Ophthalmology residency and retina fellowship have evolved tremendously over the last decade, especially over the past year and a half in response to the COVID-19 pandemic. In this roundtable, Retinal Physician convened a panel of experts in ophthalmology education to discuss this evolution. William Mieler, MD, is a retina specialist at University of Illinois, Chicago. He has been the fellowship director for 12 years, and has previously been the residency director. Lisa Olmos de Koo, MD, has been the retina fellowship program director at University of Washington in Seattle for 5 years, oversees the retina resident rotation, and attends the retina clinic at the county hospital, overseeing all of the residents who work there. She previously directed the fellowship program at the Roski Eye Institute of the University of Southern California. Royce Chen, MD, is a retina specialist at Columbia University’s New York Presbyterian Hospital. He has been the residency program director there for 4 years. He is heavily involved with surgical and clinical education of the fellows in the vitreoretinal fellowship. He also has a research fellow in retina and is involved in medical student education. Christina Y. Weng, MD, MBA, is a retina specialist at Baylor College of Medicine. She has served as the surgical retina fellowship program director for 5 years and is also involved with residents and medical students through didactics, clinical teaching, research, and mentoring. Dr. Weng leads the discussion below.

Dr. Weng: What would you say are the most significant changes that have occurred over the past year and a half in your respective training programs when it comes to fellow and resident education and training?

Dr. Olmos de Koo: Number one is that didactics and grand rounds transitioned to a virtual format.

Dr. Mieler: As far as education, I agree. As far as the clinic, we first had to define what was an emergency and what wasn’t. Once we did that, we streamlined our clinics so that the patient flow is much different, and we’ve cut back the number of patients so that we have very little interaction. A patient goes into a room, is taken for imaging, and then is taken back to the same room. The system is actually much more efficient, but we do see slightly fewer patients.

Dr. Weng: Our clinical operations also shifted, resulting in decreased patient volumes compared to prepandemic numbers. Is everyone back up to normal volume?

Dr. Olmos de Koo: Yes, although sometimes when a piece of news hits the media, such as a spike in COVID cases, we will have a lot of cancellations at the last minute and our volume will go down. But the booked volume is about par.

Dr. Chen: I think in the past month we’ve actually hit about 100%, so we recovered and got really busy. Part of the reason is that people returned from their winter in Florida. Also, the high vaccination rate in New York City has given more people confidence to come back. Flow and operations are vastly different now as well. Although the year has been painful, the benefit is that this was the time to explode everything and really think about what truly worked for education vs what was done only in the name of tradition. We have had the opportunity to decide what we should change for the future. That’s been fun to figure out. We’ve changed the way we deliver didactics to make it more case based. We also shifted to a pooled patient system with our residents because there are so many moving parts to their clinic — we had previously worked with individual templates, but I think the pooled system has allowed for more efficient care of patients when we also need to keep them physically distanced with a limited supply of rooms.

Dr. Weng: My New York colleagues tell me that at the beginning of the pandemic, residents, fellows, and even medical students were deployed to assist with COVID-19-related services. So they actually left their own specialty-specific training programs to work on the wards, intensive care units (ICUs), or wherever else they were needed. Did that affect your ophthalmology residency program at all, Dr. Chen?

Dr. Chen: Yes; every single person in our department redeployed in some way, and 7 of the residents and a couple of faculty, including our chairman and myself, went to the ICUs and did our best to help the ICU doctors. The rest manned COVID hotlines, which were ringing off the hook at the beginning because so many people wanted to know if they should get tested and how. The redeployment for us carried on for about 3 to 4 months in some kind of fashion and then gradually tapered off.

Dr. Weng: At the start of the pandemic, when the virus was spreading rampantly, we split our residency program into 2 teams so there was a backup team at all times in case one team needed to quarantine. This meant we were essentially running at half capacity, which was very challenging. Another big change was with lectures and grand rounds, which became virtual. Even OKAPs and oral boards were taken virtually, which was a unique experience. Overall morale was also negatively impacted by the pandemic for a number of different reasons. Residents and fellows were dealing with the same stresses that everyone else was dealing with, but I know there was also concern about the significantly lower surgical volume. One of the ways we responded was by developing a formal wellness initiative that will continue to be built out over this next year. That is one positive thing that came out of a trying time.

