In the United States, we are blessed that high-quality care of vitreoretinal disease is delivered by excellent fellowship-trained physicians and surgeons. Although a vitreoretinal fellowship is not mandated by law, most ophthalmologists who provide vitreoretinal care are fellowship trained. Fellowships’ strengths and weaknesses vary, but the goal of institutions that provide vitreoretinal fellowship education is to train competent and ethical surgeons and medical retina specialists. Ophthalmologists are certified by the American Board of Ophthalmology, whose mission is to certify those who have completed necessary residency training through the verification of specific core competencies. Subspecialists in vitreoretinal surgery and medicine have no such independent board to provide formal certification of competence in the field.

Vitreoretinal fellows train with one to many trained vitreoretinal clinicians, surgeons, and researchers. Fellowship educators may be university-based or private-practice clinicians with the desire and resources to train fellows. It is ultimately the judgement of the mentor or fellowship director to determine if and when fellows are competent to practice and call themselves vitreoretinal specialists.

FELLOWSHIP OVERSIGHT

Currently there is no singular, formally defined and universally accepted structure of oversight in the United States. Multiple organizations currently attempt to assess and define desired baseline characteristics of fellowship training deemed to be acceptable by the specialty, including the Association of University Professors in Ophthalmology Fellowship Compliance Committee (AUPO FCC), the American Society of Retina Specialists (ASRS), and the offices of graduate medical programs. In addition, the SFMatch serves as an organizational unit through which most fellows match into participating fellowships. However, no fellowship program is required to participate in the SFMatch, AUPO FCC, or “register” as a formal fellowship with the ASRS. Each of these organizations serves to help ensure the quality of fellowship programs, protect fellows from substandard programs, and ensure appropriate resources for excellence in training. None has a mechanism to evaluate the ultimate competence of fellows as they graduate and begin independent practice.

The AUPO FCC is a nonprofit, independent organization established in 2005 to help establish standards for subspecialty fellowship education in ophthalmology. Training standards for both surgical retina and medical retina fellowships have been established, vetted, and regularly updated through cooperative efforts of the AUPO FCC board and retina subspecialty representatives from the ASRS, Retina Society, and Macula Society. Compliant programs are those that have completed an application that guarantees appropriate oversight of fellows, adequate training resources from facilities to insurance and salary to clinical and surgical volume, and an academic focus including association with a residency program. Programs are reviewed annually through an exit survey of graduating fellows to assess if the training standards are being met. The strength of the AUPO FCC program is the provision of an “arm’s-length” assessment of programs and the backing of the major US retina subspecialty societies. The AUPO FCC helps to ensure that appropriate resources are available for fellowship training but does not directly assess competence of graduating fellows because it relies on the judgement of the fellowship directors of compliant programs to determine the successful completion of all requirements that indicate competence and preparation to graduate. In 2020, 110 fellowship programs participated in the SFMatch — 67 programs were AUPO FCC participating compliant programs, and 43 programs were not. On a fellow basis, 85 fellowship positions were filled in AUPO FCC compliant programs, whereas 41 fellowship positions were filled in programs not participating in the AUPO FCC program.

The ASRS is the largest organization of retina specialists. It serves as a national advocate for the retina subspecialty and for individuals with retina disease. Physician members of the ASRS must be ophthalmologists who have completed 1 or 2 years of fellowship training. Fellow-in-training members must complete an activity log documenting surgical and academic experience as part of the membership application to become a full member. The ASRS provides valuable education resources for fellowship education, including reading lists, virtual lecture series, webinars, online journal clubs, and ASRS Grand Rounds. The ASRS is also developing resources to assist fellowship directors in the assessment of fellow competence. These will include tools to follow surgical and medical retina progress and performance. Members may self-identify as fellowship directors and participate in the fellowship directors’ committee but do not have to attest to guidelines or standards of fellowship training on behalf of their program.

The AUPO FCC and ASRS share complementary roles in monitoring fellowship education. The AUPO FCC provides oversight of fellowship programs, ensuring that they provide adequate attending physician involvement, medical and surgical training, resources, academic opportunities, and assessment of fellowship education, while the ASRS provides a variety of educational resources and helps to assure competence by monitoring specific fellow activities. As an organization, the ASRS only admits to full membership those who have completed an ASRS-recognized fellowship and completed a formal log of surgical and academic activities that tracks numbers of surgical cases, office procedures, imaging studies, research activities, and other aspects of their training experience, hence indirectly regulating who is recognized as a retina specialist.

THE FUTURE OF RETINA FELLOWSHIP

Does the retina community need to do more to assess the competence of graduating fellows? Overall, fellowship programs graduate excellent fellows, but a weakness of the current system of training is the lack of universal training requirements, guidelines for fellow assessment and, ultimately, a single formally recognized assessing organization. The AUPO-FCC depends on voluntary participation by fellowship programs, and currently 40% of fellowship programs do not participate in the program. The ASRS only admits to full membership those who have completed fellowships and provides excellent resources to fellowship programs, but does not have a mechanism to individually assess each applying member’s competence.

Ultimately, fellowship directors determine if and when a fellow is judged to be competently and adequately trained and ready to enter practice. Going forward, all interested stakeholders (organizations, societies, attending physicians, fellows, payers, and others) will need to further determine if our current mechanisms of assessing and regulating vitreoretinal fellowships are adequate, or more likely, are in need of further consolidation under a more uniform structure that formalizes the requirements for completion and methods of oversight of all programs throughout the country. RP