Department of Ophthalmology University of the … most educated Filipinos of his time, Rizal...

70 PHILIPP J OPHTHALMOL VOL 33 NO. 2 JULY - DECEMBER 2008 PHILIPPINE ACADEMY OF OPHTHALMOLOGY

LECTURE

PHILIPPINE JOURNAL OF

Ophthalmology JULY – DECEMBER 2008VOL. 33 • NO. 2

Prospero Ma. C. Tuaño, MD

Department of Ophthalmology and Visual SciencesUniversity of the Philippines–Philippine General HospitalManila, Philippines

International Eye InstituteSt. Luke’s Medical CenterQuezon City, Philippines

Philippine Board of OphthalmologySentro Oftalmologico Jose RizalUniversity of the Philippines–Philippine General HospitalManila, Philippines

Correspondence to

Prospero Ma. C. Tuaño, MD

Room 219 Medical Arts Building

St. Luke’s Medical Center

E. Rodriguez Avenue

Quezon City, Philippines

Telephone : +63-2-7231060

E-mail : [email protected]

Delivered at the annual meeting of the Philippine

Academy of Ophthalmology, December 2007, Manila,

Philippines.

The challenges ofophthalmic-residency education

in the Philippines

27th Jose Rizal Memorial Lecture

Keywords: Ophthalmology, Ophthalmic education, Residency training, Board of ophthalmology

PHILIPP J OPHTHALMOL 2008; 33(2): 70-80 © PHILIPPINE ACADEMY OF OPHTHALMOLOGY

TODAY, we remember and honor Dr. Jose Protacio Mercado Rizal Alonzoy Realonda. As Filipinos, we are proud of his literary artistry and his politicalconvictions. As ophthalmologists, we feel a special sense of pride knowingthat Dr. Rizal shared our passion for sight and prevention of blindness. We areinspired to know that he was the second Filipino to be trained in ophthalmologyand the first to practice his profession in the Philippines.

Rizal’s entry into ophthalmologyRizal enrolled in medicine and philosophy at the University of Santo Tomas

(UST) at the age of 16. Contrary to popular belief, he did not complete hismedical studies in the country nor did he go abroad solely to pursue furthertraining in ophthalmology. He enrolled in Medicine and Philosophy at theCentral University in Madrid.

During his first year in Europe (1882), he read a scientific article written byDr. J. Garau Alemany, a military doctor, which discussed the successful treatmentof hemerolopic xerophthalmia through the ingestion of mammal and fish livers.The disease, later known as hypovitaminosis A, was prevalent and the main causeof blindness in the Philippines. A personal encounter with the author convincedDr. Rizal of the need to reduce the prevalence of blindness in the Philippines.Having learned of the failing eyesight of his mother, Dr. Rizal took a decisivestep to seek further training in ophthalmology. His illustrious preceptors inEurope included Don Santiago de Albitos in Madrid, Dr. Louis de Wecker andXavier Galezowski in Paris, Dr. Otto Becker in Heidelberg, Dr. Karl TheodoreSchweigger in Berlin, and Dr. Ernst Fuchs in Vienna.1-2

Rizal and the socio-political issues of his eraLike most educated Filipinos of his time, Rizal pondered on a greater

challenge: the emancipation of the Filipinos from Spanish rule. As his medicaland surgical skills grew, his nationalistic fervor intensified as well. Before hereturned to the country in 1887, he had published his first novel, the Noli MeTangere. His political drive inspired him to rise beyond aspiring for a lucrative

PHILIPP J OPHTHALMOL VOL 33 NO. 2 JULY - DECEMBER 2008 71PHILIPPINE ACADEMY OF OPHTHALMOLOGY

practice in medicine. It was true that he wanted to reducephysical blindness, but the threat of blindness caused byignorance seemed more pervasive and fatal. Educationwas the response to the challenge, and creative literaturewas his method of expression.

More than a century has passed since Rizal’s death, andour country faces problems of various kinds and varyingmagnitude. We are now a republic independent fromforeign rule, but still helplessly bound to local adversitiesand struggles within the political, social, professional, andeconomic arenas. Global changes affect us in more subtleways, positively or otherwise. Following the example ofour national hero, we must know how the currentproblems affect our society and our profession. It remainsour duty to face and respond to them.

Today, my task is clear. Being a member of the Philip-pine Board of Ophthalmology (PBO) and aware of therole that the PBO plays in the development of eyespecialists, I shall identify the challenges and assess thesystem of ophthalmic-residency education in the country.

THE PASTThe turn of the century brought to light the lack of

medical personnel in the face of a growing population.In 1950, there were only 3 medical schools for a populationof 20.3 million. The addition of 4 new schools within thenext decade brought the number to 7, to serve a popu-lation of 27.4 million (Sanchez FS, unpublished data).The addition of centers of medical and/or ophthalmictraining was founded on the need to serve the progres-sively increasing population (Figure 1).

