In 2013 the Ministry of Health and Long-Term Care established a task force to conduct a thorough review of Ophthalmology services in Ontario including an assessment of the future patient needs. The task force brought together medical, clinical and academic experts, administrators and system leaders from ophthalmology, hospitals, independent health facility, LHIN and Ministry to look at current strengths and opportunities for improvement. The result was a Vision Care Strategy which included recommendations for ophthalmology in Ontario. One issue identified was that of new ophthalmology graduates and the challenges to secure sufficient operating time in Ontario hospitals.
Ophthalmic education ranges from undergraduate medical school education through to residency and fellowship; more than nine years of rigorous medical and surgical training which is vital to ensuring the comprehensiveness and sustainability of Ontario’s eye-care system.
The following table outlines the academically affiliated ophthalmology sites, number of ophthalmology fellows and number of ophthalmology graduates in Ontario per year. It should be noted that many of the sub specialty fellows are foreign and return home at the completion of their training. Of the approximately 16 ophthalmology graduates in Ontario, 13 choose to stay in Ontario and practice here. The current mix of general (65%) and specialty (35%) ophthalmologists remains constant over time.
For some interventions, surgeon experience with the procedure is essential for patient safety and surgeons must perform a critical annual volume to maintain a requisite skill level and achieve low surgical complication rate.
Studies on critical mass and quality relationships focus largely on cataract surgery where it has been shown that complication rates increase as surgeon volume decreases. However, even in the highest incidence group (those who perform under 200 cataract cases/year), a recent Ontario study showed surgical complication rate were still extremely low at 0.8%.
It has been shown that the specialty surgeons who perform lower case volumes appear to operate on a higher proportion of complicated eyes which artificially increases complication rates. The numbers needed to maintain competence in specialty ophthalmology surgery have not been well studied. In one British study the rate of complication in glaucoma surgery increased only in those performing less than 10 cases per year. There is little clinically significant evidence to suggest that there are diminishing returns on quality when surgeons perform “too many” cases per year.
One concern is that new graduates are not receiving enough operating room time and are therefore unable to offer their patients appropriate surgical treatment. This often forces them to practice outside of Ontario or to abandon ophthalmology all together. A second concern is that, if ophthalmologists focus only on providing surgical services, their contribution to medical aspects of vision care may be insufficient to meet the local population needs for medical eye care.
The Eye Physicians and Surgeons of Ontario met with the Ministry of Health and Long-Term Care, and Health Critics from both the PC and NDP parties to discuss the issue. EPSO recommends that new graduates are granted access to facilities such that a minimum of 250 cataract surgeries, or 40 glaucoma/cornea, or 200 vitreoretinal surgeries per year, are performed by each surgeon respectively so that adequate skills are maintained and that new graduates can develop sustainable practices. EPSO will continue to work with Ontario’s political leaders, the MOHLTC and the OMA to have these recommendations heard and acted upon.
Reference: A Vision for Ontario; Strategic Recommendations for Ophthalmology in Ontario, The Provincial Vision Strategy Task Force, May, 2013