 So I think it's about time to get going this morning. This morning we have someone I think everyone here is familiar with, Dr. Mifflin, Program Director. He's going to talk to us about what's going to happen in the program for the next five years. Thanks, Jim. Alicia signed me up for this Grand Rounds, and we were thinking that we would have our accreditation results. We actually do have our results, which we did get a five-year accreditation. I think most of you have heard that, and that's a maximum we could have gotten, but we kind of got this nebulous email notification through the RGME office that said that we were going to have to submit a progress report of some sort. So we know we didn't get a perfectly clean slate, but the fact that we got a five-year is good, and so I was going to kind of try to specifically respond to what the ACGME gave us in terms of feedback, but we'll have to wait. It'll probably be another month or so before we know. So you'll hear from me again. But so it's not so much a five-year plan responding to our accreditation review as it is. Just kind of a, hopefully we'll generate some thoughts and healthy participation in terms of helping us direct our residency program and make it be what we want it to be. And it's kind of a fun time to do this for me because with the recent application flurry and interviews, it's always a good time to kind of self-assess and kind of see what we're doing well, think about what we could do better. And so it's a good time to reflect on that. I can tell a Mormon joke because I'm Mormon. It's not really a joke, but when the applicants come through, I always feel anybody who knows the Mormon culture and religion, it's a testimony meeting where you go and you espouse your faith. Well, when the applicants come through and I'm interviewing them, I always feel like, gosh, I mean, I'm just so enthusiastic about the program, and this is just such a great place. So I love that time when I can just really promote our program. I'm really proud of our program, proud of our residents, and certainly grateful to you all for being a part of it. So in order to know where we're going, we can look back at where we've been. It's always fun to dig up some old photos, and Paula and Glenn and Jim found some photos. So this is where we were back when I first became involved with the program as a medical student in 1989, and you might recognize some of these people. That's Dr. Olson with his stylish glasses. Man of Swartz, many of you know, Dr. Harry certainly knows him. Dr. Harry might have to, I think that, I don't know if this is Paul Olson or who that is, but Dr. Harry probably knows some of these people. He's in one of these pictures. I was hoping Dr. Barker would be here because he looks the same as he did when he was a resident. There's Alan Crandall. I don't think those are cowboy boots, and no Bolo tie. Mike Teske, any of you know Maureen Lundrigan, again Dr. Crandall. Lots of faces we recognize, the late Paul Zimmerman. I think that's Rick Anderson actually, Jane Durkin. I don't know some of these people, Jim Tweeten. This is, here's Bryce. A lot of you probably don't really know Dr. Barker, but he comes to Grand Rounds. He looks the same, a little bit more gray. And then this is kind of Maureen when I knew he came familiar with the program. Harold, he looks pretty similar. There's Roger. Yeah, just the same. You're a little fuzzy in that picture, sorry about that, Roger. So this was Dr. Olson's office in the original eye clinic and eye division. This is moving day when we're moving into the brand one. Any of you that, hopefully not too many of you have gotten called to Dr. Olson's office for disciplinary matters or what have you, but it's a little different today. This was the eye clinic, again the late Paul Zimmerman. These are some of my co-residents. And our whole eye clinic, I think there were a couple or two to three retina rooms and then there were about five lanes back here. This was the intern room. This is where I worked. And it was, I didn't even know this till Paula was digging up some of these pictures, but this was actually a framed in elevator shaft. It might have been nice to know that when I was working in it, but our whole eye clinic would have fit in the atrium of this building. And some of the old, and again this was kind of a work room. That's actually Wayne. It's our laser room, our high tech laser room at the time. So then we moved into Moran one. I had the honor, I guess, or privilege of being the first resident to actually do surgery in this building. We thought it was awesome and it was compared to our old digs. But it wasn't ideally designed. I love this picture of this was our waiting area with the exam rooms entering into the waiting area. It was chaos. This was the parking lot where the new Moran sits. This was always kind of fun to go over on the bridge between primaries and you and watch the progress. And this was the parking structure hole. And Glenn took all these pictures. I think he went over and photographed this every week during construction. We have this beautiful facility. So I just wanted to kind of acknowledge the evolution of this program and Dr. Olson's not here. But I wanted to acknowledge him and his vision of bringing what was, he was a one man division, I guess, to this amazing thing that we have now. So please don't take it for granted. And I kind of showed pictures of the physical facility. But I really think it's people that make this place great. And our people power has grown significantly too. So just trying to set the example, when we do grand rounds, we're supposed to have learner objectives. We're supposed to have disclosures. This