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DEPARTMENT OF OPHTHALMOLOGY

RESIDENCY PROGRAM MANUAL 2017-2018 ACADEMIC YEAR

TABLE OF CONTENTS Section Page # 1 EDUCATIONAL OBJECTIVES AND GOALS ............................................................. 1

A. Goals .......................................................................................................................... 1 B. Objectives ................................................................................................................. 1

2 STATEMENT OF PURPOSE ......................................................................................... 1

A. Introduction ............................................................................................................... 1 B. Core Competencies ................................................................................................... 2 C. Academic Program .................................................................................................... 2 D. Clinical Training ....................................................................................................... 3 (1) First Year Resident ........................................................................................... 3 (2) Second Year Resident ....................................................................................... 3 (3) Third Year Resident .......................................................................................... 3 E. Responsibilities of the Chief Resident ...................................................................... 3 F. Research ...................................................................................................................... 5

(1) Human Subjects Protection Program (HSPP) ................................................... 5 (2) IRB Approval ................................................................................................... 5

3 EDUCATION .................................................................................................................... 5

A. Basic Responsibilities ............................................................................................... 5 B. Core Competencies ................................................................................................... 5

(1) Patient Care and Procedural Skills ..................................................................... 6 (2) Medical Knowledge .......................................................................................... 6 (3) Practice-Based Learning and Improvement ...................................................... 6 (4) Interpersonal and Communication Skills .......................................................... 7 (5) Professionalism ................................................................................................... 7 (6) Systems-Based Practice ...................................................................................... 7

C. Required Reading ........................................................................................................ 7 D. Journal Subscriptions .................................................................................................. 9 E. Arizona Ophthalmological Society Membership ........................................................ 9

4 EDUCATIONAL LEAVE/EXTRAMURAL COURSES ............................................... 9

A. Educational Leave ..................................................................................................... 9 (1) Presentations ....................................................................................................... 9 (2) Conferences/Courses ........................................................................................ 10

B. Extramural Courses ................................................................................................... 10 C. Community Service ................................................................................................... 10 D. BLS Certification ........................................................................................................ 10

5 BASIC EQUIPMENT ........................................................................................................ 11

6 SUPERVISION POLICY AND LINES OF RESPONSIBILITY ..................................... 11 A. Supervision Policy ..................................................................................................... 11 B. Lines of Responsibility ............................................................................................... 12

7 DUTY HOURS AND FATIGUE ...................................................................................... 22

A. Duty Hours .................................................................................................................. 22 B. Fatigue ....................................................................................................................... 23

8 ON CALL DUTIES AND SCHEDULE OF ASSIGNMENTS ......................................... 24 9 CONSULTATION POLICY ............................................................................................. 26 10 RESIDENT SURGICAL EXPERIENCE .......................................................................... 27 11 QUALITY ASSURANCE POLICY .................................................................................. 30

A. QIPS Conference ...................................................................................................... 30 B. Total Quality Improvement ........................................................................................ 30

C. Continuous Quality Improvement (CQI) .................................................................... 34 12 ATTENDANCE POLICY ................................................................................................. 35

A. Clinic/Surgery ........................................................................................................... 35 B. Conferences ............................................................................................................... 35

13 LEAVES OF ABSENCE ................................................................................................. 36

A. Vacation ................................................................................................................... 36 B. Sick Leave .................................................................................................................. 37 C. Bereavement Leave .................................................................................................... 37 D. Holidays ..................................................................................................................... 37 E. Academic Time ........................................................................................................... 37 F. Education Time ........................................................................................................... 38

14 RECORDKEEPING .......................................................................................................... 38

A. Surgical and Clinical Logs .......................................................................................... 38 B. Conference Attendance Log ........................................................................................ 39

15 INCENTIVES .................................................................................................................. 39 16 FACULTY ADVISOR ...................................................................................................... 40 17 RESIDENT EVALUATION OF FACULTY, PROGRAM,

AND ASSIGNMENTS .................................................................................................... 40 A. Faculty ....................................................................................................................... 41 B. Program ..................................................................................................................... 41 C. Rotation ..................................................................................................................... 41

18 FACULTY EVALUATION OF RESIDENTS .................................................................. 41 19 OTHER EVALUATIONS OF RESIDENTS ................................................................... 42 20 ORAL AND OKAP EXAMINATIONS ............................................................................ 43

A. Oral Examinations ..................................................................................................... 43 B. OKAP Examination .................................................................................................... 43

21 CLINICAL COMPETENCY COMMITTEE .................................................................. 44 22 INTERNATIONAL ROTATION ...................................................................................... 44

23 PROMOTION (ADVANCEMENT) ............................................................................... 45 24 PROBATION AND DISMISSAL ................................................................................... 45 25 PRACTICE PRIVILEGES AND OTHER ACTIVITIES

OUTSIDE THE SCOPE OF THE EDUCATIONAL PROGRAM ................................. 45 26 BOARD ELIGIBILITY ..................................................................................................... 46 27 COMPLAINTS REGARDING WORK ENVIRONMENT ............................................ 46 28 COMMITTEES ............................................................................................................ 46 29 COUNSELING SERVICE .............................................................................................. 46 30 DRESS CODE ................................................................................................................. 45 31 ADMINISTRATIVE SUPPORT ....................................................................................... 47 32 PRE-DIPLOMA CHECKLIST .......................................................................................... 48 33 POLICIES SPECIFIC TO INSTITUTION ...................................................................... 48

A. Medical Records – BUMCT AND BUMCS ............................................................. 48 B. SAVAHCS .................................................................................................................. 50

(1) Purpose ............................................................................................................. 50 (2) Local Program Director .................................................................................... 51 (3) Facilities ........................................................................................................... 51 (4) Educational Experience .................................................................................... 52 (5) National Mandates/OSHA and National Quality Forum .................................. 52 (6) Medical Records Documentation ..................................................................... 53 (7) Medical Library ................................................................................................ 53 (8) Shared Calendars .............................................................................................. 53 (9) Fee Basic Consults ............................................................................................ 53

(10) SAVAHCS Patients After Hours/Weekends ................................................... 53 (11) Patient/Clinic Cancellation .............................................................................. 54 (12) Surgery/24-Hour Post-Op Patients .................................................................. 54 (13) Patient Notes .................................................................................................... 55 (14) Dirty Instrument Policy ................................................................................... 55 (15) Axial Lengths Calculations ............................................................................. 55

34 MEDICAL MARIJUANA ............................................................................................... 55

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1. EDUCATIONAL GOALS AND OBJECTIVES

A. Goals

The goals of the Ophthalmology Residency Program are to:

(1) Train ethical, comprehensive, and compassionate ophthalmologists.

(2) Provide residents with enough didactic instruction and clinical experience to obtain American Board of Ophthalmology (ABO) certification.

(3) Provide residents with the fundamental scientific background in ophthalmology to prepare

them to become life-long learners. (4) Provide residents with skills to practice evidence-based medicine.

B. Objectives

The objectives of the Ophthalmology Residency Program are to:

(1) Provide residents with a strong scientific understanding of the fundamentals of ophthalmology.

(2) Provide residents with clinical skills in all subspecialties of ophthalmology. (3) Provide residents with broad surgical experience in all subspecialties of ophthalmology

(4) Encourage residents to perform literature reviews and use critical thinking skills to make

informed patient care decisions.

(5) Provide residents with an understanding of ethical, legal, and moral issues involved in eye care and medical care.

(6) Provide residents with the fundamental business and managerial skills for a systems-based

practice. 2. STATEMENT OF PURPOSE

A. Introduction

The Ophthalmology Residency Program offers a three-year program that blends clinical training, academic activities, and research opportunities. There are two residents in each of the three years of the program. This handbook provides a general description of the program, the structure of the residency training at the affiliate institutions, and the standards and expectations of resident performance.

The Department of Ophthalmology staff consists of six full-time ophthalmologists at University of Arizona (UA). There is a large associate staff of affiliate/associate (“volunteer”) faculty, two full-time optometrists, two research faculty, and a supporting staff of technical personnel. There are three full-time and four part-time physicians at the Southern Arizona Veterans Administration Health Care System (SAVAHCS). Three affiliated hospitals – Banner-University Medical Center Tucson (BUMCT), Banner-University Medical Center South (BUMCS), and SAVAHCS, each with active

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inpatient/outpatient services, as well as research and teaching facilities, are involved in the residency program.

Approximately 19,000 patients per year visit the Ophthalmology clinics at Alvernon. Rotations are also provided at SAVAHCS, where there are approximately 15,000 patient visits. Residents participate in state-of-the-art diagnostic and therapeutic interventions for these patients. The residents also rotate with community physicians:

Ann McColgin, MD, and Mingwu Wang, MD, PhD; Cornea Associates Patrick Tsai, MD, MHA; Tucson Eye Care (general/glaucoma) Wayne Bixenman, MD (neuro-ophthalmology) Kathleen Duerksen, MD (oculoplastics) Brock Bakewell, MD, William Fishkind, MD, Jeff Maltzman, MD, and Brian Hunter, MD;

Fishkind, Bakewell, Maltzman and Hunter Eye Care and Surgery Center (refractive surgery) April Harris, MD, Cameron Javid, MD, Egbert Saavedra, MD, and Mark Walsh, MD; Retina

Associates Southwest Mikel Lo, MD; About Faces Cosmetic Surgery

Each facility has its own unique qualities. The Department of Ophthalmology provides intensive faculty contact with private practice in an academic setting. SAVAHCS has a resident-oriented program with excellent faculty presence. Corneal diseases are the focus of the rotation with Cornea Associates (Ann McColgin, MD, and Mingwu Wang, MD, PhD). Dr. Tsai provides experience in general ophthalmology and glaucoma in a private practice setting. Drs. Bakewell, Fishkind, Maltzman, and Hunter provide experience in a refractive surgery private practice setting. Retina Associates Southwest is a private practice setting with an emphasis on vitreoretinal conditions. Dr. Lo provides experience in oculoplastics in a private practice setting.

B. Core Competencies

In accordance with ACGME guidelines, residents are expected to develop competencies in six core areas:

Patient Care and Procedural Skills Medical Knowledge Practice-Based Learning and Improvement Interpersonal and Communication Skills Professionalism Systems-based Practice

C. Academic Program

The foundations of the didactic program of the residency are weekly conferences in the various subspecialties and weekly clinical teaching rounds. In addition, there are wet labs, unique conferences, and journal clubs. There are conferences provided by the Tucson Ophthalmological Society, an annual conference organized by the Arizona Ophthalmological Society, and occasional guest speakers at industry-sponsored events in the Tucson community. Resident participation in the Tucson Ophthalmological Society meetings is expected, unless a meeting conflicts with a scheduled resident conference, which takes priority for resident attendance.

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D. Clinical Training

During the three years of residency, residents assume increasing responsibility for patient care and education. Beginning residents are closely supervised, and then given increasing autonomy as they demonstrate proficiency and understanding. Residents prepare case presentations, organize journal clubs, and assist in teaching medical students and other residents rotating through ophthalmology. In addition, senior residents, with faculty supervision, are expected to supervise and teach junior residents. Faculty are assigned and available for consultation with the residents on all rotations.

(1) First Year Resident: The first year resident performs complete ocular examinations in the

outpatient facilities, becoming proficient in gonioscopy, indirect ophthalmoscopy, tonometry, biomicroscopy, refraction, and physiologic testing. The resident rotates through the Alvernon clinics, SAVAHCS for a continuity care clinic and oculoplastics, the practice of Dr. Wayne Bixenman for neuro-ophthalmology, the private practice of Dr. Patrick Tsai for general ophthalmology and glaucoma, the private practice of Drs. Kathleen Duerksen and Dr. Mikel Lo for oculoplastics, and the private practice of Drs. Bakewell, Fishkind, Maltzman, and Hunter for refractive surgery. The resident gains extensive experience in evaluating walk-in and emergency patients on a daily basis. The earliest encounters with ocular trauma are during the first year; and there is exposure to the subspecialty services, including contact lenses, cornea and external disease, glaucoma, neuro-ophthalmology, oculoplastics, pediatrics, and retina. The resident begins assisting at surgery during this year, and performs minor surgical procedures.

(2) Second Year Resident: The second year resident rotates through cornea and external disease,

general, glaucoma, pediatrics, and retina. The resident participates in rotations at the private practices of Dr. Wayne Bixenman, Dr. Patrick Tsai, Cornea Associates and Retina Associates Southwest. The resident also rotates at the SAVAHCS for continuity clinic and oculoplastics.

(3) Third Year Resident: During their third year, the resident serves as Chief Resident for three

months of the year and manages clinics at SAVAHCS for nine months. The resident at this stage of training performs surgery under faculty supervision. Based on the problem, the resident's experience, and attending preference, there will be successive levels of autonomy. The resident will be involved with the pre-operative and post-operative care of each surgery performed. As Chief Resident, the resident will have responsibility for scheduling their clinical and surgical duties. They will be given a block of time each week for administrative responsibilities. They will also assist in supervising the junior residents. At the conclusion of the third year, the residents are expected to be able to enter practice without direct supervision.

All residents participate in wet and dry labs, receiving instruction on surgical techniques and suturing. The wet lab is equipped with a microscope and phacoemulsification unit.

E. Responsibilities of the Chief Resident

The Chief Resident responsibilities are divided between those internal to the Department operation and external (sponsoring institution). During the senior year, the Department responsibilities (call, location, rounds presentations assignments, etc.) may be shared between the senior residents on a rotation determined by the senior residents. However, external duties may be peer selected or determined by the Program Director at the beginning of the year.

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(1) The Chief Resident is responsible for collecting vacation requests, screening vacation requests for appropriateness, and passing the information to the program coordinator. The requests will be approved by the Program Director.

(2) The Chief Resident is responsible for scheduling call for first call and back-up (second) call,

and providing the schedule to the program coordinator. The schedule must comply with duty hour standards. The scheduled will be approved by the Program Director.

(3) The Chief Resident is responsible for the content of weekly teaching rounds–creating the

schedule of presenting residents and ensuring the program content is appropriate. The Chair or Program Director will approve any outside speaker.

(4) The Chief Resident is responsible for preparing the monthly resident assignments based on the

core rotations, and providing the schedule to the program coordinator. He/she also responsible for reassigning residents as necessary, i.e. when a resident is off due to illness, or when a clinic is cancelled due to faculty illness, and providing the updated information to the program coordinator. He/she points out deficiencies or problem areas to the Program Director. The Chief Resident is also responsible for preparing the monthly medical student assignments.

(5) The Chief Resident surveys the lecture schedule, and points out deficiencies or problem areas

to the Program Director. When more than six residents are going to miss a lecture (conference, vacation, sick) on a lecture, he/she must contact the program coordinator, who will inform the lecturer, who has the option to reschedule or proceed with the scheduled lecture.

(6) The Chief Resident assures that attendance is taken at the regularly scheduled lectures. If

he/she is unable to be present, he/she assigns this task to another resident. The Chief Resident is responsible for providing accurate attendance records to the program coordinator. If a resident does not attend the entire lecture, the amount of time the resident was present for the lecture must be noted on the attendance sheet.

(7) The Chief Resident is responsible for the agenda at semi-annual resident/faculty meetings,

which are held in fall (September) and spring (March).

(8) The Chief Resident, or his designee, should attend the clinical faculty meetings to provide input about the residency program

(9) The Chief Resident facilitates collegial and professional interaction among the residents.

(10) The Chief Resident is responsible for attending the quarterly Chief Resident dinner held by the GME office. ACGME requires representation from all programs. If the Chief is on vacation/sick/emergency surgery, then another resident from the same program must attend (preferably the other senior resident).

(11) The Chief Resident is responsible for attending the annual program evaluation committee

meeting.

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F. Research

The research interests of the Department of Ophthalmology center on amblyopia, corneal diseases, glaucoma, retinal diseases, strabismus, and vision development. Optics, ocular physiology, and pharmacology are integral parts of the research program. There are always ongoing clinical studies evaluating new treatment modalities. There is also a basic science lab on the second floor of the Medical Research Building (near BUMCT).

While the Department has no formal research requirement, residents are encouraged to participate in a research project. The Department offers laboratory facilities and the guidance of faculty who are involved in full- or part-time research. The faculty will also provide education on how research is conducted, research design, hypothesis testing, statistics, and epidemiology, as well as statistical assistance. Residents are encouraged to present their research at national meetings, such as those held by the Association for Research in Vision and Ophthalmology (ARVO), the American Society of Cataract and Refractive Surgery (ASCRS), and the American Academy of Ophthalmology (AAO). The Department makes every effort to support these activities through faculty mentorship.

Research topics may include results of basic or clinical research. The objective of this requirement is to provide an understanding of the mechanics of preparation of a scientific paper as well as to strengthen the residents' ability to critically evaluate publications. If funds are available, the Department will cover the cost of all reasonable production expenses; anticipated expenditures must be pre-approved by the Department (submit request to program coordinator).

(1) Human Subjects Protection Program (HSPP): Human subjects training is required for all

residents. The CITI Course in The Protection of Human Research Subjects is available online through the HSPP at orcr.arizona.edu/hspp/training. This program should be completed within the first two months of training (by August 31, 2017). After completion of the course, the resident is responsible for providing a copy of the certificate to the program coordinator, which will be placed in the resident’s portfolio. The resident must also to complete conflict of interest (COI) training at https://uavpr.arizona.edu/COI, as well as submit a Disclosure of Significant Financial Interests, even if the resident has no significant interests to disclosure.

(2) IRB Approval: IRB approval must be obtained for all research projects involving human subjects. The “Determining Human Research” form must be provided for all research projects not requiring IRB approval. All forms are available on the HSPP website at orcr.vpr.arizona.edu.

3. EDUCATION

A. Basic Responsibilities

Each resident is primarily responsible for his/her own education. Learning begins with study, both of patients and text. The patient is the single most important teaching tool for residents, who must be treated with respect and dignity.

B. Core Competencies

In accordance with ACGME guidelines, residents are expected to develop competencies in six core areas: patient care and procedural skills, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice.

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(1) Patient Care and Procedural Skills

Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Residents: must demonstrate competence in patient care, including:

o evaluating and assessing pre-operative ophthalmic and general medical indications for surgery and surgical risks and benefits;

o managing systemic and ocular complications that may be associated with surgery and anesthesia;

o obtaining informed consent; and o providing acute and long-term post-operative care.

Residents must be able to competently perform all medical, diagnostic, and surgical procedures considered essential for the area of practice. Residents: must demonstrate competence in patient care, including:

o intra-operative skills; o performing ophthalmic procedures as primary surgeon, including:

‒ cataract; ‒ cornea; ‒ glaucoma; ‒ glaucoma laser; ‒ globe trauma; ‒ oculoplastics/orbit; ‒ retinal/vitreous; and, ‒ strabismus.

o using appropriate local and general anesthetics.

(2) Medical Knowledge

Residents must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological and social-behavioral sciences, as well as the application of this knowledge to patient care. Residents: must demonstrate competence in their knowledge of the basic and clinical sciences specific to

ophthalmology. must demonstrate competence in their knowledge of: cataract surgery, contact lenses, cornea

and external disease, eyelid abnormalities, glaucoma, neuro-ophthalmology, ocular trauma, optics and general refraction, orbital disease and ophthalmic plastic surgery, pathology, pediatric ophthalmology and strabismus, systemic disease consults, uveitis, visual rehabilitation and refractive surgery, and retinal/vitreous diseases.

(3) Practice-Based Learning and Improvement

Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning. Residents are expected to develop skills and habits to be able to meet the following goals: identify strengths, deficiencies, and limits in one’s knowledge and expertise; set learning and improvement goals; identify and perform appropriate learning activities;

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systematically analyze practice using quality improvement methods, and implement changes with the goal of practice improvement;

incorporate formative evaluation feedback into daily practice; locate, appraise, and assimilate evidence from scientific studies related to their patients’

health problems; use information technology to optimize learning; and, participate in the education of patients, families, students, residents and other health

professionals. (4) Interpersonal and Communication Skills

Residents must demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals. Residents are expected to: communicate effectively with patients, families, and the public, as appropriate, across a broad

range of socioeconomic and cultural backgrounds; communicate effectively with physicians, other health professionals, and health related

agencies; work effectively as a member or leader of a health care team or other professional group; act in a consultative role to other physicians and health professionals; and, maintain comprehensive, timely, and legible medical records, if applicable.

(5) Professionalism

Residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles. Residents are expected to demonstrate: compassion, integrity, and respect for others; responsiveness to patient needs that supersedes self-interest; respect for patient privacy and autonomy;

accountability to patients, society and the profession; and, sensitivity and responsiveness to a diverse patient population, including but not limited to

diversity in gender, age, culture, race, religion, disabilities, and sexual orientation. (6) Systems-Based Practice

Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care. Residents are expected to: work effectively in various health care delivery settings and systems relevant to their clinical

specialty; coordinate patient care within the health care system relevant to their clinical specialty; incorporate considerations of cost awareness and risk-benefit analysis in patient and/or

population-based care as appropriate; advocate for quality patient care and optimal patient care systems;

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work in interprofessional teams to enhance patient safety and improve patient care quality; and,

participate in identifying system errors and implementing potential systems solutions.

C. Required Reading

Residents should read about specific diagnostic entities encountered in clinic each day. In addition, residents should read the American Academy of Ophthalmology (AAO) Basic Clinical and Sciences Course (BCSC) completely.

The BCSC mirrors the core curriculum of basic and clinical science training in the residency program. The faculty (full-time, part-time, and volunteer) are sufficiently large and diversified to provide the clinical expertise for the didactic training. Residents are required to purchase and participate in the BCSC curriculum. Residents should have the BCSC at the start of their residency training. The BCSC is available from the American Academy of Ophthalmology (AAO) at a discount rate for members. Membership forms can be obtained by calling 415-561-8581 (www.aao.org). AAO membership is complimentary to first year residents; membership is usually not effective until July 1. To assist in the new resident’s introduction to ophthalmology, the following specific textbooks/manuals are recommended. These are:

(1) Practical Ophthalmology: A Manual for Beginning Residents (2) Fundamentals and Principles of Ophthalmology (Book 2, BCSC) (3) The Fine Art of Prescribing Glasses Without Making a Spectacle of Yourself, B. Milder and

M.L. Rubin (4) Wills Eye Manual

Practical Ophthalmology: A Manual for Beginning Residents and Fundamentals and Principles of Ophthalmology are available from the American Academy of Ophthalmology (AAO) (www.aao.org), and also. Optics for Clinicians and The Fine Art of Prescribing Glasses Without Making a Spectacle of Yourself can both be purchased from www.amazon.com. A voucher for the Wills Eye Manual is usually provided to 1st year residents by Allergan. Arizona Health Sciences Library Online Textbook Access: Many ophthalmology textbooks are available online through the Arizona Health Sciences Library website. Your will need to use your UA netID login and password to access the ebooks.

1. Go to the Arizona Health Sciences Library website at www.ahsl.arizona.edu. 2. Click the “Top resources” heading on the top banner. 3. Click “ClinicalKey | First Consult” from the dropdown list. 4. Click “ClinicalKey.” 5. Click “Books.” 6. Click “Filter By”on the left sidebar. 7. Click “Specialties” on the left sidebar. 8. Click “+ More Subspecialties” on the left sidebar. 9. Select “Ophthalmology.”

There are 50 online textbooks, which includes all subspecialties. atlases, video atlases, general ophthalmology references, differential books, therapy references, etc. Some of these books, such as Ryan’s Retina, Cornea, and Glaucoma are the go-to sources for general information on

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a topic. Of course, by the time a book goes to print some of the information requires updating and the journal articles will help fill in the contemporary gaps for presentation. ClinicalKey also has direct access to a few of the most cited ophthalmology journals, but access to a larger number may be achieved through the PubMed portion of the Arizona Health Sciences Library portal. Albert and Jakobiec’s Principles and Practice of Ophthalmology is an excellent all-round reference work in ophthalmology (available from www.amazon.com) or online through the Arizona Health Sciences Library. One should not consider the Jakobiec book to be all encompassing, and residents are expected to read other specialty textbooks and peer-reviewed literature. Residents should consult faculty members before investing in an expensive reference work.

D. Journal Subscriptions

Residents are encouraged to become a member of the AAO (membership is free). The journal, Ophthalmology, is included in the membership. Membership in the American Society for Cataract and Refractive Surgery (ASCRS) is complimentary to ophthalmology residents, and residents are encouraged to join. Members will receive the Journal of Cataract and Refractive Surgery as a benefit of membership (www.ascrs.org).

E. Arizona Ophthalmological Society Membership

Residents are encouraged to join the Arizona Ophthalmological Society (AOS) (membership is free). The AOS serves as a source of educational, social, and ethical exchange for the ophthalmologists in the state. Their annual meeting is held each spring at the High Country Conference Center in Flagstaff with excellent invited speakers. The membership application is available from the Program Coordinator. The AOS sponsors one or more residents for AAO Advocacy Day, which is held annually in Washington, DC, during spring (April 18-21, 2018). Residents are contacted by Jeff Maltzman, MD, by email when the time to apply is approaching. Interested residents should contact Dr. Maltzman and submit a completed application, including a short essay. The selected residents are required to give a short presentation to the faculty and residents at rounds after attending.

4. EDUCATIONAL LEAVE/EXTRAMURAL COURSES

A. Educational Leave

Residents are eligible for up to five (5) days of educational leave per year. This includes presentations at conferences (excluding AAO for seniors) and courses (excluding the review course for 2nd year residents). To be eligible for educational leave for conferences, see “presentations” below. To be eligible to use educational days for courses (such as CORE), residents must provide proof of attendance or vacation will apply.

(1) Presentations

Residents who present work (paper, poster, etc.) at national meetings as the presenting (first) author are eligible for up to two days educational leave (the day of the presentation, plus the day immediately before or after the presentation for travel). The resident must have a faculty member as advisor of the project and the faculty member must be a co-author. To be eligible for

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educational leave, poster printing, and travel funds (if needed/available), approval must be obtained from the Program Director or Department Head prior to submission of the abstract. To apply, complete the Resident Abstract Approval/Travel Grant Application (Forms, page 42), get the signature of the faculty advisor, and submit to the program coordinator. The application form is available online in the forms folder of “public resident files.” Presentations may also be funded by grant funds of an individual faculty member, if the presentation is for a funded research project. If a presentation is not funded by the Department, Banner, or research funds, residents must provide their own funding, but may still be eligible for educational leave.

(2) Conferences/Courses

2nd Year Review Course: Second year residents will be granted up to four days of educational

leave for the review course.

3rd Year AAO: Third year residents who attend the AAO annual meeting will be granted up to three days of educational leave, and up to $850.00 for reimbursement of eligible travel expenses. Residents must use vacation for any additional days for this conference (not eligible for additional educational days). Residents must submit receipts for eligible travel expenses to the program coordinator within 30 days after their return. Receipts not returned within the deadline will not be reimbursed.

To be eligible for reimbursement for travel expenses for conferences, residents must submit the following information to the program coordinator: (1) name and dates of conference/course, (2) email confirmation for presentation, (3) planned airline itinerary, and (4) name and address for hotel. This information must be provided at least 30 days in advance to allow time for the travel to be authorized. Travel expenses may not be eligible for reimbursement if authorization was not obtained in advance. Per University policy, there will be no reimbursement for alcoholic beverages. Residents can ONLY be reimbursed for their OWN expenses.

B. Extramural Courses

Residents are expected to attend all ophthalmology courses held in Tucson unless the meeting conflicts with a resident conference. These include Tucson Ophthalmological Society meetings, Arizona Ophthalmological Society meetings in Tucson, Residents’ Day event (Science of Eye Disease Seminar/Jorge Rodríguez Memorial Lecture), and other Department-sponsored courses. A list of these courses is made available throughout the year.

C. Community Service

Residents are required to participate in a charitable undertaking once a year. Such activities include assisting with the glaucoma/diabetic retinopathy screenings at St. Elizabeth’s Health Center, Lions Club-sponsored surgery, etc.

D. BLS Certification

All residents must be BLS certified. Banner provides free BLS recertification for residents, but it is each resident’s responsibility to schedule and attend BLS recertification courses in a way that minimizes clinic disruption. Residents can register for a course with Eryq Hastings at http://learning.bannerhealth.com/lsglm/login/bannerlogin.aspx. Evidence of current BLS certification must be provided to the program coordinator for the resident’s file.

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5. BASIC EQUIPMENT Incoming residents are required to purchase lenses for viewing the fundus. A 20-diopter lens is recommended for indirect ophthalmoscopy (panretinal 2.2 is an option). For biomicroscopy, purchase a 90-diopter lens (residents usually prefer Volk or Nikon). Resident will also need a 4- or 6-mirror gonioscopy lens (Zeiss, Posner, or Sussman), which can usually be purchased from Volk or Ocular Instruments. To begin training in strabismus and oculoplastic surgery, it is important that residents purchase a pair of operating surgical loupes with powers of 2 to 3. Lombart is the company preferred by most residents; a resident discount is available. Another item that might be helpful is an indirect ophthalmoscope. This is not required, but it will facilitate patient examinations when on call. Indirect ophthalmoscopes can be rather expensive, so this should not be a priority item. Residents are also required to have a cell phone with a local number at the start of their PGY-2 year. 6. SUPERVISION POLICY AND LINES OF RESPONSIBILITY

A. Supervision Policy

The supervision of residents in the Ophthalmology Residency program is determined by both general and situation specific considerations. General considerations include an optimal resident education experience while maintaining patient safety and quality of patient care. The principle underlying both general and situation specific supervision is the absolute necessity that there must be a well defined attending physician in charge who determines the level of resident supervision and the amount of responsibility allowed for the resident. Resident training is an educational experience designed to offer residents the opportunity to participate in the clinical evaluation and care of patients in a variety of patient care settings with a goal to develop resident physicians into independent practitioners by allowing increasing responsibilities in the assessment of patients and the development of therapeutic strategies. Thus, in our program as the resident year (PGY-2, PGY-3, PGY-4) progresses they are given graduated responsibility. However, all aspects of patient care rendered by resident physicians must receive close supervision and are ultimately the responsibility of the attending physician. Definition of Supervision Supervision is an intervention provided by a supervising practitioner to a resident. This relationship is evaluative, extends over time, and has the simultaneous purposes of enhancing the professional functioning of the resident while monitoring the quality of professional services delivered. Supervision is exercised through observation, consultation, directing the learning of the resident, and role modeling. Note: This definition is adapted from Bernard JM & Goodyear RK, Fundamentals of Clinical Supervision (2nd ed.), Needham Heights, MA: Allyn & Bacon, 1998. Categories of Supervision 1. Direct: Direct supervision exists when attending faculty are in contact with the patient and

participate in providing care together with the resident (e.g., attending physician in OR with resident).

2. Indirect

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a. Direct supervision immediately available: Attending physically present (e.g., outpatient clinic).

b. Direct supervision available: Attending immediately available via phone/electronically AND ability to be physically present if necessary (e.g., in-house or page for questions).

3. Oversight: Supervising attending reviews patient care after care has been delivered (e.g., overnight call).

4. General: General supervision exists when attending faculty are involved in patient care through instruction and the establishment of a system of patient care within which the resident must function.

Supervision and Patient Settings The Department of Ophthalmology has three major participating affiliated teaching sites (BUMCT, BUMCS, and SAVAHCS). In addition, there are several (five) affiliated teaching sites based in the offices of community ophthalmologists who have voluntary attending faculty appointments with the University of Arizona. Supervision policies will be defined for each teaching site, since there are some minor variations. However, all teaching sites have the same premise of close and careful supervision by the attending faculty who maintain the ultimate authority for patient care. B. Lines of Responsibility

The lines of responsibility flow according to experience. The senior residents are held responsible for the actions of the residents junior to them. In turn, the faculty is responsible for the actions of residents under their direct supervision. The Program Director is responsible for the education and conduct of all residents in the teaching program. The chief of service at each institution is ultimately responsible for the staff and resident physicians who are participating in patient care at the respective institution. Outpatient Clinics BUMCT and BUMCS Patients referred via BUMCT or BUMCS and seen as outpatients will be evaluated at the Alvernon Clinic. Attending faculty members will staff both general and subspecialty outpatient clinics. PGY-2 and PGY-3 residents will be assigned, on a monthly rotation, to most of these clinics. The PGY-4 Chief Resident is also assigned to the Alvernon Clinic. Supervision will be provided by the attending faculty member in charge of these clinics. Resident involvement will range from observation of attending examinations to partial or complete patient evaluations/examinations. All components of the resident examinations will be duplicated by the attending faculty. Any resident entry in the patient’s electronic medical record will be checked for accuracy by the attending faculty who will enter an attestation statement into the electronic medical record. The category of supervision will, therefore, be: (1) direct or (2a) indirect with direct supervision immediate availability. SAVAHCS At SAVAHCS, the outpatient eye clinics are managed by the residents with faculty supervision present at all times (1, direct or 2a, indirect with direct supervision, immediately available). Documentation of all patient encounters must identify the supervising practitioner and indicate the level of involvement. Four types of documentation of resident supervision are allowed: (1) Attending progress note or other entry into the medical record. (2) Attending addendum to the resident’s note.

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(3) Co-signature by the faculty implies that the supervising practitioner has reviewed the resident

note, and absent an addendum to the contrary, concurs with the content of the resident note or entry. Use of CPRS function “Additional Signer” is not acceptable for documenting supervision.

(4) Resident documentation of attending supervision. [Includes involvement of the attending (e.g.,

“I have seen and discussed the patient with my supervising practitioner, Dr. ‘X’, and Dr. ‘X’ agrees with my assessment and plan”), at a minimum, the responsible attending should be identified (e.g., “The attending of record for this patient encounter is Dr. ‘X’.)]