The increase in medical and ophthalmic traininginstitutions after 1971 was prompted by the persistentshortage of medical personnel. This shortage was tracedto the social instability and anxiety of the turbulent 1960sand 1970s from which apprehensive medical graduatesfled. The opening of residency training to foreign medicalgraduates in the United States further aggravated thesituation, resulting in “brain drain.”

Issues faced by the Philippine Board of OphthalmologyThe lack of eye specialists was perceived as early as 1945

with the organization of EENT practitioners. The PBOwas created on November 12, 1971 to look into thefollowing manpower problems:3

Lack of ophthalmologistsThere were 305 eye practitioners for a population of

40 million. It was estimated that between 1970 and 1974,less than 100 new ophthalmologists were added, while thepopulation grew by 10 million. The reasons included thelack of training programs and training centers. Moreover,66% of the 305 eye practitioners were in Metro Manila,leaving 35 out of 65 provinces without any eye physician.4

Lack of residentsThere were only 15 residents distributed among five

training hospitals and there was difficulty in attractingapplicants to the program.4-5

Lack of quality training programsThe existing programs were mostly combined EENT

programs except those of the Manila Central Universityand the University of the Philippines–Philippine GeneralHospital (UP–PGH). The teaching style was mainlypreceptorship with emphasis on surgery. The lack of astructured program led to a weak exposure in basicsubjects and inadequacy of cognitive knowledge. The lackof equipment and technology compounded the problem.6-7

Achievements of the PBOIn response to these issues, the PBO sought to:• Increase the number of ophthalmologists;• Create a standardized program for residency training

and accreditation of training centers; and• Administer examinations to qualify for diplomate

status.The formative years of the PBO (1972–1986) under

Dr. Emmanuel Almeda were marked by the followingmilestones:8

• Induction of the first diplomates in 1973;• Conduct of the first written and oral examinations

in 1977;• Adoption of a standard residency-training program

in 1976 which was approved by the Philippine College ofSurgeons and the Philippine Medical Association in 1977.It included guidelines on the scope and objectives oftraining, specific programs of activities for each year level,performance criteria, physical plan and staffing of thetraining center, and steps in accreditation.

• Establishment and accreditation of eye residencytraining programs in 1977;

• Accreditation of the Basic Course and Seminars onFigure 1. Number of medical schools and eye-training centers vs. population.

100

90

80

70

60

50

40

30

20

10

0

-10

before 1950 1951-1960 1961-1970 1971-1980 1981-1990 1991-2000 2001-2007

Population (M)

Medical Schools

Eye training centers


Ocular Diseases and Surgery conducted by the UP-PGH.The next 10 years (1987–1996) under the leadership

of Dr. Romeo V. Fajardo were witness to the followingdevelopments:

• Development of new models of residency trainingin ophthalmology (Outreach, Inverted T, Extended E);

• Accreditation of the Modified Residency TrainingProgram of the Department of Health, Institute ofOphthalmology, and Helen Keller Foundation;

• More revisions of standards regarding the residencytraining programs and preceptorship;

• Abolition of the private-practice type of trainingmethod;

• Revision of policies regarding written and oralexaminations;

• Increase of eye-training programs from 14 to 32;• Increase in eye-residency positions from 46 to 152.It was during the chairmanship of Dr. Romeo B. Espiritu

that the standards of examination, credentialing, andaccreditation processes were upgraded. These proceduresare presently being implemented by the Board:

• Revision of the PBO guidelines for accreditation in1999 and 2005;

• Documentation of individual resident’s trainingactivities through a logbook;

• Mandatory submission of an annual report bytraining institutions;

• Creation and distribution of the PBO Syllabus(curricular content) for eye-residency training;

• Revision and standardization of the oral and writtenexamination format;

• Workshops for examiners on test construction andmethods of oral examination.

THE PRESENTIn the 2005 revised guidelines for accreditation, the

PBO training objectives included the following:• To produce ophthalmologists with a well-rounded

clinical and surgical competence. They shall be qualifiedto practice ophthalmology in the local setting and capableof a global type of ophthalmology practice.

• To train ophthalmologists to possess the capabilityto undertake research and teaching.

• To inculcate among ophthalmologists the duty andthe need to aspire for continuing professional growth anddevelopment.

• To make ophthalmologists aware of their ethical andsocial responsibilities.