is kind of a soft topic, I realize. But you can still get credit for it. These are my learner objectives. Just to teach you all, remind you all a little bit about residency accreditation. I'm not going to talk too much about the strengths and weaknesses of the program. But maybe we can have discussion about that. And then suggest some planning for improvement. Part of the way that we are, the reality of the way that we're judged is our accreditation. Because the regulatory oversight kind of determines whether we can keep functioning. So that's an important part of how we judge ourselves and how we plan. It's probably not the most important way to judge ourselves. But, and I like this word enhancement. And I always thought that was funny when I was a refractive surgery fellow. You know, spin is everything. Spin is important, especially when you're dealing with regulatory agencies and stuff like that. And also when you're dealing with patients. And spin, some people think about that as a bad word. But I always thought it was funny. Well, when you screwed somebody's surgery up and they didn't get the desired result, and they needed a touch-up surgery, you were going to enhance them. It's not like a redo. It's not like a, we're enhancing you. So that's what we're going to do in our residency program. When we screw up, we're just going to enhance it. And I don't have any disclosures. Most of you know what the ACGME is. But it's our oversight administrative residency certification. And some fellowships now fall under the ACGME purview, too. The RRC, our residency review committee, is a subcommittee within the council that is made up of mostly ophthalmologists. And the current RRC for ophthalmology is all program directors or former program directors. So it's actually a really good, just since I've been program director for about nine years, there's been a really good, I guess, eight years trend towards the more motivated and proactive educators being involved in these committees. And we actually nominated, you know, when nominations come up, they nominate our residents to try to serve on this committee, too. There is a resident member. This year, our nominee was not selected, but maybe. So to be accredited, you have to comply with requirements which are set by the ACGME. And some of them are common across all training programs. So internal medicine, ophthalmology, general surgery, neurosurgery, et cetera, will have some common requirements. The evolution in the approach has been an effort to try to quantify and validate, I guess. It would be a good way of saying it. And there's a lot of bureaucratic type language that you have to sift through. But I think if you just kind of think of it in those terms, it does kind of describe what's been going on. So the requirements reflect a transition from a process-oriented resident education. And what that means to me or what I've come to learn about that is it means that residency education, physician education was more apprenticeship-based in the past, and to some extent it still is. But instead of an educator just saying, well, I can vouch that this person is trained in the modern era, that's not really going to fly. And as you might imagine with some really weak program, it's a little hard sometimes for us to relate to that because I think we have really strong programs. But if there were a really weak system, people would get trained and be vouched for and maybe not be so well-trained. There might be issues of patient safety, et cetera. So the governing body recognized this as a problem. And so there was this ongoing, stepwise plan to try to make educators prove that we're actually training people the way that we're supposed to be. Kind of the buzzword is outcomes. So what does that mean? That's part of the problem. We don't really know what outcomes means. It's partly defined by us. But somehow measuring how we're training people is what we're trying to do. And then each specialty will have specific program requirements that are adopted or proposed by the review committees. So some of the things that we're required to have are goals, detailed objectives, descriptions of how we're going to assess progress. We need to have didactics, resonance to care for patients and have progressive responsibility. We need to supervise them. We need to measure our progress. And our curriculum needs to include research. And this is always kind of a challenge because residency is a really busy time, 36 months of clinical training. But we recognize the value of research as does the ACGME. And so it's always kind of a challenge to fit that in and define what that means, what is meaningful research, how do we accomplish that. But this is what the RRC for Ophthalmology tells us, is that we need to teach residents how to do research, which I think is actually one of our weaknesses right now. I don't think we really teach residents very well how to do research. And we need to have them participate, which actually we do a pretty good job of that. And I think we're improving in that area all the time. And then we need to allocate resources and facilitate those. Most of you know these competency areas. I'm not going to really talk about these. I've belabored these in the past. I don't think they're really asked anybody about these at the site visit. But they're fairly common sense. These are things that we do need to assess and self-assess, set goals, understand the importance of. So residency for ophthalmology needs to be a 36-month program with listed skills. We need to teach residents how to do surgery. And the goal is to have somebody trained and ready for practicing independently as a comprehensive ophthalmologist