The following table summarizes supervision policies at SAVAHCS regarding new and return patients in the outpatient clinical setting. New Patient or New Consult Visit

Attending must be physically present in the clinic. Every patient who is new to the facility must be seen by or discussed with the attending.

An independent note, addendum to the resident note, or resident note description of attending involvement. Co-signature by attending alone is not sufficient documentation.

Return Visit Attending must be physically present in the clinic. Patients should be seen by or discussed with an attending at a frequency to ensure effective and appropriate treatment.

Any of the four types of documentation. The attending's name must be documented.

Outpatient Discharge

Attending will ensure that discharge from a clinic is appropriate.

Any of the four types of documentation.

Inpatient Consultation BUMCT and BUMCS PGY-2 and PGY-3 residents will spend a total of three months during their first two years of training on a consultation rotation. Monthly rotations on the consultation service will assure maximum continuity of care. Consultations requested during working hours will receive a complete evaluation by the resident (2b, indirect supervision), who will arrange to see the patient with the on-call attending faculty that same day who will provide direct supervision (1). The electronic medical record will be completed by the resident and each category of the exam will be documented and recorded by the faculty member. In addition to new patient consultations, residents will round with the on-call attending (1, direct supervision) on inpatients requiring daily follow-up examinations and a note will be entered in the patients chart by both the resident and the faculty member ((1) attending progress note, (2) attending addendum, (3) attending co-signature with attestation). Consultations that are requested after 5:00 p.m. and on weekends are seen, if necessary, by the on-call resident (PGY-2 and PGY-3) and supervision is provided by the on-call attending faculty (1, direct; or 2a or 2b, indirect). For after-hours and weekend consultation requests, the on-call resident is expected to make the appropriate decision regarding the urgency of the consult, i.e., bedside or as scheduled clinic outpatient visit. If the consultation can safely wait until the following morning, the on-call resident can communicate this to the consult resident. Senior residents and/or faculty may assist the junior resident in this decision-making process. If a particular outpatient clinic is appropriate for scheduling, then the attending faculty member staffing that clinic should provide approval.

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To facilitate smooth consultative services, it is Department policy that a member of the service requesting the consultation should communicate directly with the on-call resident; the Department discourages clerical or technical staff from handling consults being called to Ophthalmology as this reduces the ability to prioritize consultations. Also, the name of the faculty member, rather than the resident, requesting the consultation is required. When a consultation with another service is requested by Ophthalmology, it is the responsibility of the Ophthalmology on-call resident to communicate directly with a member of the requested service to facilitate the transfer of information and make arrangements for the consultation. The resident must also update the electronic consult order in EPIC. SAVAHCS At SAVAHCS, during regular hours, if an in-patient consultation is required, an effort will be made to transport the patient to the eye clinic for an examination by the senior resident in the clinic. Direct supervision (1) will be provided by the attending faculty member staffing the clinic. If transportation is not possible, the resident on the consult service will be requested to evaluate the patient at the bedside; the MOD attending faculty (medical officer of the day) in the clinic (2a, indirect supervision immediately available) will follow with his/her evaluation of the patient within 24 hours, and will provide an independent note or addendum to the resident’s note. If the ED has a need for a patient consultation during regular hours between 7:30 a.m. and 4:00 p.m., the patient will be referred to the Optometric Section clinic. After the evaluation, if indicated, the patient will be referred to the Ophthalmology Section and the senior resident in the clinic will evaluate the patient with direct (1) or indirect (2a) supervision by the attending faculty member staffing the clinic. Patients referred by the ED to the eye clinic after 4:00 p.m. will be seen by the senior resident in the eye clinic, again with either direct (1) or indirect (2a) supervision. Patients seen in the ED after-hours, with a need for ophthalmic consultation, will be seen by the first-call resident in the ED; supervision will be provided by the ED attending faculty on duty (1 or 2a); and/or the back-up senior resident on-call, and/or the Ophthalmology faculty member on-call (2b), if necessary. Inpatient Admissions BUMCT and BUMCS New patients may be admitted to the hospital from the clinic or ED setting. At times, the resident and the supervising attending will participate together (1, direct supervision) in evaluating the patient and writing admission orders. At other times, the resident will admit the patient and write orders (2a or 2b, indirect supervision, and the supervising attending must examine and evaluate the patient within 24 hours.

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Please see table below summarizing supervision policies regarding new patients, continuing inpatient care, consultations (see section above “inpatient consultation” for more detailed information), and discharge.

New Admissions Attending must see and evaluate the patient within 24 hours. The attending will review the resident note, attest to the note, and addend as necessary.

Continuing Care Attending available on as-needed basis. Consultations Attending must see and evaluate the patient within 24 hours. Discharge Resident will complete.

SAVAHCS New patients may be admitted to the hospital from the clinic or ED setting. At times, the resident and the supervising attending will participate together (1, direct supervision) in evaluating the patient and writing admission orders. At other times, the resident will admit the patient and write the orders (2a or 2b, indirect supervision, and the supervising attending must examine and evaluate the patient within 24 hours. Please see table below summarizing supervision policies regarding new patients, continuing inpatient care, consultations (see section above “inpatient consultations” for more detailed information), and discharge.

New Admissions

Attending must see and evaluate the patient within 24 hours.

An attending note or addendum documenting findings and recommendations regarding the treatment plan within one calendar day of admission (No exceptions for weekends or holidays).

Continuing Care

Attending must be personally involved in ongoing care.

Any of the four types of documentation, at a frequency consistent with the patient's condition and principles of graduated responsibility.

Consultations Attending physician must supervise all consults performed by residents.

An independent note, addendum to the resident's note, or resident note description of attending involvement. Co-signature by attending alone in not sufficient documentation.

Discharge Attending must be personally involved in decisions to discharge patient.

Co-signature of the discharge summary is required.

Operating Room (OR) Direct supervision by the attending supervising physician for ALL surgical procedures performed by the resident in the BUMCT OR, the BUMCT Surgery Center, and the SAVAHCS OR is required. There is no exception to this rule. BUMCT and Surgery Center OR History and Physical: H&P (pre-op) may be performed by resident or attending faculty. If done

by resident, supervision is either direct (1) or indirect (2a or 2b). If done by resident, attending must confirm findings within 24 hours of surgery (Day of Surgery Attending H&P co-signature). H&P is valid for 30 days.

Surgical Consent Form: May be performed by resident or attending faculty while in clinic (1, direct supervision). In some cases, attending fills out form; resident reviews surgery with patient and obtains patient signature during evaluation by resident in pre-op clinic (2a or 2b, indirect supervision). Surgical consent is valid for 30 days.

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Pre-operative Note: Pre-op note obtained by resident and signed electronically by attending the day of surgery (1, direct supervision or 2a, indirect supervision).

Brief-operative Note: Completed by resident and signed electronically by attending faculty (1, direct supervision, or 2a, indirect supervision) within 2 hours of surgery (not necessary if operative note is typed into EPIC within 2 hours)..

Operative Note: Must be completed by resident within 24 hours of surgery (1, direct supervision, or 2a, indirect supervision; signed off electronically by attending faculty.

SAVAHCS Patient notes and patient procedure resident notes must be completed the same day of the visit.

There are no exceptions. History and Physical (as part of pre-op) by Resident: Is valid for 30 days; beyond that must be

repeated or updated verbally on the phone with a physical exam at bedside. Surgical Consent Form: Must be completed by resident within 60 days before surgical procedure;

beyond that must be redone. Notify in OR consult if the patient is long distance, and then the consent can be done at bedside the morning of surgery.

Pre-Operative Note: Must be completed by resident prior to the surgical procedure the day of surgery.

Brief Operative Note: Must be completed by the resident within 2 hours of the surgical procedure.

Operative Note: Must be completed by the resident with 24 hours of the surgical procedure. Emergency Department (ED) BUMCT ED and BUMCS ED PGY-2 and PGY-3 residents will be on first call (with rare exceptions, for example, when seniors are attending the annual AAO meeting, PGY-3 residents will act in capacity of back-up call for after hours emergencies.) Senior resident (PGY-4) will act as back-up call for the ED. Ophthalmology ED call is “home call” and the Department requirement is that the resident will not be further than 30-minutes distance from the ED. The first call residents will receive extensive supervision by PGY-4 residents and attending faculty on-call (especially PGY-2 residents in the initial six months of their training). PGY-2 residents will be required to travel to the ED for the first 6-months of their residency to examine all patients when a consultation is requested by the ED. They will present all patients to the senior resident on-call to determine the necessity of the senior resident going to the ED to examine the patient +/- the need to present the patient to the attending faculty on-call (depending on the findings some patients will fall within the “must call attending list”; see below). After this 6-month period, the PGY-2 resident (and all PGY-3 residents at beginning of academic year), if deemed competent, will be able to provide consultation by phone, with referral to an outpatient clinic the following day, if appropriate. A completely equipped eye room is available in both the BUMCT and BUMCS EDs. A comprehensive list of conditions/findings has been compiled and is intended to trigger a “must call” by the first-call resident to either the senior resident or the supervising on-call attending ophthalmologist, or both (see “Must Call List” below). This rule will be strictly enforced and adhered to by junior PGY-2 and PGY-3 residents. Supervision will be available by the supervising attending in the ED for all residents (PGY-2, PGY-3, PGY-4) at all times (1, direct and 2a, indirect with direct supervision immediately available). Even though the attending ED is immediately available, if procedures are necessary, certain procedures may require (1) direct supervision by the attending ophthalmologist on-call, or residents may proceed with

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performance of procedures with indirect supervision by the attending ophthalmologist on-call (2b, indirect with direct supervision immediately available by phone/electronically) if proper training and “sign-off” have been attained (see lists under “Supervision of Procedures other than OR”). Oversight supervision (3) (e.g., supervising attending reviews care the following morning) by the attending faculty member on-call for the first-call and/or senior resident is always a possibility depending upon the condition and experience of the residents on-call. Supervision policies followed will depend upon situation specific considerations and the experience of the resident on-call. The first call and back-up residents will also cover inpatient consultations at BUMCT and BUMCS after-hours for the resident on the consult service (see section defining responsibilities of consult resident). A portable slit lamp is available in a storage room adjacent to the ICU at BUMCT. There are two indirect ophthalmoscopes: (1) in the cabinet in the ER, and (2) underneath the desk in the resident work area of the ED. At BUMCS, a portable slit lamp is available in the fast track area of the ED, and an indirect ophthalmoscope is available from the nursing station. A call list of supervising ophthalmology attending faculty will be maintained and easily accessible on-line. Duty hours will be strictly adhered to by the resident on-call. If after-hours examinations are scheduled at the Alvernon Clinic (follow-up urgent care BUMCT and BUMCS), patients must be seen at by at least two residents or a resident and faculty member. Residents are not allowed to see patients alone in the Alvernon Clinic after-hours.

SAVAHCS ED An eye call room is available in the ED, and is fully equipped for ocular examinations. ED patients will not be taken for examination to the eye clinic in building 80 after-hours. The only exception will be for the use of equipment that is not available in the ED, e.g., ultrasonography unit. If this is necessary, security will be notified by the resident and security will need to escort resident and patient to the eye clinic and standby during the entire exam. ED supervision policies defined above apply to SAVAHCS ED. An attending ED physician will be on the premises at all times to offer direct (1) or indirect (2a) supervision. The ophthalmologist attending on-call will offer either direct (1), indirect (2a or 2b), or oversight (3) supervision depending upon the situation specific conditions and the experience of the residents on-call. If an inpatient consultation is requested of the resident on-call, equipment, including a hand-held slit lamp must be transported to the bedside. The call list of supervising attending faculty will be comprised of SAVAHCS attending staff, not BUMC attending staff; the call list of supervising attending faculty will be maintained and easily accessible on-line, if necessary. Duty hours will be strictly adhered to by the resident on-call. Affiliated Preceptor Teaching Sites (Community Rotations) All residents have periodic rotations to several affiliated teaching sites (five) during their PGY-2 and PGY-3 years. A primary preceptor at each teaching site has a faculty appointment with the Department of Ophthalmology at the University of Arizona. The primary preceptor at each site will act as the supervising attending with two of the five sites having physician colleagues of the primary preceptor occasionally acting as the supervising physician. Categories of supervision at these teaching sites will be (1) direct or (2a) indirect (supervision immediately available). These categories will apply to all aspects of the teaching experience, e.g., clinical examinations, clinic procedures, and procedures in ASCs or hospital operating rooms. The residents on these community rotations will primarily act as an

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observer or assistant during performance of the clinic or surgical procedures (they will, rarely, act as the primary surgeon). Supervision of Procedures other than OR (In general, performed in ED or clinic) Requires DIRECT Supervision (attending in the room) Lid or facial lacerations involving the lacrimal system Any operating room procedure Laser to the macula Laser to peripheral retina (eg retina tear) Requires at least ONE DIRECTLY observed procedure + attending sign off before indirect supervision (attending available by phone). May also be observed by a resident that has been signed off for the procedure but sign off must be by an attending. Repair of eyelid or facial lacerations SIMPLE ( not involving the eyelid margin and no significant

disruption of the normal tissue architecture) (may also be supervised/staffed by an ED attending, but sign off must be by attending)

Insertion and removal of punctal plugs Punctal cautery Tarsorrhaphy Removal of ocular sutures Lateral canthotomy and cantholysis (at the attending’s discretion and on a case by case basis, this

may be performed emergently without the attending’s presence) Removal conjunctival/corneal foreign body Corneal or conjunctival cultures Excision of simple eyelid mass Incision and drainage of lid abscess Anterior segment OCT Intralesional injection of Kenalog Anterior chamber paracentesis (at the attending's discretion and on a case by case basis, this may be

performed emergently without the attending’s presence) Requires at least TWO DIRECTLY observed procedures + attending sign off before indirect supervision (attending available by phone). May be observed by another resident who is signed off for the procedure but signing off is by attending only. Repair of eyelid or facial lacerations COMPLEX (significant disruption of normal architecture or

involvement of the margin). Chalazion removal Adhesive repair of corneal perforations Retrobulbar or peribulbar anesthesia Laser suture lysis Subconjunctival or subtenons injections YAG laser capsulotomy Laser peripheral iridotomy Laser peripheral iridoplasty Anterior chamber and vitreous tap/inject Corneal scraping

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Requires at least TWO DIRECTLY observed procedures + Sign off before Indirect Supervision (attending available onsite) Intraocular injections Laser trabeculoplasty The following procedures may be performed with Indirect Supervision (attending available by phone) without prior observation Administer topical and oral medications, and diagnostic eye drops Removal of skin sutures Insertion of bandage or other contact lenses Removal or insertion of ocular prostheses IV injection of fluorescein for fluorescein angiography Administer local injection anesthesia other than as listed above

Transition of Care (Hand-offs) The goals for transition of care are to: Minimize the number of transitions in patient care. Ensure and monitor effective, structured hand-over processes to facilitate both continuity of care

and patient safety. Ensure that residents are competent in communicating with team members in the hand-over

process. Ensure the availability of schedules that inform all members of the health care team of attending

physicians and residents currently responsible for each patient’s care. Protocol Prior to or during the transition of patient responsibilities from one physician to another physician, there will be a person-to-person communication regarding the following: Any updates the transferring team made in the electronic transfer tool records/consult list. Any lab, radiology, or other tests that require follow-up, and the conditional plans for the results. Any pertinent recent or upcoming communication between ophthalmology and other services or

patients and patient’s family. Any foreseeable problems and conditional plans for each. Any patients currently on the ophthalmology inpatient service.

The transferring team will review the records in the electronic transfer tool/consult list before transferring care to the next team and make a note of the issues to be addressed in the upcoming personal communications with the receiving team. The receiving team will also review the records in the electronic transfer tool/consult list before accepting care and make notes of the issues to be addressed in the upcoming personal communications with the transferring team. Alternatively, the transferring and receiving physicians may review the records in the electronic transfer tool/consult list together interacting to clarify the duties and foreseeable problems which will be transferred.

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Informed means of communicating specific types of information: Consultations that have not been staffed: verbal + [electronic tool]. Patients to be seen in red eye clinic: verbal + [electronic medical record note clearly stating at

minimum the information that is required or handwritten notes with the same minimum information requirement].

Baseline Information: If a condition exists in which acute change from a baseline status is of importance, then the receiving team MUST: Best: One of the receiving team members will see the condition prior to the transfer + verbally

discuss any uncertainties with a transferring team member. Acceptable (when best is not possible): The transferring team will provide a detailed drawing/

description which is labeled + discussion with a receiving team member. or The transferring team will provide digital photographs which can be accessed by the receiving team

in a HIPAA compliant manner + discussion with a receiving team member. Requirements for transferring a consult/ED/red eye clinic patient from the hospital to an outpatient setting for follow-up is as follows: Address and phone number of follow-up clinic and directions, if required An appointment time, date, and the attending physician’s name or If the hours of clinic operation make the above impossible, then the patient name, MRN, contact

number, service or physician to be seen, and the timeframe for follow-up should be given to Yvonne Borror (694-1478) or Ruben Bustamante (694-1497) at the Alvernon clinic on the next business day for scheduling.

There will be a regular Monday clinic for the purpose of follow-up of weekend patients. The call team may establish a list of patients and follow-up times to be given to the clinic before 8:00 a.m. Monday.

Must Call Attending List 1 = Must call attending now 2 = Must call senior now 3 = Can wait < 8 hours to call attending who is seeing the patient in clinic or to be staffed next day if inpatient 4 = Can wait > 8-16 hours until being seen by an attending in clinic if outpatient or staffed as an inpatient 5 = Have patient call for appointment as instructed or staffed within 24 hours if inpatient Trauma/General 4 Admission 2,1 Ruptured globe/suspected rupture 2 Leaking surgical incision 2 Sudden loss of vision, unknown cause 4 Hyphema IOP<29, no corneal blood staining 2,1 Acute blind painful eye 2 Hyphema treated IOP >29 or corneal blood staining 4 Traumatic optic neuropathy 2 Orbital hemorrhage with APD or decreased vision or treated IOP > 25 4 Orbital blow out Fx with intact globe, symmetric eye pressures (3 mmHg) and no posterior segment pathology except edema

Cornea

4 Probable infectious keratitis 4 Corneal graft rejection 2 Partial thickness cornea laceration 4 Corneal foreign body outside central 5 mm 4 Cornea FB central 5 mm

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Cornea (continued) 3 Chemical exposure high pH with IOP asymmetrically elevated (>5 mmHg) or loss of limbal vasculature >180 degrees or pH > 8 for 30 minutes 4 Chemical exposure, red eye, symmetric lOPs, pH < 8 on arrival 2,3 LASIX flap dislocation 4 LASIX subflap infiltrates 4 Neurotrophic corneal Ulcer 4 HSV keratitis 4 HSV uveitis, corneal edema 4 HZ uveitis, lid involvement Lid/Lacrimal System 2 Full thickness lid laceration through margin 4 Dacryocystitis 4 Lid lac with no margin or lacrimal system involvement simple 2 Lac to lacrimal system 4 Preseptal cellulitis Orbit 3 Postseptal cellulitis 4 Orbital tumor/mass 4 Thyroid eye disease with optic nerve involvement 4 Lacrimal gland mass Pediatric Emergencies 4 Leukocoria child 4 New onset tropia child 3 Hyperacute conjunctivitis Glaucoma 2 Uncontrollable IOP with pain, treated IOP >35 1,2 Uncontrollable NVG (pain & IOP >35) 3 Acute angle closure, treated IOP <30 and pain much better 2,1 Acute angle closure unable to lower IOP <35 or continued pain 3 Uncontrollable Uveitis (IOP >35) 2,1 Blebitis 3 Lens induced glaucoma uncontrolled 3 Postop IOP spike uncont

Neuro 4 Amaurosis fugax 2 Optic nerve edema (R/O GCA) 4 Isolated 4-6th nerve palsy 4 Unknown new onset tropia or movement disorder 3 Pupil sparing 3rd nerve palsy 2,1 Pupil involving 3rd 3 Recent onset optic neuritis 4 Ischemic optic neuropathy 3 cavernous sinus or orbital apex syndrome lab normal, no GCA sx 3 Infiltrative optic neuropathy 2,1 Ischemic optic neuropathy lab?

or + or sx + for GCA

Retina 2,1 Peripheral retina break 2,1 Retinal detachment – call retina attending on-call 5 CSR > 45 years 2,4,5 CSR young patient 3 New loss of vision 2,1 Vitreous heme (if B-scan shows pathology other than vit heme) 2,1 Choroidal mass 3 Recent CRAO 4 Recent LOV with presumed CNV 2,1 Exogenous endoph 3 Recent CVO BVO, BRAO 4 Acute PVD with heme 2,1 Presumed Endogenous endophthalmitis (call retina on-call) 2,1 Acute posterior segment inflammation 2,1 Acute retinal necrosis 4 Acute flare of pars planitis 4 VKH, sympathetic oph 4 Acute sarcoidosis

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7. DUTY HOURS AND FATIGUE

A. Duty Hours Duty hours are defined as all clinical and academic activities related to the program, i.e., patient care (both inpatient and outpatient), administrative duties relative to patient care, the provision for transfer of patient care, time spent in-house during call activities, and scheduled activities, such as lectures, rounds, and conferences (AAO, ARVO, review course). It also includes “Sight Savers,” hospital committee meetings, and on-site resident interview time. Duty hours do not include reading studying, and preparation time spent away from the duty site. Residents are expected to be familiar with the duty hours policy (outlined below) and avoid violating the policy. Residents MUST notify the Chief Resident or Program Director for reassignment if necessary to avoid a duty hours violation.

(1) Duty hours are limited to 80 hours per week averaged over a four-week period, inclusive of all in-house call activity and moonlighting.

(2) Residents are provided with one day in seven free from all educational and clinical

responsibilities, averaged over a four-week period, inclusive of call. Vacation or leave days are not counted in the average. Averaging must occur by rotation.

(3) Resident should have 10 hours free of duty, and must have 8 hours between scheduled duty

periods. On-Call Activities Continuous on-site duty must not exceed 24 consecutive hours. Residents may remain on duty for up to FOUR additional hours to continue to provide care to a single patient. Justifications require continuity for severely ill or unstable patient, academic importance of the events transpiring, or humanistic attention to the needs of a patient or family. Under these circumstances, the resident must hand over the care of all other patients to the team assuming care and document the reasons for remaining to care for the patient in question and submit that documentation in every circumstance to the Program Director. The resident must complete the form online. The Program Director will track these episodes and report them to the Graduate Medical Education Committee (GMEC) on a quarterly basis. At-Home Call (or Pager Call) Time spent in the hospital by residents on at-home call must count towards the 80-hour maximum weekly limit. The frequency of at-home call is not subject to the every-third-night limitation, but must satisfy the requirement for one-day-in-seven free of duty when averaged over four weeks. At-home call must not be so frequent or taxing to preclude rest or reasonable personal time for each resident.

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WHAT COUNTS TOWARD DUTY HOURS All clinical activities All scheduled activities, such as lectures and rounds Hours spent in the hospital while on home call Conference hours, such as AAO, ARVO, and review course Hospital committee meetings, such as GMEC meetings and resident interviews Internal moonlighting, such as Sight Savers External moonlighting

WHAT DOES NOT COUNT Reading, studying and academic preparation time spent away from the hospital ambulatory site Voluntarily staying at the library or hospital when no additional duties are planned over the next

≥2 hours Travel time to/from conferences HOME CALL Hours spent in the hospital when on at-home call count toward the 80-hour weekly limit but do

not apply to the 8-10 hour “off duty” period which is reserved for in-house call. Frequency of at-home call is not subject to every third night or the 24+4 limit.

Exception to Maximum Duty Period Length In unusual circumstances, residents, on their own initiative, may remain beyond their scheduled period of duty to continue to provide care to a single patient. Justifications for such extensions of duty are limited to reasons of required continuity for a severely ill or unstable patient, academic importance of the events transpiring, or humanistic attention to the needs of a patient or family. If this occurs, the Exception to Maximum Duty Period Length form (see Forms, page 40) must be completed and submitted to the program coordinator within 48 hours.

B. Fatigue All faculty and residents will be educated to recognize the signs of fatigue and sleep deprivation in themselves and others, and must apply these policies to prevent and counteract its potential negative effect on patient care and learning. The GMEC requires that all residents and faculty complete the “Sleep, Alertness, and Fatigue Education in Residency” (SAFER) program yearly. This educational module, prepared by the SAFER Task Force from the American Academy of Sleep Medicine, is designed to educate on the effects of sleep deprivation. This module is presented during orientation, as well as yearly to all faculty and established residents. It is also available in the public resident files. The program will maintain a record of all who have successfully completed the training module. If a resident has signs of fatigue or sleep deprivation after extended duty, the resident is to take a strategic nap of 30 minutes, as suggested by the SAFER program, or delay participation in the next morning’s activities up to two hours. If the resident’s duty on the subsequent morning is at SAVAHCS, then the resident must contact the site director or chief resident either that morning or by 8:00 a.m. the morning of the clinic. The patients in that resident’s clinic will be distributed amongst the other residents and faculty clinics for the first two hours. The duration of rest may be extended as needed by mutual consent of the resident and the site director or chief resident. The decision for needed rest can be made by either the resident or the faculty member and must be respected.

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If a resident is scheduled to be at any of the other sites, including SAVAHCS, then the corresponding faculty of that site must be contacted directly or through the chief resident, program coordinator, or program director by the start of that clinic. If a resident is on call and determines that fatigue and sleep deprivation from continued responsibility will compromise care, then the back-up resident and then the faculty member will assume call until which time the primary resident has recovered adequately. A two-hour period is the usual time, but this may be modified accordingly.

8. ON CALL DUTIES AND SCHEDULE OF ASSIGNMENTS The resident on-call policy provides for appropriate coverage for providing the care of ophthalmologic emergencies at the BUMCT, BUMCS, and SAVAHCS. The usual policy is for two residents to be assigned at all times: a junior resident on first call and a senior resident on back-up, or second call. A faculty member is designated for on-call at BUMCT and BUMCS, and a different faculty member is designated on-call for SAVAHCS. The first call resident may take call from home, or any other location accessible by the pager, provided the resident is never more than a half an hour away from any one of the above hospitals under ordinary travel conditions. Typically, first call coverage is provided by a given resident, one week night in eight and one weekend in eight. The call schedule must be agreed upon by the first and second year residents and MUST comply with duty hours standards. The Chief Resident is responsible for scheduling call and giving the schedule to the program coordinator in a timely manner (by July 25 for August through December, and December 15 for January through June). The program coordinator MUST be notified of any changes in the call schedule. Second call coverage is usually provided by a third year resident, although, at times, a second year resident may provide back-up to a first year resident on an as-needed basis. The second call coverage is routinely performed from home approximately every fourth weekend. No more than two consecutive weekend calls are allowed; and no more than two weekend calls in a four-week period are allowed. The schedule MUST comply with duty hours standards. Again, call may be taken from home, or any other location accessible by the pager, provided the resident is never more than a half an hour away from any one of the above hospitals. Faculty take call from home on a rotation as well, with the faculty call schedule being coordinated by the program coordinator. A schedule of faculty "on-call" will be maintained at all times. The schedule includes the on-call faculty member for BUMCT and BUMCS, as well as the on-call faculty member for SAVAHCS. Whenever a resident receives an emergency call, he/she must respond appropriately. "Appropriately" usually requires the resident to see the patient; upon occasion, the inquiring service may merely be requesting guidance. If there is any chance that an injury/illness is sight or life-threatening, even if not recognized as such by the calling service, or if the ophthalmology resident is in doubt, the ophthalmology resident MUST see the patient. The PGY-2 residents, for the first six months of residency, MUST travel to the ED and see all patients if requested by the ED physician. Major vision or life-threatening situations must ALWAYS include the participation of faculty. No resident may admit or take a patient to surgery without faculty participation. A copy of the patient's medical record must be provided to faculty as soon as is practical. Patients seen by residents without faculty involvement MAY be scheduled for follow-up at the appropriate interval with a faculty member.

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After regular hours (5:00 p.m. to 7:00 a.m.), if any potential surgical case is identified by the first-call resident (PGY-2 or PGY-3), the senior back-up call resident MUST personally examine the patient to verify that surgery is necessary (exceptions are allowed for obvious trauma with photodocumentation reviewed electronically by senior and/or faculty). The faculty on-call is then notified by the senior on-call resident. If the faculty agrees with the management plan, the OR is booked for the surgery (in rare cases, e.g., when there is a slight delay in contacting the on-call faculty, the senior may proceed to book the OR to expedite the process). The faculty MUST communicate his/her desire to see the patient in the clinic, ED, pre-op holding area, etc. BEFORE wheeling the patient into the OR suite. The senior back-up call resident, in the process of examining the patient, will review the H&P with the first-call resident, review imaging available (MRI, CT), B-scan (should be printed), lab data, and other available data prior to surgery, and be prepared to review and discuss this material with the attending upon their arrival. The first-call resident is responsible for staying “in-house” until the case starts. The purpose for this is for the first-call resident to observe and participate in the admitting process, complete the H&P, learn how to manage pre-operative issues, write orders, etc. (If issues, such as duty violations, etc. prevent this responsibility, the senior resident will resume these duties.) If there is considerable delay in the start time, the faculty may allow the first-call resident to return home until the case starts. After hours, the senior back-up call resident will be expected to be the primary surgeon or assistant as deemed appropriate by the attending. The first-call resident will stay in the OR to observe the surgery. The attending surgeon will have the prerogative to alter this policy depending on the circumstances, e.g., duty hour issues, case more appropriate for first-call resident as primary surgeon or assistant, etc. The “on call” resident will receive all requests for consultations from BUMCT and BUMCS from 5:00 p.m. until 7:00 a.m. the following day and on weekends and holidays; all consultations will be phoned in by another housestaff officer or faculty member. A resident going "off call" remains responsible for the patient's follow-up care unless the resident makes another arrangement. Residents rotating off clinical services must notify the resident going "on call" of all patients for whom he/she is responsible. This is vital for the maintenance of continuity of care. While on call, residents will provide emergency and consultative services in a timely fashion and within the limits of individual competence. First year residents must consult with the second or third year resident "on-call" for all patient encounters prior to initiating care until adequate experience is obtained. There is an on-call examination room available in the Emergency Department of BUMCT, BUMCS, and SAVAHCS. Residents must not transport patients to SAVAHCS Eye Clinic unless escorted by the security guard. All BUMCT and BUMCS patients seen for follow-up urgent care on the weekends must be seen by a resident and faculty in the Alvernon clinic. Residents NEVER see patients alone in the clinic after hours. There is an on-call fully equipped examination room available in the ED of BUMCT and BUMCS. A portable slit lamp is available in a storage room adjacent to the ICU at BUMCT. There are two indirect ophthalmoscopes: (1) in the cabinet in the ER, and (2) underneath the desk in the resident work area of the ED. At BUMCS, a portable slit lamp is available in the fast track area of the ED, and an indirect ophthalmoscope is available from the nursing station. In addition, a portable slit lamp with attached indirect ophthalmoscope is housed in a storage room in the surgical ICU at BUMCS for use in examining

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inpatients who cannot be transferred to the ED. Patients seen for follow-up urgent care in the Alvernon Clinic after hours and on weekends must be seen by at least two residents or a resident/faculty attending. A SAVAHCS patient must not be seen at Alvernon and vice versa unless prior authorization is obtained. Patients Seen Through the BUMCT Emergency Room Many patients present with ocular trauma to the emergency room. Some do not need to be seen by the Ophthalmology resident on call, but the resident is notified about the need for follow-up. Under these circumstances, when the resident receives the call from the Emergency Room, he/she should obtain the following information:

(1) Patient’s name (2) Patient’s medical record number (3) Patient’s date of birth

The resident should inform the patient to obtain proper authorization for a follow-up visit. After the resident gets off the phone with the Emergency Room, he/she should call Yvonne Borror (694-1478) or Ruben Bustamante (694-1497) and leave a message on the answering machine containing the above information. The Front Desk staff should be provided with the patient’s name, medical record number, and date of birth. When the Front Desk opens, the staff will know that patients should be coming in during the day, and will assign them times as available in attending clinics. The staff will then attempt to call the patient with the appointment time, or when the patient calls, he/she will be notified regarding the time. The resident should also record all off-hours visits with patients. Call Rooms BUMCT: There is a call room adjacent to the resident lounge (room 2781), which is shared with

radiology.

BUMCS: There are two call rooms available at BUMCS (shared with Psychiatry residents). Ophthalmology Room 210 Door Code 9139 Psychiatry Room 557 Code 5312 Psychiatry residents will stay in the psychiatry ward (room 557) unless the room is full or a gender

issue arises, in which case they will spill over into call room 510. Ophthalmology resident will use call room 210 if the same sex is present, or proceed to call room 557. Note that the top bunk in the call rooms is not made, but linens should be available.

SAVAHCS: There is a shared call room available at SAVAHCS. This room is adjacent to the

Emergency Department. The Administrative Officer of the Day (AOD) in the Emergency Department can provide access into the room. The Surgical Services Office can also provide instructions on access.