Dr. Mieler: I found that grand rounds actually had much better attendance when it was held virtually, and that’s probably going to continue. Even things like the OKAPs and boards may stay virtual indefinitely, so a lot of these things are not bad options. They were forced upon us, but they actually work quite well.

Dr. Weng: One of the most critical parts of training, especially for surgical retina fellows, is getting into the OR. How did your programs handle the reduced clinical and surgical volumes? We have a Haag-Streit Eyesi Surgical simulator at one of our hospitals, so we encouraged our trainees to at least get some hands-on experience there.

Dr. Mieler: Our numbers actually did not go down. Being an academic center, we had a lot of centers refer to us because their surgery center shut down. Volume was as high if not higher during the pandemic. One fellow did get COVID; fortunately, it was a mild case, but with all the uncertainty, that was worrisome. We cut back elective surgery, but that rate is determined by how you define an elective procedure vs something that could be delayed for 3 to 4 weeks.

Dr. Chen: We had 3 months off from elective surgery, so to make up for that lost experience for residents, one of the things we developed was a series of short, case-based discussions called “eye talks” that connected residents to faculty like Stanley Chang, MD. Having virtual meetings made scheduling easier. The residents really loved that kind of access to our experienced surgeons. Since we’ve gone back to more full schedules, it’s been harder to do that, but I’m trying to bring back some of that magic. We also partnered with the HelpMeSee surgical simulation company, which has a haptic-based feedback system, to develop more of a surgical curriculum independent of the operating room.

Dr. Olmos de Koo: Our vitreoretinal surgery volume didn’t go down as much as we expected. We did do fewer surgeries when we could defer, but we still operated on retinal detachments and diabetic cases. Patients were being referred in from the community as well, so I think that accounted for the fact that volume didn’t drop much. But we still tried to make each case count, so I encouraged my fellows to record every surgery. You never know when something teachable will present itself. We do a debrief afterwards during which we review the video and talk about what we could do differently. Even if there is no video, we do a verbal deep dive. On the resident retina rotation, we strive to make sure that each resident gets at least 1 or 2 primary vitrectomy cases and does simulated pars-plana vitrectomy on the Eyesi system. The residents go through a formalized Eyesi vitreoretinal tutorial so that they can come through their vitreoretinal rotation knowing whether they want to pursue retina fellowship training.

Dr. Weng: Let’s now talk about everything outside of the clinic and operating room: for example, the interview season. Last fall, when everyone was scrambling trying to figure out how to make this work, many were still fairly new to platforms like Zoom. Hosting an interactive virtual interview day seemed a bit awkward at first, but it actually ended up working out really well for our program. While I do not expect interviews to stay virtual permanently, I think that some things will. There have been some unexpected benefits reaped as a result of these modifications we were forced to make.

Dr. Chen: The flexibility of virtual education has been fantastic and certainly the number of people attending is much higher, but I think it’s still not a full replacement for in-person contact. I think that speaks to the biggest challenge over the course of the year, which is dealing with the psyche of all of our trainees and our faculty. What I’m struggling with now is how and what to bring back in person to give trainees some kind of community within our department, because I think we see some things fraying. On the other hand, our rapid adoption of teleconferencing has allowed for so much collaboration, both inside and outside of our institution. We’re trying to find the right balance as we move forward.

Dr. Mieler: Virtual education has worked well, and I think that will continue. Small groups, however, work well in person when there can be social distancing, like our monthly surgical fellowship conference. We’ve hosted virtual events like imaging rounds, which have attracted 500 to 600 people. I think one thing that we’re having trouble with is deciding this autumn whether to interview in person. If the pandemic is such that it’s safe, we are probably going to bring back on-site interviews, but that has not yet been determined.

Dr. Chen: I always send a post-match survey to all of our residency applicants. I asked how they liked doing virtual interviews, and most people were actually pretty happy with it. They saved thousands of dollars and they didn’t have to travel. Ultimately, I don’t know that it’s my decision to make; it will be what the program directors decide together, but there are definitely pros and cons. The Association of University Professors of Ophthalmology (AUPO) and SFmatch will be doing all virtual residency interviews again this fall, but there will be open houses where applicants can visit programs after the programs submit rank lists.

