EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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September 2013 adaptive.10 Simulation training is unlikely to ever fully replace handson surgical experience. Continued efforts are necessary to develop and refine multifaceted structured training programs that include VR simulation as a cornerstone of objective resident evaluation.1,11,12 References 1. Rogers GM, Oetting TA, Lee AG, et al. Impact of a structured surgical curriculum on ophthalmic resident cataract surgery complication rates. J Cataract Refract Surg 2009;35:1956-60. 2. Henderson BA, Kim JY, Golnik KC, et al. Evaluation of the virtual mentor cataract training program. Ophthalmology 2010;117:253-8. 3. Ament CS, Henderson BA. Optimizing resident education in cataract surgery. Curr Opin Ophthalmol 2011;22:64-7. 4. Ikonen TS, Antikainen T, Silvennoinen M, Isojarvi J, Makinen E, Scheinin TM. Virtual reality simulator training of laparoscopic cholecystectomies – a systematic review. Scand J Surg 2012;101:5-12. 5. Dooley IJ, O'Brien PD. Subjective difficulty of each stage of phacoemulsification cataract surgery performed by basic surgical trainees. J Cataract Refract Surg 2006;32:604-8. 6. Daly MKG, E., Siracuse-Lee, D., Legutko, P. A. Effect on Operating Room Performance of Surgical Simulator Versus Wet-Lab Training. J Cataract Refract Surg 2013;39. 7. Privett B, Greenlee E, Rogers G, Oetting TA. Construct validity of a surgical simulator as a valid model for capsulorhexis training. J Cataract Refract Surg 2010;36:1835-8. 8. Pokroy R, Du E, Alzaga A, et al. Impact of simulator training on resident cataract surgery. Graefes Arch Clin Exp Ophthalmol 2013;251:777-81. 9. Belyea DA, Brown SE, Rajjoub LZ. Influence of surgery simulator training on ophthalmology resident phacoemulsification performance. J Cataract Refract Surg 2011;37:1756-61. 10. Saleh GM, Lamparter J, Sullivan PM, et al. The international forum of ophthalmic simulation: developing a virtual reality training curriculum for ophthalmology. Br J Ophthalmol 2013;97:789-92. 11. Henderson BA, Grimes KJ, Fintelmann RE, Oetting TA. Stepwise approach to establishing an ophthalmology wet laboratory. J Cataract Refract Surg 2009;35:1121-8. 12. Oetting TA. Surgical competency in residents. Curr Opin Ophthalmol 2009;20:5660. Editors' note: The views expressed in this article are those of the author and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the U.S. Government. Michael Rosenberg, MD Clinical professor of ophthalmology, Northwestern University Feinberg School of Medicine,Chicago While the American Board of Ophthalmology recognizes surgical competency as adjunctive to the core competencies required by the ACGME for ophthalmology residency programs, surgical training is included in the Patient Care competency of the ACGME (2012). The specific standards or metrics for competency are left to the individual programs. The individual requirements of a competent cataract surgeon are multiple: technical skill, cognitive skill, judgement, and emotional demeanor. Technical skill may be affected by visual issues (stereopsis) and physical issues (tremor). The conundrum of surgical training is how well and by what mechanisms can we train a surgeon to maximize his or her individual potential for each of the required skill sets. Within the past several years technology has been developed to aid training of technical skills (Eyesi Surgical Simulator, VRmagic, Mannheim, Germany) and cognitive skills (Cataract Master, MEEI). Previous experience of surgical simulation in ophthalmology and other specialties has shown acceptance and enthusiasm by residents, and the same was noted in the current study. This study comparing training methods (simulation or wet lab) for a very circumscribed surgical maneuver, continuous curvilinear capsulorhexis (CCC), showed no significant difference in the two groups except for a lesser time required to complete the CCC by the wet lab group. There are many subtleties that make interpretation of these results limited. Would it have been better to group the participating residents by some homogeneity in lifestyle habits before randomization so that an equal number of residents in each group had similar video game habits, sleep habits, etc.? The limited number of participants would have made this difficult, and the small sample size of design used still creates statistical unreliability. While the grading was done by the same two surgeons, the actual surgery was performed with the assistance of different attendings. Intraoperative variables such as attending assistance and attending instructions during surgery may vary considerably from one surgeon to another based on his/her own comfort level during resident surgery. Was there homogeneity in the type of cataract, the ability to visualize the anterior capsule, the location and quality of the initial incision, the comfort of the surgeon with regard to positioning and ease of focusing with the microscope pedal? The study certainly shows that preoperative introduction to surgical technique with any manual practice mechanism results in greater resident comfort and surgical success than preoperative visual training. Reference 1. Accreditation Council for Graduate Medical Education. ACGME Program Requirements for Graduate Medical Education In Ophthalmology, July 1, 2013. Stephen Sauer, MD Associate professor Department of Ophthalmology and VisualKSciences, University of Wisconsin, Madison, Wis. The study by Daly et al. addresses the greatest challenge facing surgical educators, namely, to ensure patient safety while simultaneously providing excellent teaching. The risk of complications to patients undergoing cataract surgery by residents-intraining is real,1 but avoidable. Applying Dreyfus' adult learning theory and Erikson's principles of deliberate practice to a graduated low risk to high risk exposure to the actual cataract surgery procedure can effectively meet that challenge. This study indicates that simulators can play a valuable role in the learning stages prior to entering the operating room. An interesting finding from this study was that the group of residents who trained in the wet lab took less time to complete their first CCC in the operating room than the group EW RESIDENTS 103 of residents who trained on the simulator. The authors reasonably suggest that increased familiarity with the microscope and instrumentation used in the wet lab are likely contributing factors. Because this study examined a relatively small self-selected group of participants, it would be interesting to examine the performance of a larger and broader group of residents. Further, it would be interesting to capture and analyze additional CCC performance data for each individual after his/her initial attempt. These data might shed light on whether a particular sequence or pattern of simulator integration into the traditional wet lab portion of cataract training would improve residents' readiness for the operating room and reduce the time needed to complete the CCC on actual patients. The specialty of ophthalmology will soon enter the Next Accreditation System, and the Accreditation Council for Graduate Medical Education will begin collecting a national data set on various milestones of resident performance, including surgery. In addition, impending changes in the structure of healthcare delivery and payments will likely impose financial pressures on all clinicians, but particularly those who spend valuable operating room time to teach residents. It will become increasingly important for programs to develop pedagogically sound and financially efficient processes to train residents. While there will never be a substitute for real-time operating room experience, exploring training methods and tools that will develop resident skills outside of the operating room will ultimately produce bettertrained residents and higher margins of patient safety. The authors have provided data that can begin to inform this process. EW Reference 1. Tarbet KJ, Mamalis N, Theurer J, et al. Complications and results of phacoemulsification performed by residents. J Cataract Refract Surg. 1995;21(6):661-5. Contact information Bishop: frank.bishop@med.navy.mil Rosenberg: neuro-oph1@northwestern.edu Sauer: sksauer@wisc.edu