Distribution of eye MDs in the PhilippinesIn its 1997 blindness-prevention program, the World

Health Organization (WHO) set as a goal for countriesto have “at least one ophthalmologist per 250,000

population.” The organization hopes to reach a ratio of1:100,000 for Asia in 2010 and 1:50,000 by 2020. Althoughthe Philippines achieved this goal 8 years ago, there is stilla maldistribution of eye specialists in favor of the capitalregion. The most poorly served areas are regions 5, 8, 9,12, 13, and ARMM. (Table 1)9

Distribution of PBO–ophthalmic servicesThe number of PBO diplomates increased by almost

17% between 2002 and 2007. Correlated with the 2.4%increase in population, the PBO eye MD:population ratioexhibited a slight improvement in regions 5, 6, 11, 12,Cordillera Autonomous Region (CAR), and National

Figure 2. PBO–ophthalmic services in the Philippines (2002 and 2007).

2002 2007

600,000

500,000

400,000

300,000

200,000

100,000

0

PB

O:

Po

pu

lati

on

Rati

o

Regions

All

Reg

ion

1R

egio

n 2

Reg

ion

3R

egio

n 4

Reg

ion

5R

egio

n 6

Reg

ion

7R

egio

n 8

Reg

ion

9R

egio

n 10

Reg

ion

11R

egio

n 12

CAR

NC

RC

arag

aAR

MM

1Cordillera Autonomous Region2National Capital Region3Autonomous Region for Muslim Mindanao

Table 1. Population-to-ophthalmologist ratio per region (2002).9

Population

(in million)

No. of

Eye MDs

Ratio

1:62,698

1:82,362

1:140,658

1:105,670

1:90,028

1:222,612

1:117,146

1:100,019

1:300,471

1:220,801

1:137,379

1:97,912

1:288,690

1:97,516

1:21,916

1:349,228

1:301,520

79.5

4.2

2.8

8

11.8

4.7

6.2

5.7

6.6

3.1

2.7

5.1

2.6

1.4

9.9

2.1

2.4

1,267

51

20

76

131

21

53

57

22

14

20

53

9

14

452

8

8

Total

Region 1

Region 2

Region 3

Region 4

Region 5

Region 6

Region 7

Region 8

Region 9

Region 10

Region 11

Region 12

CAR1

NCR2

Caraga

ARMM3


per year level, number of patients in the OPD and OR,conferences and research output. The centers are visitedby at least 3 board members. The facilities andinfrastructure are inspected and the senior residentsobserved and assessed in a cataract procedure. Defi-ciencies and improvements are noted and commentsprovided.

Accredited training centers and facilitiesAll the training centers possess the necessary basic

facilities such as an outpatient department and operatingroom, hospital laboratory and radiological facilities. Allthe centers also have refracting units, slitlamps, andoperating instruments for cataract and glaucomasurgeries. Collectively, 13 centers lack equipment such asvisual-field apparatus, biometer, ultrasound, fluoresceinangiography (FA), argon and Yag lasers. The PBOconsiders it acceptable for deficient training centers toaccess these equipment in neighboring hospitals.

Conferences are considered an essential componentof a residency training program. There must be at least12 department conferences a year. The university-basedcenters are the most active, followed by the private medicalcenters.

Number of patients (2005 – 2006)There were more patients, both in number and variety,

in government centers than in private hospitals. University-based government centers handled the most patients(Table 2).

Number of active faculty and specialistsAn active consultant is defined as one who holds a

specific teaching assignment, participates in the trainingof the residents for a total of 6 hours per week, and attendsat least 50% of department conferences. He should receivea satisfactory rating from the chair who is solely responsiblefor the evaluation of his performance.

There were more active consultants in the Metro Manilatraining centers than in the provinces (Table 3). In MetroManila, university-based hospitals had an average of 15consultants, while government hospitals had 6, and private

Metro Manila

University

Government

Private

Provincial

University

Government

Private

2005

15,911

15,747

3,171

4,215

4,586

1,138

2006

16,765

13,214

3,368

4,435

4,544

1,500

Table 2. Accredited training centers and average number of OPD patients.

Metro Manila

University

Government

Private

Provincial

University

Government

Private

Active Faculty

Average

15

6

20

6

5

8

Retina

4.16

1.66

3.28

0.8

1

0

Glaucoma

2

1.44

1.85

0.2

0.33

0

PL-Orbit

1.83

1.55

1.57

0.28

0.75

0

ED-Cor

3.16

1

2.42

0.28

0.5

0

Uveitis

1

0.22

0.57

0

0

0

Subspecialists

Pedia/Mot.

0.8

0.44

1.57

0.28

0.16

0

Refractive

1.5

0.11

1.28

0

0

0

N-O

1

0.44

0.57

0

0

0

Table 3. Accredited training centers and faculty (2007).

