Keywords
ophthalmology - chalazion - surgical education - residency
During ophthalmology residency, the Accreditation Council for Graduate Medical Education
(ACGME) requires each resident to be evaluated on six core competencies throughout
residency training.[1] In 2002, the American Board of Ophthalmology recommended adding surgical skills
as a seventh core competency.[1]
[2] The ACGME now provides a framework for assessing achievement of surgical milestones
to ensure that ophthalmology residents develop surgical skills related to periorbital,
intraorbital, and intraocular surgery within a span of 4 years of post-graduate training.[2]
[3] Ophthalmology residency programs provide resident surgical education through surgical
exposure and primary surgical cases, and there are a wide variety of ophthalmology
microsurgical assessment strategies that have been developed to evaluate resident
surgical skills.[4]
[5]
[6]
[7]
[8]
There have been efforts across surgical specialties to develop earlier surgical experience
in training in order to better prepare residents for more complex surgical operations.[9] For example, the American Board of Surgery mandates that general surgery residents
log 250 cases by the end of their second post-graduate year (PGY2).[10] Resident centered surgical clinics are one initiative that have been implemented
across various surgical specialties with the goal of increasing surgical autonomy
and promote earlier resident surgical experiences.[11]
[12]
[13] These clinics have been shown to be an effective and safe addition to residency
training.[11]
[12]
[13]
Chalazia are benign blockages of meibomian glands that can result in erythematous
and sometimes painful eyelid nodules. Chalazia can be managed through conservative
measures such as warm compresses and massage, or in cases of refractory chalazia,
through surgical incision and drainage. Chalazion incision and drainage is a relatively
simple surgical procedure performed by ophthalmologists, and in a cooperative patient,
this procedure can be performed safely under local anesthetic in a procedure room
or clinic. The ACGME requires residents to perform a minimum of three procedures during
their training.
This study presents the first reported resident-centric chalazion incision and drainage
clinic (chalazion clinic) in an ophthalmology residency program, which may serve as
a tool to increase procedural volume in ophthalmology training.
Methods
This study was a Massachusetts Eye and Ear Infirmary Quality Improvement initiative
and therefore was deemed exempt from review by the Massachusetts General Brigham Institutional
Review Board. All procedures followed were in accordance with the ethical standards
within the Declaration of Helsinki.
Clinic Design
The chalazion clinic was first implemented in the 2019 to 2020 academic year. It took
place weekly for a half-day and was conducted by an ophthalmology resident and supervised
by an ophthalmology attending (Chief Resident/Direct of Eye Trauma Service in 2019–2020
and an oculoplastics-trained attending in 2020–2021). All ophthalmology residents
(PGY2-PGY4) rotated through the clinic in 2019 to 2020, and exclusively PGY2s rotated
in the clinic in 2020 to 2021. Patients were referred to the chalazion clinic for
consideration of incision and drainage from numerous sources: outpatient ophthalmology
or optometry clinics both at the institution and in the community, the Ophthalmic
Emergency Department at Massachusetts Eye and Ear, and local urgent care centers and
Emergency Departments.
Residents performed all aspects of patient care including obtaining the history and
physical examination, clinical decision making, obtaining informed consent, clinical
documentation, surgical incision and drainage, providing postoperative instructions
and prescribing medications. The residents also performed all aspects of the surgical
set up, including preparing the procedure room.
On the first day of the rotation, the resident observed the oculoplastics attending
for the first few procedures. For consistency, the surgical technique for incision
and drainage was standardized for all patients, and the attending verbalized the procedure
in a stepwise fashion. After observing the first few procedures, the resident was
granted the ability to perform certain steps of the procedure as the attending saw
fit. After the first procedure day, the resident served as the primary surgeon with
autonomy granted as appropriate by the supervising attending ophthalmologist. The
attending surgeon was present and assisted the resident throughout the entirety of
each procedure. At the end of each clinic day, the attending surgeon provided verbal
feedback on their surgical performance and areas for improvement. Subjective feedback
from the residents was solicited informally throughout the academic year.
Surgical Technique
The surgical technique used for chalazion incision and drainage is as follows: after
identifying the patient and surgical site, the patient was marked and a time out for
safety was performed. A mark was then placed on the chalazion, both at the eyelid
margin and on the anterior lamellar skin, to help identify the exact location of the
chalazion. Anesthetic was provided with proparacaine drops on the ocular surface and
local infiltration of lidocaine 2% with 1:100,000 epinephrine direct on the eyelid.
A chalazion clamp was then placed and the eyelid everted. A Number 11 blade was used
to make a partial thickness linear incision (2–3 mm) into the tasal plate. A chalazion
curette was used to express the contents of the meibomian gland. Topical antibiotic
ointment was applied, followed by an eye patch. The patient was then discharged home.
Surgical Numbers
The ACGME annual resident case logs were retrospectively reviewed for the academic
years of 2018 to 2019, 2019 to 2020, and 2020 to 2021, and the total annual number
of chalazion incision and drainage procedures performed by residents of each academic
year was collected. Any chalazion incision and drainage procedure performed by a resident,
regardless of the locale in which it was performed (i.e., operating room versus clinical
procedure room) was included in order to evaluate the resident's overall surgical
experience.
