Standards for ophthalmology training networks and posts

PURPOSE OF THIS DOCUMENT
1. This document is authorised by the College as a provisional statement for consultation with ophthalmology training networks, hospital and health systems, government agencies, College Fellows and others involved in the education of ophthalmology specialists in Australia and New Zealand. It describes the College's standards for hospital-based networks that provide training in specialist ophthalmology, and for each rotational post within those networks. The College expects training hospitals and practices within networks to understand and meet these standards and thus qualify for the College's accreditation of training posts within the networks.

2. The College would like Commonwealth, State and New Zealand health and hospital agencies formally to recognise the College's standards, and undertake to implement them in cooperative partnership with the College. In preparation for formal recognition, the College:
a) authorises individuals and bodies involved in ophthalmology training to use these
standards to deliver ophthalmology training
b) invites individuals and bodies to provide comments, suggestions and feedback to
the College on any aspect of these standards.

GOAL OF THE VOCATIONAL TRAINING PROGRAM
3. The objective is to produce a specialist ophthalmologist who, on completion of training, is equipped to undertake safe, unsupervised, comprehensive, general ophthalmology practice. (An ophthalmologist wishing to train and practise in a sub-specialty will undergo further training and experience required for that sub-specialty.) The seven key roles of the ophthalmologist underpinning selection, training and assessment are: ophthalmic expert and clinical decision maker, communicator, collaborator, manager, health advocate, scholar, and professional.

SCOPE OF PRACTICE AND TRAINING
4.The College has identified 11 clinical areas of ophthalmology, and has prepared curriculum performance standards for each clinical area: glaucoma, cornea, cataract and lens, neuro-ophthalmology, ocular inflammation, ocular motility, oculoplastics, clinical refraction, paediatric ophthalmology, vitreo retinal, and refractive surgery. These curriculum standards underpin all training and assessment. Thus, each network providing ophthalmology training needs to be able to provide, to each trainee moving through rotational posts in the network, supervised training and experience that cover all of these clinical areas.


TRAINING NETWORKS AND POSTS
5.A training network (or scheme) is usually based in a major metropolitan hospital. There will be individual training posts within that hospital, and other training posts in other hospitals and (sometimes) in private practices. Any training post needs to be part of a training network. (There are some stand-alone posts for final year trainees, but these are not dealt with in this document). In Australia, the existing networks are:
6.
a) The Victoria Network
b) The Sydney Eye Hospital, NSW Network
c) The Prince of Wales Hospital, NSW Network
d) The Queensland Network
e) The South Australia Network
f) The Western Australia Network

6. In New Zealand, the existing networks are based at:
a) The Auckland City Hospital & Waikato Hospital Hamilton
b) Wellington Hospital
c) Christchurch Hospital & Dunedin Hospital

RESPONSIBILITIES OF THE COLLEGE

7. The College is responsible to:
a) establish standards for ophthalmology training networks and posts (including posts
in private settings), in consultation with health agencies and hospital systems
b) make the standards publicly available
c) inspect networks and posts to determine performance against the standards
d) accredit posts that meet the standards
e) give conditional accreditation where appropriate, and encourage hospitals to meet
the conditions necessary for accreditation
f) withhold or withdraw accreditation, and encourage hospitals to rectify deficiencies
g) inform “jurisdictions” (government health agencies) of posts that are accreditable,
and that require sustained funding in order to be utilised for training.

RESPONSIBILITIES OF HEALTH AGENCIES AND HOSPITAL SYSTEMS

8. Health agencies and hospital systems are responsible to:
a) provide the resources and infrastructure necessary to meet the service demands
for eye care in clinics and theatres
b) acknowledge that the provision of service and training are complementary, in order
to meet both the short-term expectations of patients and the medium term
expectations of the community for a trained specialist ophthalmology workforce
c) in training hospitals, provide sustained funding to enable trainees to be appointed
to posts that the College considers capable of accreditation for training
d) in training hospitals, promote and sustain a culture of teaching, training, learning
and research, by providing supplementary resources (including time) for these
activities to be efficient and effective
e) understand and apply the College's standards for networks and posts
f ) cooperate with the College in inspections of networks and posts
g) rectify deficiencies in networks and posts reported by inspectors.

AUSTRALIAN MEDICAL COUNCIL (AMC) STANDARDS
9. In its “Standards and Procedures” for the accreditation of specialist medical education and training and professional development programs, the AMC sets out three broad standards for the accreditation of hospitals and/or training positions:
a) the training organisation specifies the clinical experience, infrastructure and
educational support required of the accredited hospital and/or training position, and
implements clear processes to determine whether these requirements are met
b) the training organisation's accreditation requirements cover: clinical experience,
structured educational programs, infrastructure supports such as library, journals
and other learning facilities, continuing medical education sessions accessible to
informal the trainee trainee,dedicated time for teaching and training, and
opportunities for teaching and training in the work environment
c) the accreditation standards of the training organisation are publicly available.
10. The complete accreditation requirements of the AMC are available on request.

