Reprint of: Primary care physicians' knowledge of the ophthalmic effects of diabetes.

OBJECTIVE: Previous studies suggest that many patients with diabetes do not receive an annual dilated eye examination because of a lack of referrals from primary care physicians (PCPs). This study aims to determine the depth of knowledge of PCPs regarding diabetic eye disease. DESIGN: Cross-sectional assessment. PARTICIPANTS: Ninety-seven PCPs. METHODS: An 8-question, multiple-choice assessment was administered over a 3-month period to 208 PCPs in attendance at continuing medical education conferences. RESULTS: Ninety-seven PCPs completed the assessment. Participants had a mean total score of 5.9 of 8 possible (73.8%). Questions regarding screening, clinical findings, and prevention were answered correctly by ≥ 81% of the respondents. However, questions regarding risk factors and complications were answered correctly by less than 35% of the respondents. No difference in scores was found based on the type of residency training received or the number of years in practice. CONCLUSIONS: Although PCPs may require greater education in the complications and risk factors of diabetic eye disease, study participants demonstrated a good overall depth of knowledge regarding diabetic eye disease. Thus, previous reports of only 35% to 55% of patients with diabetes receiving an annual dilated fundus examination are likely not due to a lack of physician education.

Primary care physicians' knowledge of the ophthalmic effects of diabetes.

OBJECTIVE: Previous studies suggest that many patients with diabetes do not receive an annual dilated eye examination because of a lack of referrals from primary care physicians (PCPs). This study aims to determine the depth of knowledge of PCPs regarding diabetic eye disease. DESIGN: Cross-sectional assessment. PARTICIPANTS: Ninety-seven PCPs. METHODS: An 8-question, multiple-choice assessment was administered over a 3-month period to 208 PCPs in attendance at continuing medical education conferences. RESULTS: Ninety-seven PCPs completed the assessment. Participants had a mean total score of 5.9 of 8 possible (73.8%). Questions regarding screening, clinical findings, and prevention were answered correctly by ≥81% of the respondents. However, questions regarding risk factors and complications were answered correctly by less than 35% of the respondents. No difference in scores was found based on the type of residency training received or the number of years in practice. CONCLUSIONS: Although PCPs may require greater education in the complications and risk factors of diabetic eye disease, study participants demonstrated a good overall depth of knowledge regarding diabetic eye disease. Thus, previous reports of only 35% to 55% of patients with diabetes receiving an annual dilated fundus examination are likely not due to a lack of physician education.

Resident physician operative times during cataract surgery.

BACKGROUND AND OBJECTIVE: To determine resident physician operative times surrounding their 45th, 86th, and 121st cataract surgery. PATIENTS AND METHODS: Retrospective chart review of 375 surgical records of 25 ophthalmology residents. Groups were compared with each other and to a published surgeon. RESULTS: The mean operative times of surgeries 43 to 47, 84 to 88, and 119 to 123 were 39.9, 30.0, and 27.2 minutes, respectively. Surgical time decreased 25% from the 45th to the 86th case (P = .0002) and 9% from the 86th to the 121st case (P = .2049). Compared with a published surgeon's time of 26.8 minutes, residents' times were significantly longer around their 45th (P = .0001) and 86th surgery (P = .0012), but nearly identical around the 121st surgery (P = .7022). CONCLUSION: Significant decreases in operative time occurred between the 45th and 86th case. Smaller decreases occurred after the 86th case. Residents' operative times approach that of a published ophthalmologist around the 121st case.

Misrepresentation by ophthalmology residency applicants.

OBJECTIVES: To determine the percentage of publication misrepresentation among applicants to an ophthalmology residency, to compare that percentage with published percentages from other specialties, and to compare the number of US-trained applicants vs non-US-trained applicants found to misrepresent published articles. METHODS: Published articles in peer-reviewed journals listed on residency applications to the Jones Eye Institute from October 10, 2000, to December 1, 2004, were searched, excluding applications that were unavailable or were from current residents and faculty. The type of misrepresentation of published articles and the country of medical school training were recorded. Compared were US-trained applicants vs non-US-trained applicants to determine which group was more likely to list published articles and which group was more likely to have a misrepresented published article. RESULTS: Eight hundred twenty-one of 852 applications (96.4%) were reviewed. Five hundred fifty applicants (67.0%) were from US medical schools, and 271 applicants (33.0%) were from non-US medical schools. Two hundred one applicants (24.5%) listed peer-reviewed published articles. Misrepresentation of published articles was found in 15 applicants (5 US trained and 10 non-US trained). The mean percentage of applicants with misrepresentation per applicant pool was 1.9%, while the mean percentage per applicants listing published articles was 8.1%. The most common misrepresentation found was self-promotion on the author list (50.0%), followed by omission of other authors (25.0%), nonexistent articles (12.5%), and nonauthorship (12.5%). Foreign medical graduates were more likely to list published articles (P = .008) and to have a misrepresented published article (P = .01). CONCLUSIONS: Ophthalmology has one of the lowest reported percentages of applicant publication misrepresentation in the literature. Foreign medical graduates were more likely to list published articles and to misrepresent published articles. Self-promotion on the author list was the most common type of misrepresentation found. Residency program directors should request copies of published articles from interviewing applicants.