without supervision. And that's pretty specific language. When people graduate from the program, I have to write a letter that specifically states that this person has been trained to practice independently without supervision. But as you can imagine, the scope of practice can be pretty varied. And it depends on the community. It depends on the trainee. It depends on a lot of things. So it's really kind of a moving target. And a lot of what I've learned being program directors that a lot of the way that we interact with the regulators is kind of a guess what I'm thinking. And so people, it's really funny because we have kind of web chats and things like that among program directors. And everybody's like trying to figure out, OK, what does this mean? What did you guys do for that? Oh, we were cited for that. Oh, well, I wasn't. So that there's a little bit of that kind of uncertainty in what some of this language means. But I think most of us can kind of understand what it means to be a comprehensive ophthalmologist and practice independently without supervision. All of us who've completed training know that when you get out, sometimes you're, I mean, you're still going to feel inadequate. You're still going to feel not necessarily prepared for everything that you face. And so part of what we need to teach residents is how to deal with that issue, deal with how do you get help when you refer all that kind of stuff. So my experience, and I think others could comment too, is that you really learn a lot more once you get out. It's all on you, but this is our goal, anyway. Another thing that we kind of, it's kind of hard to do sometimes because you have individuals who may be stronger or weaker or have different interests is try to ensure an equivalent experience for all residents. That sometimes, I don't know if that's something that the review committee looked at in our, tried to make our program a little more adaptable in terms of elective time, in terms of letting residents kind of pursue their interests. So we're not always perfectly equivalent. And you realize that it would be interesting to see if that's something that they noticed. The number of outpatient visits and consultations and things like that, I mean, we probably exceed those by, and certainly, access to patients is not a problem in this program. And certainly, as the first years can attest to, they get plenty of consultations as well. And then, interestingly, because I think it's a weakness in a lot of places, or traditionally was, pathology is specifically expressed as a requirement. Dynastics, again, I'm sure you can all vouch for the fact that you do way more than that. Provide facilities at each of our training institutions. And newer requirement is that we actually need to, in many of you current residents, probably in medical school, you kind of grew up in the era of simulation, but it really wasn't something that my generation had at all. But this recognizes an important area of training, and just like, I guess, one of the models would be flight simulators for pilots, it just makes sense that you would do simulated experiences for medical trainees where there might be a lot at stake. So most of you have heard, but maybe some haven't, but we actually, through the generous donation of Paul Zimmerman's estate and some fundraising that we're doing, are going to be able to get a surgical simulator, the ISI surgical simulator, and we hope to have that in place and up and going by in June. Nice thing. We've really tried to respond to this requirement by beefing up our wet lab experience and things like that. Those compared to when Dr. Barlow was here as a first and second-year resident, we're doing a lot more. So hopefully that's helping. And then we're required to teach in these areas which are specifically delineated. We're very happy in our program to have faculty covering all of these areas. We do have plans to recruit and retain an oculoplastic person. In terms of turnover and succession, things like that, I don't really know of any anticipated faculty changes in the works. We need to assess what the trainees are learning of obvious areas, technical skills, decision-making, documentation, surgery. So really my job is to try to figure out what we need to teach with the assistance of all of you and our committee, our academic committee is highly involved in this. Our residents have actually been highly involved. And then try to design the curriculum, evaluate how it's working and modify it, improve it out. And I think we're the biggest challenge because it's a busy residency. I always tell the applicants one of our greatest strengths is one of our greatest weaknesses. It's a really busy residency, so it's a doing residency. So it's hands-on. And it seems counterproductive sometimes to do these last, maybe even all of these last three things because we're busy doing, we're learning, it's exciting, we're taking care of patients. It's really important to do the last three. And that's just the age that we live in now. I mean, this is not gonna go away. Just like Hatch isn't quite as young as me. So in Dr. Hatch's era, it's like it was the paternalistic area of medicine or era of medicine. If you look at some of the charts, I'm sure not his, but some of his peers from those days, there wasn't much written in the chart. And it was kind of like, well, I'm the doctor and what I say goes and now, I don't know at least the last 10 years and certainly in my generation of training, if it's not documented, it's not done. And that's only getting more intense and as you guys train. So now, not only do we have to document in the medical record, but we have to, we have all