Dr. Olmos de Koo: At University of Washington, we’re waiting for guidance from the AUPO Fellowship Compliance Committee because we want to align with other programs so the process can be as equitable as possible for all applicants. I think there were a lot of internal matches this year for fellowship, just because you get to know someone in person in a different way than you could with online interviews. So, I am hoping we get to transition back to in-person interviews soon, for both the program’s and the applicant’s benefit.

Dr. Weng: Dr. Chen, I know that Columbia practiced collaborative cross-training, where you invited other New York City residency programs to your educational events, and they reciprocated.¹ We implemented something similar here in Houston and statewide, and it has resulted in noticeably greater interinstitutional collaboration, because some of the barriers that used to exist have been removed by virtual platforms. This has been one of the really beneficial things to emerge from the pandemic.

Let’s shift gears to congresses. It is important for trainees to present research and network at meetings, but of course all of our meetings were virtual over the past year. Did your residents and fellows still participate?

Dr. Mieler: No, residents did not necessarily take advantage of virtual meetings as well as they could have, despite the affordability of registration.

Dr. Chen: A lot of my residents and fellows have presented at various meetings over the course of the year, and there’s a didactic benefit to that. But all of the networking goes out the window with a virtual format, so as soon as they can be in person again, I want them to get out there and start meeting people. That’s part of the fun of life.

Dr. Olmos de Koo: I think we’re all experiencing Zoom fatigue, and I don’t blame residents and fellows for feeling the same, unless they’re presenting. It’s really hard to sit in front of a screen all day and sustain attention and engagement.

Dr. Weng: I would now like to discuss the changing face of ophthalmology and retina training from a broader perspective. Some have suggested that trainees of today learn differently from generations past, and might even have a different mindset from that of their more senior educators. Dr. Mieler, what differences have you noticed with the current generation of residents and fellows compared to those that you’ve previously taught, in terms of learning style, the level of supervision they desire, types of resources they like to use, or expectations?

Dr. Mieler: Millennials are different from the previous generation of residents and fellows. Expectations are somewhat higher, which is perfectly fine. Millennials are confident, eager to learn, and not afraid to challenge the status quo or even authority at times. The self-motivation to work hard and succeed remains firmly in place.

Dr. Olmos de Koo: I think that the switch to virtual didactics has actually been very beneficial for the current generation of residents and fellows, who place a lot more emphasis on work–life balance. With the advent of remote didactics, I have also seen evidence of both parents being more equally involved in child care. For example, in the past year I have seen many male residents and fellows with their baby or child on their lap participating in Zoom fundus conference. This type of scenario is refreshing and welcome to me.

Dr. Chen: I think that I know less than my mentors did in terms of stored knowledge. There’s more just-in-time learning going on, because people can find good resources online before surgery or during a clinical exam. There is better equipment, so the average surgeon is better than the average surgeon was 20 years ago. Outcomes are better. I also think that a greater consciousness of justice and equity is breaking the mold of the traditional medical hierarchy. Although that can be uncomfortable for some and causes friction, ultimately I think it’s making us better doctors that can better take care of the demands of our patients, who also have evolved.

Dr. Weng: I think that our educational resources need to shift with the times. Generally speaking, I find that this generation of trainees prefers videos and study guides over reading assignments. Very few learners are reading textbooks cover to cover nowadays. Many favor case-based discussions over traditional lectures when it comes to didactics.

Dr. Chen: I feel like I’m often caught in between as a translator, where sometimes I explain or defend residents’ learning styles to my older colleagues, and sometimes I think a resident isn’t doing what I expect them to do. I remind myself that these are brilliant people who have succeeded in everything that they’ve done up to this point, so what I need to do is put the proper system in place that maximizes their skills and also maximizes communication across our faculty.

