The satisfaction of residents in ophthalmology towards surgical training is encouraging and globally positive throughout France. Residents valued simulation training. It seems in line with what has been reported from the specific area of Paris-Île-de-France by Martin et al. [9].
With a third of responders among the total of contacted residents, the collected declarative data can be interpreted as representative in the present study. It also corroborates that all French ophthalmology residency programs were participating in the study.
At a national level, we observed significant disparities between Paris and other regions as well as between regions themselves. It reflects a poor level of standardization nationwide for surgical training programs. According to the provided answers, the access itself to surgical training suffers from high variability in quality and for quantitative availability.
We did not focus on the causes of such disparities. The lack of standardization at the national level has been reported by other international studies [8]. It is likely that the lack of a clear national standardization for surgical training, for example through surgical goals & skills textbooks, might play a role. Rating the objectives of surgical learning programs has been proposed using the method of SMART (specific, measurable, achievable, reasonable, and time-bound) goal framework [10]. Recent studies have evaluated residency programs at the European level [11]. They determined the minimal number of procedures to be performed for each type of surgery during residency. Surgical volume is an important metrics to approach the residents’ ease to perform a specific procedure, but the ability to operate should also be determined by a senior surgeon. Learning quality of proceeding and other non-technical skills is also pivotal.
Residents could take advantage of a textbook of goals & objectives. It would serve as a tool to design surgical supervision. It would also contribute to prove surgical achievements, thus putting senior surgeons more at ease to let residents operate. Such a tool has already been discussed in the literature [12]., and can further complete a surgeon’s certification (operating license). At the same time, it would credit residents for more access to the operating room by endorsing the role of leading operator for instance.
In the United States, the ACGME (Accreditation Council for Graduate Medical Education) cleared guidelines for teaching during residency. It is in charge to enforce compliance to guidelines for residency programs. Residents are also interrogated annually, through a questionnaire, which figures their satisfaction with the residency program [13]. However, whether such feedback could be meaningful and even elaborated remains to be determined in countries, either poorly allocated for teaching programs or less centrally coordinated.
Responding residents globally described a poor access to subspecialty surgical training, in accordance with previous data [6, 7, 14]. The opportunity to practice as a subspecialist is limited compared to comprehensive ophthalmology. The more specialized the practice is, the tougher is teaching complexity. Besides, less patients are referred to subspecialists. Logically, subspecialized practice is sparsely accessed during fellowships, even potentially at a senior level. Although residents are complaining about it when interviewed, less surgeons are needed in the field. As a matter of fact, only a few future surgeons should be specifically trained. It seems then acceptable that career history of excellence should rule access to it.
Our questionnaire did not include questions regarding surgery in emergency situations, such as identifying dystopic anatomy and suturing recent open globe injuries, but we postulate that the same approach could apply for such complex procedures.
Surgical teaching has progressively evolved from relying on the Halstedian model of graduate responsibility to surgery simulation as a preliminary step in the learning course [15]. Higher standard for patient safety added to less teaching resources may have prompted the transition [16]. Simulation now serves as a key element for transition towards hands-on surgical training. The benefit has been widely demonstrated in the past decade, either using the EyeSI simulator [3, 17, 18, 19, 20, 21] or throughout other wetlabs [22, 23]. However, our study enlightens regional disparities to access simulation (drylabs and wetlabs). In French regions, accessibility varies greatly, depending on the involvement of local universities and health agencies (ARS, Agences Régionales de Santé). As a matter of fact, not all regions have a simulation platform available. In the meantime, Paris region set dry- and wetlabs widely available to residents through virtual reality surgical simulators and in-training workshops, placing simulation as a mandatory part of the resident’s preclinical training.
Obviously, we acknowledge several limitations in the present study. It is retrospectively designed. As a questionnaire optionally taken, all French residents could not be exhaustively interviewed. Nevertheless, we are grateful that a third of the residents took our questionnaire, which is meaningful for an opinion-based study. Answers were subjective. They may also reflect the lack of knowledge of residents on their access to simulation or surgery, especially among younger residents.
It is possible that some respondents to the questionnaire sent answers twice, although this eventuality seems very unlikely, given the time consumed to fill such a questionnaire, among residents, who are dealing with busy schedules in clinical practice. We would have also detected identical charts in our database in such an occurrence.
In conclusion, French Ophthalmology residents claimed satisfaction with the surgical training program they belong to, along with some regional disparities. The need for harmonization of surgical goals and objectives is underlined. The access to simulation was valued by residents, based on a progressive and supervised transition to surgical training on real patients.
Residents would support the evaluation of surgical skills, which could serve residents as an “operating license”, attest of the specific surgical knowledge they acquired and prompt their access to real surgery mastered by seniors. According to residents in ophthalmology, the program they are enrolled in should be evaluated by themselves, to improve surgical teaching.