In the Wilmer Eye Institute’s Patient Access Center for the Eye (PACE), ophthalmology resident Kapil Mishra greeted his sixth patient of day. The patient had come in complaining of sudden-onset blurred vision in his left eye. After taking a medical history, Mishra performed a thorough examination, with particular focus on the optic nerve, retina and macula. The patient had a long history of diabetes, and Mishra, a third-year resident, wanted to be sure it hadn’t affected these vulnerable tissues. After he finished the exam, Mishra sought out neuro-ophthalmologist Eric Singman, whose office was just down the hall, for his take on the situation.
Singman, the Milton and Muriel Shurr Division Chief of the PACE clinic at Wilmer, introduced himself to the patient. “I’m just going to take a look,” he said. Warm and self-assured, Singman seems the quintessential mentor figure. After a brief examination, he concurred with Mishra’s findings: The problem was a cataract, and the relieved patient scheduled an appointment to have it removed.
PACE (formerly known as Wilmer’s General Eye Service), which has been in operation since 1925, is where Wilmer residents do much of their training. Patients from around the East Baltimore community and beyond come to PACE for a full range of ophthalmology services. There, residents are supervised by dedicated Wilmer faculty, as well as by a chief resident (also referred to as the assistant chief of service) who is a fellowship-trained, junior faculty member and former Wilmer resident. Current Assistant Chief of Service Thomas V. Johnson says it’s a win-win situation, benefiting both residents and patients. “By doing rather than simply observing, residents are not only learning about eye diseases and treatment of eye diseases, but about how to help people with eye problems,” he says.
On average, some 85 patients are seen each day in PACE, including five “same-day” appointments. Patients may filter into the clinic through the emergency room, the outpatient center or just about any department within the hospital. The high patient volume provides ample opportunities for residents to learn about all kinds of eye conditions, as well as how to work with a public whose needs often go well beyond the medical. Says clinic manager Karen Shafer, “Many of these patients may have no family or support system, no consistent way to communicate, no insurance. They may have no home.” Shafer says the experience teaches the residents empathy. “The residents go way above and beyond. They may get Social Work involved, arrange transportation for patients, or obtain a voucher so the patient who lacks insurance can get a prescription. I’ve seen them give patients their cell number,” says Shafer.
Unparalleled Opportunities
At Wilmer, residents follow their own patients through their entire three-year residency in a weekly continuity clinic. They learn how to counsel their patients through the course of a disease — whether it’s an acute condition that will be cured in a couple weeks, or a chronic disease that’s going to last a lifetime. “They know how to guide patients through that, how to let them know what to expect, and how to partner with them to take care of their eyes over time,” Johnson says.
Having the relative luxury of time allows Wilmer residents to consider their patients comprehensively: While senior attending physicians may see 40 or 50 patients in a day, residents see between eight and 20. “They’re not focused on just the glaucoma or the cornea or the retina,” Johnson says. “They have more time to sit down and discuss patients’ questions — more ‘chair time’ to address all their needs.”
Wilmer residents also have unparalleled opportunities to explore subspecialties. While few ophthalmology residency programs have their own clinics within the program itself, Wilmer has seven, including retina, glaucoma, pediatrics, cornea, oculoplastics and a genetics clinic that sees the largest number of patients with Ehlers-Danlos disease in the world. “Residents see a huge amount of pathology, and they see it multiple times, so that by the time you’ve finished residency, it’s not as if you’ve seen a strange corneal presentation once, but you’ve seen it enough times so that you’re very comfortable taking care of it,” Johnson says. Last year, residents completing the program performed, on average, over 540 surgical procedures and assisted in an additional 900-plus procedures during their three-year residency.
Setting the Standard for Care and Learning
Singman says that more than the place where residents train, PACE presents opportunities for them to publish their research. Indeed, residents are strongly encouraged to perform research and publish case reports. As a resident, Johnson undertook a study that determined that a test often used to detect angle closure actually performed very poorly as a diagnostic tool. Instead, Johnson’s research established gonioscopy as the gold standard. His findings were published in the American Journal of Ophthalmology, and he presented them at the Association for Research in Vision and Ophthalmology (ARVO).
Research is also performed to measure the effectiveness of the residency program itself: In 2016, Singman published a first-of-its-kind study to establish benchmarks for measuring the efficacy and effectiveness of the program. Establishing key metrics for surgical and outpatient productivity also creates a benchmark against which other programs can be measured.
The Legacy Continues
PACE continues to evolve to address the needs of the community it serves. Residency program director Fasika Woreta is spearheading an effort to establish an eye urgent care center to reduce the number of ophthalmology visits to the emergency room by patients whose conditions aren’t actually an emergency. Woreta estimates that each year, around 2,500 patients are seen in the emergency department with eye-related complaints. “The majority of these are not emergencies and could be seen in clinic,” Woreta says.
The recent name change from General Eye Service to Patient Access Center for the Eye reflects the evolution of the center and renews the focus: providing accessible eye care to the patients who need it. As PACE continues to evolve and grow, so do the opportunities within the residency program itself. At the same time, Wilmer has kept the size of its residency program relatively small, taking in just five new residents a year. This, combined with the vast educational scope of a Wilmer residency, may help explain the large number of individuals who go on to become leaders in the field: More leaders have received their training at Wilmer than at any other institute — including more than 100 department chairs and 10 presidents of the American Academy of Ophthalmology.