these other outcome measures. And so we had a faculty meeting, I guess it was just earlier this month, where we were all kind of graded on our patient satisfaction responses. And they put up a slide anonymously, you know, thankfully. And said, well, you know, these are the people that are doing it great. These are the people that really suck. And how can we help the people that really suck? And you know, that's the reality of our eras, that we need to be documenting things, we'll be measured in a lot of different ways. And I'm not gonna go into these, but there are a lot of tools that we use to measure things. And I would just challenge you guys as residents to take some ownership, certainly the faculty know about these, to try to make sure that you are getting assessed. Take, you know, take an active role in determining, and I'll talk about this a little bit at the end of, you know, it's your job to make sure your residency is the best it can be, and that you can prove that you can do all these things. And that you're getting the learning that you wanna get. And I think some of these tools you'll find will be helpful in doing that. So our accreditation process, we just went through this, our site visit was in July, but it was literally a process of getting ready for it. It starts with an, I didn't put this on here, but an internal review by our own. We actually got pretty good reviews in our internal review. There wasn't a lot to respond to. Some concerns about the surgical curriculum and glaucoma, you know, it's just kind of been an area, partly because of the demographics of our patient population, it's just been a challenge to really do as much glaucoma surgery here as some of the other programs in the country. But overall, our internal review was pretty strong. In the past, our documentation of our residency strengths and improvements has been less than ideal in terms of this program information form. So many of you actually got to look at this. I think some of the residents look at a lot of the faculty look at it. So we really spent a lot of time in trying to improve that. This accreditation round, I think that paid off for us. Our site visitor was really pleased and didn't find much wrong with that. And then at the site visit, the visitor, site visitor is typically an educator. Our guy this time was a former program director for pediatric orthopedics. And he was actually a pretty experienced site visitor and was very commonsensical and practical. Our last site visit, we had a PhD educator who really didn't know anything about ophthalmol. It was much more difficult. So again, I think that's part of the challenge is that you never quite know what you're gonna be, what standard you'll be judged by. Anyway, this time it was somebody who really seemed, it seemed very relevant to the process. And I think that was helpful. And then thanks to all of you for interacting with this guy and hopefully being honest, but also promoting our excellent program. And then a report is filed and the committee met earlier this month. And again, we received the five year. So we knew that there is the RRC for ophthalmology. And I'll tell you just a little bit, this I know is somewhat boring, but I think it's good to know how this works. How the RRC works. I think there are seven people in the ophthalmology committee, including one resident. Each program application is reviewed by only two of the committee members and then presented to the committee for a vote. So again, there's a fair amount of subjectivity possible. I'm sure that they're, you know, try to be objective in their training. But I went to kind of a focus group at the AUPO meeting, which is a meeting of chair, chairman and program directors last January. And this RRC committee sat in front of us and let us ask them questions. And they identified these areas as areas where they, these are areas they felt were really important in determining the quality of the residency. And these are areas that they were looking at to try to determine many years of accreditation to get, to give to each program. And again, you have this kind of nebulous concept of outcome measures. So, and that's kind of left up to the programs. It's not really well spelled out what that means. So those are some of the areas that we try to work on for our accreditation process. Just to review the work hours thing, that was one of the issues on their work hours violations, which are a big concern in residency education, not so much in ophthalmology, thankfully. But, so I just wanted to throw that up there again so everybody knows what those are. I think all the residents pretty much know what they are. The only big change really in the new work hours effective this academic year is that this, it used to be kind of 24 plus six, a little bit more stringent requirements of time off between shifts. The interns know that 16 hour shift limits for interns. We've always kind of had the rule that ophthalmology review or the RRC and our own program have had rule for many years that PGY1 residents are not allowed to take home call. It's just felt that they won. I mean, this work hour rule would exclude that anyway, but even before that, they just don't really have enough experience to do. One thing that was nice is clarification of shift kind of separation. And this time off between shifts is important to clarify because when you're taking home call, that doesn't really count to this shift rule unless you just are, you stay in the hospital like Jim Bell because when he's on call, we know that he has a blackest cloud that anybody's had for a while. He pretty much just stays in house because he knows he's gonna be there the whole