Capital Region (NCR). A minimal reduction was notedin the other regions.The Autonomous Region for MulsimMindanao (ARMM) and Caraga presented a two- tothreefold deterioration in ratio because the number ofPBO diplomates drastically decreased by almost 50% in 5years (Figure 2).

Distribution of training centers and learning facilitiesAs a result of innovative training schemes, accredited

eye training programs expanded to 45 in 2002, graduating60 to 70 residents per year and raising the ratio to 1ophthalmologist for every 63,000 Filipinos. In 1979, 60%of the provinces had no ophthalmologist; in 2002 only20% did not have eye-care services. These provinces wereeither economically deprived and/or had peace-and-orderproblems.11

At present, there are 40 accredited residency-trainingprograms in ophthalmology in the country. Twenty-twoare located within Metro Manila, while 18 are scatteredthroughout the archipelago. There are about 50 to 55graduates per year, most of whom still come from the NCR.

The absence of training centers in certain regions isassociated directly with the poor distribution of eyepractitioners and PBO diplomates in the area. It followsthat the absence or lack of eye specialists in the areaprecludes the establishment of a training program in theregional hospital.

The training institutions undergo regular evaluationevery 3 years. Each institution is requested to submit anannual report that contains the roster of faculty, residents


hospitals 20. The average number of active consultants inthe provinces was much lower in each category: 6 amonguniversity-based centers, 5 among government hospitals,and 8 in the single private training center.

Number and distribution of residentsThe total number of residents taken across all training

institutions did not change much from 2006 to 2007. Anaverage of 50 to 55 residents graduated each year in thelast 5 years.

Accredited training centers and number of diplomatesThe PBO has always emphasized the importance of the

annual diplomate examinations as a measure of theeffectiveness of each training program.12 Thus, the PBOperiodically encourages training institutions to preparetheir residents for this important evaluation. Havingwritten and oral phases allow the board to ascertain theapplicants’ cognitive understanding and skills acquiredduring training.

The number of resident graduates for the past 10 yearshad reached 727 (Table 4). However, only 57% or 411had been certified as PBO diplomates. Among the 316non-diplomates, 185 failed the examinations while 131did not apply for certification. Metro Manila graduatesappeared to perform better in the examinations thangraduates from the provinces. The graduates fromuniversity programs in either Metro Manila or provinceswere more successful in passing the exams. The graduatesof private hospitals approximated the success rates ofuniversity-based centers.

CORRELATION OF DATAA 1995 report concluded that Metro Manila graduates

performed better because of more access to universityconferences and better library facilities. It added thatuniversity-based institutions fared better than thegovernment or private hospitals because of exposure toan academic atmosphere where there was bettersupervision by the faculty, more scientific conferences, andavailable technological equipment. Today, our data reflectthe same observations.

First, Metro Manila graduates have an overwhelmingadvantage over their counterparts in the provinces.Mention is made about exposure to more universityconferences, better library facilities, and better technology.This may still be true when we compare the universitiesand the government centers, but not the private centerswhich are actually more technologically endowed. Libraryfacilities are no longer very necessary with the advent ofthe Internet and audio-video teaching materials. Learningfacilities do not seem to be too different from oneinstitution to the other, although government centers

constantly suffer the disadvantage.Second, the belief that more patients meant better

training does not appear to be true. The governmentcenters reported more patients than the private hospitals,but this did not improve their PBO examinationperformance. As a matter of fact, it could have contributednegatively by demanding more service and work from theresidents at the expense of individual study and supervisedtraining.

Third, there may be a significant correlation wherefaculty is concerned. The PBO has long emphasized theneed for a devoted faculty. The PBO guidelines emphasizethe availability of 1 active faculty member for everyresident. Visiting consultants are appreciated providedthat they comply with their teaching duties.

The greater number of active consultants in university-based and private hospitals is directly related to thenumber of their successful examinees (Figure 3). It alsocorrelates closely with the number of departmentconferences. It appears that the presence of more facultymembers produces an educational atmosphere that bringsabout better interaction and supervision of the residents.

Table 4. Accredited training centers and number of diplomates (2007).

Metro Manila

University

Government

Private

Provincial

University

Government

Private

Total

597

223

214

160

130

40

89

1

727

374 (63 %)

169 (76 %)

97 (45 %)

108 (68 %)

37 (28 %)

21 (52 %)

16 (18 %)

0

411 (57%)

91

23

52

16

40

5

34

1

131

132

31

65

36

53

14

39

0

185

223

54

117

52

93

19

73

1

316 (43%)

Graduates

1995-2006

Diplomates

Did Not

Take

Exams

Failed Nondiplo-

mates

Figure 3. Average number of faculty vs. successful examinees.

