Karl C Golnik1, Jin Ye Yeo2
1Department of Ophthalmology at the University of Cincinnati, Cincinnati, OH, USA; 2AES Editorial Office, AME Publishing Company
Correspondence to: Jin Ye Yeo. AES Editorial Office, AME Publishing Company. Email: aes@amegroups.com
Expert introduction
Dr. Karl C Golnik (Figure 1) is a Professor at the Barrow Neuroscience Institute, Creighton University and the University of Arizona. He has received the American Academy of Ophthalmology’s Lifetime Achievement award, the North American Neuro-ophthalmology Society’s Merit Award, and more than 10 teaching awards throughout his career. He has given more than 1000 invited neuro-ophthalmology and medical education lectures in more than 75 countries and has over 150 publications in these fields. He is a member of the American Ophthalmological Society, the Academia Ophthalmologica Internationalis and he currently serves as a Board member and Chair for Education of the Ophthalmology Foundation. He is also Past-President and current Secretary for International Relations of the International Joint Commission on Allied Health Personnel in Ophthalmology (IJCAHPO).
Figure 1 Dr. Karl C Golnik
Interview
AES: What drove you to pursue ophthalmology?
Dr. Golnik: When I was in high school, I was involved with instructing handicapped students. I was roommates with a blind student, and we lived together for several years during college. I was somewhat interested in ophthalmology then but had no idea that I was going to be an ophthalmologist. I then went to Johns Hopkins University School of Medicine and my girlfriend’s father was an ophthalmologist. He seemed to like it a lot and that made me more interested in the field. One day I was working out at the gymnasium at the medical school and started talking with someone who was also working out. He was an ophthalmologist at Johns Hopkins Hospital and had a research lab and asked me if I would like to participate. I worked with him for a couple of years and the experience solidified my interest in ophthalmology. When I was going through my residency program, I thought I was going to be a retina specialist and I quickly realized that I really love neuro-ophthalmology and hence decided to do a fellowship in neuro-ophthalmology. I never regretted that decision and would never change a thing if I were given a chance to go back to residency or medical school. I love doing neuro-ophthalmology and also having a niche in medical education within the field.
AES: Could you provide a brief overview of your research in the development of improved methods of resident assessment? Has there been any promising findings in this area?
Dr. Golnik: I have always been interested in education. Both my parents were teachers and sometime back in the late 1990s, my friend and I realized that doctors are required to teach if they work in academics. But none of us in the United States had any instructions on how to teach. We learn how to teach by watching our mentors, but that is not always a good experience. Therefore, we decided to start a meeting called “Educating the Educators” which has now been in existence for 20 years in the United States designed to improve the teaching effectiveness of ophthalmic educators. As part of this interest in education, and as part of the United States project called “Outcome Project”, we realized that we needed new methods to assess how residents are performing. Around 20 years ago in the United States, the formal assessment for residents was done with multiple-choice questions. It is still in use and of course, there is nothing wrong with multiple-choice questions, except multiple questions are not a good way to assess important aspects of being a physician, such as surgical skills, professionalism, or communication skills. We asked ourselves: how can we assess these aspects if we are required to teach? If we believe that our residents need to be professional and have good communication skills, then we have to find a way to assess them with more structured methods than just the opinions of the resident’s evaluator after being with them for one day.
The first assessments we came up with were structured assessments of surgical skills, and we now have published at least 15 different tools for different ophthalmic surgical procedures. We started with procedures that were very common like small-incision cataract surgery and vitrectomy and trabeculectomy. There is now a long list of these assessments and they are designed to be more structured and objective. Our teaching methods also allow the residents to know exactly what evaluators look for and what it means to be competent in these procedures. Once we started working on the surgical and procedural skill assessment methods, we also started thinking about assessments in the clinic. Hence, we developed the first type of assessment called an ophthalmology surgical competency assessment rubric (OSCAR). We then worked on an ophthalmology clinical evaluation exercise (OCEX) which is an observed interaction between a resident and a patient. There are a number of boxes to check off in terms of the ability of the resident to take a history, the ability to conduct an eye examination, the ability to talk to a patient and answer questions, and then finally the ability to present that patient to the senior physician who is watching and create a differential diagnosis in managing the plan.
Next, we turned to what is not often assessed in any formal way which is professionalism, and turned to something called the 360° review, also known as multi-source feedback. The idea is to observe a resident when I am not watching them, for example, when they are with their peers, patients, or with the staff. We developed the 360° evaluation which was published to assess professionalism and communication skills as judged by peers, patients, and staff to try to get a better picture of this resident and their interactions. These evaluation tools are used widely and have been translated into a number of different languages.
AES: Currently, part of your practice follows a telehealth system. Could you share some of the benefits and challenges of using telehealth as a neuro-ophthalmologist based on your own experience?