COLLEGE STANDARDS FOR TRAINING SITE FACILITIES
11. The following facilities are essential to be available in, or close to, the ophthalmic
clinic or outpatients department:
a) Fluorescein and other angiographies
b) Photocoagulation/Argon Laser
c) NdYAG laser
d) Ultrasound: A scan
e) Automated Visual Field Test
f) Internet Access and computer facilities
g) Emergency/Casualty

12. The following facilities are desirable to be available in, or close to, the ophthalmic
clinic or outpatients department:
a) Contact lens fitting
b) Access to electrophysiology
c) Ultrasound B scan
d) Ocular pathology
e) Optic disc assessment
f) Corneal topography
g) Refractive laser

13. The following facilities are essential to be available in the operating theatre:
a) Operating microscope, with assistant's scope
b) Camera, TV monitor and video recorder
c) Video facilities
d) Sufficient Instrument trays
e) Phacoemulsification equipment
f) Vitrectomy equipment

14. The following facilities are desirable to be available in the operating theatre:
a) Dedicated theatre
b) Dedicated theatre assistant
c) Cryosurgical equipment
d) Endo laser

COLLEGE STANDARDS FOR TEACHING AND LEARNING FACILITIES
15. The following facilities and arrangements are essential:
a) Teaching programmes including didatic lectures, clinical-pathological conferences
and journal clubs.
b) Exposure to clinical research methods eg clinical trials, case reports
c) Teleconference/video facilities for teaching lectures
d) Access to pathology and micro-biology and biochemistry departments
e) Access to library of ophthalmic texts and journals in either print or electronic form
and literature search facilities
f) A base location for trainees
g) Routine radiological investigations with access to CT & MRI scanning

16. The following facilities and arrangements are desirable:
a) Close Liaison with other disciplines including neurology, neuro-surgery, plastic and
facio-maxillary surgery, endocrinology
b) Presentation and publishing of papers by trainees

COLLEGE STANDARDS FOR SUPERVISOR/TRAINEE ARRANGEMENTS
17. A training post must have a minimum of three specialist consultants, all of whom have a commitment to ophthalmic training. For every additional trainee, an additional consultant is required. Thus, four consultants are required for two trainees, five consultants for three trainees. Supervisor commitment must be demonstrated by the time spent supervising the trainee. This is verified by the formal roster document and by trainee feedback. The full time equivalent participation of consultants must be sufficient to meet the standard in paragraph 18 below.

18. It is the responsibility of the training supervisor to be accountable for the training arrangements and assessment reports, and thus to exercise judgement in identifying the clinical tutors who are qualified to train the trainees. Clinical tutors may include other consultants, visiting fellows, and final year trainees.

COLLEGE STANDARDS FOR SUPERVISION OF TRAINEES
19. The minimum requirement for any post providing surgical training in any network is to provide each trainee with four supervised clinics and two supervised theatre sessions per week. Training and experience in laser is to be additional to this minimum requirement.

20. A supervised clinic is one in which the trainee and the consultant work with patients, either in tandem or in close proximity, to enable them to discuss cases and maximise training opportunities as they present.

21. If a trainee does not need to be closely supervised in clinic, as assessed by the supervising consultant, a trainee may be regarded as 'supervised' provided at least one consultant is present in the same building as the clinic and is available to attend the clinic at any time required by the trainee during the session.

22. A supervised theatre session is one in which
a) the trainee and the consultant are present together in theatre
b) the trainee implements procedures in accordance with a plan discussed
beforehand taking into account the circumstances of each patient, and the trainee's
surgical skills as previously demonstrated in a skills laboratory, or on patients with a
consultant in attendance.

23. If a trainee does not need to be closely supervised in theatre, as assessed by the
supervising consultant, a trainee in theatre may be considered to be 'supervised'
provided at least one consultant is within the theatre complex, in theatre apparel,
available to scrub and to attend theatre at any time during the session.

24. A trainee in the first two years of training is to be closely supervised
a) to ensure patient safety
b) to enable the supervisor to monitor the developing competence of the trainee
c) to enable the supervisor to proactively identify any deficiencies in the trainee's
performance as early as possible, and implement a suitable remediation process.