25

20

15

10

5

0University Government Private University Government Private

Metro Manila Provincial

Faculty Successful Examinees

80

70

60

50

40

30

20

10

0

% S

uccessfu

l Exam

ineesA

vera

ge N

o. o

f F

acu

lty


Fourth, because of the need to expose our residents tothe widest area of ophthalmic learning, the need forsubspecialists within the faculty has also been underscored.After the 2004 and 2007 written examinations among thePBO examinees, many cited the lack of preparation,alluding to the inadequate learning opportunities in theresidency program. Insufficient exposure in pediatricophthalmology, motility, retina, and uveitis directly reflectsthe lack of consultants to guide them.

THE CHALLENGESWe have a strong contingent of eye specialists as of 2007.

We have achieved our goal of an ideal ophthalmologist-to-population ratio, except in 6 regions. We are relievedthat 80% of our provinces have eye MDs. We are satisfiedthat our residency training programs are still able toprovide around 50 to 55 graduates per year.

Nevertheless, we feel uneasy about several volatilesituations within our ranks. The persistent maldistributionof eye MDs continues to disturb us. Economically deprivedprovinces without any ophthalmic care contrast glaringlywith abundantly served areas.

Applicants in medical schools are fewer, as many areattracted to other professions like nursing. This translatesinto fewer medical graduates, and consequently, fewerapplicants in our residency programs. Migration hasdepleted our number of applicants and forced eyespecialists to consider other careers.

Growing at a rate of 2.4%, our population was projectedto reach 88.7 million in 2007. This corresponds to anincrease in the elderly population, which comprises themajority of eye patients.

A dilemma arises. The policy to establish more trainingcenters is appealing. It was implemented by the board in1980 to 1990 to keep up with the population growth.Moreover, with the encouraging discovery that regionalgraduates eventually stay in their place of training, it islogical that the planned training centers be establishedin underserved regions.9 However, the performance levelof the regional centers in the PBO examinations leavesmuch to be desired. Only 28% of regional graduates havebecome diplomates versus 63% of Metro Manila graduates.With this scenario, opening more training centers,especially in underserved regions, may further compoundthe numbers of non-diplomates, unless their testperformance rates improve. On the other hand, openingmore training centers in Metro Manila may aggravate themaldistribution problem.

The first challenge, therefore, is to work out a rationaldistribution of ophthalmic personnel and services.

Population and affluent lifestyles amid persistentpoverty denote changing morbidities. There continues tobe an extraordinary explosion of new information and

technology in the field of ophthalmology. As educators,we realize that this new information and newly acquiredskills must be added to the already long list of residencyrequirements.12 Technology has also empowered ourpatients to be aware of these new developments. Thissituation amplifies the pressure on each one of us tomaintain an acceptable level of competency because ofthe heightened expectation of the public. The promotionof medical tourism by the government suggests keenercompetition among countries in Southeast Asia. Tobecome competitive in the global arena of ophthalmologyand offer the same quality of care, ophthalmic trainingand practice must meet global expectations.

We have focused on quantity and distribution that wemay have disregarded the assurance of quality. The presentPBO is gravely concerned with the increasing number ofnon-board-certified eye practitioners.

Faced with this dilemma, the next challenge is to assurethe competence and professionalism of all eye-residencygraduates. The goal of equitable distribution must becomplemented by honest efforts to educate our residents.At the end of a 36-month training period, the graduatesought to be willing and be prepared to pass the diplomateexaminations, and to be able to practice their craft in anethical manner anywhere in the Philippines or abroad.

PROPOSALSThe task of reforming our eye-residency training

program to assure competence and professionalism isformidable. There are short- and long-term strategies.

Short-term solutionsWorkshops in evidence-based medicine (EBM) have

been sponsored by the Philippine Academy of Ophthal-mology (PAO) to call attention to the present thrusts inglobal practice. It encourages residents to practice criticalthinking and logical decision-making by using availablefacts in the literature. Complementing this effort are theworkshops in research methodology sponsored by thePAO. By stimulating the inquisitive minds of the residents,a search for answers to scientific problems allowsimportant data to be collected and added to our pool oflocal knowledge.

The PBO realizes that these 2 endeavors are both ameans and an end. The efforts enable us to gatherPhilippine data useful for teaching and learning in thelocal setting.13 They also serve to promote habits of lifelonglearning and professional growth which is one of the majorobjectives of the PBO training program. The PBO hassupported these efforts by noting their importance andincluding the principles of EBM and research in thewritten examination.

The PBO has endorsed the in-service examinations or


the ophthalmology-proficiency examination (OPEX).Started in 2004, this annual examination is given by theUP-PGH to all residents in the country. The percentileresults enable the chair to compare his residents with theoverall national rating. Thus, they act as tools to assesswhether the resident can be promoted or not. Taking theexamination not only enhances the cognitive aspect ofthe residents’ training but, likewise, sharpens their testskills prior to the PBO examination.

