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Structured approach needed for teaching ophthalmic surgery
Preoperative preparation and formative and summative feedback are critical to the teaching and learning process.
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Surgical competence is a fundamental component of ophthalmology resident and fellow education. Under the traditional apprenticeship model of Halstedian surgical training, the assessment of competence is subjectively based on cumulative experience. Trainees are therefore expected to perform at least a minimum number of certain fundamental procedures with corresponding faculty supervision and feedback. There is certainly no substitute for the value of experience in establishing competence, but our current apprenticeship model inherently lacks uniformity and objectivity. Furthermore, medicine in general is moving toward a more objective means of “quality control,” with a corresponding emphasis on improved safety and efficacy via measurable patient care outcomes.
Toward this end, the Accreditation Council of Graduate Medical Education (ACGME) and the American Board of Ophthalmology (ABO) are collaborating on a competency-based model with the Ophthalmology Milestone Project, which sets graduated benchmarks for the achievement of patient care and surgical skills, as well as the other core competencies, as residents transition through their training. While the implementation of these benchmarks and the long-term goal of utilizing outcomes measures as part of accrediting programs remain a work in progress, ophthalmology residency programs as a whole would benefit from an increased emphasis on more structure in their surgical training. Moreover, many of the tools to implement this necessary structure are readily available but underutilized.
The bulk of surgical training occurs in the operating room in real time and on real patients. This time is at a premium, and the margin for error likewise slim. Paramount to maximizing effective teaching and learning in this setting are preoperative preparation and formative and summative feedback.
Alex Mammen
Wet lab
A wet laboratory (wet lab) is an invaluable resource for preoperative preparation. While it is one of the ACGME requirements for ophthalmology residency programs, quality across the board is again variable. Improving this experience can require the collaboration of the institution, department, faculty, residents, alumni and third-party groups, including industry. Henderson and colleagues have published an excellent primer on establishing a wet lab. As highlighted in the paper and critical in our own experience at the University of Pittsburgh Medical Center (UPMC) are a dedicated wet lab coordinator, a team of core faculty, resident and fellow assistants, and a formal curriculum with frequent teaching sessions.
A formal wet lab curriculum should have prerequisite knowledge assignments and well-defined objectives. In ophthalmology, we are fortunate to have an abundance of teaching resources. However, that abundance can also be confusing for residents seeking guidance. A wet lab should have a dedicated library of text and multimedia resources from which assignments can be drawn for prerequisite reading and viewing. Examples include Marian Macsai’s Ophthalmic Microsurgical Suturing Techniques, Barry Seibel’s Phacodynamics, and Tom Oetting’s online Cataract Surgery for Greenhorns, among many others. This maximizes hands-on instruction time. Well-defined objectives for each session allow for a more objective tracking of wet lab progress.
Our monthly sessions at UPMC focus on teaching core surgical skills from comprehensive ophthalmology as well as nearly each surgical subspecialty. Examples of specific sessions include creation and closure of different corneal and scleral incisions and lacerations, penetrating keratoplasties, lid lacerations and phacoemulsification using different platforms. Initial instruction should ideally be one-on-one, with proficiency achieved through continued practice. Senior residents and fellows are instrumental in helping meet this personalized instruction goal.
Assessments and simulators
Pretests and post-tests, as advocated by Lee and colleagues, are an excellent way to assess efficacy of the cognitive portions of wet lab instruction, while an evaluation tool such as a wet lab skills obstacle course (Eye Surgical Skills Assessment Test), as proposed by Fisher and colleagues, can be utilized for the technical components.
Adjunctive instructive modalities include commercially available resources such as the Kitaro wet and dry lab kits (FCI Ophthalmics/Frontier Vision) as well as surgical simulators such as PhacoVision (Melerit Medical), MicrovisTouch (Immersive Touch) and the more prevalent Eyesi (VRmagic). All of these resources may shorten the learning curve in both the wet lab and operating room. We are currently working on incorporating our recently obtained Eyesi into the wet lab curriculum, but widespread use of simulators is currently inhibited by cost and commensurate proven validity.
The goal of a structured wet lab experience is to engender more confidence in both the trainee as well as the staffing faculty member, thereby yielding better results. Feedback should be formative, or associated with an individual case, as well as summative, at the end of a rotation, for example. Recording surgical cases can greatly assist in these feedback sessions. Trainees can then apply this feedback in future wet lab or operating room sessions. Outcome measures for surgical performance can be both qualitative and quantitative, as outlined, for example, by Cremers and colleagues in the Global Rating Assessment of Skills in Intraocular Surgery (GRASIS) and the Objective Assessment of Skills in Intraocular Surgery (OASIS).
Quality control is important in every industry and especially critical in health care. A structured approach to the way ophthalmic surgery is taught yields more uniformly qualified future ophthalmologists and thereby better results for our patients.
Visit UPMCPhysicianResources.com/Ocular to learn more about teaching ophthalmic surgery. You can also submit clinical questions or read the most recent questions asked of the UPMC Eye Center’s ophthalmology experts.