time. So Jim, we need to look at your work hours, but for most of you, and this was a question that came up and the RRC guy said, I think it was the chair of the RRC. He said, yeah, if the resident goes home and has a bowl of cereal for 15 minutes, that's considered a shift break and it doesn't count. So, and otherwise it would be unworkable because call can be busy and you have to come in if you had to separate that two or three hour visit. I just wanna say a little bit about fatigue because we definitely need to be aware of fatigue and sleep deprivation in terms of this. So, we've always tried to promote and I think all of you have completed the sleep deprivation. Matt, if you're too tired to work, you need to let us know and you'll be. Surgical logs, we kinda understand this concept of minimum numbers. This was changed a little bit last year for refractive and retina and I don't have a slide reflecting this but this has been subdivided somewhat. And for example, in terms of glaucoma lasers, we don't just count all lasers now, we need to count a certain amount of as versus SLTs. And so, in a way it's good actually, it's better to track individual procedures. So, y'all deserve a pat on the back. We got a five year accreditation. We don't have the details as I mentioned above but right when I became program director, we had an accreditation that was basically happening. We actually only got a three year that time. Our next one was a four year and now five. So, let's keep it at five. One of the things that I had to do to prepare for the accreditation process was to try to figure out what outcome projects were. What were some outcome measurements for our residency. And so, I kinda took to heart that we knew that surgical numbers was gonna be important for our program because we were cited on that actually for our glaucoma surgical numbers in our last review. We kind of intuitively knew that ward pass rates and things like that were important but we decided right after our last accreditation that we would, it just kinda made sense to, well, an outcome is where do our graduates end up? How do they feel about our program? How is our program viewed? So, we've kind of collected this data. This was actually summarized and presented as part of our accreditation application. So, our surgical numbers, some of you saw that. One of you needs to teach me how to copy a page from PDF and get it in here. But this was from last year. Actually, well, this was 2009, 2010. Again, our glaucoma, our glaucoma filtering and tubes and stuff has actually gone up. We were at 46% on glaucoma lasers is still low. Now, I'll show you at the very end, the numbers and kind of the trends for our surgical numbers and actually they look pretty good. The last year was actually a really good year but we do need to try to continue and maintain the gains. And, you know, we're, this is a, reflects our VA thing. I mean, we're typically not that low in cataract surgery percentile-wise. But I'll show you kind of a time trend at the very end. But certainly, our surgical stats are, even though we really, it's funny we have a reputation still of being incredibly high surgical volume, but we've certainly dropped some relative to other programs. We used to always be, you know, we're still pretty high, but, so this is something just, it's an objective thing that we can look at. Board pass rates. So I went through and tried to, along with some other educators, there's actually a publication on this from Dr. Odding in Iowa. But we, and some of it was collaborative stuff and I did send in our, anonymously of course, our numbers for that publication that came up with. But it's a little hard to correlate exams for numbers because of the small number, you know, statistically. We have three, well, for a long time, two graduates every year, three graduates per year now. But our, the written qualifying examination, you take that basically your year after residency completes. And it's similar to OCAPs, pretty similar. And so our first time failure rate, and this was just a five year summary that the American Board of Ophthalmology sends to us was 23%. And that's compared to a national average of 20%. So that's an area where we can improve. Now again, it trends because, you know, you have a cluster of a couple of people who don't pass, then it really drags your rate down because both numbers are really low. Contrast it with our oral exam rate, which was, nobody didn't pass for the last five years. And I do think that there may be some correlation. I think our oral exam rates actually have improved. But again, because the numbers are small, it's gonna take multiple years to decide that. But we kind of feel like our oral, our mock worlds have kind of helped our graduates with the oral boards. And then I looked at all of the data that I actually had that I could find, which was about 10 years worth. Both oral and written boards, we have a 14.3% fail, first time failure rate, compared to about 20 to 25% for US graduates, national average. Every graduate from our program has actually passed on the second, and one person had to take oral boards three times to pass, but everybody's passed. I don't know if they've changed the rule, but it used to be if you passed the third time, you had to start over, I mean, if you failed the third time, you had to start over. I'm looking at Nick, because I don't, I think that's still, I think you do have to go back and do written again if you failed third time. So thankfully that person passed. So overall, our program's doing well compared to the national average, and we have never really emphasized. I mean, last couple of years, we've kind of made more of a push