9. CONSULTATION POLICY See Inpatient Consultation under Supervision.

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10. RESIDENT SURGICAL EXPERIENCE Residents may be the primary surgeons in cases that are within the scope of their training and experience. At SAVAHCS, all of the surgery performed by residents is subject to approval by faculty. All resident surgery must be staffed by faculty. Surgical patients at BUMCT may arise from on-call consults or from faculty clinics. Surgical patients from outpatient clinics must be approved and staffed by faculty; all cases will be evaluated for appropriateness of surgery and ability of the resident to serve as the primary surgeon. Residents will be assigned to assist faculty during surgery on specific days. Monocular patients are not typically considered candidates for intraocular surgery by residents, and these surgical cases will usually be performed by faculty. In addition, other complicated surgical cases, as determined by the faculty, will be assigned to faculty for their surgery. Phacoemulsification is considered to be an advanced surgical procedure that requires prior demonstrated proficiency by the surgeon. Prior to beginning phacoemulsification surgery as primary surgeon, the resident must carefully adhere to the guidelines regarding wet/dry lab experience and surgical logs stated under total quality improvement (Section 11.B, page 30), as well as complete required reading and video viewing. Resident Surgical Patients (SAVAHCS) All patients should be given pre-op and post-op instructions on cataract surgery at the time of

approval of their surgery. All pre-operative laboratory data should be checked one week prior to the surgical date to check for

any possible contraindications to surgery. The routine labs expected are an EKG within six months, and CBC and electrolytes including glucose within one month. If the patient has other medical conditions that may affect their ability to lie flat, remain still, or has severe cardiac or pulmonary disease, anesthesia should be contacted to check for recommendations on additional work-up or specific instructions.

All patients are contacted on the day prior to surgery by PAT for instructions and to answer any

patient questions. 96 hours prior to the day of surgery, confirmation of an updated H&P, consent and any additional

pre-op clearance, as well as clearance from attending surgeon, should be noted in the surgical OR consult, e.g.: Case reviewed and discussed with Dr. X. H&P, consent is current. Patient cleared for surgery.

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Below are the operative minimum numbers per ACGME.

Ophthalmology Resident Operative Minimum Numbers

Procedure

Minimum Requirement

(Surgeon) Cataract - Total (S) Laser Surgery - YAG Capsulotomy (S) Laser Surgery - Laser Trabeculoplasty (S) Laser Surgery - Laser Iridotomy (S) Laser Surgery - Panretinal Laser Photocoagulation (S) Corneal Surgery Keratoplasty (S+A) Pterygium/Conjunctival and Other Cornea (S) Keratorefractive Surgery - Total (S+A) Strabismus - Total (S) Glaucoma - Filtering/Shunting Procedures (S) Retinal Vitreous - Total (S+A) Intravitreal Injection (S) Oculoplastic and Orbit - Total (S) Oculoplastic and Orbit - Eyelid Laceration (S) Oculoplastic and Orbit - Chalalzia Excision (S) Oculoplastic and Orbital - Ptosis/Blepharoplasty (S) Globe Trauma - Total (S)

86 5 5 4 10

5 3 6 10 5 10 10 28 3 3 3 4

S = Surgeon Procedures Only S+A = Surgeon and Assistant Procedures Residents are expected to input surgeries on which they are the first assistant as well as cases on which they are the primary surgeon. This is necessary for the program to show a progressive graduated and broad surgical experience. ACGME Definition of a Surgeon Basic Principle: To be recorded as the surgeon, a resident must be present for all of the critical portions, and must perform the majority of the critical portions of the procedure under appropriate faculty supervision. Involvement in the preoperative assessment and the postoperative management of that patient is an important element of that participation. Only the first assistant (not the second, third, etc.) may record a procedure as assistant. A resident may only record a case as assistant if the resident is first assistant to: (1) a faculty member performing the procedure, or, (2) another resident performing the procedure under faculty supervision. Clarifications (1) If a resident completes one side of a bilateral procedure, the resident can count that as one case,

surgeon. If a resident completes both sides of a bilateral procedure, this still counts as one case, surgeon. If two residents each do one side of a bilateral procedure, each resident can record the procedure as the surgeon, provided that each fulfills the stated criteria for performance as surgeon on one side.

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Example: If a resident performs a bilateral blepharoplasty, then the resident counts it as one case as surgeon. If, however, one resident does one side of the blepharoplasty and the other resident performs the procedure on the other side, each resident may record the procedure as a surgeon case.

(2) If a resident completes an operation which involves multiple procedures, the resident may record all

the procedures as separate cases, provided that the resident performs the majority of the critical portions of the procedures. However, if the multiple procedures all fall within the same subspecialty category (e.g., cataract, cornea, strabismus, glaucoma, retina/vitreous, oculoplastics/orbit, globe trauma), then only one case may be recorded.

Example: A resident performs a combined procedure involving trabeculectomy and cataract extraction. The resident may record both procedures as surgeon cases. Example: A resident performs bilateral medial rectus muscle recessions and anterior transposition of the right superior oblique muscle on a patient. The resident may record only one procedure as surgeon. Example: A resident performs a scleral buckle procedure combined with pars plana vitrectomy. The resident may record only one procedure as surgeon. Example: A resident performs bilateral blepharoplasty combined with bilateral ptosis repair. The resident may record only one procedure as surgeon.

(3) In an operation which involves multiple procedures, more than one resident may be recorded as the

surgeon, provided that the resident perform the majority of the critical portions of one or more of the procedures.

Example: During planned pars plana vitrectomy combined with phacoemulsification of cataract, one resident performs the pars plana vitrectomy while another resident performs the cataract extraction. Each resident may record the procedure they performed as a surgeon case.

Disclaimer Statement The stated minimum numbers of listed surgical procedures for ophthalmology residency education reflect the minimum clinical volume of these procedures which is acceptable per resident for program accreditation. Achievement of the minimum number of listed procedures is not tantamount to achievement of competence of an individual resident in a particular listed procedure. A resident may need to perform an additional number of listed procedures before that resident can be deemed competent in each procedure by the program director. Moreover, the listed procedures represent only a fraction of the total operative experience of a resident within the designated program length. The intent is to establish a minimum number of listed procedures for accreditation purposes, without detracting from the latitude that the program director must have to blend the entire educational operative experience for each resident, taking into account each resident's particular abilities. This requirement does not supplant the requirement that, upon the resident's completion of the program, the program director should verify that the resident has demonstrated sufficient professional ability to practice competently and independently.

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11. QUALITY ASSURANCE POLICY

A. QIPS Conference

QIPS conferences are held on a monthly basis, in a closed session limited to members of the Department of Ophthalmology. The goals of the QIPS conference are three-fold: (1) to discuss complications which have arisen during the care of patients in a free and open manner so that all may benefit from this experience without having to directly experience it themselves; (2) to provide a mechanism for monitoring the occurrence of complications, the rate of complications, and the need for remediation or modification of surgical privileges; and (3) to monitor and assess total quality improvement on an individual resident basis. B. Total Quality Improvement

It is critical and imperative for residents to participate in a total quality management program for advancement of their surgical skills. This program has several requirements as enumerated below.

Wet/Dry Lab Experience

(1) Pig eyes will be utilized for wet labs (Alvernon wet lab facility only); artificial eyes utilized in

Alvernon lab, BUMCT Surgery Center, and SAVAHCS OR. To acquire artificial or pig eyes for the Alvernon wet lab, contact the program coordinator; allow 7 to 10 days notice. To acquire artificial eyes at SAVAHCS, contact Krista Rosynski (x6106). (These eyes are to be used only at SAVAHCS; do not transport to Alvernon wet lab or BUMCT Surgery Center.)

(2) Supervision for the wet/dry labs will be provided by (a) resident only, +/- video when possible;

(b) senior resident; (c) company representative; or (d) attending (see “table” on the next page). (3) All wet/dry lab resident sessions MUST be electronically logged with information including

date, total time of session, location, type of practice, supervision (see administration section for details). The Program Director will review resident progress at the 6-month evaluation session. Incomplete resident wet/dry requirements could delay resident progression to human phaco surgery.

(4) There will be orientation sessions for PGY-2 residents for the AMO Signature Unit and for

PGY-3 residents for the Alcon Infiniti Unit (see table for details) (5) Residents are encouraged to attend extramural phaco courses sponsored by Alcon and Bausch

& Lomb (B&L): CORE Alcon Course for PGY-3 residents, CPE Alcon Course for PGY-4 residents, and B&L PGY-3 course (see Program Director for details). Expenses are paid by the sponsor.

(6) A comprehensive intramural phaco course will be sponsored annually by AMO with

Dr. William Fishkind as the primary instructor. This will be held in the Alvernon conference room in May or June of each academic year.

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Wet/Dry Lab Requirements PGY-2 PGY-3 PGY-4 1st Quarter

Lid Lac Wet Lab Canthotomy Paracentesis (Polonski, Alvernon)

Artificial/Pig Eyes x2 each (Attending) Corneal Suturing (Belin, OR9)

Alcon CPE Course/Ft. Worth (or 2nd Qtr) Corneal Suturing (Belin, OR9) (Remedial PRN)

2nd Quarter

Artificial/Pig Eyes x1 each (PGY-4, Alvernon)

CORE Alcon Course (or 3rd Qtr) Artificial/Pig Eyes x2 each (Self, video PRN)

Artificial Eyes x4 (Self, video PRN) (Remedial PRN)

3rd Quarter

Artificial/Pig Eyes x2 each (PGY-4, Alvernon) AMO Signature Demo (Pritchard ± Attending, ASC)

Artificial/Pig Eyes x2 each (Self, video PRN) Pig Eyes x2 Extracap (Attending, Alvernon)

(Remedial PRN)

4th Quarter

Artificial Eyes x2 (Attending, ASC) SLT Model Eye x1 (Altenbernd, Alvernon) Wet Lab (AMO/Fishkind, Alvernon)

Artificial Eyes x4 each (Attending, ASC or OR 9) Alcon Infiniti Demo (Adam ± Attending, OR 9) Wet Lab (AMO/Fishkind, Alvernon)

Wet Lab (AMO/Fishkind, Alvernon) (Remedial PRN)

(1) # eyes listed are minimum (2) ( ) = supervision and location (3) Program Director monitors at 6-month evaluation (4) No human phacos until requirements completed Education – Videos and Reading for Cataract Surgery

Residents are required to view surgical videos and read selected book chapters to prepare themselves for cataract surgery. The Program Director will review resident progress at the 6-month evaluations. Incomplete requirements could delay resident progression to human phaco surgery.

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REQUIRED EDUCATION VIDEOS FOR CATARACT SURGERY (https://www.eyetube.net – Cataract) First and Second Year Residents*

Wound Construction 1. Scleral Incisions (D.M. Colvard) 2. Testing Clear Corneal Incision Integrity (J.A.H.) 3. Corneal Incisions (D.M. Colvard) 4. Making a Square Incision Capsulorhexis 1. Capsulorhexis (H. Gimbel) Hydrodissection and Hydrodileneation (H. Fine) Phacoemulsification 1. Basic Divide and Conquer (D.M. Colvard) 2. Using Hydrodissection (David Chang) 3. Managing Flow and Vacuum Levels with Today’s Phaco Systems (R. Olson)

*Completion required before advancement to human cataract surgery. Third Year Residents: Cataract All of the above, PLUS

Phacoemulsification 1. Toric IOL’s 2. Malyugin Ring and Trypan Blue with Small Pupil 3. Complete IFIS Case with Iris Prolapse (Bob Oshner) 4. Horizontal Chop (David Chang) 5. Vertical Chop (David Chang) 6. A Punctured Posterior Capsule (Howard Fine) 7. Malyugin Ring System for Small Pupils (Boris Malyugin) 8. Stop and Chop Technique (Bonnie Henderson) Capsulorrhexis 1. Completing Surgery with Compromised Rhexis (B. Little) Irrigation and Aspiration 1. Management of Intraocular Iris Prolapse (G. Hirshfield) 2. Insertion of 3-Piece IOL After Capsular Tear (R. Hoffman)

Video Journal of Cataract and Refractive Surgery Another excellent source for cataract surgery videos is the “Video Journal of Cataract and Refractive Surgery.” Dr. Robert H. Osher is the editor of this video journal and he is a leader in cataract surgery innovations; he enlists some of the best cataract surgeons in the world in making

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these videos, which cover surgical complications and difficult cases. If you want to review instructions on how to place a tension ring, deal with a dropped nucleus or sculpt a very dense nucleus, this is an excellent source. The website is as follows: www.vjcrs.com and the passkey is 2389.

REQUIRED AND RECOMMENDED READING Required Reading 1. Steinert RG, ed. Cataract Surgery, 3rd ed. Saunders, 2010. (Available online through

Arizona Health Sciences Library, www.ahsl.arizona.edu.) 2. Chang DF. Phaco Chop and Advanced Phaco Techniques: Strategies for Complicated

Cataracts, 2nd ed. Slack Inc., 2013. All Residents Cataract Surgery: For a one-month rotation, the following reading schedule is recommended: Week 1 Chapters 1-7, 12, 13, 16-18 Week 2 Chapters 8-11, 14, 16 Week 3 Chapters 17-19, 21, 24-26, 29, 30, 34 Week 4 Chapters 38-40, 44-49, 54-55 Senior Residents Only Operating senior residents should have read the following by deadline dates below (Phaco Chop can be checked out by the program coordinator.) Reading Deadline: July 30 Chapter 16 Capsulorrhexis: Sizing Objectives and Pearls Chapter 17 Conquering Capsulorrhexis Complications Chapter 18 Pearls for Hydrodissection and Hydrodelineation Chapter 27 Strategies for Managing Posterior Capsular Rupture Chapter 30 Posterior Capsule Rupture and Vitreous Loss: Advanced Approaches Reading Deadline: December 31 Chapter 1 Why Learning Chopping Chapter 2 Horizontal Chopping: Principles and Pearls Chapter 3 Vertical Chopping: Principles and Pearls Chapter 4 Comparing and Integrating Horizontal and Vertical Chopping Chapter 5 Transitioning to Phaco Chop: Pearls and Pitfalls Chapter 8 Understanding the Phacodynamics of Chopping Chapter 9 Optimizing Machine Settings for Chopping Techniques Chapter 10 Optimizing the Alcon Infiniti for Chopping Chapter 25-30 Complicated Cataract Surgeries (Cataract Surgery; online) Can be completed over a one-month period. A short, multiple-choice exam will be given. A passing score on the test is required prior to starting cataract surgery at the VA. Other residents will be tested at the end of their anterior segment and/or cornea rotations based on attending preference.

Patient Surgery

(1) All residents will serve as a surgical assistant on a subspecialty defined, specified number of

surgical procedures before primary surgery of a specific procedure can be done.

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(2) Pre-operative evaluation of cases scheduled as primary surgical cases must be approved by faculty for all primary surgical cases. In addition, the pre-operative evaluation for the first three primary surgical cases must be done with faculty who will staff the first three primary surgical cases.

Surgical Logs and Evaluation Tool

(1) All residents must maintain their surgical logs and track their rate of surgical complications

on the web-based ACGME case log program (mandated by ACGME). Surgery should be logged within 24 hours of the procedure. Failure to have surgical logs up-to-date by the third working day of the month, may result in loss of surgical privileges. Surgical privileges will be restored as soon as all cases have been entered.

(2) Resident cataract surgery skills will be evaluated by a competency-based surgical tool referred to as the Phacoemulsification Assessment Tool: Resident Improvement Competency Keys. Each PGY-4 resident is required to have at least one of these forms completed, including discussion with the attending surgeon, for each surgical session (i.e., cataract surgical block). Forms should be completed by at least two surgical attendings. The forms will be monitored by the Program Director. If less than average rating scores (<3) are observed by the Program Director, he/she at their discretion, and with input from the attending surgeons, may place the resident in a remedial plan which would involve the resident returning to the wet/dry lab for further practice.

(3) At SAVAHCS, residents are expected to videotape all cataract surgery in which they act as

the primary surgeon (using the recording equipment provided with the Leica Operating Microscope). In addition, at least one of the surgical videos must be reviewed and discussed with the attending surgeon for each surgical session (i.e., cataract surgical block). One video every two months (six total) must be submitted to the program coordinator for placement in the resident’s portfolio. When possible, surgical videos submitted should be reviewed by at least two attending surgeons to ensure a diversity of surgical experience and to benefit from varied expertise of attending surgeons.

(4) At SAVAHCS, residents will strive to maintain a cataract surgery complication rate of less

than 5%. As a general policy, two complications in any 10 consecutive cataract surgeries will result in a remedial plan for that resident. This will be decided upon by the Program Director with input from the attending surgeons. The remedial plan will involve practice in the wet/dry labs with some direct observation by one or more attending cataract surgeons.

C. Continuous Quality Improvement (CQI)

Residents are encouraged to participate in the continuous improvement process in the Department of Ophthalmology. One quality improvement project that involves all residents is an individualized surgical plan for tracking surgical complications and continued improvement (Dr. Smith). The Chief Resident, or his designee, should attend the clinical faculty meetings to provide input about the residency program. Semi-annual resident/faculty meetings are held to provide direct input about the program to the Program Director and Department Head. Furthermore, residents review the teaching program electronically on a semi-annual basis. The Program Director will meet with the residents on a monthly basis. In addition, several additional, informal meetings will take place throughout the course of the year at the conclusion of rounds to address specific program issues in a timely fashion. There is also an annual review of the program by a committee consisting of the residents, Program Director, faculty members, and program coordinator.

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Residents may bring up issues anonymously. The Chief Resident may bring up issues at faculty meetings, preserving the anonymity of the source.

12. ATTENDANCE POLICY

A. Clinic/Surgery

Clinics begin at 8:00 a.m. and 1:00 p.m. at the Alvernon Clinic and SAVAHCS. Residents are expected to remain at the clinic unless excused by the supervising faculty. Residents are to be present five minutes before the start of each clinic. The resident is expected to be in the operating room and dressed appropriately before the scheduled start–15 minutes at BUMCT and 30 minutes at SAVAHCS. In addition, residents should perform a check of laboratory and diagnostic tests, review and update the history and physical if necessary, review the informed consent, and review any unusual lens calculations with the attending at least 48 hours in advance of the surgical case. Also, some of the surgical attendings wish to review cases prior to the surgery; others are content to review the surgical cases in the pre-op area the day of surgery. Please consult each surgical attending for their desired policy. The day of surgery, laboratory tests, consent form, surgical site, and lens calculations should be rechecked upon arrival to the operating room. At SAVAHCS, if everything is in order, the resident will proceed to enter a pre-operative note in CPRS, which the attending must review and then enter an addendum that indicates he/she agrees with the resident's findings.

It is BUMCT and SAVAHCS policy that the pre-operative history and physical be completed by a member of the operative team. If the physical was performed by an outside physician, it should be reviewed and cosigned by a member of the surgical team. B. Conferences

All residents must attend ALL scheduled Department conferences unless on vacation, sick leave, or involved in emergency patient care (emergency call or emergency consults).

Residents are required to attend 100% of all lectures except for vacation, SAFER, sick leave, emergency call, or the senior resident who is in surgery at the VA on Friday morning. This attendance must be attested to by the Program Director at the conclusion of the training program. Attendance is documented by the Chief Resident at all conferences and submitted to the program coordinator for permanent recordkeeping. Attendance at all conferences, etc., must be PROMPT; tardiness (more than 15 minutes late) must be documented on the attendance sheet, and credit will be given for the amount of time in attendance. Attendance is monitored, and if the resident’s attendance rate is ≥95% during the 6-month review period, the resident will receive $100 for their AAO travel fund (or an interview day) (attendance between 90-94% will earn half).

Scheduled educational activities take precedence over all clinical activities; a resident may not be called away from any teaching activity for the delivery of patient care except in the case of an emergency which cannot await the conclusion of that activity.

Rounds are held on Wednesday mornings from 7:00 to 8:30 a.m. Lectures are held on Friday mornings from 7:00 to 11:00 a.m., and other times as scheduled. Residents are required to submit the title of their rounds presentation to the program coordinator on the Friday prior to the date of their presentation. On the date of the presentation, the residents must save a copy in their electronic portfolio.

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13. LEAVES OF ABSENCE

A. Vacation

(1) Banners grants annual paid allowance of four weeks per year to residents. This time off must be used during each 12-month appointment (July 1 through June 30). If all 20 days are not used, the time cannot be carried over to the next year.

(2) Vacation must be taken in non-consecutive blocks of 5 days from Monday through Friday.

Exceptions may be made for fellowship or job interviews taken as individual vacation days. Although not encouraged, an exception may be made for a 5-day block outside Monday through Friday (such as Thursday through Wednesday of the following week).

(3) Three residents (one per year) may be on vacation at a given time. Exceptions may be made

for third year residents for fellowship/job interviews.

(4) Each resident must take one week during each quarter of the year (July through September, October through December, January through March, April through June). The week that includes Christmas is counted as a week in December. The week that includes New Year's counts as a week in January. Exceptions must be approved by the Program Director.

(5) Vacations scheduled while at SAVAHCS must be discussed and approved by the Section

Chief of Ophthalmology and Program Director. Cancellation of VA clinics must be submitted at least 45 days in advance.

(6) Residents must submit all vacation requests to the Chief Resident by July 15 for August

through December and December 1 for January through June. Vacation changes may be made with the approval of the Program Director.

(7) Priority System: Chief>Third>Second>First year when selecting weeks of vacation.

Conflicts are resolved by the current Chief. The Program Director has final say over all vacation requests.

(8) Blackout Periods

a. No vacation during July. b. No vacation during the consults rotation. c. If a resident plans to take vacation during the week prior to or after the OKAP exam

(March 18, 2018), he/she still must take the exam at the assigned time. d. No first or second year vacations during the AAO meeting (October 14-16, 2016) since

the third year residents will attend the meeting. e. No first or third year vacations during the review course – week of March 6-10, 2016

(San Antonio Ophthalmology Course (to be announced); Wills Eye Review Course, March 3-7, 2018).

f. No first or second year vacations during the month of June. g. No vacation on Residents’ Day (June 25, 2018). h. Third year residents are encouraged to use vacation during the interval between

Residents’ Day and June 30. Residency ends at the completion of the work day on June 30. If the resident wishes to leave before June 30, he/she MUST reserve vacation time for that purpose.

i. A resident may take vacation around resident interviews, but must be present for the interviews (December 8-9, 2017).

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j. A senior resident may take vacation the week of mock exams (to be determined) are given, but must participate in the orals.

k. A resident may take vacation the week of the LASIK (May 4, 2018) and Phaco (to be determined) wet labs held by Dr. Hunter, but must participate in the wet labs.

(9) Residents who have already taken vacation during a holiday may not take vacation during

that time again in the future, until all residents have had the opportunity to choose vacation during that time.

(10) Residents must use vacation to take the USMLE Step 3 examination.

B. Sick Leave

Residents are allowed a maximum of ten (10) days per calendar year. Sick leave should be reported to the Chief Resident who will notify the program coordinator. The Chief Resident will be responsible for notifying the attending(s) and appropriate staff connected with the rotation assigned to the sick resident. He/she will make arrangements to cover the sick resident's duties as completely as possible. If a resident is sick for three consecutive days, the resident must provide a physician’s note to return to work. If a note is not provided, the days the resident was out will count as vacation.

C. Bereavement Leave

Residents may take up to three paid working days as bereavement leave upon the death of a parent, parent-in-law, brother, sister, spouse, child, grandparent, grandchild, or any other person who is a member of the employee’s established household. Up to five paid working days as bereavement leave may be granted to attend or arrange funeral services out-of-state.

For this purpose, a parent is defined as a natural parent, stepparent, adoptive parent or surrogate parent. A child is defined as a natural child, adoptive child, foster child, or stepchild.

D. Holidays

Residents have six (6) holidays per year: Independence Day, Labor Day, Thanksgiving, Christmas, New Year’s Day, and Memorial Day. Residents who cannot be excused from their duties on a designated holiday will be granted another day off. The resident must notify the program coordinator of the date they will be off in place of the holiday within 10 days of the holiday worked. This “alternate” day must be one entire day.

There are SAVAHCS holidays that are not observed at Banner. On these holidays, such as

Columbus Day and President’s Day, all residents will be assigned to the UA or Alvernon Clinic. If a resident is taking the day off and/or is out of town, vacation must be taken.

E. Academic Time

Occasionally, residents will have unscheduled time due to the unforeseen need for a faculty member to cancel clinic or surgery. Residents at Alvernon clinic must attempt to contact the faculty member to whom they are assigned to determine if that faculty member has any "duties" they wish the resident to complete (and the Chief Resident should be notified.). If the faculty member cannot be contacted, the Chief Resident will make the resident assignment. (At least one resident must remain at the Alvernon clinic at all times. At SAVAHCS, a similar protocol will be followed except that the Section Chief should be involved in the decision to assign the resident a duty. Only if cleared by the faculty member and Chief Resident (and Section Chief at SAVAHCS) can the resident be excused

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from duties and be allowed to spend time in the Department conference room or resident office (but must be available by pager). F. Education Time Residents are granted five (5) educational days. This time can be used to attend review courses, conferences, or studying. Study time must be taken in the conference room or resident office.

14. RECORDKEEPING

A. Surgical and Clinical Logs

Every resident must maintain a log of all surgery he/she participates in. This log shall be kept in accordance with the definitions of surgeon or assistant as established by ACGME and must include:

(1) Diagnosis (2) Procedure (3) Surgeon or Assistant

All surgical information is entered by the resident into an online database (Resident Case Log System) maintained by the ACGME (www.acgme.org).

Under no circumstances are patient names or chart numbers to be included in this log; this protects the patient's confidentiality. Residents should, however, keep operative notes for their own records and information (complications, special management considerations, etc.).

Surgical summaries are made available monthly and at the end of the academic year (June 30) to the Program Director and respective resident. Residents are responsible for checking the accuracy and completeness of the statistics. Surgical summaries are available and discussed with the Program Director at the semi-annual reviews. The resident receives a copy of the final summary upon completion of the program.

Clinical logs are maintained to record the number of patients the resident sees each week. The resident should note how many patients are seen by subspecialty clinic, as well as the number of emergency patients. The resident enters the information into an Excel file located in their resident file. The program coordinator prints out quarterly clinical log sheets for each resident.

Maintenance of the surgical and clinical logs is the ultimate responsibility of each resident; it is impossible to assemble the log retrospectively. Timely maintenance of the surgical and clinical logs is monitored by the program; and residents who maintain their logs as required may be eligible to receive funds for their AAO travel fund (or interview time). The surgical log is a requirement for Board eligibility. Surgery should be logged within 24 hours of the procedure. Clinical logs at minimum should be entered on a weekly basis.

A signed copy of the final completed log is provided to the resident upon their completion of the program.

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B. Conference Attendance Log

The Department maintains current and permanent records of all conferences, lectures, rounds, and journal clubs. This record shall contain all of the following:

(1) Date and time (2) Number of hours (3) Topic(s) hour-by-hour (4) Title of lecture (5) Lecturer/conference leader (6) Topic for all rounds presentations and path signouts (7) Resident attendance (8) Faculty attendance

Sign-in sheets are provided for all lectures, and each resident in attendance must sign. It is the responsibility of the Chief Resident to obtain the signature of the lecturer and provide the completed and signed sheet to the program coordinator immediately after the lecture. The chief resident is also responsible for ensuring accuracy in attendance, including noting any lateness and reasons for absences.

Patients presented and discussed for a QIPS Conference will be recorded by the faculty member in charge of the QIPS Conference in accordance with the policy of the BUMC Quality Assurance office. QIPS documents are legal documents and any cases to be discussed must be recorded on a special form and submitted to the faculty coordinator.

15. INCENTIVES Residents will earn incentives for completion of documentation and lecture attendance as indicated in the table below. The 1st year residents will earn funds for travel to the AAO meeting during their senior year. The 2nd year residents will earn interview days. Documentation must be submitted in a timely fashion–on or before the deadline. Residents who are off on the due date are required to submit by the deadline; extensions will not be granted for time off. Documentation for the 6-month review includes all supporting documentation listed on the 6-month semi-annual review checklist (see Forms, page 38). The quarterly reports include completion of the surgical log, clinical log, and duty hours. Lecture attendance must meet the requirements (≥95% of all lectures). Excused absences will be provided only for vacation, SAFER, sick leave, emergency call, or the senior resident who is in surgery at the VA on Friday morning (as documented by the Chief Resident). The Chief and program coordinator must be informed of these exceptions on the day of the lecture or the absence will not be excused. It is each resident’s responsibility to sign the attendance sheet provided for each lecture (blank sheets are available if a sheet is not provided). At the end of each lecture or lecture session, the Chief Resident should provide the sign-in sheet(s) to the program coordinator. Those who attend 90-94% of the lectures will earn $50 (or 0.5 interview day). Some lectures are recorded so that residents have an opportunity to review missed lectures. However, reviewing the material does not count toward attendance requirements. Any improprieties in the truthful representation of attendance, tardiness, etc. will be viewed as unprofessional conduct and appropriate consequences will ensue.

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AAO Travel Funds 1st Year Residents

Oct Jul-Dec Mar Jan-Jun

6-Month Review Packet Submitted by Due Date $100 $100 Lecture Attendance Meets Requirements $100 $100 Quarterly Reports Submitted by Due Date $25 $25

(Maximum is $450. This is in additional to the funds provided by Banner.)

Interview Days 2nd Year Residents


6-Month Review Packet Submitted by Due Date 1 1 Lecture Attendance Meets Requirements 1 1

Quarterly Reports Submitted by Due Date 0.5 0.5

(5 interview days maximum accrual) 6-Month Review Packet = all documentation required to be submitted to complete the packet Quarterly Reports = surgical and clinical logs 16. FACULTY ADVISOR Each resident will choose a faculty member (either full-time, part-time, or affiliate/associate “volunteer”) to serve as a faculty advisor. The Program Director and Department Head are not eligible to serve as a faculty advisor. The resident should meet at least twice a year to keep the advisor apprised of career goals, progress in the residency, and difficulties as they arise. This advisor will serve as the resident's advocate. The faculty advisor can be changed by the resident, if necessary. First year residents should choose an advisor within their first three months of residency. Residents must inform the program coordinator of their faculty advisor. In November and May, each resident must complete a mentoring plan (self-assessment and self-reflection) (Forms, pages 21-24) to identify their strengths, deficiencies and limits in knowledge and expertise, as well as set learning and improvement goals. Then, the resident must meet with their faculty advisor to discuss their self-assessment, at which time the assessment will be signed. The signed assessment must be submitted to the program coordinator by November 15 and May 15. The assessment will be reviewed with the Program Director during the 6-month evaluation (January and June). The resident must submit the mentoring plan by the deadline to be eligible to receive $100 for their AAO travel fund (or interview time) for the 6-month review period. 17. RESIDENT EVALUATION OF FACULTY, PROGRAM, AND ASSIGNMENTS

A. Faculty

Residents evaluate the full-time clinical faculty twice a year using an online evaluation system (www.new-innov.com). Research and affiliate/associate (“volunteer”) faculty are evaluated once a year (May/June). To preserve anonymity, resident evaluations of the faculty are tabulated anonymously.

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In December and June, each resident will participate in an evaluation of individual full-time clinical faculty in the areas of:

(1) Clarity of lectures (2) Completeness of curriculum (3) Effectiveness of lectures (4) Organization of material (5) Suggested improvements

The evaluations will not be submitted to individuals other than the Department Head and Program Director. A sample of the evaluation form for clinical faculty is found in the Forms section (pages 30-31). A sample of the form for research and affiliate/associate (“volunteer”) faculty is also in the Forms section (page 29). B. Program

Residents evaluate the overall residency program twice per year. A six-month evaluation of the program is completed in November (Forms, pages 32-33) on the online evaluation system (www.new-innov.com). All comments remain anonymous and are summarized into a single report that is provided to the Program Director and clinical faculty for review. In April or May, residents complete an annual review of the program (Forms, page 28) on the online evaluation system. Both evaluations are mandatory.

C. Rotation

Pre-Rotation Review: At the beginning (within the first week) of each rotation, the resident is required to review the goals and objectives for that rotation together with the attending, and confirm that they have done so online through New Innovations (see “Confirming Curriculum” in the Appendices for instructions, pages 10-13). The confirmation must be done within the first week of the rotation. Residents who complete/confirm in a timely fashion may be eligible to receive $100 for their AAO travel fund (or interview time) for the 6-month review period. Travel funds will be reduced $25 if not submitted within the required timeframe. Evaluation: At the end of each rotation, the faculty will review the resident’s performance using an online evaluation system (www.new-innov.com). Once the faculty has completed the evaluation, the resident will be notified that the evaluation is available for signature. Residents who sign all evaluations in a timely fashion may be eligible to receive $100 for their AAO travel fund (or interview time) for the 6-month review period.