COLLEGE STANDARDS FOR TRAINEES' SURGICAL EXPERIENCE
25 The College has prepared three tables of surgical procedures (see Attachment B),
drawn from the curriculum standards for each clinical area:
Table A: Surgical procedures that trainees must perform autonomously by the end of training
Table B: Surgical procedures that trainees must have assisted at, and have a good practical knowledge of, by the end of training
Table C: Surgical procedures that trainees should have a good understanding of by the end of training

26 It is essential that the rotation plan for each trainee over years one to four provides appropriate experience in each clinical area, and provides the surgical training experiences as set out in the above tables.

27 It is difficult to specify the minimum number of times that a trainee needs to take a particular surgical procedure to completion, in order for the trainee to be regarded as competent in that procedure. Under normal experience, the trainee by the end of year two should have performed a minimum of fifty supervised intra-ocular procedures.

COLLEGE STANDARDS FOR TRAINEES' CLINICAL EXPERIENCE
28 Over the four years in a training network, the trainee is to receive supervised training and experience, and be assessed, according to the College's curriculum standards in each of the clinical areas set out in paragraph 4 above.

29 The trainee is to be involved in a minimum of four supervised outpatient clinics each week. This should include experience in both specialist and general eye clinics offering training in methods of examination. Trainees are to be involved in the management of ophthalmic casualties, probably by way of an emergency roster. Trainees should be involved in clinical audit, and also in teaching at postgraduate and undergraduate levels where possible.


FACTORS SPECIFIC TO A POST
30 There can be factors that might require or allow specific adjustment to the way in which a particular post is considered to meet the standards set out above, for example:
a) a post with particular attributes, such as exposure to indigenous eye care, might be
accredited even if some other standards are not met
b) some posts will be suitable for a trainee in years one and two, but not for a trainee
in years three and four, and vice versa
c) a post might offer surgical experience that would be satisfactory for a rotation period
of 3-4 months, but not for a period of 6 months or longer.









































LIST of ALL SURGICAL Procedures CONTAINED IN RANZCO's CLINICAL Curriculum Performance Standards

oCTOBER 2004


Preamble

This document brings together surgical procedures contained in the College's curriculum performance standards for clinical areas. It has been extensively peer reviewed and is valid at October 2004. The curriculum performance standards documents from which these standards are drawn will be reviewed in 2007.

The College expects that all training networks in Australia and New Zealand will be able to provide supervised training experiences in the procedures listed, appropriate to the table in which each procedure appears. In cases where appropriate training in a procedure is unlikely to be available, the director of training should seek advice from the Censor in Chief.

The Tables

Tables 1, 2 and 3 bring together all of the surgical procedures that are contained in the College's clinical curriculum performance standards.

These three tables indicate the level of mastery to be attained by trainees by the end of their training:
procedures that trainees must be able to perform autonomously are listed in Table 1;
procedures that trainees must have assisted at and have a good practical knowledge of are listed in Table 2;
procedures that trainees should have a good understanding of are listed in table 3.

Use of This Document

The College requires directors of training, term supervisors, clinical tutors and trainees to use these tables to plan and track training and assessment.



Table 1 – Surgical Procedures That Trainees Must Perform Autonomously By the End of Training

Curriculum Performance Standard/Sub-specialty
Procedure
Reference in Curriculum Performance Standards
Cataract and Lens
Peribulbar block
CT 5.8.1

Retrobulbar block
CT 5.8.1

Cataract extraction using phacoemulsification
CT 5.9.1 to CT 5.9.12

Implantation of an intraocular lens
CT 5.9.8

Anterior vitrectomy for vitreous prolapse into anterior chamber
CT 5.10.2
Glaucoma
Argon laser peripheral iridotomy
GL 5.7.2

YAG laser peripheeral iridotomy
GL 5.7.2

Argon laser trabeculoplasty
GL 5.7.1

Trabeculectomy including the use of releasable sutures and antimetabolites
GL 5.8.2

Peripheral iridectomy
GL 5.8.4

Combined cataract and glaucoma surgery
GL 5.8.3
Cornea
Removal of embedded corneal foreign body
F 3.1.1

Corneal scraping for microbiological evaluation
CE 3.8.2

Superficial keratectomy
CE 5.5.7

Excision of pinguecula
CE 5.5.6

Excision of pterygium including the use of conjunctival autograft and flaps
CE 5.5.6

Suturing of corneal and scleral lacerations
CE 5.5.8

Application of glue and contact lenses for corneal perforations
CE 5.5.9

Lateral tarsorrhaphy
CE 5.5.2

Electrolysis and cryotherapy in the treatment of trichiasis
CE 5.5.4

Stromal reinforcement (puncture)
CE 5.5.14
Oculoplastics
Repair of ectropion including use of skin grafts
OP 5.9.3

