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Ophthalmology residents need specific, dedicated programs focused on surgical training
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During the last decade, ophthalmology has gained credit as a highly sophisticated surgical specialty. In the past, eye surgeons were among the first to use the operating microscope, and since then, the number of procedures, techniques and technologies have exploded and become more and more refined. Similarly, invasiveness has greatly decreased with the development of microincisions and local or even topical anesthesia. We are also asked to produce high volumes while reducing operating times. This is typically the case of cataract surgery, which evolved from intra/extracapsular extraction under general anesthesia with an inpatient regimen to phaco/femto under intracameral anesthesia/mydriasis with IOL implantation through a tiny incision of less than 2 mm in an ambulatory setting. More recently, the universe of vitreoretinal surgery has been revolutionized by the introduction of transconjunctival sutureless vitrectomy. Personally, my standard approach to complex retinal detachment is 27-gauge pars plana vitrectomy under panoramic viewing.
Suddenly, operations that lasted hours with complex maneuvers can now be completed by a single surgeon and the OR nurse in less than 1 hour. Patients have also dramatically changed. They know that most conditions can be fixed with a high success rate and a perfect and timely recovery. Therefore, their expectations have increased and they are highly demanding.
This complex scenario has many implications, and some of them apply to the issue of surgical training and exposure of residents to surgery during their learning program. There are major differences among different countries and sometimes the different institutions.
A recent survey showed that in Canada the mean number of full cases performed by ophthalmology residents postgraduate year (PGY) 5 is 324 cataracts, nine trabeculectomies and 48 horizontal muscles. Most PGY2 to PGY5 students perform more than 10 laser procedures of each type surveyed. Subspecialty surgical volumes varies and is lowest for scleral buckle, refractive laser, penetrating keratoplasty and floor fracture. The majority of residents receive up to 10 hours per week of teaching and 4 to 6 weeks of Royal College study time.
As said, there may be differences in different areas, as evidenced by research conducted in Hong Kong and China. In a study, ophthalmology residents in China reported strikingly less surgical experience and supervision and lower satisfaction than Hong Kong Special Administrative Region (HKSAR) residents. The number of cataract procedures performed by HKSAR trainees (extracapsular, median 80; phacoemulsification, median 20) exceeded that for Chinese residents (extracapsular, median 0; phacoemulsification, median 0). In India, most residents perform their first ophthalmic surgery during the first year of residency and attend the operation theater multiple times a week.
In France and many European countries, implementation of surgical skills assessment during residency seems necessary. A surveyed population appears dissatisfied with the current arrangements. A step-by-step evaluation combining surgical simulations, wet lab and live patient procedures has been suggested.
Due to the lack of such programs, many ophthalmology residents travel to developing countries where they have the opportunity to receive surgical training, mostly in cataract surgery by the local ophthalmologists, while paying a fee for each surgery performed. I have volunteered for many years in different countries and would never consider this service as a mere opportunity for training my residents on “fragile” and possibly less demanding patients. Patients and ethics should always come first.
However, establishing a formal educational program on surgical teaching during residency has become not only needed but mandatory if we want to adequately form the ophthalmic surgeons of tomorrow.
Obviously, a model of hands-on resident training is extremely useful in increasing the surgical rate. However, the above cited issues should be kept in consideration. Alternative training programs with gradual acquisition of surgical skills should be planned. Today, technology advancements also involve equipment for training in medicine. New simulators, such as the Eyesi (VRmagic), allow residents to practice on a dummy linked to a software that projects a 3-D image of different conditions, such as cataracts or retinal diseases, on which physicians can operate. Most of us are more familiar with wet labs, usually equipped with multiple work spaces, microscopes, cameras, head models and fresh animal eyes. I personally started phacoemulsification through a memorable wet lab course led by Dr. Buratto and Dr. Zirm, who gave me the ABCs of modern cataract surgery. Most recently, dry lab and wet lab tools such as the Kitaro kit (FCI Ophthalmics) have been introduced. Residents can practice techniques repeatedly without the added complication of long preparation times and costly live tissue samples. These tools simulate the stages of cataract surgery using both a wet and dry lab environment to allow new surgeons the ability to train repeatedly on basic surgical techniques.
A step-by-step evaluation combining surgical simulations, wet and dry lab training, and live patient procedures has been suggested to develop surgical skills during residency. The time to pass the simulator and wet lab curriculum is usually predictive of the time and overall performance in the operating room. Of note is that patients may accept surgery performed by well-trained residents, as shown by surveys.
Recently, the Medical School of the University of Udine opened a simulation center aimed at educating and training medical students, residents, physicians and health personnel. Our clinic has established a step-by-step surgical training program that includes attending and observing live patient procedures, reviewing video clips, practicing with dry and wet labs, and finally performing surgical procedures on patients with the assistance of an expert surgeon. We are now looking forward to having the simulator, which will increase the surgical skills of the residents before acting on a live patient.
Also, university and teaching hospitals should be treated differently by payers in terms of minimum surgical volumes requested and reimbursement per procedure because more time and resources are spent for the training of residents.
In conclusion, modern ophthalmology has become a surgical specialty, and residents should be educated with specific and dedicated programs before hands-on performance. Remember, patients first!
- References:
- Ajay K, et al. Indian J Ophthalmol. 2015;doi:10.4103/0301-4738.158067.
- Daly MK, et al. J Cataract Refract Surg. 2013;doi:10.1016/j.jcrs.2013.05.044.
- Koukkoulli A, et al. J Surg Educ. 2015;doi:10.1016/j.jsurg.2014.12.015.
- Le K, et al. Can J Ophthalmol. 2016;doi:10.1016/j.jcjo.2016.04.017.
- Nehls SM, et al. J Cataract Refract Surg. 2014;doi:10.1016/j.jcrs.2013.11.042.
- Pittner A, et al. J Cataract Refract Surg. 2016;doi:10.1016/j.jcrs.2016.03.031.
- Sikder S, et al. Clin Ophthalmol. 2015;doi:10.2147/OPTH.S69970.
- Tranchart H, et al. J Fr Ophtalmol. 2015;doi:10.1016/j.jfo.2015.03.008.
- Young AL, et al. BMC Med Educ. 2015;doi:10.1186/s12909-015-0440-0.
- For more information:
- Paolo Lanzetta, MD, OSN Europe Edition Chairperson of the Editorial Board, can be reached at Istituto Europeo di Microchirurgia Oculare, Via M.A. Fiducio, 8; 33100 Udine, Italy; email: paolo.lanzetta@iemo.eu.
Disclosure: Lanzetta reports no relevant financial disclosures.