18. FACULTY EVALUATION OF RESIDENTS Each resident will meet at least twice a year with the Program Director for a formal evaluation of the resident's performance. A sample six-month resident evaluation by the faculty is found in the Forms section on pages 1-18. After the faculty complete an online individual evaluation of the residents, the information for each resident is summarized into a single report and provided to the Program Director. The evaluation will be signed by both the resident and Program Director during the six-month evaluation. All evaluations will be shared with the resident in a confidential conference; strengths, deficiencies, and plans for the correction of deficiencies, if they exist, will be discussed. An appeals mechanism is provided for a resident should he/she feel that the evaluation is inaccurate or unfair. To this end, the

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resident may request a formal meeting with the Program Director, any or all Department faculty members, and his/her faculty advisor. If the Department Head and/or Program Director then reviews and changes the evaluation, the prior evaluation will be destroyed. In addition, at the end of each monthly rotation and quarterly (July-September, October-December, January-March, April-June) for other rotations (such as continuity clinic and senior rotations), the faculty will evaluate the resident’s performance during the rotation. In the last few days of the rotation, the resident is responsible for meeting with the faculty and having an evaluation completed for that rotation. After the online evaluation is completed by the faculty and signed by the resident, the evaluation will be printed by the program coordinator and provided to the Program Director for review at the resident’s six-month evaluation. Sample rotation evaluation forms are found on in the Forms section (pages 1-18). The Ophthalmic Clinical Evaluation Exercise (OCEX) is a tool developed by the ABO taskforce to assess core residency competency in the areas of patient care skills, medical knowledge and interpersonal skills (Ophthalmology 2004;111:1271-1274). A one-page checklist (Forms, page 25) will be used during observed resident/patient encounters. It is expected that the evaluation will be performed with each resident at least annually. To fulfill the ACGME mandate that ophthalmic residency programs teach and access all six competencies, residency programs need valid assessment tools to show that surgical competence has been achieved. The Phacoemulsification Assessment Tool: Resident Improvement Competency Keys (Forms, page 27) is designed to facilitate assessment and teaching of surgical phaco skills. Surgical procedures are broken down to individual steps and each step is graded on a scale of beginner, intermediate, and advanced. The Phacoemulsification Assessment Tool should be completed at the end of the case and immediately discussed with the resident to provide timely, structured, specific performance feedback. PGY-2 and PGY-3 residents will have a Phacoemulsification Assessment Tool completed by the attending surgeon for ALL surgical phaco cases in which they assist, perform some steps of the procedure, or are primary surgeon for the case. PGY-4 residents will have one form completed per operative session for a surgical phaco case in which they are the primary surgeon. The form must be signed by both the resident and attending surgeon, and submitted to the program coordinator for placement in the resident’s portfolio. It is the responsibility of the resident to obtain and submit the forms. Residents who submit the forms as required may be eligible to receive $100 for their AAO travel fund (or interview time) during the 6-month review period. It will be the responsibility of the senior resident at SAVAHCS to videotape each one of his/her surgical cataract cases; at least one of these per operative session will be selected to be reviewed by the attending surgeon that same day, either between cases or at the end of the surgical session. The resident must submit three recorded cases per six months–one at the beginning, during the middle and at the end of the six-month period. 19. OTHER EVALUATIONS OF RESIDENTS In addition to the faculty evaluations, the residents are evaluated by technicians and patients. The technicians complete a written evaluation (Forms, page 37) on a semi-annual basis and submit them to the program coordinator, who summarizes the information. The summary is reviewed at the resident’s six-month evaluation with the Program Director. On a monthly basis, the technician or faculty gives a questionnaire (Forms, page 26) to a patient(s) seen by the resident and requests the patient to complete and return to the program. A copy of all questionnaires are available for review at the resident’s six-month evaluation with the Program Director.

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20. ORAL AND OKAP EXAMINATIONS

A. Oral/Written Examinations

Senior residents will participate in one oral examinations (“mock orals”) each year (April/May). The topics tested include anterior segment/optics, cornea/uveitis, glaucoma, neuro-ophthalmology, oculoplastics, pediatric ophthalmology, and posterior segment. The PGY-2 and PGY-3 residents will participate in a written examination each year (January/February). The Program Director will receive a written summary of each resident’s performance, and will discuss the results of the exam with each resident individually.

B. OKAP Examination

All residents participate annually in the Ophthalmic Knowledge Assessment Program (OKAP) given by the ABO. The examination is taken at an authorized examination site. The results of each resident's examination will be used as one of the criteria for performance measurement. Resident performance on the OKAPs will be the basis for the milestone defined by the ACGME (Medical Knowledge, MK-1; see table below).

Medical Knowledge Residents must demonstrate knowledge of established and evolving clinical, epidemiological, and social-behavioral sciences, as well as the application of this knowledge to patient care. Residents must demonstrate level-appropriate knowledge in the following core domains: General Medicine, Fundamentals and Principles of Ophthalmology; Optics and Refraction; Ophthalmic Pathology and Intraocular Tumors; Neuro-Ophthalmology; Pediatric Ophthalmology and Strabismus; Orbit, Eyelids, and Lacrimal System; Cornea, External Disease, and Anterior Segment Trauma; Lens and Cataract; Refractive Management and Intervention; Intraocular Inflammation and Uveitis; Glaucoma; Retina/Vitreous. MK-1. Demonstrate level-appropriate knowledge Has not Achieved Level 1

Level 1 Level 2 Level 3 Level 4 Level 5 Articulates knowledge of pathophysiology, clinical findings, and therapy for ophthalmic conditions routinely managed by non-ophthalmologists

Demonstrates basic knowledge of pathophysiology, clinical findings, and therapy for common ophthalmic conditions routinely managed by ophthalmologists

Demonstrates advanced knowledge of pathophysiology, clinical findings, and therapy for commonly encountered ophthalmic conditions and demonstrates basic knowledge of pathophysiology, clinical findings, and therapy for less commonly encountered conditions

Demonstrates advanced knowledge of pathophysiology, clinical findings, and therapy for less commonly encountered ophthalmic conditions

Educates junior resident and medical students and contributes to the body of knowledge of pathophysiology, clinical findings, and therapy for ophthalmic conditions

Individual scores will remain confidential, known only by the Department Head, Program Director, and respective resident. The results will be used by the Program Director as one of many criteria in evaluating resident performance. In addition, the results will be used by the Department in identifying programmatic strengths and weaknesses. Each resident will meet with the Program Director to discuss the results of their exam.

The OKAP examination reports individual subject scores, overall scores, and "core knowledge" scores as a percentile for all residents at the same level of training. If the resident scores below the 30th percentile on the overall OKAP exam, the resident will be required to read all subsections in

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which the score was below the 30th percentile. If the resident performs in the 30th percentile or greater on the overall exam but below the 30th percentile on an individual subsection, the resident will be required to read the subsection in which the score was below the 30th percentile. The resident should meet with the faculty member who is responsible for the subsection. During the meeting, the resident will develop a written plan for study, along with a schedule of readings. The resident will keep a log of their reading schedule, including the date and time the reading started, the date and time the reading finished, and pages covered. Completion of the study program is reviewed with the Program Director at the 6-month review. Additional subsection testing may be required. The resident who has an overall score below the 30th percentile on the OKAPs are forbidden from moonlighting and will not be eligible to apply for travel grants for presentations at conferences (such as ARVO and ASCRS).

Residents scoring above the 75th percentile in an individual subsection will be recognized for their achievement by notification of the faculty member responsible for that area and the Department Head. Scoring below the 30th percentile will be reflected in the Department Head’s letters of recommendation and the resident’s summative evaluation.

21. CLINICAL COMPETENCY COMMITTEE

The Clinical Competency Committee (CCC) will review all resident evaluations semi-annually (December and June). The CCC is also responsible for advising the Program Directors regarding resident progress, including promotion, remediation, and dismissal, and for preparing and assuring that the milestones for each resident are reported to the ACGME semi-annually. The CCC consists of at least three program faculty who are appointed by the program director.

22. INTERNATIONAL ROTATION South Campus residents may participate in international rotations—one week in the 1st year and one week in the 2nd year. 1st Year (PGY-2) Resident

Nogales with Dr. Maria Ramirez Spanish immersion One week (Monday-Thursday) Reimbursement for mileage/parking fee Program coordinator will arrange; notify if

interested

Additional Opportunity (1 week) Must complete one week in Nogales in fall Nogales with Dr. Maria Ramirez One week (Monday-Thursday) in spring Reimbursement for mileage/parking fees Program coordinator will arrange; notify if

interested

2nd Year (PGY-3) Resident Department-sponsored activity Transportation/lodging expenses usually

covered by the program Not required to participate in Mexico

Additional Opportunity (1 week) Must participate in Department-sponsored

activity Approval by Program Director and

Department Head Meet University policies for international

rotation – notify program coordinator at least 6 months in advance so required paperwork can be submitted for approval)

Activity must occur after OKAPs Expenses not covered

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23. PROMOTION (ADVANCEMENT) Residents are advanced to positions of higher responsibility on the basis of evidence of their progressive scholarship and professional growth. This evidence includes satisfactory completion of rotations, documented attendance at educational activities, and an assessment of the resident’s progress in achieving competence in patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism and systems-based practice. This advancement is communicated to the GME Office by the annual submission of a promotion letter or summative evaluation (for graduating residents). 24. PROBATION AND DISMISSAL In the event that a resident's overall progress is considered to be "unsatisfactory," he/she shall be placed on probation, but only after full consultation with the Department Head, Program Director, and faculty. Probationary status shall be acknowledged in writing and accompanied by goals and objectives to be achieved in a reasonable amount of time (but in no case, greater than 6 months). If the identified deficiencies are not remedied during the probationary period, the resident may be subject to dismissal; the appeals mechanism noted in Section 18 and all the College of Medicine appeals mechanisms shall pertain should they be desired by the resident. The UA College of Medicine Resident Physician Probation Procedures, Nonrenewal Procedures, and Suspension and Dismissal Procedures are kept on file (see program coordinator). Time spent on probation will be made up at the discretion of the Program Director. A resident may be immediately pulled from surgery and put on probation if he/she is felt to pose a risk to patients. 25. PRACTICE PRIVILEGES AND OTHER ACTIVITIES OUTSIDE THE EDUCATIONAL

PROGRAM Moonlighting is discouraged because it detracts from the educational activities within the Department of Ophthalmology. Exemptions may be granted by the Program Director, in special circumstances. Moonlighting may be done by a resident ONLY after consultation with the Program Director and Department Head. Malpractice insurance coverage is provided by the University only for activities within the scope of a resident's educational curriculum; moonlighting activities are not covered. After approval, if it is found that moonlighting activities are interfering with learning, moonlighting must be discontinued. Moonlighting without permission is prohibited and is grounds for suspension and/or dismissal. Residents who have received an overall score below the 30th percentile on their OKAPs, have received a “notice of deficiency,” or are on academic probation are forbidden from moonlighting. Residents who do choose to moonlight must keep a log of their hours and report them to the program coordinator weekly, as well as enter the hours into duty hours in New Innovations. Hours spent moonlighting are counted toward total duty hours and may be limited if total allowable hours worked in a given period is exceeded. All moonlighting hours MUST be recorded in your duty hours.

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26. BOARD ELIGIBILITY For a resident to be considered Board eligible, the Department Head must certify that the resident has satisfactorily completed the prescribed length of residency training, which is 36 months. The resident must also hold a valid and unrestricted license(s) to practice medicine in the United States. For details, see the ABO website (www.abop.org). In the event that a resident has been placed on formal probationary status, the Department Head will consult with the Program Director and Department faculty to determine whether the time on probationary status shall be counted toward the Board of Ophthalmology’s time requirement. Typically, time accrued while a resident is on official probation is NOT considered time "in good standing" in the program and is NOT usually applicable to the requisite 36 months of training. Additional training may be deemed necessary prior to granting certification of satisfactory completion of the residency program. The resident shall have the right to appeal as noted in Section 18. 27. COMPLAINTS REGARDING WORK ENVIRONMENT The Graduate Medical Education Office and the Graduate Medical Education Committee strive to create an environment where residents can raise issues confidentially and without fear of retaliation. To this end, residents are provided several avenues in which they may communicate and exchange information on their working environment and their educational programs. First of all, residents are encouraged to discuss all issues with their Program Director, faculty mentor/advisor, Chief Resident and/or Department Head. Residents are encouraged to contact the GME Office at 626-7878 with any concerns about their ability to confidentially raise issues. 28. COMMITTEES Residents are encouraged to participate in hospital committees. Each year, the residents select a representative and alternate to serve on the Graduate Medical Education Committee, an institutional committee charged with the responsibility of monitoring and advising on all aspects of residency education. Residents interested in participating in a committee should contact the program coordinator for information. 29. COUNSELING SERVICE A counselor is available to discuss any issues of a personal or professional nature for residents and their families at no charge. Dr. Larry Onate may be contacted at 325-9176, and his office is located at 2340 N. Tucson Blvd, Suite 110.

30. DRESS CODE At times when patient contact is anticipated, residents must dress and present themselves in a manner which is appropriate to the profession of medicine. Residents are expected to wear recently laundered white lab coats at their faculty’s instruction, and name tags at all times while in the clinic. Residents

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should follow the general guidelines addressed in the Banner policy (see appendices; also available in the public resident files folder). Lab coats and laundry service for these coats are provided. 31. ADMINISTRATIVE SUPPORT A secretary is not appointed for the residents, but administrative assistance is available as follows:

A. Computer Issues: Computers with software for word processing, graphics, presentations, and Internet access is available for use by residents in the resident office. Photo, slide, negative and document scanners are also available. Residents are expected to prepare their own documents. If problems occur with the computers or printer, please contact UA College of Medicine ITS at 626-8721.

VPN Access: For remote access to your files, it will be necessary to locate the specific location of your files. The first time accessing your files remotely, call the COM IT service desk for assistance. You can reach them at 626-8721 from 7:30 AM to 5:30 PM. The link for remote access is http://vpn.arizona.edu; requires your NetID username and password.

B. Poster Printer: A printer is available for printing research posters. The template for poster

presentations is available on the Department’s website at www.eyes.arizona.edu/deptforms.html (“Template for Posters”). When the document is ready for printing, submit the file to the program coordinator via email, USB drive, or CD-ROM.

C. Travel

To be eligible for reimbursement for travel expenses for conferences, residents must submit the following information to the program coordinator: (1) name and dates of conference/course, (2) email confirmation for presentation, (3) planned airline itinerary, and (4) name and address for hotel. This information must be provided at least 30 days in advance to allow time for the travel to be authorized. Travel expenses may not be eligible for reimbursement if authorization was not obtained in advance. Per University policy, there will be no reimbursement for alcoholic beverages. Residents can ONLY be reimbursed for their OWN expenses.

AAO: Third year residents who attend the AAO annual meeting will be granted up to three

days of educational leave, and up to $850.00 for reimbursement of eligible travel expenses. Residents must use vacation for any additional days for this conference (not eligible for additional educational days). Residents must submit receipts for eligible travel expenses to the program coordinator within 30 days after their return. Receipts not returned within the deadline will not be reimbursed.

Conference Presentations: Residents who are granted travel funds for a presentation

(paper, poster, etc.) at national meetings are eligible for up to two days educational leave (the day of the presentation, plus the day immediately before or after the presentation for travel). Residents must submit receipts for eligible travel expenses to the program coordinator within 30 days after their returns. Receipts not returned within the deadline will not be reimbursed.

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International: South Campus PGY-2 residents who rotate in Nogales will be reimbursed for mileage and parking fees. Residents must submit departure/return time, mileage, and

parking receipts within 30 days of the travel date. The resident is responsible for their own food and hotel accommodations.

Hotel accommodations and most food will be provided for the residents who rotate in Kino

Bay (or other designated location). Specific details will be provided when available.

D. Departmental Purchases: Any purchases (such as wet lab materials) that will be paid for by the Department must be approved by the Program Director. After approval is received, the purchase request must be submitted to the program coordinator who will inform you of purchase requirements (purchase order, credit card, etc.). Be sure to plan ahead, since it could take a couple of weeks (or longer) to get the paperwork processed before the purchase can be authorized.

32. PRE-DIPLOMA CHECKLIST At the end of thirty-six (36) months, residents are to obtain initials documenting completion of the following pre-diploma checklist (see Forms, page 41) prior to receiving their diploma. Diplomas will not be handed out prior to the final day of the residency program. 33. POLICIES SPECIFIC TO INSTITUTION

A. BUMCT AND BUMCS

(1) Medical Records

Medical records, for both inpatients and outpatients, must be maintained in a timely fashion and according to BUMCT and BUMCS policies. All entries must be legible and complete. The resident's 4-digit identification code MUST ALWAYS be affixed to his/her signature. All new patients or initial examinations must include the following: Pertinent history and notation of allergies Best corrected vision Motility Visual field to confrontation External examination Slit lamp Intraocular pressure Fundus examination Impression Plan

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A pre-operative exam and note by the staff or resident must be recorded within 30 days of surgery. The format is as follows, and all items must be present in a single note: Visual acuity with manifest refraction Manifest refraction Slit lamp examination OU Intraocular pressure OU Fundus examination Surgical indications (with specific functional complaints) Risk and alternatives discussed

(a) Operative notes on all resident surgeries and discharge summaries on all patients admitted by the resident must be dictated/entered by the residents; this is part of the educational experience.

(b) Operative notes must be dictated/entered on the day of surgery and reviewed by the

resident and faculty before being signed and placed in the patient's medical record. (c) Discharge summaries must be dictated/entered at the time of discharge and reviewed by

the resident and faculty before being signed and placed in the patient's chart. At the time of surgery and discharge, all abnormal laboratory study and test results must be noted in a progress note and all these items must be addressed with an appropriate plan for follow-up.

All medical records must be completed as soon as possible after discharge and in no case more than seven (7) days after discharge.

(d) Delinquent medical records are a cause for disciplinary action within the Department.

Records not cleared within one week will result in temporary cessation of surgical privileges.

(e) Within the Department, residents are required to document their clinical and surgical

experience online. The scope of this responsibility is outlined in Section 14. Orders on Patient Charts

(a) It is BUMCT and BUMCS policy that all orders on patients' charts be entered at the time they are given; however, some flexibility is provided by individual nursing stations as reasonable and appropriate.

(b) All signed orders, consult requests, progress notes, etc., must be accompanied by the

physician's 4-digit identification code; this will facilitate the interpretation of illegible writing.

(c) When a verbal order is accepted by the floor staff, that order should be countersigned by

the resident before leaving the hospital if the order is given during the daytime, or first thing in the morning if the order is given during the night.

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(2) Department of Anesthesiology Guidelines for Patient Preoperative Preparation

T*T*These guidelines apply to patients with normal gastric emptying who are scheduled for elective surgery. Patients with delayed gastric emptying (e.g., diabetic, obese, opioid use) may need longer period of fasting. Patients may be fasted longer than this for surgical indications, but members of the Anesthesiology Department will not delay elective surgery for fasting if these guidelines are followed. **Clear liquids= water, sugar water, apple juice, tea, Pedialyte, black coffee Gastric tube feedings: stop clear liquids 2 hours before surgery; stop other liquids 6 hours before surgery Jejunal tube feedings may be continued up until the times of surgery Patients with normal gastric emptying who meet these criteria will be considered “fasted” for any elective procedure conducted under moderate sedation, deep sedation, general anesthesia, or major regional anesthesia at BUMC. These are the minimum acceptable fasting periods. Patients who have delayed gastric emptying may be instructed to fast for longer periods. Patients may also be instructed to be NPO longer for surgical indications, or to facilitate later changes in the time of surgery.

B. SAVAHCS

(1) Purpose

Residents rotate through SAVAHCS for one half-day continuity clinics per week during their first and second year of residency, and for nine months of the third year of their residency. Additionally, a first or second year resident manages the oculoplastic clinic. The third year residents who are rotating full-time through SAVAHCS return to the administrative offices of the Department of Ophthalmology for didactic lectures and conferences.

The clinic at SAVAHCS is considered a "resident clinic," and residents are supervised by faculty who act as “consultants” and are present at all times. This allows the resident the opportunity to take significant responsibility for patient evaluation and management. This "team approach" provides a very good educational experience at all levels within the training program. In addition, the clinics offer a wide variety of general patients in addition to concentrated exposure to subspecialty patients in the subspecialty clinics.

NPO Guidelines* Ingested Material Minimum Fasting Period Clear liquids** Stop 2 hours before surgery Human milk Stop 4 hours before surgery Infant formula or non-human milk Stop 6 hours before surgery Light meal (e.g., toast and clear liquids) Stop 6 hours before surgery Heavy meal (e.g., fatty foods, meat, alcohol, large volume)

Stop 8 hours before surgery

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During the third year VA rotations, residents are expected to become adept at:

(a) Anterior segment examination techniques, including reading prescriptions and refracting (b) Posterior segment examination techniques, including indirect ophthalmoscopy (c) Cataract surgery (d) Corneal surgery (e) Glaucoma surgery (f) Retina surgery (g) Laser of eye disease (h) Surgical management issues, both pre- and post-operatively (i) Medical management of all ocular problems.

(2) Local Program Director

The Ophthalmology Section at SAVAHCS is under the direction of the Section Chief, Robert Lindberg, DO, and he administers the daily operations of the clinic. Issues which affect the overall program are brought to the attention of the Program Director and Department Head. These are dealt with at the Department level and changes must be approved by the Section Chief and the Program Director.

SAVAHCS is considered a Dean's hospital with academic programs under control of the UA College of Medicine. Ophthalmology is considered a section and, as such, is under the direct auspices of the Surgical Service. The Surgical Service takes an active role in overseeing the financial aspects of the Ophthalmology Service and is responsible for distributions of salary funds and purchase of equipment. The UA Department of Ophthalmology with the approval of the SAVAHCS administration and Surgical Service appoints all SAVAHCS faculty and the Program Director. Control of the SAVAHCS academic curriculum and resident assignments, and decisions in academic matters, are directed by the Section Chief who must have full approval by the Program Director and Department Head at the UA College of Medicine.

The teaching faculty are members of SAVAHCS and UA Department of Ophthalmology faculty. These faculty are consultants with or without compensation, and include Drs. Belin, Carrozza, Dryden, Lindberg, Pugazhendhi, Thomas, and Villavicencio.

The program at SAVAHCS is evaluated by the Department of Ophthalmology via the standard formal resident evaluation of rotations conducted twice a year by the Program Director, the annual overall evaluation of the teaching program, and the formal evaluation of the individual faculty teaching efforts.

(3) Facilities

The facility at SAVAHCS is well suited for the residents and faculty members who participate in the clinic. There are six fully equipped ophthalmology examination lanes. There is a separate laser facility in the clinic with a solid-state multi-wavelength laser, diode, Nd:YAG laser, SLT laser, and an infrared diode laser. Other equipment available includes: automated perimetry, digital fundus and anterior segment photography, specular microscopy, and fluorescein angiography. The eye clinic is equipped with A/B Scan Ultrasound, IOL Master, Cirrus ocular coherence tomography, and Pentacam anterior segment tomography,

The operating room is equipped with a Leica and Zeiss operating microscope, a Centurion (Alcon) phacoemulsification unit, an anterior/posterior segment vitrectomy unit (Alcon Constellation) with endolaser, and a video monitor on the operating microscope. The operating room has capabilities for all intraocular and extraocular ophthalmologic procedures.

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(4) Educational Experience

The didactic lectures and clinical conferences take priority over all other activities except emergency patient care. The schedule is arranged so that there are no conflicts during lecture time or clinical conference time for any of the residents. The Chief Resident or his/her designee is assigned to take attendance at all clinical conferences and to turn in this attendance to the program coordinator. This is recorded electronically and periodically monitored by the Program Director. Attendance by the faculty at morbidity and mortality conferences and weekly rounds is expected and noted by the Department Head.

(5) National Mandates/OSHA and National Quality Forum

SAVAHCS implements all national quality forum initiatives, OSHA requirements, and other national mandates related to patient access and timely follow-up. All residents are expected: to know the national patient safety goals and the yearly updates, which can be found on

TUCNET. to know the proper procedure for the emergency “codes” which are located above the printer

in the front office. to know location of the fire extinguisher (in eye clinic laser room and in the back hallway

across from the OmniCell room) and the code cart (adjacent to the nurses station in the medical subspecialty clinic).

to comply with OSHA standards in their patient examining rooms. to comply with SAVAHCS confidentiality policy including NO patient identifiable material

in paper format and, if used, with permission, the material must be locked at all times unless being visualized by the treating provider.

to use universal protocol for all procedures. to be prepared for surprise inspections. to have reusable medical equipment (RME) compliant documentation on file at the VA and

be signed off for competence to comply with care of equipment in the examining rooms, which is on a list on the back of

each door. to have the date of expiration (28 days from opening date) marked on the bottle of all drops

and reusable medication vials in the examining rooms. Which need to be locked in the room’s med box when not in use. (If it is not marked, it must be thrown away during unscheduled impromptu inspections that occur every 1-2 months.)

The above is explained in the national patient safety, universal protocol and ambulatory care/surgery guidelines at the following:

Accreditation Program: Ambulatory Health Care National Patient Safety Goals

https://www.jointcommission.org/assets/1/6/2017_NPSG_AHC_ER.pdf

Accreditation Program: Office-Based Surgery National Patient Safety Goals https://www.jointcommission.org/assets/1/6/2017_NPSG_OBS_ER.pdf

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(6) Medical Records Documentation

There are specific components that must be completed on all EMR records of a visitation. These include:

Diagnosis Visit Type Procedure Service Connection Diabetic Screening Update Signature

If these are not complete, the record is suspended and held for edits and will appear on a list to be completed. Please comply and develop good habits when you start.

(7) Medical Library

Lynne Flance is very helpful in finding and retrieving articles for patient treatment.

(8) Shared Calendars

a. Attending Call Calendar: There is an attending call calendar that is set up, and all

residents should be able to access to check call coverage. http://intranet.visn18.med.va.gov/tucson/60412/

b. Surgical Calendar: All residents are given VA email access. There is a surgical

scheduling calendar that is accessible to all residents via Outlook (VA email). As you book surgeries, check the faculty call calendar for vacation and then put surgery in appropriate booked spot. Try to be accurate in maintaining this calendar, as well as completing all SAVAHCS-required paperwork for booking of routine and emergency surgery.

c. Resident Clinic Calendar: Designates clinic and OR assignments and supervisory

faculty.

(9) Non-VA Care Consults

Non-VA Care consults must be scheduled with review and approval by the Section Chief. SAVAHCS requires that these are distributed equally between all contracted providers. However, specific providers may be requested if they are the sole provider, other providers are not taking patients, or other “special circumstances.” Do not enter specific provider names in consults unless there is documentation of a need for a specific provider. Direct all consults for eyes to the attention of Sandra Palenga, RN.

(10) SAVAHCS Patients After Hours/Weekends

SAVAHCS urgent care and post-op patients must be seen at SAVAHCS. When seen at the University Ophthalmology Clinic no true medical record is established and the visit is legally considered not to have taken place at all. There are obvious legal implications to this, and in particular, SAVAHCS provides liability coverage only for those services provided at SAVAHCS, or those performed under a contractual arrangement and with prior authorization of SAVAHCS

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administration. In addition, in the absence of a BUMC medical record, the University does not provide liability coverage.

For practical purposes, the only SAVAHCS patients who can be seen at the University Ophthalmology Clinic are those being referred for services that cannot be provided at SAVAHCS (ERG’s, urgent IVFA’s, certain subspecialty consultations, etc.), and these patients become registered at the University at that time.

(11) Patient/Clinic Cancellation

There are to be NO cancellations of SAVAHCS individual patients or clinics without approval of the Section Chief and Program Director. This policy is necessary to meet the wait time requirements of the cataract mandate program. SAVAHCS policy is no clinic cancellations less than 30 days. Exceptions can be made for career and fellowship interviews and emergent personal issues (such as sick leave). See the Section Chief for exceptions.

When you need to cancel a clinic(s) at the VA, submit an electronic request on TucNet (available only on desktops at the VA). Clinics will NOT be cancelled less than 45 days in advance except for emergency situations

and unplanned surgical cases. All requests for clinic cancellation must be submitted through the automated electronic

program available on TucNet. The official date of the request will be the TucNet submission date. Care/Service Line Chiefs are required to review leave requests and ensure that clinics are not

cancelled less than 30 days in advance. Care/Service Line approvals/denials to requests will be processed within 72 hours. It is advisable to print a copy of your request for your records. This must be done BEFORE you hit the "Submit" button. All requests must be submitted at least 30 days in advance.

Also: All residents are expected to return to clinic on time even if surgery runs over. The attending

can complete the case. Residents CANNOT leave clinic to go to surgery if there are patients waiting to be seen. Residents CANNOT reschedule patients already checked into the clinic and waiting to be seen

because of time pressure.

(12) Surgery/24-Hour Post-Op Patients

One-day post-op appointments should be made with patient at the time of pre-op visit. Residents must notify front desk personnel of any changes to post-op appointments prior to the

patient’s arrival in clinic. When scheduling patient appointments during “off” hours, especially post-op patients, it is the

resident’s responsibility to arrange with patient and patient’s family. A new visit must be created in CPRS at the time of visit.

ALWAYS use VA email when communicating with VA patients (Secure Messaging is best for this purpose).

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(13) Patient Notes

Make sure CPRS notes are attached to the correct appointment. You must click on the provider/location tab next to the patient’s name at the top of the toolbar of the patient’s chart to do this properly. The CPRS system rejects any annual appointments that do not have notes attached. These appointments have to be tracked and replaced. A new clinic visit can and must be created for any “off” hour visits. Residents will be shown how to create a new visit during orientation. Additionally, CPRS notes created for Emergency Department or inpatient visits need to be written as an Eye Clinic note, not an emergency department or inpatient note. To do this, you would again click on the New Note tab, and then type in ‘TUC EYE OPHTH-URGENT’, or Tuc Eye and scroll down to the Urgent designation and click it. Then, begin your note.

(14) Dirty Instrument Policy

Dirty instruments CANNOT be placed in the clean utility room (OmniCell room). Transport boxes are kept in the OmniCell room. The doctor also needs to take a transport box when they get an instrument out of the OmniCell. Once the instrument is dirty, it must be placed in the transport box and walked over to the Dirty Utility Room 2317 (across from the conference room; code 4531). The doctor is not allowed to wear gloves while walking the box over. Once inside the dirty room, the doctor must don gloves to remove the instrument from the transport box and place it in the dirty “Eye Bin.” Then, the doctor must get a cavi-wipe and wipe the inside and outside of the box. Then, take off their gloves, wash hands and then walk the box back to the OmniCell room for safe keeping.

(15) Axial Length Calculations

See the appendix for information on axial length calculations.

34. MEDICAL MARIJUANA In 2010, Arizona voters passed Proposition 203 to legalize medical marijuana (MMJ) for "qualifying patients" with "debilitating medical conditions," including glaucoma. The law requires patients seeking medical marijuana to receive a "recommendation" from a "doctor" to receive a MMJ card. Implementation of the state law has been delayed by a lawsuit filed in U.S. District Court challenging the law's federal legality. It is against federal law to prescribe marijuana and this should never be done. However, patients may request that residents recommend them for MMJ based on a glaucoma diagnosis. Medically, the position of the American Glaucoma Society is that ophthalmologists NOT recommend MMJ. Legally, federal law prevails at the VA, where policy is NOT to recommend MMJ. At Alvernon, BUMCS, and BUMCT, residents work under their medical training license through the Department, and Department policy is that residents may NOT, under any circumstances, recommend MMJ.

OPHTHALMOLOGY

GOALS AND OBJECTIVES

OPHTHALMOLOGY GOALS AND OBJECTIVES Table of Contents

PROGRAM ............................................................................................................................................ 1 POSTGRADUATE YEAR

1. First Year (PGY-2) Resident ...................................................................................................... 2 2. Second Year (PGY-3) Resident .................................................................................................. 5 3. Third Year (PGY-4) Resident ..................................................................................................... 7

ROTATION

1. Chief Resident ............................................................................................................................. 9 2. Comprehensive/Continuity Clinic/General ................................................................................. 14 3. Consults/Call ............................................................................................................................... 21 4. Contact Lens/Refraction ............................................................................................................. 28 5. Cornea and External Disease ...................................................................................................... 33 6. General/Glaucoma ...................................................................................................................... 49 7. Glaucoma .................................................................................................................................... 40 8. International ................................................................................................................................ 57 9. Neuro-ophthalmology ................................................................................................................. 60

10. Oculoplastics ............................................................................................................................... 65 11. Pediatric Ophthalmology and Strabismus ................................................................................... 72 12. Refractive Surgery ...................................................................................................................... 80 13. Vitreoretina ................................................................................................................................. 85

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PROGRAM GOALS AND OBJECTIVES

Goals The goals of the Ophthalmology Residency Program are to:

1. Graduate ethical and compassionate comprehensive ophthalmologists with the knowledge, skills and confidence required to enter into practice.

2. Educate residents in a supportive environment where patient care is provided by a faculty who model behaviors to be emulated.

3. Provide residents with didactic instruction and clinical experience that will enable them to obtain American Board of Ophthalmology certification upon graduation.

4. Provide residents with the fundamental scientific background in ophthalmology to prepare them to become life-long learners.

5. Provide residents with skills to practice evidence-based medicine.

Objectives The objectives of Ophthalmology Residency Program are to:

1. Provide residents with a strong scientific understanding of the fundamentals of ophthalmology through a combination of mentoring and didactic education.

2. Provide residents with clinical skills in all subspecialties of ophthalmology. 3. Provide residents with broad surgical experience in all subspecialties of ophthalmology. 4. Encourage residents to perform literature reviews and use critical thinking skills to make

informed patient care decisions. 5. Provide residents with an understanding of ethical, legal, and moral issues involved in eye care

and medical care. 6. Provide residents with the fundamental business and managerial skills for a systems-based

practice.

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POSTGRADUATE YEAR GOALS AND OBJECTIVES

1. First Year (PGY-2) Resident a. Goals

During the first year of residency, the PGY-2 resident is expected to become a member of the eye care team at the University of Arizona and to establish a reputation for reliable and trustworthy behavior in all aspects of their professional life. In the clinic, during the first year, the resident will learn recognize the normal eye examination and to be able to reliably describe deviations from normal. It is not expected that a first year resident will accurately diagnose all manner of eye conditions, but they should recognize deviations from normality and be reliable in bringing them to the attention of others. In the operating room, the resident will become a skilled assistant, will read about the surgeries that they are assisting in, and will assist in the preoperative evaluation and postoperative care of the patients whose surgeries they are assisting in. In the hospital and while on call, the first year resident will develop confidence in their ability to serve as a member of a team that will provide all levels of eye care for all presenting eye emergencies and urgencies. During the first year of residency, the resident will develop a base of basic knowledge through the study of the American Academy of Ophthalmology Basic and Clinical Science curricula, and will develop in-depth knowledge in focal areas through preparation of grand rounds. b. Objectives Competency-based objectives during the first year of residency relate specifically to the rotation in which the residents participate. Patient Care Global aspects of patient care that are not rotation-specific include:

Development of emergency department specific eye care skills and knowledge, where a patient presenting with either global trauma or eye specific complaints are properly evaluated and managed.

Development of telephone communication skills with patients and attendings, as often the first year eye resident is the first line of communication when a patient calls after hours.