Statistical Analysis
The mean, standard deviation, median, and range were determined for number of chalazion
incision and drainages performed per resident. Considering the relatively larger variances
in the data, quasi-Poisson regression was used to analyze the yearly trend over the
3 year period in both PGY2 procedure numbers as well as all residents', with the year
being the predictive variable. Considering the skewed distribution of counts, Kruskal–Wallis
rank sum test was used to compare the number of procedures in the 3 years followed
by a pairwise comparison, and a Benjamini–Hochberg method was used for p-value correction. All statistical analyses were performed using R-project Statistical
Software version 4.1.2 (Vienna, Austria, 2021).
Results
A total of 72 chalazions were drained by residents in the academic year 2018 to 2019;
91 in 2019 to 2020; and 202 in 2020 to 2021 ([Table 1]). A resident from any class year performed a mean of 3.0 incision and drainages
in 2018 to 2019 prior to the founding of the clinic, 3.8 in 2019 to 2020, and 8.4
in 2020 to 2021, with medians of procedures per resident of 2.0, 3.0, and 2.0 for
respective academic year. When evaluating PGY2s only, the average number of chalazion
incision and drainages increased from 2.1 per year in 2018 to 2019 to 22.3 per year
in 2020 to 2021, a near 10-fold increase, with a median of procedure per resident
of 2.0, 4.5, and 24.0 for respective academic year. A majority of PGY2s (75% or 6
of the 8 total residents in the PGY2 class) performed this procedure prior to the
implementation of the chalazion clinic (i.e., two residents did not log any chalazion
procedures that academic year), and all (100% or 8 of 8) PGY2 residents performed
this procedure in 2020 to 2021, when the chalazion clinic became a standardized part
of the PGY2 residency curriculum.
Table 1
Results
|
2018 to 2019
|
2019 to 2020
|
2020 to 2021
|
|
PGY2s only
|
All residents
|
PGY2s only
|
All residents
|
PGY2s only
|
All residents
|
|
Mean (SD) of procedures per resident
|
2.1 (0.7)
|
3.0 (0.7)
|
4.1 (0.8)
|
3.8 (0.7)
|
22.3 (2.1)
|
8.4 (2.2)
|
|
Median of procedures per resident
|
2.0
|
2.0
|
4.5
|
3.0
|
24.0
|
2.0
|
|
Range of procedures for residents
|
0 to 6
|
0 to 11
|
0 to 7
|
0 to 10
|
9 to 28
|
0 to 28
|
|
Sum of cases performed per academic year
|
17
|
72
|
33
|
91
|
178
|
202
|
|
Proportion of residents with at least one logged case
|
6 of 8
|
15 of 24
|
7 of 8
|
19 of 24
|
8 of 8
|
14 of 24
|
For PGY2s, there was also a significant difference in the number of procedures performed
among the 3 years (adjusted p-value <0.01 between 2018 to 2019 and 2020 to 2021; as well as 2019 to 2020 and 2020
to 2021). There was no significant change between 2018 to 2019 and 2019 to 2020 (adjusted
p-value of 0.08). For all residents, there was no significant change in number of procedures
across the 3 years (p = 0.56). Quasi-Poisson regression analysis for yearly trend found that there was
a statistically significant yearly increase in the number of procedures performed
per resident over the 3-year period of study. The incidence rate ratios were 3.89
(CI 2.85–5.52, p <0.001, yearly increase rate of 289%) for the PGY2s and 1.75 (CI 1.24–2.54 p <0.002, yearly increase rate of 75%) for all residents.
Discussion
The implementation of the chalazion clinic is a tool for earlier and consistent surgical
exposure for ophthalmology residents. The chalazion clinic resulted in increased performance
of chalazion incision and drainage among residents during the 2020 to 2021 academic
year. To the best of our knowledge, this is the first report of a resident-centric
chalazion incision and drainage clinic in the United States.
Several factors contributed to the establishment of the chalazion clinic. Prior to
the implementation of the chalazion clinic, the chalazions were referred to the oculoplastics
service for evaluation and management. The volume of chalazion referrals became so
high that the service was not always able to accommodate urgent consultations. Furthermore,
oculoplastics faculty often performed these procedures as primary surgeons, as residents
were not always immediately available, and residents would have inconsistent exposure
and difficulty finding opportunities to participate in the procedure. Hence, a plan
was proposed to establish the chalazion clinic to address the high volume of referrals,
help patients be seen in a timely fashion, and allow for more consistent resident
participation while maintaining faculty supervision.
With the concept in place, the chalazion clinic was established quickly. There was
an adequate volume of patients as Massachusetts Eye and Ear is a large referral center.
The clinic accepted direct referrals for evaluation and possible drainage from within
the hospital system as well as from local urgent care centers, primary care clinics,
and emergency departments. There was also an available minor surgical suite equipped
with operative equipment and appropriate set up and an ophthalmology attending [Chief
Resident/Direct of Eye Trauma Service] in 2019–2020 and an oculoplastics-trained attending
in 2020–2021) available to supervise the clinic weekly to ensure proper resident teaching
and supervision. Consistent supervision for each academic year and a centralized location
for this procedure allowed surgical experiences to be more uniform across all residents.
