encourage all residents to seek out educational opportunities like this offered by various companies in the industry.


That weekend got me thinking about the state of ophthalmic resident education in America. Although there are positive aspects of residency, there are also areas in which improvements could be made. First, most residents attending the course had experience with devices from only a single manufacturer. Why is this problematic? Many residents may go through their education thinking that phaco machine X is the only option, or that microscope Y is the only one that you should use, or that if you do not implant a certain brand of IOL you will end up with unhappy patients.

Now, understandably, educational institutions must adhere to certain regulations and likely can’t afford to switch vendors too often; however, residents’ education should be unbiased. Residents should remember that if one company were the absolute best, everyone would work with that company. Many companies in the ophthalmic industry make quality products that should be used during training. You would not want to join a practice that used only a venturi-based machine, when you had never even tried using one until operating on your first private patient.

Residents’ education should promote the concept that a variety of devices and approaches may be suitable for use in providing optimal patient care. Residents can be exposed to different technologies in the cities in which they operate. Program directors can encourage their residents to shadow various surgeons so that they are exposed to a variety of techniques. We also need a competitive industry to continue to bring technology to the next level.

When my father, Larry Patterson, MD, trained (not quite the dinosaur age), residents were taught by third-year residents. Today, without an attending physician present, Medicare will not reimburse the practice. Therefore residents no longer learn to operate solo, make tough decisions independently, or navigate through a clinic on their own; thus, residents, especially those in the large programs, rarely have the ability to fail. And you can’t learn unless you initially fail—just ask Michael Jordan, who thankfully realized his high school coach didn’t know the beast that would awake inside him.

Residents are often taught that they will not be able to compete without a fellowship. I could not disagree more. I will finish residency with more than 300 cataract cases, 100 plastics procedures, 400 intravitreal injections, 100 retinal and glaucoma laser cases, and many other procedures. There is no reason I shouldn’t be able to thrive as an ophthalmologist, and when I have to perform a procedure that I am not familiar with, I can refer the patient. Residents who do not wish to do a fellowship should resist the pressure to go down that path solely out of fear that they will not be able to survive in the real world.


It isn’t all bad in residency land. Programs are continuing to emphasize the importance of the Basic and Clinical Science Course (BCSC); my program meets weekly to review hundreds of pages of BCSC material. With this intense education, my classmates and I are being taught the important basics of ophthalmology and, most importantly, are becoming accomplished clinicians at the same time. Training programs across the country continue to stress the importance of learning the basics before we learn the complexity of the specialty. Mastering the knowledge of the BCSC is essential to becoming a great physician; after all, you must learn to walk before you run.

As the academic chief in my program, I have sought expert opinions from community ophthalmologists. Often, residents are taught by lifetime academic employees. This approach neglects to teach residents about private practice. At my program, we bring in private practice subspecialists to offer advice and examples. This gives residents the opportunity to explore both academic and private practice and see which route will best fit. My suggestion is for attendings all over the country to become involved with their local residency programs. My father comes monthly to our program to lecture on the business of ophthalmology and refractive cataract surgery, and it is a valuable experience for all.


Residents in America are getting the best training in the world. Thanks to industry and ophthalmic mentors spending their precious weekends with residents like myself, I am continuing to get the training required to be an excellent ophthalmologist. To continue this process, residents need help. The future of ophthalmology is currently training; it is up to you to feed this generation and teach them everything you know. As the old saying goes, “Give a man a fish, and you feed him for a day. Teach a man to fish, and you feed him for a lifetime.” Get out of your comfort zone and teach us to fish. We need you.