(1)
Newcastle Eye Centre Royal Victoria Infirmary, Newcastle upon Tyne, UK
Cataract phacoemulsification training poses a unique challenge of learning a delicate, complex task in which only one person can operate at any given time. The majority of patient’s remain awake during surgery and training usually has to proceed in a setting of service provision [1].
Not only is an understanding of how the process of phacoemulsification surgery will be taught is important for the novice surgeon, it is equally important for the experienced surgeon embarking on a phacoemulsification teaching role to determine how to teach the novice surgeon. Given the plethora of techniques possible for every stage of the cataract procedure, the Trainer may no longer perform surgical steps in a basic fashion. Instead advanced skills, developed over years of practice will be applied to complete their own cases. Though important to ensure acquisition of a broad repertoire of skills by the end of training, the novice surgeon needs to be taught basic, fundamental phacoemulsification skills initially. The novice surgeon may fail to perform advanced intraocular movements if their confidence or skill level has not developed sufficiently, consequently it may not be appropriate to mimic such techniques. Surgical steps should not be ‘challenging’ but rather remain well within the Trainee’s competency and comfort level. The book aims to provide a framework for phacoemulsification training: concepts are introduced over the course of the book and a training program for the Trainer to follow. Important concepts will be repeated in successive chapters to reiterate the concept for the Trainee.
The Trainer and novice surgeon need to be aware of preconceived assumptions that may influence training progress (Tables 1.1 and 1.2. Such assumptions are easily overlooked and both Trainer and Trainee need to agree on a surgical development plan before training commences.
Table 1.1
Novice surgeon assumptions
Trainer will continue coaching in a similar style to previous Trainers |
Not true |
Trainer will not change Trainee’s technique |
Depends on Trainee’s ability and change may be required |
All instructions or rules apply to every scenario |
Basic, fundamental rules apply, but need to be adapted as experience is gained |
Whole phacoemulsification cases should be attempted as quickly as possible to progress |
Not true |
As numbers performed increase, more challenging cases should be attempted |
Surgery should not be challenging at the novice surgeon stage but rather perceived as a comfortable progress; if novice finds cases too challenging then they should not have attempted to do it Ask yourself “Could I immediately operate on another case?” If mentally or physically the answer is no, or if the Trainer found supervising stressful, then stick to straight forward cases until more progress has been made |
Trainer enjoys supervising |
Not necessarily true |
Trainer is able to teach surgical phacoemulsification skills in a fundamental basic fashion and avoids the temptation to teach advanced skills that they themselves would use if performing the procedure |
Remember they have had years to perfect their technique style and their perfect intra and extra ocular bimanual movements |
Table 1.2
Trainer assumptions
Trainee is open and transparent about prior surgical experience and areas of perceived difficulty |
It is better to inform a Trainer about how much surgery has been done so expectations are met and appropriate learning opportunities are given |
Trainee will disclose what aspects of procedure they have previously found tricky or the stages when take over is usually required |
A Trainer will eventually note areas of concern but training time is wasted and it is better to tackle the issues early on |
Trainee will not chase numbers or whole cases |
Trainee understands and uses same terminology for “anatomical direction” when performing intra operative movements as Trainer |
Trainee understands and uses same terminology for surgical instruction as the Trainer |
Trainee will stop operating immediately when asked |
Trainee has spent time reflecting on surgical technique |
The Trainer and novice surgeon should clarify terminology that will be used during training, as misunderstanding instructions can lead to operating being stressful. This can be avoided by developing a common language for instruction. Suggested terminology will be covered in each chapter.
With a novice surgeon, modular step-by-step training can be performed. For Trainees who have surgical experience but are struggling, identification of the root cause of surgical issue is required. The Trainee needs to highlight one or more of the parts of the operation causing anxiety. Often, the surgical step identified by the Trainee is not the step causing the problem. A good Trainer can use the Trainee’s concerns however, to identify the true root cause and focus on a solution.
1.1 Theatre Training Time
Theatre training time can be wasted by not spending a little bit of time thinking about non-patient events. Box 1.1 highlights steps that the Trainee is advised to review and reflect on. The number of learning opportunities can be drastically reduced by events that hinder and reduce available training time. A few minutes wasted per case may mean the difference in gaining additional surgical opportunities during the same theatre list. Time should not be made up by trying to rush surgery.
Box 1.1 Trainee Surgical Steps that Can Maximise Theatre Training Time
Hand washing and donning of gown/gloves.
Tip: make sure you have been shown how to scrub, apply gown, in a sterile manner. Ensure gown and gloves are ready before scrubbing in order to avoid waiting for sterile packs to be opened.
Ensure staff know how your name is spelt for their record keeping – preventing queries whilst operating.
Preparation of microscope/ chair adjustment.
Tip: ensure microscope lens surface is clean and view is good before you start. Residual dried splashes from previous surgery may hinder the view. Reset and centre microscope before operating (or even better, at the end of each procedure in preparation for the next).
Ensure microscope pupillary distance is correct. If Trainer and Trainee’s inter pupillary distance differs, adjust before you start or ensure microscope caps are available.
If recording surgery, ensure recording device is ready before you scrub up.
Ensure correct instruments available in a timely fashion.
Tip: Tell staff what instruments you prefer (if different from current Trainer) so they are available from the start. Ensure microscope lens surface is clean and view is good before you start. Residual dried splashes from previous surgery may hinder the view. Reset and centre microscope before operating (or even better, at the end of each procedure in preparation for the next).
Tip: Ensure that the surgical flow is not interrupted by requesting items that were anticipated at pre-operative assessment (for example; intracameral phenylephrine for patients on Tamsulosin). Good pre-operative handover is essential.
Simulation practice: Discuss with your Trainer what simulation practice for each part of the procedure should be done as well as the level of simulation competency required before live patient surgery.
1.2 Training Progress
Training progress should proceed smoothly. A whole case can be broken down in to modules (each module covered by a chapter in this book). A stepwise approach is recommended throughout training. As small parts of the procedure are learnt (competently) these can be combined until a whole case is performed. It is important that Trainees don’t try to progress too quickly to perform whole cases. If a module cannot be performed competently, then errors will be compounded as the case progresses, leading to difficulty and potential adverse events. Though tempting to shift attention from one surgical module to another, the agreed step should be focused on. Variation reduces consistency in the training regime and it will be noticeable that the novice surgeon is unable to maintain surgical technique from week to week, with cases often requiring the Trainer’s intervention. As a consequence, both novice and Trainer could get frustrated with progress. The ideal training progress pattern deviates for a Trainee in difficulty (Fig 1.1).
Fig. 1.1
Training progress. (a) Ideal surgical progress for a novice surgeon (solid line), whole cases with instruction (open arrow) progressing to cases with minimal instruction (solid arrow). (b) Training curve for a trainee in difficulty. Ideal training progress (solid line), Poor training progress (dotted line). Start of modular steps (black star), start of whole cases under instruction (open arrow). Surgical progress slows and Trainee struggles to complete whole cases without regular intervention (solid arrow). Assessment point at which Trainee in difficulty is recognised and surgical competency expectation is not met (arrow head)
Trainees can often be self-aware if they are not progressing and it is often worth asking such a question to judge whether insight is appreciated. It is important to recognise a surgeon struggling to make progress as soon as possible. Delay results in wasted training time and compounds the difficulties. In some instances the supervising Trainer may not be able to identify the problematic root cause but appreciates the Trainee is struggling. In such instances, a fresh perspective from a new supervisor may be required.
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