Initial development of communication skills required to allow the efficient establishment of a consulting relationship to meet a patient’s eye care needs.

Medical Knowledge Global medical knowledge objectives during the first year of residency can be summarized by the

expectation that Basic and Clinical Sciences Course material of the American Academy of Ophthalmology is the reading expectation for the first year.

It is not expected that first year resident will have time for broad reading of textbooks; that is expected during the second year of residency.

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The resident is expected by the end of the first week of residency to have read the Wills Eye Manual from cover to cover, and to be able to quickly and efficiently use this text in its current edition as the primary guide for protocol-driven care in the emergency room and after hours consultations.

Professionalism Demonstrate compassion, integrity, and respect for others, including patients, their families, and

all fellow employees regardless of their job classification. Respect patient privacy and autonomy. Be sensitive and responsive to a diverse patient. In particular, if a resident is not fluent in

Spanish, it is expected that appropriate translators will be used so that effective doctor/patient communication can occur.

Conduct themselves in a courteous, neat and professional manner at all times. Residents are expected to acquaint themselves with the dress code requirements of the hospitals that they are rotating through and respect the requests of the parent institution.

Be available at all times on after-hours call duty, whether primary or back-up call. This includes getting a cell phone that is a local number that does not require a long distance call to access the resident.

Complete all dictations and paperwork in a timely manner. Discharge dictations must be completed by the time of discharge and operative dictations immediately following the surgical procedure.

Attend all educational activities including conferences, lectures, and journal clubs. Attendance is taken, this is a small program and your participation is essential for the experience to be good for all parties.

Demonstrate timeliness in arrival to clinics, ORs and lectures. If you are not early, you are late! When disagreements arise as they will, seek a respectful solution. For issues between residents, it

is best to involve the Chief Resident first to mediate a solution. Practice-Based Learning and Improvement Make a point of each day, writing down the medical record number of a patient that you have

seen, and then reading something about that diagnosis. Each exam room has internet connectivity. Learn the library on-line resources and access those

resources while the patient is in the room. Review key findings with your attending after each patient encounter, and when you do not see a

key finding, try to get the patient back into a room. As a general rule, we have plenty of exam rooms and more patients than you can hope to see

during the course of a day. It is preferable that you learn as much as possible from each patient that you see, than learn little from many patients. There will be time in your later years of residency to develop rapidity; during the first year concentrate on developing diagnostic skills.

Use your time with patients to develop your portfolio. Interpersonal and Communication Skills Develop methods to communicate effectively with patients and their families across the spectrum

of our community. Become proficient at rapidly and effectively presenting the eye history and exam to your fellow

residents and attendings. Work effectively as a member of a health care team or other professional group. Act in a consultative role to other physicians and health professionals.

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Maintain comprehensive, timely, and legible and intelligible medical records. Your responsibilities in documenting patient visits have medicolegal implications. Learn your charting responsibilities.

Each hospital has different charting requirements and methods for order entry. Avoid verbal orders; you must sign them anyway within 24 hours, so take the time to enter any orders extemporaneously and you will save time overall.

Systems-Based Practice Work effectively in various health care delivery settings and systems relevant to their clinical

specialty. Ophthalmology is a consultative service and your future success will be determined in large

measure by how well you communicate with your referring physicians. Learn now how to communicate effectively.

Advocate for quality patient care and optimal patient care systems. Maintain medical records in a timely manner.

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2. Second Year (PGY-3) Resident (in addition to PGY-2 requirements)

a. Goals During the second year (PGY-3), expectations are placed on the resident to develop competency at readily identifying the most common eye diseases, identifying the pathology accurately, and being able to develop a plan for care. The second year resident is to assist in surgery, developing surgical skills and competences in preparation for extensive surgical experience in the third year. During the second year of residency, the didactic education goals center upon developing in-depth knowledge on a daily basis by focal reading on the subspecialty rotation that the resident is participating in, while reviewing the BCSC core material on an ongoing basis. By doing so, the resident is expected to develop a broad knowledge of the breadth of the ophthalmic literature. b. Objectives

Patient Care During the second year emphasis shifts from learning general ophthalmology do developing a

nuanced education in the various specialties. During the second year, you will have increased patient care expectations from the faculty. In the second year, residents are expected to be sufficiently skilled that they can serve as effective

teachers to medical students and other health care providers. In the second year it is expected that residents will learn to recognize more than one presenting

problem and develop a coherent management plan that addresses all the problems of a given patient.

Medical Knowledge While the primary educational source material remains the AAO BCSC, on each rotation there

will be a secondary reading list that utilizes both journal articles and reference texts. It is your responsibility to obtain these materials and study them in a timely manner.

The expectation is that reading the BCSC should now be a review process, and references that are presented in the BCSC can now be explored.

The sophistication of Rounds presentations is expected to increase as a result of the greater level of intellectual sophistication.

In the operating room, evidence of wet lab practice should be evident. Professionalism Demonstrate an ability to confidently communicate the risks and benefits of surgery to a patient

in preparation for the VA experience. Manage angry patients and their families in a respectful and calm fashion. Manage the patient with non-organic disease in an appropriate fashion. Demonstrate sensitivity with patient confidentiality issues being judicious in their choice or

words and choice of timing in discussion of patient issues. Practice-Based Learning and Improvement Develop a portfolio of patient encounters that link reading with specific diagnoses on a recurring

basis.

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Begin to differentiate care that is practiced on the basis of evidence from care that is delivered empirically. When evidence based care recommendations can be made, make care recommendations accordingly.

Interpersonal and Communication Skills Communicate complications compassionately and clearly to patients and their families. Work effectively as a leader of a health care team or other professional group. Systems-Based Practice Incorporate considerations of cost awareness and risk-benefit analysis in patient care. Demonstrate flexibility in clinical care balancing patient financial needs with the clinical situation

at hand to ensure the best possible outcome. Understand how conclusions within the medical literature if implemented will impact the larger

medical climate.

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3. PGY-4 Resident (in addition to PGY-2 and PGY-3 requirements) a. Goals The senior year (PGY-4) of resident education is intended to be a time of skill and knowledge consolidation, and a time where surgical confidence develops. Basic skills are trained on a repetitive basis. The ability to develop a differential diagnosis and develop a management plan matures. Leadership skills are emphasized and confidence to establish an independent practice is instilled. A major goal for third year residents is employment or continued training upon completion of the third year. Thus, time is dedicated to career counseling and time off is provided for job and fellowship interviews. During the third year of residency, the resident is expected to develop and polish their surgical skills and interpersonal skills for patient management by managing a practice at SAVAHCS. Additionally, during the final year of residency, the resident is expected to demonstrate leadership and administrative skills during their rotation as Chief Resident. During Chief Residency, the resident will serve as administrator for the residency program in many respects and will be the assistant to the Program Director for the day-to-day operations of the residency program. The Chief Resident is directly involved in dealing with the problems encountered during the routine operation of a clinical service. b. Objectives

Patient Care Recognize the difference between the routine and the challenging patient, and learn to use VA

teaching staff for the challenging patient while effectively communicating the care of the routine patient.

Spend time reviewing cataract surgery recordings in order to develop an appreciation for the earliest time a problem might have been recognized. Use the recordings to improve the next case.

Continue to utilize the wet lab for surgical practice. Facilitate patient care in the operating room as well as in the pre and post-operative areas. Medical Knowledge Develop a vocabulary that will allow an accurate portrayal of the eye findings of an

individual basis that is sufficiently nuanced to describe the incremental improvement or worsening of a patient.

Manage or supervise the more junior trainees (e.g., medical students or medical residents) in the management ocular emergencies (e.g., central retinal artery occlusion, giant cell arteritis, chemical burn, angle closure glaucoma, endophthalmitis).

Perform more advanced external and adnexal surgical procedures (e.g., lacrimal gland procedures, complex lid laceration repair, e.g., canalicular and lacrimal apparatus involvement).

Professionalism Model respect, compassion, and integrity in interactions with surgical patients. Model a commitment to excellence and on-going professional development.

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Demonstrate a commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices demonstrate sensitivity and responsiveness to patients’ culture, age, gender, and disabilities.

Practice-Based Learning and Improvement Track your own surgical results to identify trends in your practice. Develop vigilance for complications, and as they arise, review the recordings to see when they

might have been avoided. Participate in the department Morbidity and Mortality process to allow others to learn from your

experience. Apply knowledge of study designs and statistical methods to the appraisal of clinical studies and

other information on diagnostic and therapeutic effectiveness. Interpersonal and Communication Skills Demonstrate ability to disclose medical errors and complications to patients and families in a

compassionate manner. Maintain a calm and rational demeanor in dealing with angry patients, staff, fellow residents and

faculty. Systems-Based Practice Participate in identifying systems errors and in implementing potential systems solutions. Understand third party payers and practice management issues, including billing and coding, cost

containment, and quality assurance and improvement. Know how to partner with health care managers and health care providers to assess, coordinate,

and improve health care and know how these activities can affect system performance.

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ROTATION GOALS AND OBJECTIVES 1. Chief Resident

a. Goals

The goals of the Chief Resident rotation are to develop leadership skills and to develop experience in administration and practice management in preparation for the transition from a resident to an independent practitioner. During the Chief rotation, the senior (PGY-4) resident is expected to develop insight into practice management from both the human resources and financial stance. While the academic setting does not mirror the private practice environment, there are management skills to be developed in terms of making expectations clear, assignment of responsibility, and management of financial systems. Additional skills required beyond medical knowledge include schedule management and patient flow, as well as those administrative tasks required for credentialing and insurance. Many financial operations of billing and collections involve a specialized vocabulary, and a goal is to develop this vocabulary for later use in practice. Each third year (PGY-4) resident will spend three months as Chief Resident. It is expected that during this time, they will demonstrate hands-on management of the residency under the direct supervision of the Program Director. The Chief Resident will assist the Program Director on the day-to-day operation of the residency program in serving as an administrator for the residency program in many respects. The Chief Resident will be directly involved in dealing with the issues encountered during the routine operation of a clinical service. They will assist the program coordinator in determining that resident logs are appropriately maintained. They will confer daily with the Department Head, and assist the Department Head in understanding the needs of the residency program as the program evolves over time. They will work with the junior residents in the development of their portfolios. The Chief Resident will monitor the clinical assignments of the first (PGY-2) and second (PGY-3) year residents, and will mediate problems regarding call and vacation as they arise. They will be responsible for tracking attendance of the residents at educational events. The Chief Resident will be assigned patients with urgent problems and to follow up trauma-related surgeries performed at BUMC. The Chief Resident will have each patient staffed by an attending and may choose the attending based on availability and the subspecialty needs of the problem. In this way, the Chief Resident will run their own clinic within the ongoing Alvernon faculty clinics. As these clinics will not always be full, the Chief will also be assigned to an attending clinic where they will assist that clinician. Every effort will be made for the Chief Resident to see their own post-operative cases and to follow-up the ruptured globes and other BUMC surgical traumas.

The Chief Resident will have input into which clinic they are assigned based on their subspecialty interests. The Chief Resident will also oversee the consults rotation. The Chief Resident will be expected to function as a typical resident in the clinic of each attending, except as otherwise required. In addition, the Chief Resident will continue to develop their surgical

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skills. They will spend time with the anterior segment and clinical cataract surgeons to refine technique and patient management skills (see goals and objectives for comprehensive ophthalmology rotation.) b. Objectives PGY-4 residents are expected to meet the objectives for level 4.

Level 2 Level 3 Level 4 PATIENT CARE AND PROCEDURAL SKILLS PC-3. Office Diagnostic Procedures: Ultrasonography

Describe principles of, indications for, and techniques of ocular A- and B-scan ultrasonography

Perform A- and B-scan and interpret basic findings (e.g., retinal and choroidal detachment, axial length)

Utilize A-scan data to calculate intraocular lens (IOL) power; interpret complex A- and B-scan ultrasonography (e.g., choroidal melanoma)

PC-7. OR Surgery: Cataract

Perform selected portions of cataract surgery, including wound construction and microsurgical suturing

• Perform informed consent for cataract surgery • Describe phacoemulsification instrument settings and how they facilitate the procedure • Describe categories of IOLs, advantages, and disadvantages • Perform cataract surgery • Perform post-operative care of cataract surgery patients

• Perform cataract surgery proficiently, including complex technical aspects • Describe indications and insertion techniques for premium IOLs to correct astigmatism and provide near correction

PRACTICE-BASED LEARNING AND IMPROVEMENT PBLI-2. Locate, appraise, and assimilate evidence from scientific studies related to their patients' health problems

• Ranks study designs by validity and generalizability to larger populations, and identifies critical threats to study validity • Distinguishes relevant research outcomes from other types of evidence • Cites evidence supporting several commonly used techniques in own practice

• Applies a set of critical appraisal criteria to different types of research, including synopses of original research findings, systematic reviews and meta-analyses, and clinical practice guidelines • Critically evaluates information from others, including colleagues, experts, pharmaceutical representatives, and patients

Demonstrates a clinical practice that incorporates principles and basic practices of evidence-based practice and information mastery

PBLI-3. Participate in a quality improvement project

• Conducts stakeholder analysis • Determines project purpose and goals

• Defines project process and outcome measures • Displays longitudinal data over time • Describes quality improvement (QI) methodology for data analysis and problem solving

• Demonstrates effective team leadership • Initiates basic steps for implementing change

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Level 2 Level 3 Level 4 PROFESSIONALISM PROF-1. Compassion, integrity, and respect for others; sensitivity and responsiveness to diverse patient populations

• Consistently demonstrates behavior that conveys caring, honesty, and genuine interest in patients and families • Demonstrates compassion, integrity, respect, sensitivity, and responsiveness • Exhibits these characteristics consistently in common and uncomplicated situations • Usually recognizes cultural and socioeconomic issues in patient care

• Exhibits these characteristics consistently in most relationships and situations • Consistently recognizes cultural and socioeconomic issues in patient care

• Exhibits these characteristics consistently in complex and complicated situations • Mentors junior members of the health care team

PROF-2. Responsiveness to patient needs that supersedes self-interest

• Almost always completes patient care tasks promptly and completely; is punctual; is appropriately groomed • Manages fatigue and sleep deprivation • Identifies impact of personal beliefs and values on practice of medicine

• Consistently completes patient care tasks promptly and completely • Manages personal beliefs and values to avoid negative impact on patient care

Mentors junior members of the health care team to manage barriers to effective patient care

PROF-3. Respect for patient privacy and autonomy

• Almost always recognizes and implements required procedures for patient involvement in human research • Informs patients of rights; involves patients in medical decision-making

• Consistently recognizes and implements required procedures for patient involvement in human research • Informs patients of rights; involves patients in medical decision-making • Mentors junior members of the health care team regarding protection of patient privacy

Role models behavior regarding protection of patient privacy

PROF-4. Accountability to patients, society, and the profession

• Almost always recognizes simple conflict of interest scenarios • Consistently completes medical record-keeping tasks promptly and completely • Almost always recognizes limitations and requests help or refers patients when appropriate

• Consistently recognizes and takes appropriate steps to manage simple conflict of interest scenarios • Consistently completes medical record-keeping tasks promptly and completely • Consistently acts within limitations and seeks help when appropriate

Consistently recognizes and takes appropriate steps to manage more complex conflict of interest scenarios

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Level 2 Level 3 Level 4 INTERPERSONAL AND COMMUNICATION SKILLS ICS-1. Communicate effectively with patients and families with diverse socioeconomic and cultural backgrounds

• Develops working relationships in complex situations across specialties and systems of care • Counsels patients at appropriate level for comprehension regarding disease, and engages in shared decision-making • Negotiates and manages simple patient/family-related conflicts

• Uses appropriate strategies to communicate with vulnerable populations and their families • Actively seeks information from multiple sources, including consultations • Counsels patients regarding emotionally difficult information, such as blindness; uses appropriate technique for "breaking bad news"

• Sustains working relationships during complex and challenging situations, including transitions of care • Demonstrates effective integration of all available sources of information when gathering patient-related data • Counsels patients regarding impact of higher-risk disease and intervention; directs patients to resources • Negotiates and manages conflict in complex situations

ICS-2. Communicate effectively with physicians, other health professionals, and health-related agencies

• Produces comprehensive, timely, and legible ophthalmic medical records • Recognizes need for, identifies, and requests appropriate consultant • Performs appropriate basic ophthalmology care transition • Manages conflicts within peer group

• Performs more complex subspecialty care transitions; ensures accurate documentation and face-to-face communication where needed • Manages conflicts within department

• Effectively and ethically uses all forms of communication, including face-to-face, telephone, electronic, and social media • Coordinates multiple consultants • Manages complex multisystem care transitions

ICS-3. Work effectively as a member or leader of a health care team or other professional group

• Describes role and responsibility of each team member • Prepares for team role and fulfills assignments • Follows institutional policies

• Implements team activities as directed by team leader • Identifies individual vs. group collaborative roles

• Selects, evaluates, provides feedback, and remediates team members • Develops goals and strategies for various departmental team activities • Delegates activities to team members and oversees them appropriately

c. Required Reading

Steinert RG, ed. Cataract Surgery, 3rd ed. Saunders, 2010. (Available online through Arizona

Health Sciences Library, www.ahsl.arizona.edu.) Chang DF. Phaco Chop and Advanced Phaco Techniques: Strategies for Complicated Cataracts,

2nd ed. Slack Inc., 2013.

Operating senior residents should have read the following by deadline dates below (Phaco Chop can be checked out by the program coordinator.)

Reading Deadline: July 30 Chapter 16 Capsulorrhexis: Sizing Objectives and Pearls Chapter 17 Conquering Capsulorrhexis Complications Chapter 18 Pearls for Hydrodissection and Hydrodelineation Chapter 27 Strategies for Managing Posterior Capsular Rupture Chapter 30 Posterior Capsule Rupture and Vitreous Loss: Advanced Approaches

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Reading Deadline: December 31 Chapter 1 Why Learning Chopping Chapter 2 Horizontal Chopping: Principles and Pearls Chapter 3 Vertical Chopping: Principles and Pearls Chapter 4 Comparing and Integrating Horizontal and Vertical Chopping Chapter 5 Transitioning to Phaco Chop: Pearls and Pitfalls Chapter 8 Understanding the Phacodynamics of Chopping Chapter 9 Optimizing Machine Settings for Chopping Techniques Chapter 10 Optimizing the Alcon Infiniti for Chopping Chapter 25-30 Complicated Cataract Surgeries (Cataract Surgery; online)

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2. Comprehensive/Continuity Clinic/General a. Goals

The goal of the comprehensive ophthalmology experience is to develop the experience and knowledge required to competently and confidently enter into the general practice of ophthalmology upon graduation, and to learn the appropriate use of consultative services in ophthalmic care. Comprehensive ophthalmology encompasses the core of all subspecialties, and as such within each practitioner, a different level of expertise within each of the subspecialties is expected to develop. Recognizing your own strengths in patient care, and the appropriate time to refer, is a core objective in the practice of general ophthalmology. b. Objectives

Comprehensive ophthalmology skills encompass the common skills of our faculty and the types of patient care experiences encountered in a general ophthalmology practice. Specific objectives for clinic experience follows. PGY-2 residents are expected to meet the objectives for level 2. PGY-3 residents are expected to meet the objectives for level 3. PGY-4 residents are expected to meet the objectives for level 4.

Level 2 Level 3 Level 4 PATIENT CARE AND PROCEDURAL SKILLS PC-1. Patient Interview

• Acquires accurate and relevant problem-focused history for common ocular complaints • Obtains and integrates outside medical records

Obtains relevant historical subtleties that inform and prioritize both differential diagnoses and diagnostic plans, including sensitive, complicated, and detailed information that may not often be volunteered by the patient

Demonstrates, for junior members of the health care team, role model interview techniques to obtain subtle and reliable information from the patient, particularly for sensitive aspects of ocular conditions

PC-2. Patient Examination

• Performs and documents a complete ophthalmic examination targeted to a patient's ocular complaints and medical condition • Distinguishes between normal and abnormal findings

• Distinguishes between normal and abnormal findings • Consistently identifies common abnormalities; may identify subtle findings

Identifies subtle or uncommon findings of common disorders and typical or common findings of rarer disorders

PC-2. Patient Examination: External

Detect obvious abnormalities (e.g., ptosis, exophthalmos); assess 5th and 7th cranial nerve function

Identify less obvious abnormalities e.g., mild ptosis, lid retraction, globe dystropia)

Detect or verify most subtle abnormalities; confirm presence or absence of pertinent disease-specific findings (e.g., floppy lid, subtle retropulsion resistance)

PC-2. Patient Examination: Ocular Motility

Accurately test and record ductions, versions, saccadic and pursuit movements; detect obvious ocular misalignment; identify nystagmus

Accurately measure alignment with prisms; detect less obvious misalignment; distinguish phoria and tropia

Detect or verify subtle motility abnormalities; classify common nystagmus patterns

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Level 2 Level 3 Level 4 PC-2. Patient Examination: Pupils

Accurately grade pupil size and reactivity; detect obvious asymmetry and RAPD

Detect less obvious abnormalities (e.g., mild RAPD, efferent defect, sympathetic denervation); perform and interpret pharmacologic testing

Detect or verify subtle abnormalities (e.g., light-near dissociation); search for associated neurologic findings (e.g., lid or motility abnormalities)

PC-2. Patient Examination: Slit Lamp Biomicroscopy

Identify anterior segment structures; recognize common corneal and conjunctival abnormalities, iritis

Recognize less obvious abnormalities (e.g., corneal edema, endothelial loss, dysplasia)

Detect or verify subtle abnormalities (e.g., corneal thinning); search for associated findings (e.g., orbital signs)

PC-2. Patient Examination: Tonometry

Accurately measure intraocular pressure in routine patients using applanation

Combine or modify techniques in patients with abnormal corneas or limited cooperation (e.g., Tono-Pen, average Goldmann readings 90 degrees apart)

PC-2. Patient Examination: Ophthalmoscopy (Direct and Indirect)

• Perform slit lamp indirect ophthalmoscopy • Recognize normal optic nerve and retinal appearance; detect obvious abnormalities (e.g., optic atrophy, papilledema, retinal detachment)

• Perform slit lamp ophthalmoscopy with the Hruby, +78, +90 lenses, 3-mirror contact lens, and trans-equator (pan-funduscopic) contact lens • Detect less obvious abnormalities (e.g., early glaucomatous excavation, macular degeneration, large retinal tear) • Perform indirect ophthalmoscoy and peripheral retinal examination

Detect or verify subtle abnormalities and unusual presentations (e.g., mild maculopathy, shallow detachment, subtle tear); perform scleral depression

PC-3. Office Diagnostic Procedures: Ocular Lubrication Testing

Describe indications for and perform tests to identify dry eye syndrome and exposure keratopathy (e.g., assessment of tear film breakup time, corneal stain with fluorescein and rose bengal dyes, Schirmer test)

Perform diagnostic temporary punctal occlusion

PC-3. Office Diagnostic Procedures: Ultrasonography




PC-4. Disease Diagnosis

Recalls and presents clinical facts of the history and basic eye exam without higher level of synthesis, and generates at least one item of the differential diagnosis for common ophthalmologic disorders

• Abstracts and reorganizes elicited clinical findings • Prioritizes potential causes of patient complaint; compares and contrasts diagnoses under consideration • Generates more focused differential diagnosis and organized final assessment

• Organizes clinical facts in a hierarchical level of importance; identifies discriminating features between similar patients • Generates focused differential and evaluation strategy to finalize diagnosis • Verifies diagnostic assessments of junior members of health care team

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Level 2 Level 3 Level 4 PC-5. Non-Surgical Therapy

Describes categories of medications (e.g., lubricant, antibiotic, anti-inflammatory, anesthetic); describes basic pharmacology of drug therapy and broad indications/contraindications for medical therapy of common ophthalmic conditions; describes routes of drug administration (e.g., topical, oral, periocular, intravenous) and dosing regimens

• Initiates therapy with medication for common ophthalmic diseases; monitors for adverse drug reactions and interactions • Describes indications for oral and intravenous therapy; recognizes possible racial, gender, and genomic differences in outcomes of medical therapy • Demonstrates ability to use electronic prescribing; demonstrates competence in periocular injections

• Manages and individualizes medical therapy for more complex ophthalmic conditions • Recognizes indications for alternative therapies, including surgical intervention; integrates environmental/behavioral factors • Manages complications Considers non-medical factors, such as cost, convenience, and ability to receive medication • Demonstrates competence in intravitreal injections

PC-6. Non-Operating Room (OR) Surgery: Laser Procedures

• Identify mode of tissue interaction, therapeutic effect, side effects, complications, safety issues • Describe appropriate laser settings • Use equipment effectively with correct contact lens, including peripheral retina, lens capsule

Perform glaucoma (e.g., iridotomy, trabeculoplasty) and retina (e.g., panretinal photocoagulation, laser retinopexy for isolated retinal breaks) procedures

Perform more complicated retinal procedures (e.g., diabetic focal/grid macula, repeat panretinal photocoagulation laser retinopexy or large or multiple breaks)

PC-6. Non-Operating Room (OR) Surgery: Chalazion Excision

• Lists indications and describes relevant anatomy and pathophysiology of disorder • Identifies findings that are indicators for the procedure and potential post-operative complications • Describes anesthetic and surgical technique, mechanism of effect, and specific instruments required • Performs directed pre-operative assessment; administers anesthesia and performs procedure with direct supervision; provides appropriate post-operative care

• Administers anesthesia and performs procedure with indirect supervision • Recognizes intra- and post-operative complications

• Administers anesthesia and performs procedure with oversight supervision • Manages intra- and post-operative complications

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Level 2 Level 3 Level 4 PC-6. Non-Operating Room (OR) Surgery: Excision/Biopsy of Lid Lesion








PC-7. OR Surgery: Globe Trauma

• Describe common setting for globe trauma and injury prevention • Describe use of protective eye shield in potential globe rupture • Perform examination under anesthesia for suspected globe rupture • Prepare patient with suspected rupture for surgery • Describe surgical steps to identify globe rupture • Describe techniques and sutures for repair of ruptured globe

• Obtains informed consent for ruptured globe repair • Perform closure of corneal or scleral wounds • Manage ruptured globes post-operatively, including complications

Perform repair of complicated corneal and scleral wounds

MEDICAL KNOWLEDGE MK-2. Demonstrate level-appropriate knowledge applied to patient management

Demonstrates level-appropriate knowledge for patient management on PGY-2 rotation

Demonstrates level-appropriate knowledge for patient management on PGY-3 rotations


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Level 2 Level 3 Level 4 SYSTEMS-BASED PRACTICE SBP-2. Incorporate cost-effectiveness, risk/benefit analysis, and IT to promote safe and effective patient care

• Describe scenarios in which ophthalmologist may affect cost-effectiveness in patient care • Describes specific cost options for most frequently ordered tests and medications • Utilizes EHR, where available, to order tests and reconcile medications for patients • Uses information systems for patient care, including literature review

Often practices cost-effective care

• Consistently practices cost-effective care • Applies risk-benefit analyses in ophthalmic care • Contributes to reduction of risks of automation and computerized systems by reporting system problems









PROFESSIONALISM PROF-1. Compassion, integrity, and respect for others; sensitivity and responsiveness to diverse patient populations




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Level 2 Level 3 Level 4 PROF-2. Responsiveness to patient needs that supersedes self-interest












INTERPERSONAL AND COMMUNICATION SKILLS ICS-1. Communicate effectively with patients and families with diverse socioeconomic and cultural backgrounds








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Level 2 Level 3 Level 4 ICS-3. Work effectively as a member or leader of a health care team or other professional group




c. Required Reading

First Year (PGY-2) Resident

American Academy of Ophthalmology. Basic and Clinical Science Course, Section 2: Fundamentals and Principles of Ophthalmology.

*Kanski JJ. Signs in Ophthalmology: Causes and Differential Diagnosis. Mosby/Elsevier, 2010.

*Bowling B. Kanski’s Clinical Ophthalmology: A Systematic Approach. Saunders, 2016. *Elliott DB. Clinical Procedures in Primary Eye Care. Edinburgh; New York:

Elsevier/Butterworth Heinemann, 2007.

Second Year (PGY-3) Resident

*Sadda SR. Ryan’s Retinal Imaging and Diagnosis. Saunders Elsevier, c2013. *Levin LA, Albert DM, eds. Ocular Disease: Mechanisms and Management.

Saunders/Elsevier, 2010. *Spaeth GL. Ophthalmic Surgery: Principles and Practice. Edinburgh: Elsevier, 2012. *Kanski JJ. Synopsis of Clinical Ophthalmology. Saunders, 2013.

*Available online through the University of Arizona Health Sciences Library,

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3. Consults/Call a. Goals

The overall goal of the consult rotation is to develop experience with managing the types of ophthalmological problems patients demonstrate in a tertiary care setting, either through admission to the eye service, consultation from another service for evaluation of an ophthalmological problem, or for the patients who present to the emergency department during non-call hours. The consult resident will work with, and be instructed by, the faculty member who is assigned to consults. The consult resident is responsible for the care of patients at the three sites where inpatient care is conducted: BUMCT, BUMCS, and SAVAHCS. The continued care of eye service inpatients at the three hospitals, and ongoing care that is required for consultations, as well as emergency room care during the hours of 7:00 a.m. to 5:00 p.m. Monday through Friday, are the responsibility of the consult resident. The consult resident is expected to be on-site of the three participating institutions during these hours. This is not a call activity and is not call from home. The consult resident must ensure adequate transition of care from the call team after hours, on weekends, and on holidays. The first goal of the consult rotation is to learn the care and management of patients in an inpatient setting, frequently who are admitted to the hospital following complex trauma, or who have been admitted to other services but who have ophthalmic manifestations of systemic disease. The second goal of the experience is to develop experience in the systems management of inpatients, and to develop collegial relationships with other services. A third goal is to obtain surgical experience in the management of trauma patients by participating in surgery that is performed at the participating inpatient hospital when performed by another service. A final goal is to provide the junior resident with opportunities to learn independent time management skills in a graduated manner and to learn the systems wide aspects of health care that follow from inpatient admission, including the development of a cost-effective care plan for a patient, and planning for outpatient services following discharge. This rotation also provides an opportunity for development of research projects and rounds presentations, as well as study for basic sciences. A study log is recommended. b. Objectives

The consult service is conducted in an inpatient setting, frequently at the bedside of patients who are unable to travel to an eye examination room. As such, the objectives differ from those presented in the outpatient clinic environment.

PGY-2 residents are expected to meet the objectives for level 2. PGY-3 residents are expected to meet the objectives for level 3.

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PC-2. Patient Examination: Pupils












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Level 2 Level 3 Level 4 PC-3. Office Diagnostic Procedures: Neuroimaging (CT and MRI)

Describe indications for neuroimaging in ophthalmology; identify major MR sequences (e.g., T1, T2, FLAIR, fat suppression)

Recognize normal anatomy of orbits and parasellar regions

Identify major abnormalities (e.g., orbital and parasellar tumor, stroke, multiple sclerosis [MS] lesions





PC-5. Non-Surgical Therapy








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Level 2 Level 3 Level 4 PC-8. Consultation • Provides specific,

responsive ophthalmologic consultation to other medical specialties • Recognizes urgent versus non-urgent ophthalmic consultation • Examines inpatient at bedside, including visual acuity and field, portable slit lamp exam (+ fluorescein stain), intraocular pressure (IOP) measurement, ophthalmoscopy • Communicates findings (written and oral) to consulting service

• Recognizes ophthalmic emergencies and immediate, necessary interventions • Provides appropriate differential diagnosis and initiates non-surgical treatment plan • Orders ancillary testing; requests ophthalmic subspecialty involvement when indicated • Maintains continuing communication with other involved medical specialists

• Identifies consultations requiring surgical intervention, including procedural options and timing • Interprets ancillary tests, and formulates and initiates treatment plan independently • Coordinates treatment plan with multiple specialties





SYSTEMS-BASED PRACTICE SBP-1. Work effectively and coordinate patient care in various health care delivery systems

• Describes systems of care within residency program • Demonstrates awareness of need for safe transitions of care; lists potential impediments to safe and efficient transitions of care within and between systems

• Identifies impediments to safe and efficient transitions of care within and between systems • Manages routine transitions safely

• Proposes solutions to impediments to safe and efficient transitions of care within and between systems • Manages complex transitions of care within and between systems • Demonstrates leadership potential for systems changes

SBP-2. Incorporate cost-effectiveness, risk/benefit analysis, and IT to promote safe and effective patient care




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Level 2 Level 3 Level 4 SBP-3. Work in inter-professional teams to enhance patient safety, identify system errors, and implement solutions

• Reports problematic processes, including errors and near misses to supervisor • Defines process for safe and efficient patient hand-offs, including basic communication techniques

• Analyzes causes of adverse events through root cause analysis (RCA) • Applies process for safe and efficient patient hand-offs, including basic communication techniques

• Develops content for and facilitates patient safety morbidity and mortality (M&M) conference focusing on system-based errors in patient care • Supervises communication process for patient hand-offs and on-call responsibilities • Analyzes shared team experience (e.g., procedure) with debriefing to solve problems













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d. Reading (*required)

The following are available online through the University of Arizona Health Sciences Library, www.ahsl.arizona.edu. *Kaiser P, Friedman NJ, Pineda R. The Massachusetts Eye and Ear Infirmary Illustrated

Manual of Ophthalmology, 4th ed. Philadelphia: Saunders, 2014. *Liu GT, Volpe NI, Galetta SL. Neuro-ophthalmology: Diagnosis and Management.