The PBO encourages all residents to participate in thepostgraduate courses organized by the various trainingcenters. A minimum number of CME units will berequired.

Postresidency/preboard review classes have beenaround for quite a while. Sponsored initially bypharmaceutical companies using diplomate members asreviewers, the program has been reformatted. Attendancein the course has been statistically correlated with animproved performance in the PBO examination.

The PBO has encouraged training centers to considerconsortiums, linkages, merger, and affiliations as a strategyto enhance their training programs.14 It allows institutionsto identify their weaknesses and search for partners whocan solve the problems. A clear example is a governmentfacility with an abundance of patients but lacks faculty andtechnological resources. The ideal complement can be aprivate hospital with few patients but enough faculty andophthalmic equipments. Links can also be forged betweentraining institutions and private eye centers which offercutting-edge technology.

The active faculty must be composed not only ofcomprehensive ophthalmologists but also subspecialists.The teaching of the residents needs proper supervisionwhen patients with specialty problems are referred fortreatment. Consequently, the PBO has mandated thatsubspecialists shall become part of the faculty plantilla.

To assist the various centers in acquiring theirspecialists, the PAO has established an ad hoc committeeto plan and organize a body that can supervise andstandardize the local fellowship programs. The latter isenvisioned to augment the pool of specialists who can beequitably distributed among the different training centers.

There are plans to revise the residents’ logbook.Changes shall include a more systematic listing of surgicaland laser procedures and complications. The role of thetraining officers will be emphasized in the logbookthrough updated reporting of the performance of theresident from structured checklists.

Long-term solutionA long-term solution is our attempt to meet global

demands. Consistent with Dr. Rizal’s advocacy, educatingthe ophthalmologist is our long-term solution. Theobjective is to establish a competency-based residency

training program through the development andenforcement of a relevant and practical curriculum.

In general, ophthalmic-residency education involves theinteraction of the resident-learner, consultant-teacher, andcurriculum.

The resident–learner is an adult. Hence, the applicationof the principles of andragogy, broadly referred to aslearner-focused education, is encouraged over pedagogywhich embodies teacher-focused education. The resident,faced with a rapidly increasing body of knowledge andtechnology, duty-bound to gain surgical competence andpressured into a lifelong process of education will have tobe educated within a community of adult learners.

Malcolm S. Knowles (father of adult learning) asserted5 components of adult learning:15

1. Motivation: adults need to know WHY they arelearning something new;

2. Self-directed learning: adults want control over theirlearning experiences;

3. Needs-assessment driven: adults are aroused by arelevant problem;

4. Context: prior personal experiences influencelearning;

5. Application in “real world”: adults need to knowHOW learning can be used.

The teacher is primarily a competent eye doctor butmust be equally adept as an educator. According to DavidKolb, he should be an expert, a strong motivator, an ablefacilitator, and a role-model. He transcends his clinicalexpertise by being a skilled educator who creates a positivelearning environment, clarifies the purpose for thelearner, and shares feeling and thoughts, but does notdominate or intimidate the learner. As a role-model, hedisplays hard work, honesty, kindness, and other examplesof righteous social behavior.15

This is the most essential aspect of our new residencytraining program. Our analysis of the local residencyproblems points to our lack of qualified and dedicatedteachers—those who can and are willing to temper theirclinical practice with effective mentoring.

We were fortunate that St. Luke’s International EyeInstitute recognized the problem and organized aworkshop entitled “Educating the Educators” on October15-16, 2007. As specified in the course objectives, theparticipants:

• were able to develop a step-wise approach tocurriculum development for residency training programsincluding surgery, wet lab and lasers;

• learned techniques to improve teaching effectivenessin residency training programs;

• gained the knowledge and tools to assess theresidents for new domains on resident competency;

• understood the intricacies of program accreditation





















and individual certification in the USA and other countries.A curriculum is a planned educational experience. It

is a learning plan containing philosophy, content,approach, and assessment. It is a formal document thatincludes structure/process of programmatic learning. Itis an educational plan with goals/objectives, topics covered,and methods for learning, teaching and evaluation. Weneed a plan because there is so much to teach and learn,but limited time and resources.

A curriculum is subdivided into knowledge base, corecompetencies, learning experiences, and assessmenttools.16 Bearing in mind that ophthalmic educationinvolves developing cognitive knowledge and surgicalskills, we expect our residency curriculum to be a practicaland efficient blend of the aforementioned contents andour needs in the Philippine setting.