Repair of involutional ptosis
OP 5.9.5

Wedge resection of eyelid
OP 5.9.6

Lateral canthal advancement
OP 5.9.6

Nasolacrimal probing and syringing
OP 5.9.8

Punctal snip procedures
OP 5.9.9

Punctal occlusion
OP 5.9.10

Tarsoconjunctival cautery
OP 5.9.11

Repair of lid lacerations
OP 5.9.12

Functional upper lid reduction
OP 5.9.13

Basic evisceration and enucleation
OP 5.9.14

Incision and curettage of tarsal cysts
OP 5.9.15

Eyelid biopsy
OP 5.9.18

Conjunctival biopsy
OP 5.9.19

DCR
OP 5.9.21
Ocular Motility
Resection and recession of rectus muscles
OM 5.6.3 and OM 5.6.4

Use of adjustable sutures in recession of recti
OM 5.6.5

Inferior oblique recession
OM 5.6.7
Vitreoretinal
Argon laser pan retinal photocoagulation (PRP)
RV 4.4.2

Focal argon laser photocoagulation of peripheral retinal lesions
RV 4.4.2

Vitreous biopsy
RV 3.5.1

Intravitreal injection
RV 4.5.4

October 2004

Table 2 – Surgical procedures that trainees must have assisted at and have a good practical knowledge of by the end of training


Curriculum Performance Standard/Sub-speciality
Procedure
Reference in Curriculum Performance Standards
Cataract and lens
Cataract extraction using ECCE
CT 5.9.1 TO CT 5.9.12
Glaucoma
Laser cycloablation
GL 5.7.4

Glaucoma drainage tube insertion
GL 5.8.7
Cornea
Penetrating and lamellar keratoplasty
CE 5.5.10

Procurement of donor corneal tissue
CE 5.5.11

Injection of botulinum toxin to induce ptosis
CE 5.5.3
Oculoplastics
Eyebrow lift
OP 5.10.18

Repair of orbital floor fracture
OP 5.10.19

Intubation of nasolacrimal system
OP 5.10.13

Medial and lateral canthoplasty techniques
OP 5.9.17

Cosmetic upper and lower lid reduction
OP 5.10.11

Full thickness eyelid reconstruction
OP 5.9.6

Enucleation with integrated orbital implant
OP 5.10.14

Eyebrow lift
OP 5.10.18
Vitreoretinal
Retinal detachment repair using intraocular gases and scleral buckle
RV 4.5.3

Pars plana vitrectomy
RV 4.5.3

Retinopathy of prematurity screening
P 1.10.2

Paediatric EUA
P 1.10.2

October 2004
Table 3 – Surgical procedures that trainees should have a good understanding of by the end of training


Curriculum Performance Standard/Sub-speciality
Procedure
Reference in Curriculum Performance Standards
Cataract and Lens
Cataract extraction using ICCE
CT 5.9.1 to CT 5.9.12

Astigmatic keratotomy (AK) and limbal relaxing incisions (LRI)
CT 5.9.11

Lensectomy and vitrectomy for infantile cataract
P 5.4.7
Glaucoma
Argon laser iridoplasty
GL 5.7.5

Goniotomy
GL 5.8.8

Trabeculotomy
GL 5.8.8

Cyclocryotherapy
GL 5.8.5
Cornea
Conjuctival flaps: local and Gunderson
CE 5.5.12

Limbal stem cell autograft and allograft
CE 5.5.13

Excimer laser PTK
CE 5.5.15
Oculoplastics
Correction of cicatricial entropion
OP 5.10.1

Correction of myopathic ptosis
OP 5.10.4

Posterior lamellar reconstruction
OP 5.10.5

Orbitotomy
OP 5.10.6

Orbital decompression
OP 5.10.6

Orbital extenteration
OP 5.10.6

Complex orbital fractures
OP 5.10.20

Eyelid recession
OP 5.10.7

Socket reconstruction
OP 5.10.15

Lacrimal gland surgery
OP 5.10.17

Frontalis sling
OP 5.10.4

Assessment of gold weight required for upper lid implantation
OP 5.10.22

Implantation of eyelid weight for facial palsy
OP 5.10.23

Skin resurfacing
OP 5.10.21
Ocular motility
Vertical muscle techniques for correction of vertical strabismus
OM 5.6.7

Kestenbaum-Anderson techniques for the correction of nystagmus
OM 5.6.8
Refractive surgery
PRK and LASEK
RS 4.1.1

LASIK
RS 4.1.1

Holmium LTK
RS 4.1.1

CK
RS 4.1.1

Clear lens extraction and IOL implantation
RS 4.1.2

Phakic IOL implantation
RS 4.1.2

October 2004