Philadelphia: Saunders Elsevier, c2010. *Singh A, Hayden BC. Ophthalmic Ultrasonography. Elsevier, c2012. *Kanski JJ. Signs in Ophthalmology: Causes and Differential Diagnosis. St. Louis:

Mosby/Elsevier, 2010. Gault JA, Vander JF. Ophthalmic Secrets in Color, 4ed. Elsevier, c2016. Schuman JS. Rapid Diagnosis in Ophthalmology: Glaucoma and Lens. Philadelphia: Mosby

Elsevier, c2008. Trobe JD. Rapid Diagnosis in Ophthalmology: Neuro-ophthalmology. Philadelphia:

Mosby/Elsevier, c2008. Carter KD, Alford M. Rapid Diagnosis in Ophthalmology: Oculoplastic and Reconstructive

Surgery. St. Louis, MO: Mosby Elsevier, 2008. Strominger MB. Rapid Diagnosis in Ophthalmology: Pediatric Ophthalmology and

Strabismus. Elsevier, c2008. Roy FH, Fraunfelder FW, Fraunfelder FT. Current Ocular Therapy, 6th ed. Philadephia, PA;

Edinburgh: Elsevier Saunders, 2008. Dutton JJ. Radiology of the Orbit and Visual Pathway. Philadelphia: Saunders Elsevier,

c2010. Fraunfelder FT, Fraunfelder FW, Chambers WA. Clinical Ocular Toxicology: Drugs,

Chemical and Herbs. Philadelphia, PA: Elsevier Saunders, 2008.

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4. Contact Lens/Refraction a. Goals

The contact lens rotation is conducted by Rand Siekert, OD, and is a combined rotation in which the resident learns both practical aspects of fitting and education in theoretical basis for contact lens care. Additionally, during this rotation, the resident will extensively review the BCSC series for optics and refraction for the contact lens service is a great opportunity for understanding the theoretical underpinnings of ophthalmic optics. b. Objectives PGY-2 residents are expected to meet the objectives for level 2.

























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Level 2 Level 3 Level 4 PC-2. Patient Examination: Vision Testing (Refraction and Retinoscopy)

• Accurately measure and document VA, routine refractive errors, and color and field deficits, including Amsler grid • Perform simple retinoscopy

Perform more difficult refractions; use retinoscopy to refine technique and diagnose

• Perform complicated refractions, including post-operative; apply specialized visual tests (e.g., vertical prism test for non-organic visual loss) • Troubleshoot most spectacle-related problems

PC-2. Patient Examination: Contact Lenses

Performs basic contact lens exam

• Describe corneal topography and how it is applied in contact lens fittings • Perform complete and accurate lensometry and keratometry measurements

• Accurately fit both soft and rigid contact lenses for most patients • Accurately identify and treat common contact lens-related problems

PC-3. Office Diagnostic Procedures: Corneal Pachymetry and Topography

Describe indications for pachymetry and tomography; interpret basic abnormalities (e.g., irregular astigmatism, corneal thinning)

Perform and interpret corneal topographic and pachymetric measurements, and apply these to refraction, contact lens fitting, glaucoma management

Perform and interpret advanced corneal topographic and pachymetric measurements, and apply these to refractive surgery












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Level 2 Level 3 Level 4 MEDICAL KNOWLEDGE MK-2. Demonstrate level-appropriate knowledge applied to patient management






















• Consistently recognizes and implements required procedures for patient involvement in human research • Informs patients of rights; involves patients in medical decision-making • Mentors junior members of the health care team


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Level 2 Level 3 Level 4 regarding protection of patient privacy

















c. Specific Educational Objectives The first year (PGY-2) residents are required, and all residents are encouraged, to attend the contact lens conferences.

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For the conference, the resident should choose a recently-seen case that illustrates a particular common problem in contact lens care. The case is used as a jumping-off point to discuss the mechanisms of the problem and the appropriate management. The conferences are mediated by Dr. Siekert in the conference room of the administrative offices of the Department of Ophthalmology. d. Required Reading List

CLAO Guide to Basic Sciences and Clinical Practice. Contact Lenses, 2nd ed. Little, Brown and Company.

Mandell, R., Contact Lens Practice. Fourth Edition, 1988, Thomas. Required Chapters: 5. Consultation, Examination and Prognosis 6. Basic Principles of Rigid Lenses 7. Fitting Methods and Philosophies 11. Clinical Procedures 12. Lens Care and Storage 13. Inspection and Verification 14. Symptomatology and Refitting 17. Basic Principles of Hydrogel Lenses 20. Inspection and Verification 21. Lens Care and Storage 22. Symptomatology and Refitting 23. Bandage Lenses 25. Extended Wear 27. Aphakia 30. Keratoconus 33. Contact Lens Instruments Bennet, E., & Henry, V. Clinical Manual of Contact Lenses. First Edition, 1994, Lippincott. Required Chapters: 6. Rigid Gas Permeable Lens Problem-Solving 12. Hydrogel Lens Problem Solving 14. Bifocal Contact Lenses 17. Irregular Cornea 18. Management of Contact Lens-Associated or Induced Pathology

Efron N. Contact Lens Complications. Edinburgh: Elsevier Saunders, 2012.

(Available online through the University of Arizona Health Sciences Library, www.ahsl.arizona.edu.)

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5. Cornea and External Disease

a. Goals

The primary educational goals of the residents on the cornea and external disease rotation is to develop facility in the examination of cornea and external disease patients, understanding in the basic physiology of the cornea, and ability to identify common pathological conditions and understand the judicious use of antibiotics, corticosteroids, non steroidal inflammatory drugs in the pharmacological regimen as well as understand the indications for surgical procedures. b. Objectives PGY-2 residents are expected to meet the objectives for level 2. PGY-3 residents are expected to meet the objectives for level 3. PGY-4 residents are expected to meet the objectives for level 4.





















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Level 2 Level 3 Level 4 PC-2. Patient Examination: Slit Lamp Biomicroscopy















PC-3. Office Diagnostic Procedures: Optic Coherence Tomography (OCT)/Confocal Laser Tomography

Describe principles of, indications for, and techniques of OCT and CLT in analyzing retina and optic disc

Interpret basic OCT and CLT findings (e.g., nerve fiber layer thinning, macular edema, optic disc excavation)

Interpret complex findings (e.g., epiretinal membranes); identify artifacts





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PC-6. Non-Operating Room (OR) Surgery: Excision/Biopsy of Lid Lesion




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Level 2 Level 3 Level 4 PC-6. Non-Operating Room (OR) Surgery: Temporal Artery Biopsy








PC-7. OR Surgery: Cornea

• Describe concepts of corneal astigmatism/ refractive error, stromal scarring, and endothelial function, and their surgical management • Perform corneal foreign body removal at slit lamp

• Obtains informed consent for common corneal surgeries • Perform suture removal at slit lamp Perform first assist in Descemet’s stripping endothelial keratoplasty (DSAEK) or penetrating keratoplasty surgery • Describe techniques of corneal patch grafting, gluing, chelation of band keratopathy, conjunctival flaps, laser refractive surgery, and amniotic membrane grafting • Perform suturing of corneal wounds (traumatic or surgical) • Perform pterygium surgery

• Perform limbal relaxing incisions or arcuate keratotomy as part of cataract surgery • Perform post-operative care for common keratorefractive surgeries • Recognize and initiate management of common post-operative complications (e.g., graft rejection)

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Level 2 Level 3 Level 4 PC-7. OR Surgery: Globe Trauma








SYSTEMS-BASED PRACTICE SBP-2. Incorporate cost-effectiveness, risk/benefit analysis, and IT to promote safe and effective patient care












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Level 2 Level 3 Level 4 PROFESSIONALISM PROF-1. Compassion, integrity, and respect for others; sensitivity and responsiveness to diverse patient populations
















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c. Additional Delineation of Resident Responsibilities At the Alvernon Eye Clinic, the residents will evaluate patients with complete faculty supervision. They are to do complete examinations on new patients including formulation of diagnoses and treatment. On existing patients, the examination should be directed toward the appropriate problem with reaffirmation of diagnosis, estimation of progress of therapy, checking results (labs, cultures, biopsies, etc.), and recommendation for future therapy. The resident is responsible for seeing all emergency cornea patients and those referred by outside ophthalmologists or optometrists. The resident will contact faculty to discuss findings and management. d. Routine for New Patients Following check in at the front desk, patients are seen by the resident. Patient interviews will include identification of chief complaint, history of the current medical condition, a complete review of systems, a complete review of past medical and surgical history, a listing of known medical allergies, a listing of current medications, past ocular history, past surgical history, family medical history, family ocular history and psycho/social analysis as is detailed in the new patient evaluation. Residents should neutralize the lenses, check the visual acuity and refract the patients that are less than 20/25. Recheck intraocular pressure, if abnormal. The residents should record all of the

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pertinent data and this is to be co-signed by the faculty. Patients that are coming in with a question of herpes simplex keratitis or keratitis of unknown ideology should have corneal sensation prior to administration of fluorescein or proparacaine for intraocular pressure assessment. Once the anterior segment is examined, the patient can be dilated and presented to the attending physician for completion of the examination or the patient may be completed by the resident and then the diagnoses entered as well as the treatment plan and then presented to faculty. For those patients who have the posterior pole exam done by the resident, the estimation of cup/disc ratio, macular and peripheral pathology should be identified both with a 78- or 90-diopter lens and a 20-diopter lens for the peripheral retina. A differential diagnosis should be formulated and discussed with faculty. For follow-up patients, the resident may check the patient in themselves or rely on the technician to check the patient in. Where the residents are checking the patients in, they should obtain chief complaint, interval ocular history, any changes in the interval medical history or review of systems, record the medications taken, record the allergies and then perform the appropriate ophthalmological examination including visual acuity, refraction where visual acuity is less than 20/25, intraocular pressure, pupil reaction, visual field by confrontation and extraocular motions and slit lamp examination. The diagnosis should be recorded as well as treatment planned. The patient should be dilated if it is deemed appropriate, i.e., visual acuity that cannot be corrected, no recent dilation (2 years for routine patients 65 or older or 5 years for patients less than 65 years of age) in the chart or post-operative patients that have not previously been dilated since intraocular surgery. Any laboratory testing that is required should be noted by the resident on a daily appointment card or calendar and then followed up as appropriate within the time interval that the laboratory results will be obtained. These should then be recorded and communicated both to the faculty and to the patient. The lab results should be followed, as appropriate. e. Chart Review In general, the patients that a resident has any question on should be discussed with faculty before the patient is discharged. The resident should record the name of the patient and either hold the chart aside or request the chart at the end of the clinic so that this can be discussed. It is very important that residents bring up questions regarding patient management and care that they do not understand at the time of the examination. f. Reading List Rather than have assigned reading for each week, residents will be asked to keep a log of the assigned reading chapters. As they see patients that fit into the appropriate categories, they are expected to read the chapters from the basic science text that are appropriate, as well as the review articles that are provided. By the end of each year, they should have gone through the entire cornea and external disease book. In April of each year, they submit their logs so that any areas that are deficient can be completed by the end of the year. g. Surgery The residents who are assigned to the operating room with a corneal/external disease faculty member will act as first assistant. The resident is expected to review the chart prior to the day of surgery or prior to the actual surgical procedure so that they understand what procedure is to take place. The resident should introduce themselves to the patient prior to surgery together with the attending. In the case of cataract surgery, the resident should review what the IOL choice was based on and identify any unusual circumstances with the particular case. If there are any unusual procedures or events that

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have occurred during surgery, they are expected to discuss these with the attending before and after surgery. They are responsible for dictating the operating report. The faculty will always verify and co-sign the report if the resident dictated. They are also responsible for reviewing the tapes with the attending surgeon of any cases where a complication occurred and to be sure there are tapes available at the BUMCT Outpatient Surgery Center. The attending surgeons and the library have reference video tapes on phacoemulsification surgery, cornea transplant surgery, refractive surgery and reading materials on other anterior segment surgical procedures. The resident is expected to be up to date on the latest techniques of these surgical procedures and when patients are scheduled they are expected to be versed in discussing what the surgical techniques are and what the relative risks and benefits of each approach are. They are expected to review new procedures (book and video) prior to surgery. Preoperative surgical patients require a complete medical history and physical form which should be completed on every patient by either the nurse practitioner or the resident. If the residents are performing these activities, they need to make sure that the reason for the visual disability is recorded, that the cataract's eye is identified and marked correctly, the expectations for improved visual acuity are recorded and realistic, the patient is made aware, and all their questions answered. Residents need to meet the patient before surgery, especially if they are involved in the case and obtain their consent to participate during the surgical procedure (together with and without the attending). The faculty will be responsible for the contact. h. Consent In general, the resident is asked to assure that the consent form has been signed by the patient and faculty. This should be performed by faculty. i. Emergency Coverage Occasionally corneal ulcers and anterior segment trauma will be referred in. These patients are followed by faculty and resident on the service during their complete hospital stay or during the acute phase of their illness. j. Research Residents are encouraged to participate in either basic or clinical research projects while on the service and during the year. Those who are interested should discuss this with faculty. There is no specific research expectation, however, and residents may satisfactorily complete this rotation without performing research. k. Required Reading

American Academy of Ophthalmology. Basic and Clinical Science Course, Section 8: External Disease and Cornea. (This should be read in its entirety each academic year.)

Spalton DJ. Atlas of Clinical Ophthalmology. Mosby, 2004. *McMannis MJ. Cornea. Elsevier, 2017. *Krachmer JH. Cornea Atlas. New York: Saunders/Elsevier, c2014. *Brightbill FS, ed. Corneal Surgery: Theory, Technique and Tissue. London: Mosby, c2009. *Available online through the University of Arizona Health Sciences Library, www.ahsl.arizona.edu.

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6. General/Glaucoma a. Goals

The goal of the comprehensive ophthalmology experience is to develop the experience and knowledge required to competently and confidently enter into the general practice of ophthalmology upon graduation, and to learn the appropriate use of consultative services in ophthalmic care. Comprehensive ophthalmology encompasses the core of all subspecialties, and as such within each practitioner, a different level of expertise within each of the subspecialties is expected to develop. Recognizing your own strengths in patient care, and the appropriate time to refer, is a core objective in the practice of general ophthalmology. Glaucoma is a disease characterized by slow progression over many years. Decision making for the glaucoma patient requires review of quantitative and qualitative data to detect changes in the patient’s status that would necessitate a change in management. The goal of the glaucoma rotation is to develop expertise in the diagnosis and management (both medical and surgical) of glaucoma, including both primary open angle glaucoma and the more unusual glaucomas. Skill and expertise is expected to develop with experience. b. Objectives

Comprehensive ophthalmology skills encompass the common skills of our faculty and the types of patient care experiences encountered in a general ophthalmology practice. Specific objectives for clinic experience follows. PGY-2 residents are expected to meet the objectives for level 2. PGY-3 residents are expected to meet the objectives for level 3. PGY-4 residents are expected to meet the objectives for level 4.













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Level 2 Level 3 Level 4 PC-2. Patient Examination: Ocular Motility












PC-2. Patient Examination: Gonioscopy

Describe principles and indications, and properly perform basic techniques of gonioscopy Recognize normal angle structure; identify angle closure

Grade more questionable angles using compression and lens tilting; identify more subtle features (e.g., neovascularization, recession, synechiae)

Perform in technically difficult examinations; detect or verify subtle abnormalities (e.g., pigmentation, plateau iris)








PC-3. Office Diagnostic Procedures: Perimetry

Describe fundamentals of perimetry, including kinetic and static techniques; interpret perimetry in routine optic nerve and central nervous system (CNS) disorders

Interpret perimetry in more complex optic nerve disorders, including glaucoma, and CNS disorders, including homonymous and bitemporal defects

Interpret complex perimetric results, including change over time, using statistical algorithms; identify artifacts





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Level 2 Level 3 Level 4 PC-3. Office Diagnostic Procedures: Ocular Lubrication Testing























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Level 2 Level 3 Level 4 PC-6. Non-Operating Room (OR) Surgery: Chalazion Excision








PC-6. Non-Operating Room (OR) Surgery: Temporal Artery Biopsy




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Level 2 Level 3 Level 4 PC-7. OR Surgery: Cataract




PC-7. OR Surgery: Glaucoma

• Describe indications for glaucoma surgery • Describe basic steps and goals of glaucoma surgery • Identify common post-operative findings

• Obtains informed consent for common glaucoma surgeries (e.g., trabeculectomy, tube shunt, ciliary body ablation) • Assist on and perform selected portions of selected procedures • Perform post-operative evaluation, and identify post-operative complications

• Perform common glaucoma surgeries (e.g., trabeculectomy, tube shunt, ciliary body ablation) • Perform post-operative care for uncomplicated glaucoma surgery patients • Manage post-operative complications for common glaucoma surgeries













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Level 2 Level 3 Level 4 PRACTICE-BASED LEARNING AND IMPROVEMENT PBLI-2. Locate, appraise, and assimilate evidence from scientific studies related to their patients' health problems




















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Level 2 Level 3 Level 4 PROF-4. Accountability to patients, society, and the profession
















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7. Glaucoma

a. Goals Glaucoma is a disease characterized by slow progression over many years. Decision making for the glaucoma patient requires review of quantitative and qualitative data to detect changes in the patient’s status that would necessitate a change in management. The goal of the glaucoma rotation is to develop expertise in the diagnosis and management (both medical and surgical) of glaucoma, including both primary open angle glaucoma and the more unusual glaucomas. Skill and expertise is expected to develop with experience. b. Objectives

PGY-2 residents are expected to meet the objectives for level 2. PGY-3 residents are expected to meet the objectives for level 3. PGY-4 residents are expected to meet the objectives for level 4.

















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Level 2 Level 3 Level 4 PC-4. Disease Diagnosis
















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Level 2 Level 3 Level 4 PC-7. OR Surgery: Glaucoma




















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Level 2 Level 3 Level 4 PBLI-3. Participate in a quality improvement project




















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c. Additional Delineation of Glaucoma Service Resident Responsibilities

Format for Patient Examination First Year (PGY-2) Residents: First year residents shall shadow the glaucoma faculty, observing and

learning examination and test interpretation. The resident will be questioned about the patient management and encouraged to ask questions when appropriate. Respect for the patient and their wishes must always be considered, as well as the efficiency with which the patient is examined. Ideally, questions that may be inappropriate during examination or thought of at a later time may be reviewed at a later time. The resident is responsible in this case for recording the patient’s name, studies, etc., that would be helpful for later review. As the resident progresses in understanding and skill, they will progress toward the second year resident format.

The glaucoma faculty may assign various topics through the rotation for discussion during lulls. The

resident should familiarize themselves with the topic beforehand. The glaucoma faculty will supervise resident performed surgery on animal eyes in the wet lab. A

trabeculectomy, express shunt, and tube shunt surgery should be attempted during each year. The resident should become familiar with the steps of surgery, the reason for each step, variation on the

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regimen and the instruments used to perform each surgery. The resident will be responsible for securing the animal eyes. Second Year Residents: Patient charts are placed in the box outside of the examination room and a white flag is put out, indicating that the patient is ready to be seen by the resident. On new patients, the resident reviews the chart and summarizes the patient’s history to date, performs a complete anterior segment slit lamp exam, indirect ophthalmoscopy, and stereo disc biomicroscopy with a 78-diopter lens. The discs and fundus are drawn, findings are noted, and the resident formulates and writes an impression and plan. The chart is then placed in the patient box outside of the room and the green flag is put out to indicate that the resident has completed the examination. For follow-up patients, the resident reviews the chart and summarizes the patient’s history to date, performs a complete anterior segment slit lamp exam and examines the fundus and disc through undilated pupils, unless a note has been made previously to dilate the patient, or the patient has a complaint requiring dilation. The resident then writes the impression and plan. The chart is placed in the box and the green flag is put out. d. Chart Review In general, no discussion of patients occurs in the examination room. At the end of the session, whenever possible, faculty, resident and students will discuss patients seen during the course of the day. Patients may be used as a starting point from which to delve into mechanisms of disease and treatment. e. Surgery Residents should review the records of the patient before surgery and be familiar with the planned procedure and therapeutic options. Surgical techniques and instrumentation should be reviewed even if the resident will not perform the surgery. All pre-op surgical patients require the following:

A complete glaucoma evaluation including IOP, slit lamp, indirect examination and gonioscopy, impression and plan.

Recording of the examination in the EHR. A medical history and physical form must be completed for every patient. If the patient has

medical problems, then a medical consultation needs to be arranged. Consent: The resident should be well versed in the indications, risks, and potential complications for all commonly performed glaucoma procedures. f. Emergency Coverage Occasionally, angle closure and other glaucoma emergency cases are referred after hours. It is the responsibility of the resident on-call (not the resident on glaucoma) to work-up such patients.

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g. Required Reading

First Year (PGY-2) Resident American Academy of Ophthalmology. Basic Clinical and Science Course, Section 10:

Glaucoma. Second Year (PGY-3) Resident *Shaarawy TM, Sherwood MB, Hitchings RA, Crowston JG, eds.. Glaucoma. 1st or 2nd ed.

Baltimore: Saunders Ltd, 2015. *Schuman JS. Rapid Diagnosis in Ophthalmology: Lens and Glaucoma. Philadelphia: Mosby

Elsevier, c2008. *Stamper RL. Becker-Shaffer’s Diagnosis and Therapy of the Glaucomas. Mosby/Elsevier,

c2009. www.gonioscopy.org

*Available online through the University of Arizona Health Sciences Library, www.ahsl.arizona.edu.

Reference Text for Topical Reading on Individual Patients Humphrey-Zeiss. Owner’s Manual for HFAII Perimeters.

To be read and assimilated by completion of third year (PGY-4):

Quality of Care Committee, Glaucoma Panel. Primary Open-Angle Glaucoma and Primary Angle Closure. Preferred Practice Pattern. San Francisco: American Academy of Ophthalmology.

Quality of Care Committee, Glaucoma Panel. The Glaucoma Suspect. Preferred Practice Pattern. San Francisco: American Academy of Ophthalmology.

Latest Reports on the Following Studies Glaucoma Laser Trial Research Group. The Glaucoma Laser Trial (GLT). 2. Results of

argon laser trabeculoplasty versus topical medicines. Ophthalmology. 1990;97:1403-1413. Advanced Glaucoma Intervention Study (AGIS) Early Manifest Glaucoma Treatment (EMGT) Collaborative Initial Glaucoma Treatment Study (CIGTS) Ocular Hypertension Treatment Study (OHTS) Trabeculectomy vs. Tube Shunt Study (TVT)

Additional glaucoma resources are available for check-out at the red box dispensary in Dr. Altenbernd’s office.

Surgical DVDs on express shunt placement and Ahmed valve placement Eyetube and Youtube have a rich source of surgical videos

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8. International

a. Goals To develop an understanding of healthcare delivery from a global perspective, and to learn of

appropriate interventions for healthcare delivery in countries outside of the United States. To develop cultural competency with respect to the immigrant population from Central

America and Mexico. To develop some facility with ophthalmic Spanish language skills through an immersion

experience with a native Spanish-speaking ophthalmologist.

b. Objectives Level 2 Level 3 Level 4 PATIENT CARE AND PROCEDURAL SKILLS Greets Patient Always greets patient in

Spanish. Always greets patient in Spanish.

Always greets patient in Spanish.

PC-1. Patient Interview








PC-2. Patient Examination: Diabetic Retinopathy Screening

Usually screens for diabetic retinopathy. Understands prevalence among Hispanic Americans

Always screens for diabetic retinopathy. Understands prevalence among Hispanic Americans

Always screens for diabetic retinopathy. Understands prevalence among Hispanic Americans.









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MK-2. Reviews LALES Reviews findings of Los Angeles Latino Eye Study (LALES)













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INTERPERSONAL AND COMMUNICATION SKILLS ICS-1. Learn Spanish Phrases

Learns 20 Spanish phrases regarding the eyes and symptoms of eye diseases

ICS-1. Communicate effectively with patients and families with diverse socioeconomic and cultural backgrounds








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9. Neuro-Ophthalmology a. Goals

The resident educational goal in neuro-ophthalmology is to develop knowledge and diagnostic skills in neuro-ophthalmology in order to diagnose and treat the types of conditions expected to be encountered during the general practice of ophthalmology. This educational goal is met through exposure to patients in the general eye service, in the pediatric eye service, and during a subspecialty rotation with a preceptor. While neuro-ophthalmology is frequently encountered during the general ophthalmology rotation, subspecialty education in neuro-ophthalmology is provided by Wayne Bixenman, MD, a preceptor in our Department. Because of the considerable overlap between the neuro-ophthalmology examination and the pediatric ophthalmology examination, many of the neuro-ophthalmology objectives in terms of patient skills are developed during the pediatric rotation. Consultations for neuro-ophthalmologic patients are obtained through consults in the hospital or in clinic, and may be presented to Dr. Bixenman for assistance in patient care. b. Objectives


















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PC-3. Office Diagnostic Procedures: Neuroimaging (CT and MRI)












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Level 2 Level 3 Level 4 PC-7. OR Surgery: Globe Trauma




















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Level 2 Level 3 Level 4 PROF-3. Respect for patient privacy and autonomy












c. Resident Responsibilities for the Neuro-Ophthalmological Service

The residents are encouraged to do complete examinations, assessments, suggestions for testing, and listing of therapeutic options. In general, any discussions of these options should be made with the attending physician, out of range of patients, prior to discussion with the patient and the family.

Format for Patient Examination: Following check-in, patients are screened by a technician, who will take a pertinent history, list medications, record intraocular pressure, list current glasses prescription, and take auto-refraction measurement. Generally, visual field examinations will be performed prior to the examination with the attending physician, and will be available for review with the chart. With the attending physician, the resident reviews the chart and participates in the information gathering process. The resident will observe the complete neuro-ophthalmological exam as performed by the attending, with direct participation as directed by the attending. The examination will include assessment of pupillary reflex, ocular motility, color vision, stereoscopic vision, slit lamp examination, and dilated fundoscopy. At the completion of the exam, he attending and the resident

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will then discuss the assessment and plan with the patient, including prognosis and appropriate follow-up. d. Chart Review In general, no discussion of patients occurs in the examination room. At the end of the session, whenever possible, faculty, resident and students will discuss patients seen during the course of the day. Patients may be used as a starting point from which to delve into mechanisms of disease and treatment. e. Emergency Coverage Occasionally, neuro-ophthalmic problems present on both an inpatient and outpatient basis. It is the responsibility of the resident on-call to work-up such patients. f. Required Reading

American Academy of Ophthalmology. Basic and Clinical Science Course, Section 5: Neuro-ophthalmology.

*Liu GT, Volpe NJ, Galetta SL. Neuro-ophthalmology: Diagnosis and Management. Saunders Elsevier, c2010.

*Trobe JD. Rapid Diagnosis in Ophthalmology: Neuro-ophthalmology. Philadelphia: Mosby/Elsevier, c2008.

*Dutton JJ. Radiology of the Orbit and Visual Pathways. Saunders Elsevier, c2010.


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10. Oculoplastics

a. Goals

The goal of the oculoplastics rotation is to develop the knowledge of eye and orbit anatomy along with the required surgical skills, to address the most commonly encountered congenital and acquired structural lesions of the eye, and the proper management of eye adnexal trauma. The basic goals for the first year (PGY-2) residents are to become familiar with the basic anatomy of the eyelid, lacrimal apparatus and orbit, and to be able to recognize the deviations from normal and their anatomic origins. The second year (PGY-3) residents are expected to increase their knowledge base by awareness of congenital malformations, such as congenital ptosis, and to deal with progressive pathologies, such as thyroid ophthalmopathy. The third year (PGY-4) residents require much more complex knowledge of facial trauma and recognition of advanced reconstructive techniques that would be required subsequent to trauma.

b. Objectives






















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Level 2 Level 3 Level 4 PC-2. Patient Examination: Ophthalmoscopy (Direct and Indirect)












PC-6. Non-Operating Room (OR) Surgery: Nasolacrimal Probing and Irrigation

Perform basic lacrimal assessment (e.g., dye testing, punctal dilation, canalicular probing)

Perform basic lacrimal procedures (e.g., lacrimal drainage testing, irrigation, dye disappearance test) and lacrimal intubation

Perform advanced lacrimal assessment (e.g., intra- and post-operative testing, canalicular probing in trauma)

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Level 2 Level 3 Level 4 PC-6. Non-Operating Room (OR) Surgery: Chalazion Excision












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Level 2 Level 3 Level 4 PC-7. OR Surgery: Oculoplastics/Orbit

• Demonstrate basic lid and skin suturing techniques • Close simple wounds not involving the eyelid margin • Provide appropriate post-operative care for selected procedures

• Use functional symptoms and exam findings to generate a treatment plan for oculoplastic care • Assess facial and eyelid trauma to develop a treatment plan • Obtains informed consent for oculoplastic procedures • Close complex wounds, including those involving the eyelid margin

• Demonstrate and incorporate knowledge of facial anatomy into treatment plan • Weigh alternative treatment options and describe risks and benefits of each • Perform basic oculoplastics procedures (e.g., tarsal strip, blepharoplasty, ptosis repair, closure of complex wounds) • Perform simple flaps and grafts • Interpret facial imaging

















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Level 2 Level 3 Level 4 PROF-3. Respect for patient privacy and autonomy




















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c. Additional Delineation of Resident Responsibilities At the SAVAHCS, the residents are responsible to see patients in a manner similar to those at the the Alvernon Eye Clinic. However, the residents are expected to take more of a leadership role in the examination and treatment of patients. The residents act as the primary liaison between the patient and the attending physician. The residents are also responsible for the flow and scheduling of oculoplastics at the SAVAHCS, as well as scheduling of surgery and follow-up of these patients. Format for Patient Examination: Following check-in, patients are screened by a technician, who will take a pertinent history, list medications, and note visual acuity. Some patients may require a visual field examination, which will be done at this time, prior to the resident examination. The resident reviews the chart and summarizes the patient’s history to-date and performs a complete refraction and assessment of visual acuity. This is followed by complete documentation of ocular motility. An anterior slit lamp examination is performed, followed by dilated fundus microscopy. Prior to dilation, the attending physician will repeat motility examination, as well as assessment of visual acuity. During this time, the resident should continue with the next patient. d. Chart Review In general, no discussion of patients occurs in the examination room. At the end of the session, whenever possible, the attending, resident and students will discuss patients seen during the course of the day. Patients may be used as a starting point from which to delve into mechanisms of disease and treatment. e. Emergency Coverage Occasionally, oculoplastics problems present on both an inpatient and outpatient basis. It is the responsibility of the resident on-call to work-up such patients. f. Required Reading

American Academy of Ophthalmology. Basic and Clinical Science Course, Section 7: Orbit, Eyelids, and Lacrimal System.

*Cantisano-Zilkha, Haddad A. Aesthetic Oculofacial Rejuvenation. Saunders Elsevier, c2010.

*Kim P. Asian Blepharoplasty and the Eyelid Crease. Chen WPD. Edinburgh: Elsevier, 2016.

*Dutton JJ. Atlas of Clinical and Surgical Orbital Anatomy. Elsevier/Saunders, 2011. *Chen WPD, Khan JA. Color Atlas of Cosmetic Oculofacial Surgery. Saunders Elsevier,

c2010. *Tyers AG, Collin RJO. Colour Atlas of Ophthalmic Plastic Surgery. Butterworth-

Heinemann/Elsevier, c2008. *Putterman AM. Cosmetic Oculoplastic Surgery. Philadelphia: Saunders, c1993. *Dutton JJ. Radiology of the Orbit and Visual Pathways. Saunders Elsevier, c2010. *Nerad JA, Carter KD. Alford M. Rapid Diagnosis in Ophthalmology: Ophthalmic

Plastic Surgery. St. Louis, MO: Mosby Elsevier, 2008. *Long JA. Surgical Techniques in Ophthalmology: Oculoplastic Surgery. Elsevier, Inc.,

c2009.

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*Korn B, Kikkawa D, eds. Video Atlas of Oculofacial Plastic Reconstructive Surgery. Elsevier, 2017.


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11. Pediatric Ophthalmology and Strabismus a. Goals

The goal of the pediatric ophthalmology rotation is to develop facility at the diagnosis and management of the most commonly encountered pediatric eye problems. Manual diagnostic skills that will be developed include strabismus classification and deviation measurement, measurement of visual acuity, and measurement of refractive error. b. Objectives

PGY-2 residents are expected to meet the objectives for level 2, plus level 3 of the following: PC-2 Patient Examination: Slit Lamp Biomicroscopy PC-2 Patient Examination: Ophthalmoscopy Direct and Indirect PC-6 Non-Operating Room Surgery: Nasolacrimal Probing and Irrigation PC-7 Operating Room Surgery: Strabismus

PGY-3 residents are expected to meet the objectives for level 3.

















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Level 2 Level 3 Level 4 PC-7. OR Surgery: Strabismus

• Perform selected portions of strabismus surgery, including extraocular muscle suturing • Perform post-operative care of strabismus surgery patients

• Obtains informed consent for strabismus surgery • Perform horizontal strabismus surgery recession and resection • Manage intra- and post-operative complications of strabismus surgery

• Perform vertical and oblique muscle strabismus surgery • Describe surgical considerations for re-operations in strabismus surgery

















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Level 2 Level 3 Level 4 PBLI-3. Participate in a quality improvement project




















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c. Pediatric Ophthalmology Specific Delineation of Resident Responsibilities

The pediatric ophthalmology rotation differs from other rotations in that the resident seldom sees a young child in the absence of faculty due to the tendency for a child to “wear out” during an examination, thereby decreasing the utility of the examination. For this reason, the resident works at the elbow of faculty. Dr. Smith expects you to learn how to work up pediatric patients on your own. The first days of the rotation will be starting to learn the pediatric exam, including stereo acuity testing, visual acuity testing, and alignment. You are expected to take charts from the check-in area and initiate work-up of patients without prompting after this period and should grow comfortable with prism and acuity measurements. You should try and follow your patients so that you can do the dilated and retinoscopy exams as well. The resident may leave clinic and consult reference text while clinic is in session. Often, the best learning is accomplished while a patient is reviewed at the same time as reference material is available.