Dr. Golnik: In my opinion, there are not a lot of benefits. The main benefit is perhaps that I can be wherever I might be in the world and review a case with a patient on the phone or the computer and give an opinion. That is the only advantage. There are many disadvantages and I do not personally like telehealth very much because I cannot do parts of the neuro-ophthalmology exam and that is not an optimal way to evaluate patients with neuro-ophthalmologic problems. Telehealth is something that can expand the reach and availability of neuro-ophthalmic care but certainly not my preferred mode. I prefer to be able to sit across from the patient, interact with them and conduct the neuro-ophthalmology exam.
AES: As the recipient of numerous awards for teaching excellence, could you share what you think makes your teaching outstanding? What are some lessons and values that you impart to your students?
Dr. Golnik: Something that I think makes my teaching outstanding is that I like to do it. I love to teach and I am not sure if that is enough but that is an important aspect. I think it is important to create a good learning environment where students are not berated for asking questions, instead, you want to encourage questions because the goal in teaching is not the teaching, but for the students to learn. So that is my goal, for the students to learn and to make my teaching student-based. I think part of the reason I win teaching awards is because I try to give effective feedback. If my students are doing something well, I tell them, and if they are not doing something well, I tell them how they can improve based on my observation. Giving effective feedback is crucial, not only for students who are not doing well but also for those who are doing well, which can be challenging at times.
I think the most important lesson I impart and try to role model for my students is communication. Communication is critically important to patient care because it is critically important to patients. Being humble and explaining the situation to the patient, even if you do not know what exactly is going on, is important.
AES: As the Ophthalmology Foundation’s Chair for Education, what areas of ophthalmology education do you believe can be improved?
Dr. Golnik: There are several things that we are working on right now, which revolve around the idea of standardization. Across the different countries across the world, there is no oversight nor standards that are being followed by residency programs. Because of that, the ophthalmology foundation with myself as chair of the accreditation committee has developed a residency training program accreditation guide to communicate what it takes to have a good program or at least a program that meets a minimum international bar. The reason for accreditation is to try to ensure that a training program has the appropriate resources to train residents well and that those resources include faculty access to patients’ surgical experience, the right equipment et cetera. We are currently working on a whole system now for accrediting residency training programs at both a basic and advanced level.
I think the biggest single thing to improve residency education around the world is to try to make sure that training programs are meeting standards so that someone who has graduated from a program in one country is very fairly similar in terms of their training to someone who graduated from another program. It is a big goal, but I think it is a very important goal and that is, I believe, the single most important thing to improve ophthalmology residency training around the world.
When I travel around the world and talk with residents, a lot share that they do not know how they are performing. Another reason why we have done a lot with these assessments I have discussed is that they are meant to be formative, not summative. A summative assessment would be passing or failing a residency, a rotation, or an exam. Most of the assessments that I mentioned, such as the OSCAR and OCEX, are tools meant to guide the resident and give the resident specific frequent feedback on how they are doing.
AES: Having served as a consultant for the World Health Organization (WHO), what are your thoughts on the next steps for human resource development in global eye care?
Dr. Golnik: In ophthalmology, our ophthalmologists are necessary for the finest eyecare. However, the concept of the eyecare team is crucial. You cannot be an efficient ophthalmologist if you are involved in multiple tasks such as taking the patient’s history, checking their vision, and checking their blood pressure. You need to have a team that is assisting you and certainly in my practice, I have several assistants. I have some of our doctors who are very busy and have five assistants who are people who just graduated from high school. They may not have a lot of prior experience but with some train on-the-job training, they are crucial to our ability to see a lot of patients in the day and still provide good care. The WHO also believes that according to their documents, how to make ophthalmologists more efficient is one of the biggest emphases. It is a very slow process to train ophthalmologists or to increase the number of trained ophthalmologists, whereas you can take people right out of high school and in a very short time train them to be valuable assistants to ophthalmologists. Thus, this idea of the eyecare team is essential to improving the human resource development in global eyecare. I am also the secretary of education for a group called the International Joint Commission on Allied Health Personnel and Ophthalmology and that group is highly involved with the training and certification of allied ophthalmic personnel (AOP), which is the term the WHO prefers for the rest of the eyecare team.
AES: How has your experience been as the Associate Editor-in-Chief of AES?
Dr. Golnik: It has been a great experience so far. I have been really happy with the AES and the administrative processes. The team worked on several projects that have gone smoothly compared with other journals where we have done similar projects, so I think the experience has been good.
AES: As the Associate Editor-in-Chief, what are your expectations for AES?
Dr. Golnik: Communication is very important so I expect timely responses to emails, clarity in communication and to continue to receive high-quality manuscripts for review.