Bence Tasnadi
Medical students and foundation doctors are concentrating more on portfolio creation as a result of the increased competition for admission to UK ophthalmology programs in recent years. Senior colleagues often urge prospective applicants to get the so-called “low-hanging fruit” – achievable portfolio points that require comparatively little time input. Simulation training is one such possibility under the ST1 evidence framework for ophthalmology. Simulation seems to provide a significant return on investment, awarding one point for every four hours of pertinent activity. Beneath this seeming accessibility, though, comes a more complicated and unfair reality.
A key component of contemporary ophthalmology education is simulation training. Technological developments have made it possible to practise microsurgical techniques, slit-lamp inspection, and emergency situations in a secure setting. Research indicates that simulation enhances patient safety, boosts technical performance, and quickens trainees’ learning curves (1). Ophthalmology training programs have increasingly incorporated simulation into formal curricula in recognition of these advantages. However, there are still disparities in access to these services, especially before training.
Ophthalmic simulation facilities are concentrated in specific areas of the UK and are frequently connected to large teaching hospitals, academic institutions, or deaneries with ample funding. Through local courses, undergraduate instruction, or foundation placements, students and foundation physicians located in these regions may regularly encounter simulation. Others may have few or no comparable chances, especially those training in rural areas or tiny district general hospitals. Because of this, candidates might have to travel long distances, frequently at their own expense, in order to attend simulation sessions that add to their portfolio.
Important concerns regarding accessibility and justice are brought up by this discrepancy. Those with less money or more personal obligations are disproportionately affected by travel fees, lodging costs, and time away from clinical responsibilities. Even if they are driven and academically competent, medical students from broader participation backgrounds and foundation doctors without study budgets may find it more difficult to pursue remote possibilities. In this situation, simulation points – which are supposedly among the most accessible portfolio accomplishments – may instead exacerbate already-existing geographic and socioeconomic disparities (2).
Variability in awareness and informal access exacerbates the problem. Some people gain from being introduced to ophthalmology at a young age through regional teaching leads, medical school societies, or mentors who can help them get into simulation sessions. Without these networks, others could have trouble finding or securing spots in pertinent courses. Therefore, access is influenced not only by geography but also by institutional familiarity and social capital – factors that portfolio scoring systems seldom take into account.
The use of simulation points should be questioned because the ophthalmology ST1 portfolio is intended to evaluate dedication and training readiness. Engagement with simulation clearly shows skill growth and motivation, but it may also reflect opportunity rather than merit. While equally dedicated peers elsewhere encounter structural obstacles, applicants located in simulation-rich locations may accrue points quite easily. This begs the question of whether different access to resources is sufficiently taken into account by the scoring systems in use today.
There are a number of viable solutions that should be taken into account. Standardising access could be aided by the growth of regional simulation hubs, which are backed by national organisations like the Royal College of Ophthalmologists. Disparities may also be lessened by increased use of virtual platforms, transportable simulation units, and subsidised training for foundation physicians and students (3). As an alternative, portfolio score could be modified to account for contextual considerations, preventing applicants from being punished for uncontrollable restrictions.
In conclusion, even though the UK training pathway appropriately values ophthalmic simulation training, its accessibility is far from consistent. Not every potential applicant can equally pursue these “low hanging” portfolio items due to social, economic, and geographic differences. Examining whether existing methods unintentionally favour opportunity over potential is crucial given the increasing competition for ophthalmic training. Maintaining fairness and diversity in the future ophthalmic workforce will require ensuring equitable access to simulation or modifying assessment frameworks appropriately.
References
- Lee R, Raison N, Lau WY, Aydin A, Dasgupta P, Ahmed K, Haldar S. A systematic review of simulation-based training tools for technical and non-technical skills in ophthalmology. Eye (Lond). 2020 Oct;34(10):1737-1759.
- Cheetham NJ, Cantle F, Guise A, Steves CJ. Socioeconomic diversity of doctors in the United Kingdom: a cross-sectional study of 10 years of Labour Force Survey social mobility data. BMJ Open. 2025 Sep 9;15(9):e097178.
- Hunt SV, Dean WH, Kerins V, Brown A, Buchan JC. Response to: Cost and time resourcing for ophthalmic simulation in the UK: a Royal College of Ophthalmologists’ National Survey of regional Simulation Leads in 2021. Eye (Lond). 2022 Oct;36(10):2069.