Resident surgical clinics have been implemented in other specialties, such as plastic
surgery and general surgery, and have been shown to be safe and effective additions
to increase surgical autonomy.[11]
[12]
[13] For example, a 4-year review of a single institution resident-centric clinic in
a general surgery department demonstrated the safety and efficacy of their clinic
and found no significant difference in their 30-day complication rate between patients
operated on by residents versus attendings. They also surveyed both patients and residents
and noted positive patient satisfaction scores and positive resident feedback.[13]
The establishment of a resident-centric chalazion clinic increased primary surgical
numbers, particularly for PGY2 residents, thus supporting the idea that a chalazion
clinic could be a useful tool to expanding early surgical experiences. Establishing
this clinic allowed for a trend of increasing chalazion-related procedure numbers
in the PGY2 class, with a yearly increase rate of 289 and 75% on average for the PGY2s
and all residents, respectively over the 3-year period. The changes were not effective
instantly, but the intervention became statistically significant after one academic
year. There was a possible increasing trend on the number of the procedures done among
all residents classes over 3 years, but the increase was not significant.
Importantly, all PGY2 residents logged a range of 9 to 28 cases. This is compared
to six of the eight total PGY2 residents logging a range of one to six cases prior
to initiation of this clinic, with two of eight logging zero cases in the academic
year. This could suggest either more consistent logging and an increased capture rate,
or a more consistent resident exposure to this procedure across the class. This clinic
decreased the likelihood that residents would not achieve the surgical minima set
forth by the ACGME, as all residents met the requirements once the clinic once established.
There has been a considerable effort across ophthalmology residency programs worldwide
to improve resident surgical skills.[4] While chalazion incision and drainage is not a technically challenging procedure,
this clinic allowed the less experienced residents to have earlier exposure operating
in the periorbital area. They also learn basic surgical principles such as preoperative
preparation and set-up, patient positioning, surgical field preparation, exposure,
lighting, instrument handling, local anesthesia, and postoperative care.
Subjective feedback regarding the clinic was solicited informally throughout each
academic year, and it was consistently positive across residents. Residents enjoyed
having a centralized place to experience some surgical autonomy and comfort with a
procedure early on in their residency. Anecdotally, ophthalmologists across the hospital
system have noted the benefit of the centralization of a chalazion clinic due to ease
and timeliness of referrals.
It can be difficult to increase surgical case volume during residency training, as
there may be a limited number of surgical teachers or cases that are appropriate for
trainees. The chalazion clinic was an easily implemented program that increased surgical
exposure to a specific surgical procedure, particularly impacting the PGY2 residents.
The current literature on surgical outcomes in various surgical fields suggests that
increased surgical volume is associated with improved surgical outcomes.[14]
[15] This has also been shown within ophthalmology, where experienced cataract surgeons
with increased annual caseloads demonstrated lower complication rates.[16] While chalazion incision and drainages procedures historically have low complication
rates, these types of minor procedures introduced earlier in surgical curricula may
benefit the less experienced surgical trainees. By increasing their procedural volume
earlier in their training, they have the potential to improve their fine motor skills
and their surgical confidence.
There are limitations to this study. The data was gathered from ACGME surgical case
logs, which is based on residents' self-reported data. As only three chalazion procedures
are required to graduate, some residents may not fully log all cases performed once
they have met the minimum criteria. However, residents may be more likely to log multiple
procedures done in one day in a dedicated clinic, rather than a procedure performed
sporadically throughout their training. Additionally, the change in procedure numbers
per resident in the 2019 to 2020 was less so than in the 2020 to 2021 academic year.
This may have been due to several factors. First, the referral base for the clinic
after its establishment was smaller, and so the number of procedures performed each
day in the 2019 to 2020 academic years was fewer overall. As word of mouth and more
established referral patterns spread across the hospital system, the number of procedures
booked per day increased in the 2020 to 2021 academic year. The clinic was also supervised
by an oculoplastics trained attending in 2020 to 2021, as opposed to the chief resident,
which may have influenced referral patterns. Also, the numbers may be aberrantly low
due to the COVID-19 pandemic affecting several months of the 2019 to 2020 and 2020
to 2021 academic years, with complete shutdown of clinic for several months in the
2019 to 2020 academic year, and resumption of clinic in July 2020. Lastly, given the
small sample size, the statistical analysis may be skewed and the power of the Poisson
distribution is possibly low.
The implementation of a resident-based chalazion clinic provides proof of concept
of a dedicated minor procedure clinic centered around ophthalmology resident education.
To the best of our knowledge, this is the first description of a dedicated chalazion
clinic in ophthalmology training. Our model allowed ophthalmology PGY2 residents in
particular to experience a large increase in early surgical volume with the establishment
of this clinic, which may allow less experienced trainees to begin developing surgical
skills and confidence. As the residency program integrated with PGY1s in the 2021
to 2022 academic year, PGY1s have now been able to participate as well. This is an
exciting area of expansion as it allows even more trainees to begin developing earlier
procedural skills.