to try to promote good performance on OCAPs, but we've not really pushed this historically. So we've done pretty well. OCAPs, I mean, this kind of reflects the lack, I think, of a push really to do well on OCAPs, but I looked at all of the OCAP data I could find for our program, and there were a couple of years that were missing. I don't know if the scores come to Dr. Olson, and this was actually before I was program director, but we had a few years where they were actually missing. So I didn't have all the years, but tried to do some kind of a statistical analysis. I mean, nothing panned out. The only thing that really panned out is that every person who failed their written, well, there was actually one or two, I think, that who failed their written OCAPs actually had scores above 20, but this is a bad indicator. If you score below 20, 20th percentile on OCAPs, there's a pretty high chance that you'll fail written boards. So that was really the only thing I could glean from OCAPs, and I think part of that is because some people don't study for it. They just say, well, I'm just gonna go into a cold and see what I learned, and I think, or see what I know, I'm not necessarily opposed to that. I mean, I think there might be some value to that, but I don't know. I don't know what to say. I mean, we've had third years. We've definitely had third years in our program who have not studied for OCAPs, and then they've done great on their written, qualifying exam. I don't think any of them have gotten below 20th percentile and passed though. So that's just kind of, it's a way maybe to assess yourself. Now, the pass rate for written qualifying exam varies by year because sometimes it tests harder than others, but around 30 to 33% is usually what you have to get to. So that's actually below the threshold of passing that 20th percentile. Fellowships was another thing we wanted to look at, and I was kind of surprised when I actually, we haven't really tabulated this, but we've had a lot of people go into fellowships in the last 10 years. And this is Utah, so it's kind of in bread, because if you look, a lot of these fellows are staying here, but we feel like our fellowship programs are competitive with anywhere, and it's not a diss to our residents. I mean, many times our fellows are kept here because they're the best applicants. It's not because they have some kind of a pipeline, we turn out stellar residents. But anyway, I thought that was actually good. And I actually don't have any data on what other programs do, but I think this is comparable or certainly probably better than average. The other thing is jobs are usually, our residents are sought after for good jobs, people saying, so-and-so is thinking about retiring, do you have any good residents coming up through the ranks that we can recruit and talk to? And so this place has a reputation of turning out graduates who can actually function, who've achieved that level of competency that we talk about where they can actually practice and do surgery and do a good job. Our residency applications have kind of, we had a little plateau maybe 2007 through 2009, but we've kind of gone up, up and up and up, much to Alicia's delight. She just loves processing them all, much to Dr. Warner's delight, because I think she looks at every single one. And so it's a thank you, Dr. Warner, thank you, Alicia, thank you, Elaine. But I think one of the things that, again, is heartening for me is to see these applicants come and they're very excited about our programs. And many of them are super strong applicants and they have interviewed elsewhere, and hopefully they're not just brown nosing when they give us positive reviews and say, you know, you really do have a good residency. I'm sure that at least some of them are sincere. Another thing that we looked at in terms of our outcome projects is our surveys. Again, that was on that list of hot button items that the RRC wanted to take into account. Our ACGME surveys, you've all done those now, I think. Residents have done it. And I think looking back at about the last three or four years, these are some trends of potential concerns that have come up. These are all kind of responded to at a low frequency, I think at the most. You know, probably, I think the 2008-2009 survey, and as you know, they're not perfectly constructed or worded, so there's some opportunity for misreading or error. But concerns about fellows, somehow interfering, you know, kind of that love-hate relationship with fellows, they teach me a lot. Great, they can call them, they support me when I'm on call, but yeah, I think they're gonna do more cases if they weren't here. So that's a concern that, you know, I think it's a valid concern, and residents are honest about expressing that. And that's one of our challenges as we go forward, is how to balance that. There were some concerns on the recent survey about confidentiality of board OCAP scores, and also maybe evaluations. And I think part of that was, you know, we met about some of these things. I think part of that was a communication issue as much as anything. Not sure that there are any real major issues with that anymore, but it's something that we're gonna continue to watch. Supervision, one resident said, yeah, I'm not supervised. I'm not sure what to do with that, because I don't think it's, it's not my experience, but I was a little worried about that one, but I wasn't able to get specifics on that. Work hours, similar, some outlier responses that weren't ever really, well, really only one resident. So it's always kind of hard to know if the question was misread or mismarked or whatever. I mean, these could actually trigger some