In the United States, the entire 7,800 residency-education programs under the Accreditation Council forGraduate Medical Education (ACGME) are undergoingreform. The reformation is motivated by advocates ofchange from the consumers (public) who demandaccountability and proof of quality; from the governmentwho is concerned with spiraling health expenses; and themarket (business corporations and insurance companies)who expect physicians to be aware of basic businessprinciples and systems-based practice.17 Locally, motivationis more down-to-earth; we are more concerned with thedistribution, competency, and professionalism of eye care.

Knowledge baseInitiated by the International Council of Ophthal-

mology (ICO), a new set of curriculum contents andguidelines has been developed for adoption by interestedcountries. Adoption means that the curriculum shall fitthe prevalence of diseases and standards of medicalpractice, as well as the cultural, economic, and politicalconditions in the country.

Five years ago, the PBO circulated among theaccredited training programs a syllabus that specified theknowledge to be learned and the technical skills to bedeveloped for each year level of the three-year residencyprogram on the following subspecialty areas:

Similarly, the ICO curriculum is an outline for 3 yearsof supervised ophthalmic training at progressively moreadvanced levels. Its contents are more detailed and specificand include extra categories of knowledge in the field oflow vision and ophthalmic practice and ethics.18

Core CompetenciesThe PBO is concerned with the increasing numbers of

non-board-certified eye practitioners. With manygraduates failing or not willing to take the examination,we may draw the conclusion that our training is inade-quate. Our long-term proposal is revision and enhance-ment of the present PBO residency-training curriculumwhere our ultimate objective is an assurance of the compe-tency and professionalism of our residency graduates.From a content-based curriculum, which espousesexposure to a specific content for a specific time, we willevolve into a competency-based curriculum which definesdesired outcomes, namely competency and profes-sionalism. From simply completing a rotation of 1 monthin a service, the program assures that the educationalobjectives within the service have been met.

A paradigm shift is occurring in the field of medicaleducation. The traditional “apprenticeship” (“know how,”“tell how,” “show how”) model of residency education hasserved us well in the past but needs reinvigoration to meetthe challenges of the modern health-care environment.With regard to the focus on learner performance (learningoutcomes), the current objective is to apply medicalknowledge by “doing”.17

The ACGME attests that our residency trainingprograms have met the core educational missions ofknowledge and skills transfer; but there is more to beinga competent physician than just application of science andtechnology in medicine. The shift involves a change fromapprenticeship to a competency-based program, fromteaching what the teacher “wants to teach” to teachingwhat the learner “needs to know” (Table 6).

The ACGME in the late 1990s determined six corecompetencies. This present set has been narrowed downfrom the work of previous commissions tasked to identifydomains of curriculum development. The six compe-tencies which have been adopted in turn by the ICO arebriefly described. The ICO defines each competency in


terms of tasks and skills that the residents shall demonstrate.19

1. Patient careResidents must be able to provide patient care that is

compassionate, appropriate, and effective for thetreatment of health problems and the promotion ofhealth. It means “what you do…”.

2. Medical knowledgeResidents must demonstrate knowledge about

established and evolving biomedical, clinical, cognate (e.g.epidemiological and socio-behavioral) sciences and theapplication of this knowledge to patient care. It means“what you know…”.

3. Practice-based learning and improvementResidents must be able to investigate and evaluate their

patient-care practices, appraise and assimilate scientificevidence, and improve their patient care practices. Itmeans “how you get better…” through constant appraisaland assimilation of current medical practices.

4. Interpersonal and communication skillsResidents must be able to demonstrate interpersonal

and communication skills that result in effectiveinformation exchange and learning with patients,patients’ families, and professional associates. It means“how you interact with others…” , like patients, their families,and your colleagues.

5. ProfessionalismResidents must demonstrate a commitment to carrying

out professional responsibilities, adherence to ethicalprinciples, and sensitivity to a diverse patient population.It means “how you act and behave…”.

6. System-based practiceResidents must demonstrate an awareness of and

responsiveness to the larger context and system of healthcare and the ability to effectively call on system resourcesto provide optimal care. It means “how you interact with thesystem…”, like the Philippine Health Insurance Corpo-ration (PhilHealth), Bureau of Internal Revenue, health-maintenance organizations (HMO), and medical societies.

In 2002, the American Board of Ophthalmology (ABO)added surgical competence as the seventh.20

The overall goal is to integrate the core competenciesinto each of the knowledge areas enumerated by the PBOand the ICO in order to have a comprehensive trainingin ophthalmology. The competencies must be developedas the resident rotates among the various subspecialties.As part of the total design of our residency trainingprogram, the process of integration will entail the

following considerations, foremost of which are three.16

A. Learning experiences/Approaches to learningTraining shall be provided through a combination of

lectures, supervised patient care, and graduated, hands-on procedural and surgical experience, research andindependent study. Beyond lectures are interactivesessions, small group discussions, and problem-basedlearning.