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The primary textbook for learning the basics of pediatric ophthalmology and strabismus is the BCSC from the American Academy of Ophthalmology. Reading has been broken into approximately 25-page segments, to be spaced over time that the resident is on the pediatrics service. Along with each reading assignment, there is a reference article for the resident to read. It is the resident’s responsibility to keep up-to-date on the reading, and ask Dr. Miller or Dr. Smith questions that suggest that he/she has done some of this reading. With regard to the operating room, surgery starts on time, and if Drs. Miller/Smith does not see the resident at the start of the case, the surgical scrub tech will get the opportunity to first assist! Although the cases are scheduled for starting at 7:30 a.m., the usual start time is around 7:15 a.m., as the anesthesia team needs to get two rooms started, and they like to start the ophthalmology room first. This means the resident should be in the OR at around 7:00 a.m. and dressed, so that the patient can be seen beforehand in the holding area. The resident is expected to have his/her surgical plan for each patient. Pre-operative evaluations are conducted on Friday mornings, and the resident is expected to see the patients and repeat all motility measurements to confirm the surgical plan and what is hoped to be accomplished in the operating room. There are instances when Dr. Miller and/or Dr. Smith will be out of town on Friday, and so if parents have questions that the resident is not able to answer, Dr. Miller or Dr. Smith will call them. It is important to understand that any child with a cough or cold will need to be rescheduled because of the increased risk of general anesthesia complications under these conditions. Strabismus surgery has approximately a 1-in-4 reoperation rate, and the parents need to understand this high reoperation rate is present. Dr. Miller will also quote the parents about a 1-in-16,000 chance of either death or other disastrous complication arising from general anesthesia, or also about a 1-in-16,000 chance of a significant intraocular complication that could lead to loss of the eye. The resident must make sure that the parents are aware of these risks. Follow-up examinations after surgery are essential. Usually, these examinations are conducted at 8:00 a.m. on Wednesday morning for Dr. Miller and 8:30 a.m. d. When Dr. Miller and/or Dr. Smith is Unavailable There are occasions when Dr. Miller and/or Dr. Smith will be out of town, and during this time, telephone messages from patients will be directed to the resident’s attention by the technicians. The resident should try and answer as many phone calls as possible. The doctors will add you to the inbox during times away, at which point you will be expected to manage simple problems and phone calls. If the resident needs to contact Dr. Miller, or Dr. Smith, try his/her cell phone or contact Rosanna (Dr. Smith) or Pat (Dr. Miller), who usually has a phone number. Also, Dr. Miller tries to check his email at least once a day when he is gone. Dr. Miller’s cell phone is (520) 661-6524 and home (520) 742-9849. e. Reading Assignments (see public resident files)

View the videotape, “Anatomy and Embryology of the Eye” by Smollen Lid Disorders, Infectious and Allergic Ocular Diseases, Lacrimal Drainage System

‒ Kushner BJ: Early office-based vs. late hospital-based nasolacrimal duct probing. Arch Ophthlamol 1995;113:1103-1104.

‒ Kassoff J, Meyer DR: Early office-based vs. late hospital-based nasolacrimal duct probing - a clinical decision analysis. Ophthalmology 1995;113:1168-1171.

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Diseases of the Cornea and Anterior Segment, Iris Abnormalities ‒ Idrees F, Vaideanu D, Fraser SG, Sowden JC, Khaw PT: A review of anterior segment

dysgeneses. Surv Ophthalmol 2006;51:213-231. Pediatric Glaucoma

‒ DeLuise VP, Anderson DR: Primary infantile glaucoma (congenital glaucoma). Surv Ophthalmol 1983;28(1):1-19.

Childhood Cataracts ‒ Hutchinson AK, Drews-Botsch C, Lambert SR: Myopic shift after intraocular lens

implantation during childhood. Ophthalmology 1997;104:1752-1757. ‒ Amaya L, Taylor D, Russell-Eggitt I, Nischal KK, Lengyel D: The morphology and

natural history of childhood cataracts. Surv Ophthalmol 2003;48:125-144. Uveitis, Vitreous and Retinal Diseases and Disorders

‒ Cryotherapy for Retinopathy of Prematurity Cooperative Group: Multicenter trial of cryotherapy for retinopathy of prematurity. Arch Ophthalmol 1993;111:339-344.

Optic Nerve Disorders, Ocular Tumors in Childhood, Phakomatoses ‒ Knudson AG: Mutation and cancer: statistical study of retinoblastoma. Proc Natl Acad

Sci 1971;68(4):820-823. ‒ Abramson DH, Schefler AC: Update on retinoblastoma. Retina 2004;(6):828-848.

Craniofacial Malformations, Ocular Findings in Inborn Errors of Metabolism, Ocular Trauma in Childhood ‒ Marcus DM, Albert DM: Recognizing child abuse. Arch Ophthalmol 1992;110:766-767. ‒ Harley RD: Ocular manifestations of child abuse. J Pediatr Ophthalmol Strabismus

1980;17(1):5-13. ‒ Aryan HE, Ghosheh FR, Jandial R, Levy ML: Retinal hemorrhage and pediatric brain

injury: etiology and review of the literature. J Clin Neurosci 2005;12(6):624-631. Decreased Vision in Infants and Children, Learning Disabilities, Dyslexia, and Vision

‒ Good WV, Jan JE, DeSa L, Barkovich AJ, Groenveld M, Hoyt CS: Cortical visual impairment in children. Surv Ophthalmol 1994;38:351-364.

Strabismus, Anatomy of the Extraocular Muscles, Motor Physiology, Sensory Physiology ‒ Hubel DH, Weisel TN: Binocular interaction in the striate cortex of kittens reared with

artificial squint. J Neurophysiol 1965;28:1041-1057. Amblyopia

‒ The Pediatric Eye Disease Investigator Group: A randomized trial of Atropine vs patching for treatment of moderate amblyopia in children. Arch Ophthalmol 2002;120:268-278.

Introduction to Strabismus, Diagnostic Techniques for Strabismus ‒ Prism Adaptation Study Research Group: Efficacy of prism adaptation in the surgical

management of acquired esotropia. Arch Ophthalmol 1990;108:1248-1256. Esodeviations

‒ von Noorden GK: A reassessment of infantile esotropia (SLIV Edward Jackson Memorial Lecture). Am J Ophthalmol 1988;105(1):1-10.

Exodeviations ‒ Coffey B, Wick B, Cotter S, Scharre J, Horner D: Treatment options in intermittent

exotropia: a critical appraisal. Optom Vis Sci 1992;69(5):386-404. Vertical Deviations, A and V Patterns, Special Forms of Strabismus, Nystagmus

‒ Molarte AB, Rosenbaum AL: Vertical rectus muscle transposition surgery for Duane's syndrome. J Pediatr Ophthalmol Strabismus 1990;27:171-177.

Surgery of the Extraocular Muscles ‒ Guyton DL: Strabismus surgery. pp. 85-113.

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American Academy of Ophthalmology. Basic and Clinical Science Course, Section 6: Pediatric Ophthalmology and Strabismus.

*Lambert SR, Lyons CJ, eds. Taylor and Hoyt’s Pediatric Ophthalmology and Strabismus, 5th ed. Edinburgh: Elsevier, 2017.

*Strominger MB. Rapid Diagnosis in Ophthalmology: Strabismus. Elsevier, c2008.


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12. Refractive Surgery

a. Goals

The primary educational goals of the residents on the refractive surgery rotation are to understand the physiology of the cornea and anterior segment, the refractive errors, and to develop facility in the examination of patients, understanding the laser technology, the various refractive surgical procedures, and ability to identify common pathological conditions and understand the judicious use of antibiotics, corticosteroids, non-steroidal inflammatory drugs in the pharmacological regimen, as well as understand the indications for surgical procedures, and to learn how to manage possible complications. The goals are met through exposure to patients with faculty at the Alvernon Eye Clinic and during a subspecialty rotation with a preceptor during the first year of residency.

b. Learning Objectives

Underlying Concepts of Refractive Surgery o Contribution of the corneal layers and shape to the optics of the eye o Computerized corneal topography o Wavefront analysis o Biomechanics of the cornea o Corneal wound healing o Laser biophysics

Incisional Corneal Surgery o Incisional correction of myopia o Incisional correction of astigmatism

Photoablation o Photorefractive keratectomy, laser subepithelial keratomileusism, and epithelial laser in

situ keratomileusis o Laser in situ keratomileusis o Wavefront-guided surface ablation and LASIK

Intraocular Surgery o Phakic intraocular lenses o Bioptics o Clear lens extraction (refractive lens exchange) o Toric intraocular lenses o Multifocal intraoculenses o Accommodating intraocular lenses o Wavefront-designed intraocular lenses o Light-adjustable intraocular lenses

Accommodative and Nonaccommodative Treatment of Presbyopia o Theories of accommodation o Nonaccommodative treatment of presbyopia o Accommodative treatment of presbyopia

Considerations after Refractive Surgery o IOL calculations after refractive surgery o Retinal detachment repair after LASIK o Corneal transplantation after refractive surgery

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PGY-2 residents are expected to meet the objectives for level 2.

Level 2 Level 3 Level 4 PATIENT CARE AND PROCEDURAL SKILLS PC-2. Patient Examination: Slit Lamp Biomicroscopy




















c. Additional Delineation of Resident Responsibilities

At the Alvernon Eye Clinic, the residents will evaluate patients with complete faculty supervision. They are to do complete examinations on new patients including formulation of diagnoses and treatment. On existing patients, the examination should be directed toward the appropriate problem with reaffirmation of diagnosis, estimation of progress of therapy, checking test results (topography, Pentacam, Wavescan), and recommendation for future therapy. The resident is responsible for seeing all emergency patients call the faculty immediately and those referred by outside ophthalmologists or optometrists. The resident will contact faculty to discuss findings and management.

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d. Routine for New Patients

Following check in at the front desk, patients are checked in by the resident. Patient interviews will include identification of chief complaint, history of the current medical condition, a complete review of systems, a complete review of past medical and surgical history, a listing of known medical allergies, a listing of current medications, past ocular history, past surgical history, family medical history, family ocular history and psycho/social analysis as is detailed in the new patient evaluation. Residents should neutralize the lenses, check the visual acuity and refract the patients that are less than 20/25. Recheck intraocular pressure, if abnormal. The residents should record all of the pertinent data and this is to be co-signed by the faculty. Patients that are coming in with a question of herpes simplex keratitis or keratitis of unknown ideology should have corneal sensation prior to administration of fluorescein or proparacaine for intraocular pressure assessment. Once the anterior segment is examined, the patient can be dilated and presented to the attending physician for completion of the examination or the patient may be completed by the resident and then the diagnoses entered as well as the treatment plan and then presented to faculty. For those patients who have the posterior pole exam done by the resident, the estimation of cup/disc ratio, macular and peripheral pathology should be identified both with a 78-or 90-diopter lens and a 20-diopter lens for the peripheral retina. A differential diagnosis should be formulated and discussed with faculty.

A complete list of tests to be done prior to refractive surgery is available in the clinic. The resident should assure all are performed and accurate. The manifest refraction MR and cycloplegic MR should be carefully done. A thorough history of the patient’s past medical history, current medications, and previous and current ocular conditions should be documented. For follow-up patients, the resident may check the patient in themselves or rely on the technician to check the patient in. Where the residents are checking the patients in, they should obtain chief complaint, interval ocular history, any changes in the interval medical history or review of systems, record the medications taken, record the allergies and then perform the appropriate ophthalmological examination including visual acuity, refraction where visual acuity is less than 20/25, intraocular pressure, pupil reaction, visual field by confrontation and extraocular motions and slit lamp examination. The diagnosis should be recorded as well as treatment planned. The patient should be dilated if it is deemed appropriate, i.e., visual acuity that cannot be corrected, no recent dilation (2 years for routine patients 65 or older or 5 years for patients less than 65 years of age) in the chart or postoperative patients that have not previously been dilated since intraocular surgery. Any laboratory testing that is required should be noted by the resident on a daily appointment card or calendar and then followed up as appropriate within the time interval that the laboratory results will be obtained. These should then be recorded and communicated both to the faculty and to the patient. The lab results should be followed, as appropriate.

e. Chart Review

In general, the patients that a resident has any question on should be discussed with faculty. The resident should record the name of the patient and either hold the chart aside or request the chart at the end of the clinic so that this can be discussed. It is very important that residents bring up

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questions regarding patient management and care that they do not understand at the time of the examination.

f. Reading List

Rather than have assigned reading for each week, residents will be asked to keep a log of the assigned reading chapters. At the beginning of the rotation, they are to review the assignment with the attending. As they see patients that fit into the appropriate categories, they are expected to read the chapters from the basic science text that are appropriate, as well as the review articles that are provided. By the end of each year, they should have gone through the entire refractive surgery book. In April of each year, they are to submit their logs so that any areas that are deficient can be completed by the end of the year.

g. Surgery

The residents who are assigned to the operating room with refractive surgery faculty member will act as first assistant or observer. The resident is expected to review the chart prior to the day of surgery or prior to the actual surgical procedure so that they understand what procedure is to take place. The resident should review all calculations and pre-op information and data, and identify any unusual circumstances with the particular case. If there are any unusual procedures or events that have occurred during surgery, they are expected to discuss these with the attending before and after surgery. They are responsible for reviewing the tapes with the attending surgeon of any cases where a complication occurred and to be sure there are tapes available at UPH Outpatient Surgery Center. The attending surgeons and the library have reference video tapes on refractive surgery and reading materials. The resident is expected to be up to date on the latest techniques of these surgical procedures and when patients are scheduled they are expected to be versed in discussing what the surgical techniques are and what the relative risks and benefits of each approach are. They are expected to review new procedures (book and video) prior to surgery. Pre-operative surgical patients require a complete medical history and physical form which should be completed on every patient by either the nurse practitioner or the resident. If the residents are performing these activities, they need to make sure that the reason for the visual disability is recorded, that the surgical eye is identified and marked correctly, the expectations for improved visual acuity are recorded and realistic, the patient is made aware, and all their questions answered. Residents need to meet the patient before surgery, especially if they are involved in the case.

h. Consent

In general, the resident is asked to assure that the consent form has been signed by the patient and faculty. This should be performed by faculty.

i. Emergency Coverage

These patients are followed by faculty and resident on the service.

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j. Research

Residents are encouraged to participate in either basic or clinical research projects while on the service and during the year. Those who are interested should discuss this with faculty. There is no specific research expectation, however, and residents may satisfactorily complete this rotation without performing research.

k. Required Reading

American Academy of Ophthalmology. Basic and Clinical Science Course, Section 14:

Refractive Surgery. (This should be read in its entirety each academic year.) Azar DT, Gatinel D, Hoang-xuan T. Refractive Surgery, 2nd ed. Mosby, 2006. Wang M. Corneal Topography in the Wavefront Era: A Guide for Clinical Application.

Thorofare, NJ: Slack, Inc., 2006. Agarwal S, Agarwal A, Agarwal A. Step by Step Corneal Topography. Maryland

Heights, MO: Jaypee Brothers Medical Publishers, Inc., 2006. Krueger RR, MacRae S, Applegate RA. Wavefront Customized Visual Correction.

Thorofare, NJ: Slack, Inc., 2004. *Hampton RF. Surgical Techniques in Ophthalmology: Refractive Surgery. Elsevier,

c2008. *Brightbill FS, ed. Cornea Surgery: Theory, Techniques, and Tissue. London: Mosby,

c2009.


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13. Vitreoretina

a. Goals The goal of the retina rotation is to master the diagnosis and either recommend or deliver appropriate therapy for disorders of the retina and vitreous, through mastery of the direct examination skills and through mastery of the ancillary testing that is performed b. Objectives

PGY-2 residents are expected to meet the objectives for level 2. PGY-3 residents are expected to meet the objectives for level 3. PGY-4 residents are expected to meet the objectives for level 4.

























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Level 2 Level 3 Level 4 PC-2. Patient Examination: Ophthalmoscopy (Direct and Indirect)












PC-3. Office Diagnostic Procedures: Fluorescein Angiography

• Describe principles of, indications for, and techniques of fluorescein angiography in analyzing the retina and optic disc (e.g., phases of the angiogram) • Interpret basic fluorescein angiography in common retinal disorders (e.g., diabetic retinopathy, cystoid macular edema)

Interpret fluorescein angiography in less common retinal diseases

Interpret fluorescein angiography in complex retinal vascular and other diseases (e.g., occult and recurrent choroidal neovascular membranes)





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PC-7. OR Surgery: Retinovitreous

• Perform intra-vitreal injections • Describe indications for and associated risks of intra-vitreal injections

• Perform intra-vitreal injections • Describe indications for, and techniques and complications of pars plana vitrectomy and sclera buckling surgery; assist on retinal surgery • Describe indications for, and techniques and complications of radiation therapy for ocular tumors (e.g., radioactive plaque localization,

• Obtains informed consent for vitreoretinal surgery • Perform parts of a scleral buckling surgery and/or pars plana vitrectomy for retinal detachments





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c. Retina Rotation Specific Delineation of Resident Responsibilities

The residents will be evaluating patients alongside the attending physicians. The residents are encouraged to do complete examinations, assessments, suggestions for testing, and listing of therapeutic options. In general, any discussions of these options for further diagnosis and management should be made with the attending physician, out of range of patients, prior to discussion with the patient and the family. Format for Patient Examination: Following check-in, patients are screened by a technician, who will take a pertinent history, list medications and note visual acuity and dilate the patient. On new patients, the resident reviews the chart and summarizes the patient’s history to date, performs a complete anterior segment slit lamp exam and gonioscopy when necessary. The resident then places dilating drops. After dilation is complete, the resident performs a complete fundus examination with indentation, ophthalmoscopy when necessary. The patient is sent for photographs and fluorescein angiograms as indicated. Following the angiogram, the angiogram is reviewed with faculty and the impression is recorded in the chart. The fundus examination is completed and documented in the chart, as well. The patient is then left in the room and the attending completes the examination. For follow-up patients, the resident reviews the chart and summarizes the patient’s history to date. The resident performs a complete anterior segment and examines the fundus with 60- and 90-diopter lenses. A complete examination is performed with indirect ophthalmoscopy, as well. After the resident documents the findings in the chart, he will write the impressions and plan. The patient is left in the room to await the arrival of the attending physician. d. Chart Review In general, no discussion of patients occurs in the examination room. At the end of the session, whenever possible, the attending, resident and students will discuss patients seen during the course of the day. Patients may be used as a starting point from which to delve into mechanisms of disease and treatment. e. Surgery In general, the resident acts as a first assistant at surgery. The resident is expected to do a pre-op evaluation on any patient that the resident is to operate on. In addition, the resident follows all patients post-operatively.

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Residents should review the records of the patient before surgery and be familiar with the planned procedure and therapeutic options. Surgical techniques and instrumentation should be reviewed even if the resident will not perform the surgery. All pre-op surgical patients require the following:

A complete retinal evaluation including drawings of pertinent pathology. Recording of the examination in the office chart. A medical history and physical form must be completed for every patient. If the patient has

medical problems, then a medical consultation needs to be arranged. The surgical coordinator will assist in doing this.

Consent: In general, the resident is not asked to get informed consent for surgical procedures. This is typically done by the attending. The resident should, however, be well versed in the indications, risks and potential complications for all commonly performed glaucoma procedures. f. Emergency Coverage Occasionally, retinal detachment, hemorrhages, and other problems with acute vision loss may occur. It is the responsibility of the resident on-call to work-up the patients with the assistance of the Chief Resident. The faculty on-call should be notified or consulted regarding any relevant findings. g. Research The resident on the retina service is encouraged to participate in a clinical or basic science research project. There is no specific research requirement. h. Retina Conference Retina lectures are given on a regular schedule by many of the full-time and affiliate faculty. The residents on the retina service at the time should bring relevant cases and be prepared to present them to the other residents and the faculty who are present. Case discussions may be used as a jumping-off point to further illustrate certain retinal diseases. i. Fluorescein Angiography (FA) Conference Residents are expected to attend all FA conferences. All residents are expected to present cases. Residents are expected to read and evaluate FAs at a level appropriate for their training.

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j. Required Reading

General Reference for Topical Reading on Selected Patients

*Schachat AP, Sadda SR, Hinton DR, Wilkinson CP, Wiedemann P. Ryan’s Retina. Elsevier, Inc., c2018.

First Year (PGY-2) Resident Complete: American Academy of Ophthalmology. Basic and Clinical Science Course, Section 12,

Retina and Vitreous. American Academy of Ophthalmology. Basic and Clinical Science Course, Section 9,

Intraocular Inflammation and Uveitis. Berkow JW, Flower RW, Orth DH, Kelley JS. Fluorescein Angiography and Indocyanine

Green Angiography: Technique and Interpretation. Ophthalmology Monograph 5, 2nd ed. Oxford University Press; 1997.

Folk JC, Pulido JS: Laser Photocoagulation of the Retina and Choroid. Ophthalmology Monograph 11. Oxford University Press; 1997.

Others: Reference as necessary Second Year (PGY-3) Resident Repeat: American Academy of Ophthalmology. Basic and Clinical Science Course, Section 12,


Intraocular Inflammation and Uveitis. Berkow JW, Flower RW, Orth DH, Kelley JS. Fluorescein and Indocyanine Green

Angiography: Technique and Interpretation. Ophthalmology Monograph 5, 2nd ed. Oxford University Press; 1997.


Complete: Fishman GA, Birch DG, Holder GE, Brigell MG. Electrophysiologic Testing in Disorders of

the Retina, Optic Nerve, and Visual Pathway. Ophthalmology Monograph 2, 2nd ed. Oxford University Press, 2001.

Gass JDM. Stereoscopic Atlas of Macular Diseases: Diagnosis and Treatment. 4th ed. St. Louis: Mosby, c1997.

Hilton GF, McLean JB, Brinton DA. Retinal Detachment: Principles and Practice. Ophthalmology Monograph 1, 2nd ed. San Francisco: American Academy of Ophthalmology, 1995.

Others: Reference as necessary

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Third Year (PGY-4) Resident Repeat: American Academy of Ophthalmology. Basic and Clinical Science Course, Section 12,


Intraocular Inflammation and Uveitis. Berkow JW, Flower RW, Orth DH, Kelley JS. Fluorescein and Indocyanine Green

Angiography: Technique and Interpretation. Ophthalmology Monograph 5, 2nd ed. Oxford University Press; 1997.


*Brinton DA, Wilkinson CP. Retinal Detachment: Principles and Practice, 3rd ed. Oxford University Press, 2009.

Complete: Ryan SJ, ed. Retina. 2nd ed. St Louis; Mosby-Year Book; 1994. Wilkinson CP, Rice TA. Michels Retinal Detachment. 2nd ed. Mosby; 1997. Others: Reference as necessary All Residents *Duker JS, Waheed NK, Goldman DR, eds. Handbook of Retinal OCT: Optical Coherence

Tomography. London; New York: Saunders/Elsevier, 2014. *Singh AD, Hayden BC. Ophthalmic Ultrasonography. Edinburgh; New York: Elsevier

Saunders, 2012. *Agarwal A. Gass’ Atlas of Macular Diseases. Edinburgh: Elsevier Saunders, 2012. *Yannuzzi LA. The Retinal Atlas. Saunders Elsevier, 2010. *Sadda SR. Ryan’s Retinal Imaging and Diagnosis. Saunder Elsevier, c2013. *Bhavsar AR. Surgical Techniques in Ophthalmology: Retina and Vitreous Surgery. Elsevier,

c2009. *Niederhuber JE, Armitage JO, Doroshow JH, Kastan MB, Tepper JE. Abeloff’s Clinical

Oncology, 5th ed. Churchill Livingstone Elsevier, c2014.



FORMS

FORMS

Evaluation Forms and Milestones ........................................................................................................ 1 Faculty Evaluation of Resident Rotation 6-Month Review of Resident: Faculty/Self, Peer Journal Club Presentation Evaluation .................................................................................................. 19 Mentoring Plan (Self-Assessment/Self-Reflection) ............................................................................. 21 Ophthalmic Clinical Evaluation Exercise (OCEX) .............................................................................. 25 Patient Questionnaire ........................................................................................................................... 26 Phacoemulsification Assessment Tool: Resident Improvement Competency Keys ........................... 27 Resident Annual Program Review Evaluation ..................................................................................... 28 Resident Evaluation of Associate/Affiliate (“Volunteer”) Faculty ...................................................... 29 Resident Evaluation of Full-Time Clinical Faculty ............................................................................. 30 Resident 6-Month Evaluation of Program (December) ....................................................................... 32 Resident Evaluation of Rotation .......................................................................................................... 34 Rounds Evaluation ............................................................................................................................... 35 Technician Evaluation of Resident ...................................................................................................... 37

6-Month Semi-Annual Review Checklist ............................................................................................ 38

Authorization for Release of Information ............................................................................................ 39

Exception to Maximum Duty Period Length ....................................................................................... 40

Pre-Diploma Checklist ......................................................................................................................... 41

Resident Abstract Approval/Travel Grant Application ........................................................................ 42

1

EVALUATION FORMS AND MILESTONES Most of the questions on the faculty evaluation of the resident on each rotation and semi-annually on their overall performance are based on the ACGME milestones. The ACGME milestones were designed for the review of resident performance and reporting to the ACGME. “Milestones are knowledge, skills, attitudes, and other attributes for each of the ACGME competencies organized in a developmental framework from less to more advanced. They are descriptors and targets for resident performance as a resident moves from entry into residency through graduation. Milestones are arranged into numbered levels. Selection of a level implies that the resident substantially demonstrates the milestones in that level, as well as those in lower levels. A general interpretation of levels for the Ophthalmology milestones:

Level 1: The resident demonstrates milestones expected of a resident who has had some education in ophthalmology.

Level 2: The resident is advancing and demonstrating additional milestones. Level 3: The resident continues to advance and is demonstrating additional milestones;

the resident consistently demonstrates the majority of milestones targeted for residency. Level 4: The resident has advanced so that he or she now substantially demonstrates the

milestones targeted for residency. This level is designed as the graduation target. Level 5: The resident has advanced beyond performance targets set for residency, and is

demonstrating “aspirational” goals which might describe the performance of someone who has been in practice for several years. It is expected that only a few exceptional residents will reach this level.” --- ACGME Ophthalmology Milestone Project

Faculty Evaluation of Resident Rotation The milestones for each rotation are listed in the goals and objectives section of the manual. 6-Month Review of Resident Faculty Evaluation of Resident and Self Evaluation: The milestones for the semi-annual review for both the faculty evaluation of the resident and the self evaluation are as follows:

PATIENT CARE AND PROCEDURAL SKILLS o PC-1. Patient Interview o PC-2. Patient Examination o PC-2. Patient Examination: External o PC-2. Patient Examination: Ocular Motility o PC-2. Patient Examination: Pupils o PC-2. Patient Examination: Slit Lamp Biomicroscopy o PC-2. Patient Examination: Ophthalmoscopy (Direct and Indirect)

2

o PC-4. Disease Diagnosis o PC-5. Non-surgical Therapy o PC-7. OR Surgery: Globe Trauma

MEDICAL KNOWLEDGE o MK-2. Demonstrate level-appropriate knowledge

SYSTEMS-BASED PRACTICE o SBP-1. Work effectively and coordinate patient care in various health care delivery

systems o SBP-2. Incorporate cost-effectiveness, risk/benefit analysis, and IT to promote safe

and effective patient care o SBP-3: Work in inter-professional teams to enhance patient safety, identify system

errors, and implement solutions

PRACTICE-BASED LEARNING AND IMPROVEMENT o PBLI-1. Self-Directed Learning 1. Identify strengths, deficiencies, and limits in one's

knowledge and expertise 2. Set learning and improvement goals 3. Identify and perform appropriate learning activities 4. Use information technology to optimize learning

o PBLI-2. Locate, appraise, and assimilate evidence from scientific studies related to their patients' health problems

o PBLI-3. Participate in a quality improvement project

PROFESSIONALISM o PROF-1. Compassion, integrity, and respect for others; sensitivity and responsiveness

to diverse patient populations o PROF 2. Responsiveness to patient needs that supersedes self-interest o PROF-3. Respect for patient privacy and autonomy o PROF-4. Accountability to patients, society, and the profession

INTERPERSONAL AND COMMUNICATION SKILLS o ICS-1. Communicate effectively with patients and families with diverse

socioeconomic and cultural backgrounds 1. Rapport development 2. Interview skills 3. Counsel and educate 4. Conflict management

o ICS-2. Communicate effectively with physicians, other health professionals, and health-related agencies 1. Comprehensive, timely, and legible medical records 2. Consultation requests 3. Care transitions 4. Conflict management

o ICS-3. Work effectively as a member or leader of a health care team or other professional group 1. Clinical team (outpatient clinic, inpatient consult service) 2. OR team 3. Professional work group (e.g., QI committee)

Peer Evaluation: The milestones are the same as above except the medical knowledge section has been omitted. The milestones are listed on the following pages.

3

ACGME MILESTONES PATIENT CARE AND PROCEDURAL SKILLS Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health.