kind of response from the ACGME because they're kind of egregious because we absolutely must not violate these things. Residents need to be supervised. If they say they're not being supervised, that's really bad. Work hours, they don't have a high tolerance for allowing work hours violations that aren't addressed. This was another one, kind of like the fellow thing. I realized research is not the primary mission of the clinical training residency program, but it's important I want to do it. I need you to support me in doing it. So I think all of the responses, and they're actually very understandable. Some people all want to do more research. They all want time and support to do that. And it's one of those challenges that we have to kind of figure out. Surgical experience, same thing. Everybody wants to do more surgery. Didactics, some valid concerns, which I think have been, for the most part, improved, but we always want more input and we want your feedback. So we actually did our own survey monkey survey. We've done this for about five years now too. These are the questions we asked because I was worried about those outcomes things, like what do they mean? I have no idea what they mean. I said, well, let's ask our graduates. So we asked them if they were satisfied with their experience. Again, I wrote the survey so it's inherently flawed, but we just tried to get some ideas. Did my residency prepare me for a fellowship or practice? Could I, was I prepared for boards? How was my surgical training? Would I recommend this? And as you can imagine, the response rate wasn't perfect. We got different levels of response. At last year, I had Elaine send it to, I think the recent five year graduates to try to survey everybody because we had small numbers to start with, but at least initially, and then when we surveyed people on their exit from residency, satisfaction rate was really high. I think as they got further from training, they might have, and then that's why like, for example, this was only one respondent hadn't taken board yet. So I didn't really know what to say, but as they got a little bit further out, there were some people who were 10%, 18%, maybe didn't respond favorably to some of these categories, and then there were some neutral responses too. These are all the favorable, like excellent or very good responses. Neutrals weren't included in this. So we have a few people who, you know, I mean, I think hopefully that validates the survey a little bit. There are some concerns and some of our graduates are not feeling adequately prepared for the written qualifying exam. It was kind of interesting again though, and I think thank you, Jason, for 100% even in this larger group so that they were better prepared for oral exams. So I think that's an example of how our mock boards have, you know, it's something that we've done to change our residency that's actually maybe improved our outcomes. So we have some things to work on. In spite of all of that, one, and again, we had some people who weren't totally happy recommending our residency, and that, you know, to me, that's concerning. I wanna see that number be 100%. These are some subjective comments, and we won't take a lot of time reading those, but kind of just reflect what was on the, some people want more surgery, some people have concerns about didactics, better, et cetera. And we changed the survey. Unfortunately, we didn't make it friendly to get written comments the last year we did it, so we need to change it back to where we get written comments. So in terms of, you know, a five-year plan of how to respond to our ACGM review, I don't really have a specific one because we don't have the specifics of how we did. We know we did well, but we don't have anything that we can actually respond to. But one of the things that I wanna convey is that part of this competency stuff is, you know, I think it can drag us down a little bit if we're just satisfied with being competent and not always trying to be the best we can be. And for both faculty and residents, it's important to understand if it's not documented, it didn't happen, so that means for skills, that means for all the stuff you're supposed to be doing, and you really need to be proactive in trying to help us collect that data. And I think in a big institution, we really have to worry about what I call the lowest common denominator phenomenon. Well, I've met my minimum level, so I'm good. You know, I'm gonna go golfing or whatever. Not that golf is bad, but I think each of us needs to set a goal to improve, constantly improve. And we may end up at different levels, but if we're always trying to improve, we're gonna be where we wanna be. So one of the things that specifically, I think we need to work on as a residency is promoting balance in the surgical experience, and we need to set some specific goals, which we have for glaucoma. And again, it's not a reflection on our glaucoma faculty. They're not here, but I'm gonna defend them. Well, Jason's here. I think it's more a reflection of our practice patterns and population. But the ACGME doesn't care about that. I got away with kind of justifying and explaining away that on our PIF this time. I don't think that it's gonna work five years from now. So we need to somehow improve our training. It may be through simulation, it may be through wetlands, it may be through some of the stuff we're already doing, but that's an area we need to target specifically. We need to think about this fellow thing and how to maybe improve the balance. And we're not gonna solve that one today, but maybe that's something that the residents can meet with myself and Jeff on and decide if there are