A meta-analysis of studies of publication misrepresentation by applicants to residency and fellowship programs.

PURPOSE: Many studies from various fields of medicine about the accuracy of residency and fellowship applications have reported disturbing percentages of candidates with publication misrepresentation on their applications. However, other similar studies have found much lower percentages. No evaluation of these types of studies is currently available to explain this disparity. Therefore, this study evaluated the wide range of percentages of applicants with publication misrepresentation reported in the literature. METHOD: Studies of residency and fellowship applicant misrepresentation were identified and reviewed. Using uniform inclusion criteria, the data reported by each study were recalculated to determine the percentage of candidates with misrepresentation. RESULTS: Thirteen out of 18 studies (eight residency and five fellowship) found in the literature from 1995 to 2008 reported sufficient details to perform a recalculation. The most common type of misrepresentation reported was listing nonexistent articles, followed by errors in authorship order and nonauthorship. After recalculation, the mean percentage of candidates with misrepresentation per applicant pool decreased significantly (7.2% to 4.9%, P = .03048). No study characteristic, such as sample size, was found to be predictive of the percentage of applicants with misrepresentation. No difference was found in the percentage of applicants with misrepresentation in residency versus fellowship programs. CONCLUSIONS: The variance in study results of misrepresentation decreases when uniform inclusion criteria are applied. Caution must be used in directly comparing the results of these studies as originally reported. Program directors should be aware that self-promotion in the authorship list is a common form of misrepresentation.

Diphenhydramine as a topical ocular anesthetic.

OBJECTIVE: To determine whether 5% diphenhydramine solution has an anesthetic effect when administered topically to rabbit corneas. DESIGN: Experimental study. PARTICIPANTS: Twenty white New Zealand rabbits. METHODS: Twenty rabbits at the University of Arkansas for Medical Sciences received 1 drop of 5% diphenhydramine solution in the left eye and 1 drop of balanced salt solution in the right eye. Corneal sensation was then measured with a Cochet-Bonnet esthesiometer at 30-, 60-, and 90-minute intervals. Rabbits were observed for conjunctival reaction. Follow-up fluorescein and Rose Bengal slit-lamp examinations were then performed to assess toxicity. RESULTS: Diphenhydramine solution at a 5% concentration demonstrated a significant anesthetic effect 30, 60, and 90 minutes after instillation (p < 0.0001, p = 0.0001, p = 0.0164, respectively). Mild conjunctival injection occurred in all diphenhydramine-treated eyes. No toxic effects on the corneal epithelium were observed. CONCLUSIONS: When applied topically to rabbit corneas, 5% diphenhydramine solution has a significant anesthetizing effect compared with salt solution (control eyes). Topical diphenhydramine may be a safe alternative in patients requiring topical anesthesia who have multiple allergies to topical anesthetics. Additional studies are needed to determine a dose-response curve and to further evaluate corneal toxicity prior to use in humans.

Glare testing in patients with cataract after dilation.

PURPOSE: To learn whether dilating the pupil will have an impact on glare testing for cataract evaluation. DESIGN: Evaluation of diagnostic test. PARTICIPANTS: Fifty-four adult patients at the Jones Eye Institute at the University of Arkansas for Medical Sciences. METHODS: One eye of each patient was randomized for study. The pupil size, visual acuity (VA) using the Early Treatment Diabetic Retinopathy Study (ETDRS) acuity chart, and glare testing with the Brightness Acuity Tester (BAT) at the medium setting were performed. The patients' eyes were then dilated with all measurements repeated. Each patient was then graded for cataracts using the Lens Opacification Classification System III by an independent observer. MAIN OUTCOME MEASURES: VA and BAT results. RESULTS: Compared with undilated BAT results, 29 of 54 patients (53.7%) lost 1 or more lines of vision during BAT testing after dilation. Undilated BAT results were predicted to within 1 line of accuracy in 44 of 54 patients (81.5%) by adjusting the dilated BAT result by the change in VA from dilation. With this method, results were predicted to within 2 lines of accuracy in 52 of 54 patients (96.3%). CONCLUSIONS: BAT results are affected by dilation half of the time and can be adjusted by the change in VA from dilation to predict undilated BAT results.

Patient perceptions of professionalism: implications for residency education.