Milestone Level 1 Level 2 Level 3 Level 4 Level 5 PC-1. Patient Interview

Obtains and documents basic history for ophthalmic complaint




Incorporates new information from literature to tailor interview questions


• Describes components of complete ophthalmic examination • Performs the basic parts of a screening or bedside eye examination without special equipment




Incorporates into clinical practice new literature about exam techniques

PC-2. Patient Examination: Vision Testing (Refraction and Retinoscopy)

Check visual acuity (VA) in each eye with a near card and perform confrontation visual field testing

• Accurately measure and document VA, routine refractive errors, and color and field deficits, including Amsler grid • Perform simple retinoscopy

Perform more difficult refractions; use retinoscopy to refine technique and diagnose

• Perform complicated refractions, including post-operative; apply specialized visual tests (e.g., vertical prism test for non-organic visual loss) • Troubleshoot most spectacle-related problems

Develop advanced techniques for measuring vision in unusual circumstances

PC-2. Patient Examination: Contact Lenses

Performs basic contact lens exam

• Describe corneal topography and how it is applied in contact lens fittings • Perform complete and accurate lensometry and keratometry measurements

• Accurately fit both soft and rigid contact lenses for most patients • Accurately identify and treat common contact lens-related problems

4

Milestone Level 1 Level 2 Level 3 Level 4 Level 5 PC-2. Patient Examination: External

Describe components of external exam




Develop advanced techniques for assessing external exam findings in unusual circumstances


Describe components of ocular motility exam; test versions and ductions




Recognize and classify complex eye movement abnormalities at subspecialty level


Describe components of pupil testing, including test for relative afferent pupillary defect (RAPD)




Recognize and classify pupillary abnormalities at subspecialty level


Describe components of slit lamp exam; identify corneal abrasion




Recognize and classify anterior segment abnormalities at subspecialty level


Describe purpose of gonioscopy




Recognize and classify gonioscopic abnormalities at subspecialty level


Describe applanation technique of measuring intraocular pressure



Develop advanced techniques for measuring intraocular pressure in unusual circumstances

5

Milestone Level 1 Level 2 Level 3 Level 4 Level 5 PC-2. Patient Examination: Ophthalmoscopy (Direct and Indirect)

• Identify optic nerve using direct ophthalmoscopy • Estimate optic nerve cup-disc ratio




Recognize and classify complex optic disc and retinovitreous abnormalities at subspecialty level

PC-3. Office Diagnostic Procedures

Describes role of office diagnostic procedures in diagnosis of ophthalmic disease

Selects and/or performs appropriate routine diagnostic tests and imaging procedures based on a patient’s ocular complaints and medical condition

Interprets routine findings; recognizes indications for advanced diagnostic tests and imaging procedures

Interprets unusual findings, identifies artifacts; employs routine and advanced diagnostic tests and imaging procedures according to evidence-based medicine

Performs and interprets findings at subspecialty level


Describe role of perimetric tests to quantify and categorize visual loss in damage of the visual pathway




Recognize and classify complex perimetric abnormalities at subspecialty level


Describe purpose of corneal pachymetry and topography




Recognize and classify complex pachymetry and topography abnormalities at subspecialty level


Describe role of office testing to identify dry eyes



Develop advanced techniques for quantifying ocular lubrication in unusual circumstances

6

Milestone Level 1 Level 2 Level 3 Level 4 Level 5 PC-3. Office Diagnostic Procedures: Ultrasonography

Describe role of ultrasonography for diagnosis when ocular media not clear




Recognize and classify complex ultrasonographic abnormalities at subspecialty level


Describe purpose of OCT and CLT




Recognize and classify complex OCT and CLT abnormalities at subspecialty level

PC-3. Office Diagnostic Procedures: Fluorescein Angiography

Describe role of fluorescein angiography in diagnosis of retinal and optic nerve disease

• Describe principles of, indications for, and techniques of fluorescein angiography in analyzing the retina and optic disc (e.g., phases of the angiogram) • Interpret basic fluorescein angiography in common retinal disorders (e.g., diabetic retinopathy, cystoid macular edema)

Interpret fluorescein angiography in less common retinal diseases

Interpret fluorescein angiography in complex retinal vascular and other diseases (e.g., occult and recurrent choroidal neovascular membranes)

Recognize and classify complex fluorescein angiographic abnormalities at subspecialty level

PC-3. Office Diagnostic Procedures: Neuroimaging (CT and MRI)

Describe basic principles of CT and magnetic resonance (MR) imaging




Recognize and classify complex CT & MRI abnormalities at subspecialty level


Describes basic clinical features of common ophthalmic disorders, (e.g., red eye, glaucoma, cataract, diabetic retinopathy)




Incorporates most current literature findings in formulation of differential diagnoses

7

Milestone Level 1 Level 2 Level 3 Level 4 Level 5 PC-5. Non-Surgical Therapy

Describes basic concepts of ophthalmic pharmacotherapy (e.g., most common topical diagnostic and therapeutic agents)




Adopts new therapies based on continuing medical education (CME) and literature review; identifies gaps in care and process for improvement

PC-6. Non-Operating Room (OR) Surgery

Describes essential components of care related to non-OR surgery (e.g., informed consent, indications and contraindications for surgery, pertinent anatomy, anesthetic and operative technique, potential intra- and post-operative complications)

For each procedure: • Lists indications and describes relevant anatomy and pathophysiology of disorder • Identifies findings that are indicators for the procedure and potential post-operative complications • Describes anesthetic and surgical technique, mechanism of effect, and specific instruments required • Performs directed preoperative assessment; administers anesthesia and performs procedure with direct supervision; provides appropriate post-operative care


• Administers anesthesia and performs procedure with oversight supervision • Manages intra- and postoperative complications

Reviews individual outcome and process measures, and participates in practice improvement

8

Milestone Level 1 Level 2 Level 3 Level 4 Level 5 PC-6. Non-Operating Room (OR) Surgery: Laser Procedures

Describe use of laser in ophthalmology




Perform laser procedures at subspecialty level


Describe purpose of nasolacrimal probing and irrigation




Perform nasolacrimal probing and irrigation in unusual circumstances at subspecialty level







9

Milestone Level 1 Level 2 Level 3 Level 4 Level 5 PC-6. Non-Operating Room (OR) Surgery: Excision/Biopsy of Lid Lesion












10

Milestone Level 1 Level 2 Level 3 Level 4 Level 5 PC-7. OR Surgery Describes essential

components of care related to OR surgery (e.g., informed consent, indications and contraindications for surgery, pertinent anatomy, anesthetic and operative technique, potential intra- and post- operative complications)

For each specified procedure: • Lists indications for procedure selection; describes relevant anatomy and instrumentation for procedures, including calibration and operation of the microscope; describes necessary post-operative care • Identifies common intra- and post-operative complications, and performs post-operative care managing common complications • Prepares and drapes for extra-ocular and intra-ocular procedures • Describes methods for regional and general anesthesia • Performs portions of selected Level 2 procedures

• Obtains informed consent and performs specified Level 3 procedures • Identifies and manages less common intra- and post-operative complications

• Obtains informed consent and performs specified Level 4 procedures • Identifies and manages uncommon intra- and post-operative complications



Describe indications and technique of cataract surgery




Perform cataract surgery at subspecialty level

PC-7. OR Surgery: Strabismus

Describe indications for and technique of strabismus surgery

• Perform selected portions of strabismus surgery, including extraocular muscle suturing • Perform post-operative care of strabismus surgery patients

• Obtains informed consent for strabismus surgery • Perform horizontal strabismus surgery recession and resection • Manage intra- and post-operative complications of strabismus surgery

• Perform vertical and oblique muscle strabismus surgery • Describe surgical considerations for re-operations in strabismus surgery

Perform strabismus surgery at subspecialty level

11

Milestone Level 1 Level 2 Level 3 Level 4 Level 5 PC-7. OR Surgery: Cornea

Describe indications for and technique of cornea surgery

• Describe concepts of corneal astigmatism/ refractive error, stromal scarring, and endothelial function, and their surgical management • Perform corneal foreign body removal at slit lamp

• Obtains informed consent for common corneal surgeries • Perform suture removal at slit lamp Perform first assist in Descemet’s stripping endothelial keratoplasty (DSAEK) or penetrating keratoplasty surgery • Describe techniques of corneal patch grafting, gluing, chelation of band keratopathy, conjunctival flaps, laser refractive surgery, and amniotic membrane grafting • Perform suturing of corneal wounds (traumatic or surgical) • Perform pterygium surgery

• Perform limbal relaxing incisions or arcuate keratotomy as part of cataract surgery • Perform post-operative care for common keratorefractive surgeries • Recognize and initiate management of common post-operative complications (e.g., graft rejection)

Perform cornea surgery at subspecialty level

PC-7. OR Surgery: Glaucoma

Describe indications for and technique of glaucoma surgery




Perform glaucoma surgery at subspecialty level

12

Milestone Level 1 Level 2 Level 3 Level 4 Level 5 PC-7. OR Surgery: Oculoplastics/ Orbit

Describe indications for and technique of oculoplastic/orbit surgery

• Demonstrate basic lid and skin suturing techniques • Close simple wounds not involving the eyelid margin • Provide appropriate post-operative care for selected procedures

• Use functional symptoms and exam findings to generate a treatment plan for oculoplastic care • Assess facial and eyelid trauma to develop a treatment plan • Obtains informed consent for oculoplastic procedures • Close complex wounds, including those involving the eyelid margin

• Demonstrate and incorporate knowledge of facial anatomy into treatment plan • Weigh alternative treatment options and describe risks and benefits of each • Perform basic oculoplastics procedures (e.g., tarsal strip, blepharoplasty, ptosis repair, closure of complex wounds) • Perform simple flaps and grafts • Interpret facial imaging

Perform oculoplastic/orbit surgery at subspecialty level

PC-7. OR Surgery: Retinovitreous

Describe indications for and technique of retinovitreous surgery

• Perform intra-vitreal injections • Describe indications for and associated risks of intra-vitreal injections

• Perform intra-vitreal injections • Describe indications for, and techniques and complications of pars plana vitrectomy and sclera buckling surgery; assist on retinal surgery • Describe indications for, and techniques and complications of radiation therapy for ocular tumors (e.g., radioactive plaque localization,

• Obtains informed consent for vitreoretinal surgery • Perform parts of a scleral buckling surgery and/or pars plana vitrectomy for retinal detachments

Perform retinovitreous surgery at subspecialty level


Describe indications for and technique of globe trauma surgery




Perform globe trauma surgery at subspecialty level

13

Milestone Level 1 Level 2 Level 3 Level 4 Level 5 PC-8. Consultation

Describes the role of ophthalmology consultation in systemic disease

• Provides specific, responsive ophthalmologic consultation to other medical specialties • Recognizes urgent versus non-urgent ophthalmic consultation • Examines inpatient at bedside, including visual acuity and field, portable slit lamp exam (+ fluorescein stain), intraocular pressure (IOP) measurement, ophthalmoscopy • Communicates findings (written and oral) to consulting service

• Recognizes ophthalmic emergencies and immediate, necessary interventions • Provides appropriate differential diagnosis and initiates non-surgical treatment plan • Orders ancillary testing; requests ophthalmic subspecialty involvement when indicated • Maintains continuing communication with other involved medical specialists

• Identifies consultations requiring surgical intervention, including procedural options and timing • Interprets ancillary tests, and formulates and initiates treatment plan independently • Coordinates treatment plan with multiple specialties

Participates in ophthalmic subspecialty consultation when indicated

MEDICAL KNOWLEDGE Residents must demonstrate knowledge of established and evolving clinical, epidemiological, and social-behavioral sciences, as well as the application of this knowledge to patient care. Residents must demonstrate level-appropriate knowledge in the following core domains: General Medicine; Fundamentals and Principles of Ophthalmology; Optics and Refraction; Ophthalmic Pathology and Intraocular Tumors; Neuro-Ophthalmology; Pediatric Ophthalmology and Strabismus; Orbit, Eyelids, and Lacrimal System; Cornea, External Disease, and Anterior Segment Trauma; Lens and Cataract; Refractive Management and Intervention; Intraocular Inflammation and Uveitis; Glaucoma; Retina/Vitreous

Milestone Level 1 Level 2 Level 3 Level 4 Level 5 MK-1. Demonstrate level-appropriate knowledge

Articulates knowledge of pathophysiology, clinical findings, and therapy for ophthalmic conditions routinely managed by non-ophthalmologists

Demonstrates basic knowledge of pathophysiology, clinical findings, and therapy for common ophthalmic conditions routinely managed by ophthalmologists

Demonstrates advanced knowledge of pathophysiology, clinical findings, and therapy for commonly encountered ophthalmic conditions and demonstrates basic knowledge of pathophysiology, clinical findings, and therapy for less commonly encountered conditions

Demonstrates advanced knowledge of pathophysiology, clinical findings, and therapy for less commonly encountered ophthalmic conditions

Educates junior residents and medical students and contributes to the body of knowledge for pathophysiology, clinical findings, and therapy for ophthalmic conditions

MK-2. Demonstrate level-appropriate knowledge applied to patient management

Demonstrates level-appropriate knowledge for patient management on ophthalmology rotation




Demonstrates post-residency-level knowledge for patient management on PGY-4 rotations

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SYSTEMS-BASED PRACTICE Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care.

Milestone Level 1 Level 2 Level 3 Level 4 Level 5 SBP-1. Work effectively and coordinate patient care in various health care delivery systems

Describes basic levels of systems of care (self-management to societal)

• Describes systems of care within residency program • Demonstrates awareness of need for safe transitions of care; lists potential impediments to safe and efficient transitions of care within and between systems

• Identifies impediments to safe and efficient transitions of care within and between systems • Manages routine transitions safely

• Proposes solutions to impediments to safe and efficient transitions of care within and between systems • Manages complex transitions of care within and between systems • Demonstrates leadership potential for systems changes

Leads systems change at micro and macro levels

SBP-2. Incorporate cost-effectiveness, risk/benefit analysis, and IT to promote safe and effective patient care

• Describes scenarios in which physician may affect cost-effectiveness in patient care • Explains the role of the Electronic Health Record (EHR) in prevention of medical errors




• Advocates for cost-effective care and use of risk-benefit analyses within health care system • Recommends systems re-design for faulty processes

SBP-3. Work in inter-professional teams to enhance patient safety, identify system errors, and implement solutions

• Describes epidemiology of medical errors and differences between medical errors, near misses, and sentinel events • Describes role of teamwork and communication failure as a leading cause of preventable patient harm

• Reports problematic processes, including errors and near misses to supervisor • Defines process for safe and efficient patient hand-offs, including basic communication techniques

• Analyzes causes of adverse events through root cause analysis (RCA) • Applies process for safe and efficient patient hand-offs, including basic communication techniques

• Develops content for and facilitates patient safety morbidity and mortality (M&M) conference focusing on system-based errors in patient care • Supervises communication process for patient hand-offs and on-call responsibilities • Analyzes shared team experience (e.g., procedure) with debriefing to solve problems

Creates curriculum to teach teamwork and communication skills to health care professionals

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PRACTICE-BASED LEARNING AND IMPROVEMENT Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and lifelong learning. Residents are expected to develop skills and habits to be able to meet specified goals.

Milestone Level 1 Level 2 Level 3 Level 4 Level 5 PBLI-1. Self-Directed Learning 1. Identify strengths, deficiencies, and limits in one’s knowledge and expertise 2. Set learning and improvement goals 3. Identify and perform appropriate learning activities 4. Use information technology to optimize learning

• Identifies gaps in personal knowledge and expertise • Accepts feedback appropriately • Demonstrates ability to utilize online resources for patient care

• Assesses performance by self-reflection and review of feedback and evaluations • Develops a learning plan, based on feedback, with supervision • Utilizes review articles or practice guidelines to answer specific questions in clinical practice

• Develops learning plan independently with accurate assessment of competence and areas for continued improvement • Often utilizes appropriate evidence-based medicine to answer specific questions while providing care

• Utilizes self-directed learning with little external guidance • Consistently uses evidence-based medicine to answer specific questions while providing care • Utilizes system or process for staying abreast of relevant changes in clinical practice

Contributes to development of best evidence supporting clinical practices

PBLI-2. Locate, appraise, and assimilate evidence from scientific studies related to their patients' health problems

• Describes basic concepts in clinical epidemiology, biostatistics, and clinical reasoning • Categorizes design of a research study




Describes basic concepts in clinical epidemiology, biostatistics, and clinical reasoning Categorizes design of a research study


dentifies quality gaps in health care delivery




• Leads complex projects • Utilizes advanced quality measurement and display tools

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PROFESSIONALISM Residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles.

Milestone Level 1 Level 2 Level 3 Level 4 Level 5 PROF-1. Compassion, integrity, and respect for others; sensitivity and responsiveness to diverse patient populations

• Recognizes and never participates in verbal or physical abuse of patients, peers, staff, or supervisors, or sexual harassment • Recognizes and never participates in discrimination based on gender, age, culture, race, religion, disability, sexual orientation, or socioeconomic status




• Role models behavior demonstrating compassion and respect for others, and for cultural and socioeconomic issues in patient care • Develops organizational policies and education to support the application of these principles


Recognizes and never demonstrates refusal to perform assigned tasks, answer pages or calls, or avoidance of scheduled call duty




• Role models behavior demonstrating compassion and respect for others • Develops organizational policies and education to support the application of these principles


Conforms to Health Insurance Portability and Accountability Act regulations




• Mentors residents involved in administration of research projects involving humans • Develops organizational policies and education to support the application of these principles

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Milestone Level 1 Level 2 Level 3 Level 4 Level 5 PROF-4. Accountability to patients, society, and the profession

Recognizes and never participates in: deception regarding level of education and experience; demeaning other practitioners; plagiarism, falsification of records, misrepresentation of education Almost always completes medical record-keeping tasks promptly and completely Always identifies self as resident to patients




• Assumes leadership and mentoring role in management of more complex conflict of interest scenarios • Develops organizational policies and education to support the application of these principles

INTERPERSONAL AND COMMUNICATION SKILLS Residents must demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals.

Milestone Level 1 Level 2 Level 3 Level 4 Level 5 ICS-1. Communicate effectively with patients and families with diverse socioeconomic and cultural backgrounds 1. Rapport development 2. Interview skills 3. Counsel and educate 4. Conflict management

Develops positive relationship with patients in uncomplicated situations Describes factors that affect communication (e.g., language, use of interpreters, other family in the room, anger, depression, anxiety, and cognitive impairments) Engages in active listening, teach-back, and other strategies to ensure




Counsels patients regarding unusual or experimental therapies, including clinical trial participation when indicated Mentors junior members of the health care team to improve communication skills

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Milestone Level 1 Level 2 Level 3 Level 4 Level 5 ICS-2. Communicate effectively with physicians, other health professionals, and health-related agencies 1. Comprehensive, timely, and legible medical records 2. Consultation requests 3. Care transitions 4. Conflict management

• Produces comprehensive, timely, and legible non-ophthalmic medical records • Describes importance and procedure for request of consultation • Lists steps for appropriate care transition Manages one-on-one conflicts




• Develops models/approaches to managing difficult communications • Manages conflicts with superiors and payers

ICS-3. Work effectively as a member or leader of a health care team or other professional group 1. Clinical team (outpatient clinic, inpatient consult service) 2. OR team 3. Professional work group (e.g., QI committee)

• Understands concept of the medical team with respect to clinical care, medical research, and quality improvement • Defines purpose of various teams in which he or she participates




• Develops institutional and organizational strategies to improve team functions • Trains physicians and educators to develop effective teams for clinical care, medical research, and quality improvement

ICS-4. Effectively present didactic and case-based educational material to physicians and other health care professionals

Organizes clear and accurate non-ophthalmic case presentation with level-appropriate diagnostic and management recommendations

• Organizes case presentation for basic ophthalmic conditions, with diagnostic and management recommendations • Presents focused literature review, including basic science and pathophysiology data where pertinent • Effectively presents material to non-physician medical personnel

• Organizes case presentation for more complex ophthalmic conditions, with diagnostic and management recommendations • Presents comprehensive literature review and includes randomized controlled clinical trials and preferred practice guidelines where appropriate • Effectively presents educational material to physicians in other specialties

• Schedules, organizes, and implements case-based and didactic conference program • Mentors junior colleagues and critiques their presentations

Provides leadership for conference implementation


APPENDICES

Appendices

A-Scan Biometry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Canthotomy and Cantholysis: A Sight-Saving Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Checklist for Pre-op of Cataract Surgery Patients at SAVAHCS . . . . . . . . . . . . . . . . . . . . . . . 8 Confirming Curriculum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 CPT Codes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Poster Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Sign-Out Tools and Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Survival Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 VERGE Software for Event Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Work-Related Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Banner Dress Code Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 1st Year Residents Only Optics Manual Pediatric Rotation Disk (CD in back of binder)

ADMINISTRATIVE

Quick Reference Guide

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QUICK REFERENCE GUIDE CHECKLIST

Submit Information Form (ASAP) Submit PGY-1 Certificate of Completion, Final Evaluation, Rotations (ASAP) Submit copy of USMLE Step 3 results Submit GMEC Nomination (by Monday, July 10) Submit copy of BLS Card (by Friday, July 14) Read Program Manual and Goals/Objectives (confirmation due by August 1) Human Subjects Protection Program (complete by August 31)

DEPARTMENT “EYES” EMAIL https://email.eyes.arizona.edu resident list serve: [email protected] Residents PGY-4 Lauren Imbornoni, MD [email protected] C. Kiersten Pollard, MD [email protected] Jillian Wang, MD [email protected] Samuel Werner, MD [email protected] PGY-3 Colin McInnis, MD [email protected] Kyla Teramoto, MD [email protected] Kristina Voss, MD [email protected] Christianne Wa, MD [email protected] PGY-2 Alex Beazer, MD [email protected] Joseph Carr, MD [email protected] Jessica Lien, MD [email protected] Andrew Zhou, MD [email protected] Program Directors UA Joseph Miller, MD, MPH [email protected] South Campus Todd Altenbernd, MD [email protected] Coordinator Pat Broyles [email protected] phone: 322-3800 x202 PAGERS Digital Page #: 694-4480 Residents must carry pagers during all work hours. RESIDENT OFFICE If you have any problems with the equipment in the resident office, please contact the program coordinator with details so the problem can be resolved. Computer Issues: Computers with software for word processing, graphics, presentations, and Internet access is available for use by residents in the resident office. Photo, slide, negative and document scanners are also available. Residents are expected to prepare their own documents. If problems occur with the computers or printer, please contact UA College of Medicine ITS at 626-8721.

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VPN Access: For remote access to your files, it will be necessary to locate the specific location of your files. The first time accessing your files remotely, call the COM IT service desk for assistance. You can reach them at 626-8721 from 7:30 AM to 5:30 PM. The link for remote access is http://vpn.arizona.edu; requires your NetID username and password. If you are the last person to leave the building, you MUST set the alarm at the front door. If the alarm ever goes off when you leave, you MUST call the phone number below the alarm. SHARED CALL ROOMS BUMCT: There is a call room adjacent to the resident lounge (room 2781), which is shared with

radiology. BUMCS: There are two call rooms available at BUMCS (shared with Psychiatry residents). Ophthalmology Room 210 Door Code 9139 Psychiatry Room 557 Code 5312 Psychiatry residents will stay in the psychiatry ward (room 557) unless the room is full or a gender

issue arises, in which case they will spill over into call room 510. Ophthalmology resident will use call room 210 if the same sex is present, or proceed to call room 557. Note that the top bunk in the call rooms is not made, but linens should be available.

SAVAHCS: There is a shared call room available at SAVAHCS. This room is adjacent to the

Emergency Department. The Administrative Officer of the Day (AOD) in the Emergency Department can provide access into the room. The Surgical Services Office can also provide instructions on access.

MEAL ALLOWANCE Residents are given a meal allowance at BUMCT and BUMCS for times when on call in the hospital at night. Although the meal allowance is not intended for residents taking home call, both hospitals have provided limited meal allowance for those residents who take at-home call and will continue to do so again this year. The meal allowance at BUMT is $11/night and BUMCS is $10/night. The number of nights allotted per PGY level is as follows: BUMCT BUMCS PGY-4 10 nights 4 nights PGY-3 25 nights 8 nights PGY-2 25 nights 8 nights The meal allowance is for personal food/beverages and residents should not be purchasing food/beverages for others. Merchandise or bulk purchases are not allowed (for example, buying 10 bottles of water at one time). ONLINE RESIDENT SCHEDULES/INFORMATION www.eyes.arizona.edu/residents.html (or click on “dept info/forms” on bottom of email sign-in page) • Resident schedules (vacation, rounds, call, lectures) • Monthly resident/faculty call schedule • Residency program manual • Residency goals and objectives

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CALL SCHEDULE Notify Pat of any call changes. CLINICAL LOGS Excel file in Resident Files

Enter the number of outpatients seen by subspecialty. Patient counts in one category only. For example, if you see a patient with a cornea and glaucoma problem, enter in one subspecialty but not both. In addition, enter the number of inpatient visits and emergency visits.

SURGICAL LOGS www.acgme.org Data Collection Systems - Resident Case Log System Surgical cases should be entered within 24 hours. Sites Southern Arizona VA Healthcare System Banner University Medical Center Tucson (BUMCT) Banner University Medical Center South (BUMCS) Cornea Associates Retina Associates Southwest PC Fishkind, Bakewell, and Maltzman Eye Care and Surgery Center SCHOLARLY ACTIVITIES www.new-innov.com (Portfolio) Enter all scholarly activities – presentations and publications. This information should be logged within 10 days of the presentation. The information will be printed and submitted for review by the Program Director at your semi-annual review. Categories Abstracts Chapters Publications - Peer-reviewed Publication - Non-peer reviewed Grants

Presentations - Journal Club Presentations - Location Presentations - National Presentations - Rounds

Enter all pertinent information (all information that you would include on your CV.) Do not attach files. Files should be stored in the “Scholarly Activities” section on Resident Files.

DUTY HOURS www.new-innov.com

Residents are expected to be familiar with the duty hours policy (outlined below) and avoid violating the policy. Residents MUST notify the Chief Resident or Program Director for reassignment if necessary to avoid a duty hours violation.

(1) Duty hours are limited to 80 hours per week averaged over a four-week period, inclusive of all in-house call activity and moonlighting.

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(2) Residents are provided with one day in seven free from all educational and clinical

responsibilities, averaged over a four-week period, inclusive of call. Vacation or leave days are not counted in the average. Averaging must occur by rotation.

(3) Resident should have 10 hours free of duty, and must have 8 hours between scheduled duty

periods.

WHAT COUNTS TOWARD DUTY HOURS All clinical activities All scheduled activities, such as lectures and rounds Hours spent in the hospital while on home call Conference hours, such as AAO, ARVO, and review course Hospital committee meetings, such as GMEC meetings and resident interviews Internal moonlighting, such as Sight Savers External moonlighting

WHAT DOES NOT COUNT Reading, studying and academic preparation time spent away from the hospital ambulatory site Voluntarily staying at the library or hospital when no additional duties are planned over the next ≥2

hours Travel time to/from conferences HOME CALL Hours spent in the hospital when on at-home call count toward the 80-hour weekly limit but do not

apply to the 8-10 hour “off duty” period which is reserved for in-house call. Frequency of at-home call is not subject to every third night or the 24+4 limit.

LOGGING DUTY HOURS Rotation assignments are entered into New Innovations and updated weekly. Duty hours are monitored by the hospital on a monthly basis. Residents must review duty hours and make any changes needed, such as assignment, time, or

location. Residents must enter all home call – “Home - Called In” and “Home - Not Called In.” Enter time

spent in the hospital as “Home - Called In” (do not count travel time). Change the location, if necessary (default is BUMCT).

The remainder of the hours are recorded as “Home - Not Called In.” Residents must record all moonlighting hours. Resident must enter all consult hours. Change the location, if necessary (default is BUMCT). MAINTENANCE OF LOGS/DUTY HOURS Maintenance of the surgical and clinical logs is the ultimate responsibility of each resident; it is impossible to assemble the log retrospectively. At minimum, data must be entered on a weekly basis. The log is a requirement for Board eligibility.

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DOCUMENTATION TIMELINE Documentation Completion Date Core Rotation Pre-Rotation Review of Goals and Objectives

Submit signed document(s) to program coordinator within 7 days of start of the rotation

Core Rotation Evaluations Evaluation by Faculty

Resident Evaluation of Rotation

Completed by faculty and forwarded to resident for signature Complete within 7 days of completion of the rotation

Clinical and Surgical Logs Weekly; must be up-to-date on the 3rd working day of each month

Duty Hours Up-to-date by 3rd working day of each month Phacoemulsification Submit completed documents on a weekly

basis Mentoring Plan (Self-Assessment/Self-Reflectance) November 15

May 15 6-Month Evaluation

Evaluation of Teaching Program Evaluation of Clinical Faculty Evaluation of Self and Peers Scholarly Activities (List & Files)

July to December - early December January to June – late May/early June

Incentives Residents will earn incentives for completion of documentation and lecture attendance as indicated in the table below. The 1st year residents will earn funds for travel to the AAO meeting during their senior year. The 2nd year residents will earn interview days.

AAO Travel Funds 1st Year Residents


6-Month Review Packet Submitted by Due Date $100 $100

Lecture Attendance Meets Requirements $100 $100

Quarterly Reports Submitted by Due Date $25 $25

(Maximum is $450. This is in additional to the funds provided by Banner.)

Interview Days 2nd Year Residents


6-Month Review Packet Submitted by Due Date 1 1

Lecture Attendance Meets Requirements 1 1

Quarterly Reports Submitted by Due Date 0.5 0.5

(5 interview days maximum accrual)

6-Month Review Packet = all documentation required to be submitted to complete the packet Quarterly Reports = surgical and clinical logs

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Documentation must be submitted in a timely fashion–on or before the deadline. Residents who are off on the due date are required to submit by the deadline; extensions will not be granted for time off. Documentation for the 6-month review includes all supporting documentation listed on the 6-month semi-annual review checklist (see Forms, page 117). The quarterly reports include completion of the surgical log, clinical log, and duty hours. RESIDENT LECTURES Lecture attendance must meet the requirements (≥95% of all lectures). Excused absences will be provided only for vacation, SAFER, sick leave, emergency call, or the senior resident who is in surgery at the VA on Friday morning (as documented by the Chief Resident). The Chief and program coordinator must be informed of these exceptions on the day of the lecture or the absence will not be excused. It is each resident’s responsibility to sign the attendance sheet provided for each lecture (blank sheets are available if a sheet is not provided). At the end of each lecture or lecture session, the Chief Resident should provide the sign-in sheet(s) to the program coordinator. Those who attend 90-94% of the lectures will earn $50 (or 0.5 interview day). Some lectures are recorded so that residents have an opportunity to review missed lectures. However, reviewing the material does not count toward attendance requirements. Any improprieties in the truthful representation of attendance, tardiness, etc. will be viewed as unprofessional conduct and appropriate consequences will ensue. VA CLINIC CANCELLATIONS There are to be NO cancellations of SAVAHCS individual patients or clinics without approval of the Section Chief and Program Director. This policy is necessary to meet the wait time requirements of the cataract mandate program. SAVAHCS policy is no clinic cancellations less than 30 days. Exceptions can be made for career and fellowship interviews and emergent personal issues (such as sick leave). See the Section Chief for exceptions. When you need to cancel a clinic(s) at the VA, submit an electronic request on TucNet (available only on desktops at the VA). Clinics will NOT be cancelled less than 30 days in advance except for emergency situations and

unplanned surgical cases. All requests for clinic cancellation must be submitted through the automated electronic program

available on TucNet. The official date of the request will be the TucNet submission date. Care/Service Line Chiefs are required to review leave requests and ensure that clinics are not cancelled

less than 45 days in advance. Care/Service Line approvals/denials to requests will be processed within 72 hours. It is advisable to print a copy of your request for your records. This must be done BEFORE you hit the "Submit" button. All requests must be submitted at least 30 days in advance. HUMAN SUBJECTS PROTECTION PROGRAM Human subjects training is required for all residents. The CITI Course in The Protection of Human Research Subjects is available online through the HSPP at orcr.arizona.edu/hspp/training. This program should be completed within the first two months of training (by August 31, 2017). After completion of the course, the resident is responsible for providing a copy of the certificate to the program coordinator, which will be placed in the resident’s portfolio. The resident must also to complete conflict of interest (COI) training at https://uavpr.arizona.edu/COI, as well as submit a Disclosure of Significant Financial Interests, even if the resident has no significant interests to disclosure. .

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BUSINESS CARDS Generic business cards can be found at the front desk of the Alvernon Clinic in the cabinet on the wall “behind the staff.” Please feel free to take the amount you will need. There is a space to add your name and title. FACULTY ADVISOR Each resident will choose a faculty member (either full-time, part-time, or affiliate/associate “volunteer”) to serve as a faculty advisor. The Program Director and Department Head are not eligible to serve as a faculty advisor. The resident should meet at least twice a year to keep the advisor apprised of career goals, progress in the residency, and difficulties as they arise. This advisor will serve as the resident's advocate. The faculty advisor can be changed if necessary by the resident. First year residents should choose an advisor within their first three months of residency. Residents must inform the program coordinator of their faculty advisor. In November and May, each resident must complete a mentoring plan (self-assessment and self-reflection) (Forms, pages 87-90) to identify their strengths, deficiencies and limits in knowledge and expertise, as well as set learning and improvement goals. Then, the resident must meet with their faculty advisor to discuss their self-assessment, at which time the assessment will be signed. The signed assessment must be submitted to the program coordinator by November 15 and May 15. The assessment will be reviewed with the Program Director during the 6-month evaluation (January and June). The resident must submit the mentoring plan by the deadline to be eligible to receive $100 for their AAO travel fund (or interview time) for the 6-month review period. RESIDENCY ISSUES There are many opportunities to bring up issues with the residency program. You may address the issue via email or at a resident/faculty meeting, which are scheduled twice a year (around September and March). Approximately once a month the program director(s) will meet with residents (either all residents or just the senior residents) to address any issues. Junior residents can discuss any issue with the Chief Resident who can bring up the issue (without identifying the source) at one of these meetings or at a faculty meeting. COMMITTEES Residents are encouraged to participate in hospital committees. Each year, the residents select a representative and alternate to serve on the Graduate Medical Education Committee, an institutional committee charged with the responsibility of monitoring and advising on all aspects of residency education. For a full list of committees, contact the program coordinator. HOLIDAYS Residents have 6 holidays per year: Independence Day, Labor Day, Thanksgiving, Christmas, New Year’s Day, and Memorial Day. Residents who cannot be excused from their duties on a designated holiday will be granted another day off. The resident must notify the program coordinator of the date they will be off in place of the holiday within 10 days of the holiday worked. This “comp” day must be one entire day. There are SAVAHCS holidays that are not observed at Banner. On these holidays, such as Columbus Day and President’s Day, all residents will be assigned to the UA or Alvernon Clinic. If a resident is taking the day off and/or is out of town, vacation must be taken. SICK LEAVE Residents are allowed a maximum of ten (10) days per calendar year. Sick leave should be reported to the Chief Resident who will notify the program coordinator. The Chief Resident will be responsible for

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notifying the attending(s) and appropriate staff connected with the rotation assigned to the sick resident. He/she will make arrangements to cover the sick resident's duties as completely as possible.

If a resident is sick for three consecutive days, the resident must provide a physician’s note to return to work. If a note is not provided, the days the resident was out will count as vacation. BEREAVEMENT LEAVE Residents may take up to three paid working days as bereavement leave upon the death of a parent, parent-in-law, brother, sister, spouse, child, grandparent, grandchild, or any other person who is a member of the employee’s established household. Up to five paid working days as bereavement leave may be granted to attend or arrange funeral services out-of-state. For this purpose, a parent is defined as a natural parent, stepparent, adoptive parent or surrogate parent. A child is defined as a natural child, adoptive child, foster child, or stepchild. TRAVEL FOR CONFERENCES/COURSES To be eligible for reimbursement for travel expenses for conferences, residents must submit the following information to the program coordinator: (1) name and dates of conference/course, (2) email confirmation for presentation, (3) planned airline itinerary, and (4) name and address for hotel. This information must be provided at least 30 days in advance to allow time for the travel to be authorized. Travel expenses may not be eligible for reimbursement if authorization was not obtained in advance.

Per University policy, there will be no reimbursement for alcoholic beverages. Residents can ONLY be reimbursed for their OWN expenses. AAO: Third year residents who attend the AAO annual meeting will be granted up to three days of

educational leave, and up to $850.00 for reimbursement of eligible travel expenses. Residents must use vacation for any additional days for this conference (not eligible for additional educational days). Residents must submit receipts for eligible travel expenses to the program coordinator within 30 days after their return. Receipts not returned within the deadline will not be reimbursed.

Conference Presentations: Residents who are granted travel funds for a presentation (paper, poster, etc.) at national meetings are eligible for up to two days educational leave (the day of the presentation, plus the day immediately before or after the presentation for travel). Residents must submit receipts for eligible travel expenses to the program coordinator within 30 days after their returns. Receipts not returned within the deadline will not be reimbursed.

International: South Campus PGY-2 residents who rotate in Nogales will be reimbursed for mileage

and parking fees. Residents must submit departure/return time, mileage, and parking receipts within 30 days of the travel date. The resident is responsible for their own food and hotel accommodations.

Hotel accommodations and most food will be provided for the residents who rotate in Kino Bay (or

other designated location). Specific details will be provided when available. Departmental Purchases: Any purchases (such as wet lab materials) that will be paid for by the Department must be approved by the Program Director. After approval is received, the purchase request must be submitted to the program coordinator who will inform you of purchase requirements (purchase order, credit card, etc.). Be sure to plan ahead, since it could take a couple of weeks (or longer) to get the paperwork processed before the purchase can be authorized.

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INFORMATION FORM Information Needed – This is needed for reports, etc. You may have provided this information to the GME Office, but I do not have access to those records. Name: ________________________________________ Current Address:_______________________________________________________________ Home Phone: ___________________________ Cell: ___________________________ Birthplace: _____________________________ Race: __________________________ Ethnicity: ________________________ NetID ___________________________ Emergency Contact (Name/Phone): _________________________________________________ Dietary Restrictions: _____________________________________________________________

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