At present, our residency program utilizes theoutpatient department (OPD) for interacting directly withpatients. It is one of the most powerful tools for trainingbecause all the competencies can be sharpened. Withinthe OPD, subspecialty clinics are also effective indeveloping the six competencies and enhancingspecialized medical knowledge.

Conferences focus on the domain of medicalknowledge, interpersonal communication, and practice-based learning. It is primarily useful for the resident whois presenting a case or topic.

Medical missions can be reinvented for the benefit ofall concerned. It can be transformed into communityservice and utilized as part of resident education.

B. AssessmentThe old tools for assessment are written and oral

examinations. The written test questions are pooled fromall the training centers, are rigorously screened by a panelof experts, and undergo post-test analysis. The PBO oralexaminations have evolved from single examiner-constructed test questions in the 1980s to standardizedmodels with uniform rating scales and grading systemswith the examinee facing a panel of 4 examiners ratherthan a single examiner.

Efficient as the system may be, what is measured areonly knowledge and skills after residency training. Whatis lacking and must be developed is a structured in-serviceevaluation that can provide a formative feedback and allowthe training officer to correct deficiencies of the residentbefore residency ends.

Assessment tools are available and constantlyundergoing validation. Because each competency is aconcern, it shall be matched to the appropriate assessmenttool. Each assessment tool has its advantages anddisadvantages which makes it suitable for one competencyover another.20-28

Examples include:• Patient care – structured checklist (eg.OCEX, OCAT);• Medical knowledge – written and oral examinations

(OPEX);• Practice-based learning, eg. journal club and chart

audit – structured checklist;• Interpersonal skills – 360° evaluation (peer, patient);


• Professionalism – 360° evaluation (peer, patient);• Systems-based practice – 360° evaluation (peer,

patient);• Surgery – logbook, structured checklist (eg. OASIS,

GRASIS, ESSAT).

C. Surgical trainingIt is now considered desirable for supervised surgical

training to begin as soon as possible after entry into theophthalmic educational system. Following the Dreyfussmodel of skills acquisition, graduated levels ofimprovement shall occur, commensurate with the trainee’seducation and set of skills. A resident starts as a novice,continues as a beginner and an advanced beginner, beforebecoming proficient, and finally becomes an expert.26 Inaddition to acquiring intra-operative skills, the traineemust acquire abilities for pre-operative selection of suitablesurgical candidates and in postoperative care.

Didactics prepare the residents through readingprograms, lecture series, videotapes, and Web-based systemof instruction.29 These are complemented by structuredpreparatory exercises such as practice surgery on animaland outdated eye-bank eyes, dissection of cadavers,simulations and virtual surgery.30-31 Assisting senior expertsurgeons on a regular basis is a time-honored and helpfuleducational activity for the trainee.32 Constructivefeedback completes the elements of surgical training.Videotaping surgery performed by trainees is extremelyhelpful, both for the surgeon in training and the mentor.

CONCLUSIONAs an academic endeavor, ophthalmic education is

directed towards a widely diversified audience thatincludes residents, undergraduate medical students,fellows, and practicing ophthalmologists.

In addressing the advocates of ophthalmic education,the ICO has also developed curricular programs forundergraduate medical students, fellowship training, andfor continuing medical education. It urges us to establishan identical approach to training in these areas.18

We are fortunate that the stakeholders responsible forthe education of each group are already in place. TheAssociation of Ophthalmology Professors (APOP),organized in 1991, aims to unite the professors involvedin the teaching of undergraduate medical students.33

Meanwhile, the PAO has organized a committee to overseethe burgeoning fellowship programs. The PAO committeeon continuing ophthalmology education is responsiblefor updating all practicing eye MDs.

I see the PBO exerting its leadership in mobilizingresources to improve the residency curriculum. It shallask the UP-PGH Department of Ophthalmology andVisual Sciences to align the Basic Course lectures to

current global standards. It shall deputize the St. Luke’sophthalmology faculty to continue its present endeavorin enhancing the PBO syllabus with the ICO curriculum.It shall mobilize selected training centers to experimenton innovative schemes of teaching and assessment. It shallcoordinate with the other stakeholders to promote thegrand scheme of educating the ophthalmologist.

It is said that a lectureship is a discourse given by aperson who has spent a significant portion of his life inpursuit of answers and solutions on a particular subject.It now appears that the timeline has reversed. A challengehas been posed. The PBO accepts the challenge, remem-bering the admonition of the great ophthalmologist, Dr.Jose P. Rizal: “It is a useless life that is not consecrated to agreat ideal. It is like a stone wasted on the field withoutbecoming a part of any edifice.”

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