things that we can do. I think a really important thing that all of the faculty need to do, and maybe sometimes senior residents can help with this is manage expectations. Junior residents are more likely to be disgruntled because their life isn't always fun for them when they're on the console service and they're taking more call. So it's nice if the more senior guys can put their arm around them, guys and gals, say, hey, you know what, I'm doing a ton of surgery. Thanks a lot for slogging away at the VA through that clinic. Same thing for research. Sometimes it's just not realistic to be able to have a lab and a research assistant and dedicated time during the day. I mean, that's just not what residency's about. So part of my job and all of our job is to manage, same thing, you know, you gotta slog, you gotta serve, you gotta grind at the VA to get patients, you gotta get experience. I mean, we have to be better at managing our expectations on this. I mean, one of the things, again, that comes through and interviewing, well, I interview a lot of fellow applicants, obviously, for Cornea and we have a really strong Cornea fellowship and we get people from great places and we're just like, gosh, I mean, you guys have it so good here, the text refracted. You know, I mean, you don't have this indigent hospital where you're seeing 90 patients in a half day and you don't have any supervision. So I think we need to work to manage expectations and I think that'll actually improve our satisfaction. So it's not that these things don't need to be changed necessarily, they can be improved but part of it is just managing expectations. I also think we can do a better job of mentoring residents and I really want the residents to kind of try to be proactive on this. You don't have perspective to know where you should be going and what you should be doing when you're a first year resident and you really need a partnership with faculty to do that. Some of you have done it very successfully, I think others kind of get, they're just under the radar and nobody's really finding them and help. Research, it's improving and our publication rate is much better than it was five or even, well 10 years ago, even five years ago. So we're doing well but we need to maintain our gains. And then this one is for the residents, it's just, I think owning this as a resident, as a trainee, what do I need to know for my career? What's my role and am I participating in proving that I'm ready? And if you guys will do that, that'll make everybody's job easier and you need to push the faculty on that because I know a lot of times you print off your form, even in my clinic, you come up and we're super busy and we don't fill it out. It's somehow just kind of being persistent, be the nagging person until it gets done. My biggest concern, let me put the laser pointer, Jason's not paying attention, is this. Because we depend so heavily on the VA, my number one goal the next two years is to somehow improve our predictability quotient with the VA. We have to somehow get more security in our contracting, in our agreements, whatever. I mean I'm gonna work, I'll just promise you guys I'll do whatever I can to try to promote that, knowing that I may have no power. I know Jason and I both at times feel helpless because despite all we do, we depend so heavily on the VA, sometimes we just can't make any inroads with the administration. I mean it's just funding issues, there are hardheadedness issues, there are a lot of political issues. It's tough, but that's my biggest concern. And then just, I think this is one that we all need to be aware of. I don't totally understand millennials, there are different values to some extent, there are different expectations for what the role, our role should be. And that's something that's changing. A physician nowadays isn't the same as a physician even from when I train. And I think balance is important, family is important, recreation is important. The reality may just be that we're gonna become more shift worker type professionals or whatever, but somehow we need to kind of hang on to what's best about our profession and that's that special privilege that we have to take care of patients and it's really, it's more than a job. That's something that, I don't know, hopefully that we can continue in our residency to promote that. And I think a lot of people who go into medicine just inherently have that desire to serve and do their best and sacrifice to some extent in there. But it is something that is changing a bit. So we don't have much time, couple minutes, but I'm happy to answer questions. Actually, we're out of time. Throughout your ideas, definitely would love to meet again with the residents. They're such a flurry coming into the accreditation process and it's like this sigh of relief that we have our goal was achieved. And but we still need to be proactive. I know some of the chiefs, their glaucoma numbers aren't what I want them to be. I mean, we need to focus on these things. We need to kind of keep going. Any comments, questions? All right, thank you. Oh. Look on it, look on it for rockers, I know. So is that progressing? Well, the university, it's kind of one of these bureaucracy. That's a perfect example of the lowest common denominator scenario, where we have, I don't know how many, 25 specialties trying to use the same system. It's ridiculous. We're gonna use Epic, Epic is it. Weave and ophthalmology, we decided to be one of the last people to do it because we're not happy with the product, it's ridiculous. I mean, 10 years, 12 years ago, I was on the American Committee and we were looking at next-gen and you know, all these, it's.