Dr. Olmos de Koo: What has really been effective for me is spelling out my expectations, whether they be old school or not. I actually give a 1-page document to the residents coming on the retina rotation, which explains these expectations, such as giving faculty a courtesy reminder before going out on vacation. That’s a good practice that may not be something they would necessarily think to do, but knowing the expectation serves them well. For our fellowship, we have developed a handbook and we ask them to read it through before starting.

Dr. Weng: I agree and tend to do the same thing now. I try to have a sit-down with trainees on the first day of the rotation to tell them when they are expected to be in clinic, what I expect them to do when they are here, and to also elicit their expectations of the rotation. One of the other things I’ve noticed is that today’s trainees expect and value feedback, so I try to provide that as much as possible. For example, after I operate with a resident or fellow, we will have a quick debrief to review what they did well and what they need to improve, as well as surgical tips that I may not have been able to convey intraoperatively.

Finally, I want to pivot our discussion to diversity. Diversity has increased in medicine over the past several decades, but perhaps not as quickly in some fields such as ophthalmology and retina. I would love to hear your thoughts on this and what steps can be taken to continue the progress that has been made to ensure diverse representation in our field, especially by women and under-represented minorities.

Dr. Olmos de Koo: I feel strongly that it’s important to connect with diverse medical students and even high school students to expose them to opportunities in medicine, ophthalmology, and even retina early on. This will create a pipeline of students and residents from diverse backgrounds and ultimately help us reach our goal.

Dr. Mieler: Keith D. Carter, MD, as past president of the American Academy of Ophthalmology, started the Minority Ophthalmology Mentoring (MOM) program, a partnership between the American Academy of Ophthalmology and the AUPO, aimed at the younger generation of medical students and trying to get them involved in ophthalmology. It’s gotten off to a very successful start. I’ve served on the board of trustees for 4 years. I agree that it’s critical to connect with people earlier in life to let them know what we do. That can be very successful in increasing diversity in ophthalmology.

Dr. Chen: I’m proud of the fact that about one-third of our residency in the last 5 years has been made up of talented under-represented minorities. I didn’t realize what a positive impact this would have for patients and physicians alike. I see residents interacting with our Dominican and West African patients, and I see the trust and connection born from having a doctor who looks like they do. I think our specialty is moving in the right direction, but we still need to move faster.

Dr. Weng: Organizations like the American Society of Retina Specialists and Women in Ophthalmology actually have dedicated mentoring programs for women and for under-represented minorities. The number of women and men entering ophthalmology is nearly equal, but in surgical retina, it’s not quite there yet. I agree that it takes deliberate action at the top levels as well. If you have a less diverse faculty, those who are rotating through the service may find it harder to picture themselves in that field. So I think it’s very important for us to be intentional about making sure that our faculty, our leadership, and our boards are diverse.

Dr. Olmos de Koo: As a Latina woman, I would strongly agree with that. I have an anecdote to share. One day, one of my Spanish-speaking patients, whom I treated for a retinal tear at the charity care clinic, brought her young adult son with her to her follow-up appointment. From the conversation, I could tell that her son was very bright and interested in understanding his mother’s condition. I asked about his background and he shared that he had recently graduated from college and was working toward an ultimate goal of attending medical school, so I invited him to come to my retina clinic and shadow me. I was happy that I got the chance to model a career possibility for a young person who might not have otherwise considered this field. Similarly, I try to model balancing parenthood with being a retina surgeon for my residents and fellows, particularly my female trainees who might be otherwise hesitant to consider surgical retina due to the traditional reputation of it not being a family-friendly field.

Dr. Chen: Given the kind of demographic shift that we’ve had in our residency over the last several years, I’ve also noticed a positive effect with the medical students in that I see more minority medical students becoming interested in ophthalmology, because they have more mentors like them. So, I think the benefits go down the line as long as this continues.

Dr. Weng: There’s definitely a ripple effect. Thank you all so much for being part of this enlightening discussion. RP

Editor’s note: listen to discussion of this article on The Retina Podcast at www.retinapodcast.com .

REFERENCE

1. Chen RWS, Abazari A, Dhar S, et al. Living with COVID-19: a perspective from New York area ophthalmology residency program directors at the epicenter of the pandemic. Ophthalmology. 2020;127(8):e47-e48. doi:10.1016/j.ophtha.2020.05.006