OBJECTIVES The purpose of this study was three-fold: to identify which behavioural, communicative and personal presentation characteristics most closely represent patients' views of professionalism; to determine whether patients perceive resident doctors as displaying these characteristics, and to explore whether or not resident doctor professional behaviour creates an impression of clinical competence to the degree where patients perceive a decreased need for Attending Physician involvement. METHODS We carried out a descriptive, cross-sectional study at an academic centre. An anonymous, voluntary four-question survey with multiple items was administered to all adult patients or the parents of paediatric patients attending an ophthalmology clinic who were seen by a resident doctor followed by an Attending Physician. RESULTS A total of 133 of 148 (90%) surveys were returned. All the itemised characteristics of professionalism were reported to be important or very important to the majority of participants.The most important were: 'Pays attention to my concerns' (90%); 'Is compassionate' (83%), and 'Speaks in terms that I can understand' (83%). Although 85% of respondents reported that resident doctors demonstrated all the characteristics of professionalism listed on the survey, 83% of participants stated that it was important or very important that residents have Attending Physician involvement. CONCLUSIONS Patient-centred components of professionalism, such as communication skills and compassion, are more important to patients than social behaviours, such as appearance and acknowledgement of family members. Resident doctors are perceived to display a high level of professionalism during patient care. Patients clearly desire direct resident doctor

Implementing a structured oral examination into a residency program: getting started.

BACKGROUND AND OBJECTIVE: To describe the steps involved in implementing a structured oral examination into a residency program PATIENTS AND METHODS: Existing oral examination format was evaluated and deficiencies addressed by creating a structured examination and increasing the frequency of administration to ophthalmology residents at the University of Arkansas for Medical Sciences. RESULTS: A structured oral examination was implemented. It provided both a realistic simulation of the board certification examination and a process that was a useful teaching method and assessment tool. It was valuable in addressing the Accreditation Council for Graduate Medical Education (ACGME) competencies. CONCLUSIONS: Oral examinations can be a versatile means of teaching and assessing resident physicians. Although the implementation process can be onerous, once in place, it can become an efficient tool for assessing all categories of the ACGME competencies and can provide valuable training in oral examination performance.

Weight effect of saline accumulation in surgical drapes.

BACKGROUND: Positive vitreal pressure during phacoemulsification is a known risk factor for posterior capsule rupture. Knowledge of modifiable causes of positive vitreal pressure is imperative to aid in its management intraoperatively. The aim of our study was to determine whether the weight from the accumulation of a large volume of saline in the surgical drapes could have an effect on intraocular pressure in patients. Such an effect could indicate a source of posterior vitreal pressure in patients undergoing prolonged phacoemulsification. METHODS: In 23 adult patients undergoing phacoemulsification at the Jones Eye Institute at the University of Arkansas for Medical Sciences, intraocular pressure readings were taken before and after the addition of 500 cc of saline to the surgical drapes and taken again after removal of the saline. RESULTS: Statistically significant differences in intraocular pressure were found between the baseline measurement, the measurement with saline, and the measurement after saline removal. No differences in the rise in intraocular pressure were found according to age, race, sex, or which eye was tested. INTERPRETATION: Accumulation of a large volume of saline in surgical drapes has a modest effect on intraocular pressure. This may indicate a contributing cause of posterior vitreal pressure during prolonged phacoemulsification.

Defining the core competency of professionalism based on the patient's perception.

BACKGROUND: To better define professionalism using a 10-question multiple-choice survey of patient preferences. METHODS: One hundred and ninety-one adult patients (response rate: 52% +/- 5%) completed a survey over a 3-week period in resident and faculty ophthalmology clinics in a university setting in a rural portion of the southern USA. Most patients voluntarily provided information on gender, race and age. Data are reported at proportions +/- 95% confidence intervals. RESULTS: Patients desire a degree of formality from their physicians in the form of a handshake (61% +/- 7%), greeting of family members (69% +/- 7%) and in addressing oneself as doctor. They also prefer note taking by the physician while speaking with them. However, patients do not think that the wearing of a white coat is necessary. Most patients assume (84% +/- 5%) that the physician washes his/her hands. Surprisingly, patients (60% +/- 7%) are willing to maintain a relationship with a physician despite the use of medical jargon. We found few differences related to gender and none related to race. Women (64% +/- 9%) preferred a closed door during the exam. Men (81% +/- 8%) either did not want the physician to wear a white coat or said that it made no difference. Those younger than 46 years (67% +/- 10%) preferred the door closed compared with those who were older (45% +/- 10%). CONCLUSIONS: Our study helps to define professionalism by providing concrete examples of the expectations of patients in the southern USA during physician interaction. Minor adjustments to the patient encounter based on these findings may increase patients' perception of professionalism, creating a higher level of trust. These are teachable precepts that can be incorporated into residency training.

An anterior chamber mass discovered after routine cataract surgery.

A 68-year-old man was noted to have an anterior chamber mass shortly after uneventful cataract surgery. The mass was believed to be iatrogenic in nature and necessitated surgical removal because of intermittent obstruction of vision. The patient was observed closely and achieved a good visual outcome with no complaints. This case is described to illustrate a potential hazard of modern clear cornea cataract surgery.