Residents more confident in clinical skills than nonclinical

It is no surprise that residents are ready to be ophthalmologists upon graduation but feel ill-prepared to practice ophthalmology. Most residencies offer outstanding clinical training, good surgical volume, informative didactic sessions, etc., and the Accreditation Council for Graduate Medical Education (ACGME) closely monitors the programs for quality assurance. In addition, there are Ophthalmic Knowledge Assessment Programs (OKAPs) and board exams that are meant to test our ophthalmic knowledge. On graduation, we are ready and able to diagnose and treat a wide variety of ocular conditions.

A wide range of solutions

I can envision a wide range of possible solutions. Several residency programs already invite local attorneys to make presentations about contract negotiation, disability insurance, etc. I have heard of several state eye societies holding seminars on coding and billing. Recently, the American Academy of Ophthalmology (AAO) published a wonderful text that will accompany the Basic & Clinical Science Course series, entitled The Profession of Ophthalmology: Practice Management, Ethics, and Advocacy. All of these efforts represent a great start.

Many would suggest improving on this foundation by making lectures on these topics a part of our regular didactic schedule.

Perhaps we could invite some of the part-time professors who maintain busy community practices to share their understanding of "nonclinical" medicine with the residents. Program directors could institute mentoring programs, similar to the one studied by Dr. Tsai et al.,^2,3 which would help residents acquire and maintain these skills. Others would suggest that the ACGME could step in, by requiring this content under the heading of its core competencies.⁴ Some would suggest going even further, by incorporating this information as part of the OKAP or ophthalmology board exam.

In my mind, many of these ideas would improve how well we are prepared in "nonclinical" medicine, but I still would consider them passive learning-just as reading about or taking a written test on cataract surgery is passive compared with actually doing cataract surgery, which I would consider active learning.

A thought experiment

In keeping with the general philosophy that one learns by doing and not by watching, I thought it would be an interesting thought experiment to apply this viewpoint to the question at hand: is there a way to incorporate "nonclinical" medicine fundamentally into the resident experience without diluting the high level of clinical medicine we already learn?

The answer I came up with: make the resident clinic as similar to private practice as possible, including coding and billing, and make residents' salaries based on productivity. At first I thought this was a truly wacky idea, but as I think about it more, the logic of it seems increasingly valid.