Eyeworld

EW NEWS & OPINION 36 April 2017 Research highlight by Michelle Stephenson EyeWorld Contributing Writer ing innovations may be needed both in surgical training and early career monitoring and mentoring processes to ensure we provide the highest quality of care," he added. Dr. Campbell said that although cataract surgery was used as a model for this study, many other surgical specialties place similarly intense de- mands on trainees. "The outcomes we observed may be reflective of issues facing many technically chal- lenging surgical fields," he said. He noted that Queen's Univer- sity has taken strong steps toward improving residency training by becoming the first institution in Canada to fully transition all of its postgraduate residency programs to a competency-based medical edu- cation framework. "This approach incorporates greater use of surgi- cal simulation and clearly defined learning outcomes to help ensure that trainees have mastered all of the skills that are expected of them," he explained. "The new educational paradigm also includes the development of a more comprehensive and objective assessment system and specific at- tention to the transition to inde- pendent practice. It's our view that these initiatives will improve the educational outcomes of residents at Queen's and beyond as this new approach spreads," he added. EW Reference 1. Campbell RJ, et al. New surgeon outcomes and the effectiveness of surgical training: A population-based cohort study. Ophthalmolo- gy. 2017 Jan 24 [epub ahead of print]. Editors' note: Dr. Campbell has no financial interests related to his com- ments in this article. Contact information Campbell: rob.campbell@queensu.ca de-identified billing numbers. All ophthalmologists who entered prac- tice during the study period were included in the study. Surgeons who performed fewer than 25 cataract procedures per year were excluded from the study because outcomes for very low-volume surgeons may not be generalizable. A surgeon's surgical volume has been found to influence surgical outcome and was included as a co- variate. It was defined as the number of cataract procedures performed by the surgeon in a calendar year. A total of 9,932 (0.7%) cata- ract patients experienced one of the adverse events that was being evaluated: 6,588 (0.5%) patients experienced a posterior capsule rupture, 1,648 (0.1%) had a dropped lens fragment, 294 (0.02%) experi- enced retinal detachment, and 1,402 (0.1%) were identified as having suspected endophthalmitis. One hundred forty-four sur- geons began practice during the study period. High complication rates were more common at earlier career stages and steadily became less common with increasing years of practice. In fact, surgeons in their first year of practice were more than nine times more likely to have high complication rates than surgeons in their tenth year. Surgeons' adverse event rates were also more variable earlier in surgeons' careers, with many new surgeons achieving very low complication rates and others experiencing much higher rates. The risk of a patient experiencing an adverse event decreased by approx- imately 10% per year of surgeon independent practice. Improving training "The need to train new surgeons is an absolutely essential part of a sustainable healthcare system. How- ever, our study suggests that ongo- gery also has a learning curve, which makes it a good model for other technical procedures facing similar issues. Additionally, cataract surgery outcomes are not affected by the quality of postoperative inpatient hospital care, and measurable, non- mortality adverse cataract surgical event indicators have been previous- ly established. "Cataract surgery is a highly technically challenging procedure to learn, and even tiny missteps can mean the difference between success and serious complications. As a result, despite years and years of dedicated training, not all graduates appear equally ready for the chal- lenges of independent practice. In our study, while most new surgeons had excellent outcomes, some had much higher complication rates than surgeons at later career stages," Dr. Campbell explained. Study methods and results He and his colleagues analyzed all isolated cataract procedures in patients 66 years of age or older be- tween January 1, 1997, and Decem- ber 31, 2013, in Ontario, Canada. More than 80% of cataract proce- dures are performed on patients in this age demographic. Several healthcare databases were linked to examine four serious complications: posterior capsule rupture, dropped lens fragments, retinal detachment, and suspected endophthalmitis. During this time period, 1,431,302 cataract operations were performed that met the study in- clusion criteria. Of these, 303,236 (21.2%) were performed in academic surgical centers. The median patient age was 77 years, and 26.1% of these patients had diabetes. A median of nine prescription medications were used during the year before surgery. Surgeons were identified by their specialty code and unique A recent study found that surgeons in their first year of practice were more than nine times more likely to have high complication rates than surgeons in their tenth year. A recent Canadian popu- lation-based study has found that surgical com- plications are significantly more likely early in sur- geons' careers. This study suggests that interventions may be needed during surgical training as well as early independent career monitoring and mentoring processes. This study was conducted because recent reports have raised questions about the technical proficiency of newly graduating surgeons, and surveys of clinical department leaders, surgical training program directors, and trainees have indicated a widespread perception that graduating surgeons may lack adequate training. Gaps in educa- tion may be due to training program financial constraints, pressure to im- prove hospital efficiency, shortened training periods, and limitations on trainee work hours. Robert J. Campbell, MD, MSc, Department of Ophthalmology, Queen's University, Kingston, Can- ada, and his colleagues conducted this population-based retrospective study to investigate the association between a surgeon's number of years of independent practice and the risk of adverse events during or after cataract surgery. Cataract surgery is the most frequently performed surgical pro- cedure in most developed countries, with more than 3 million operations performed each year. Cataract sur- Surgical complications significantly more likely early in surgeons' careers this is a viable option that should be encouraged for colleagues in the de- veloping world. "It lasts for months in the refrigerator," he said. "You could have a bottle in every little clinic around the world—it costs them just $1 to make a bottle in the pharmacy." Hopefully, this would make strides into saving sight, he concluded. EW References 1. Isenberg SJ, et al. Prospective, Randomized Clinical Trial of Povidone-Iodine 1.25% Solu- tion versus Topical Antibiotics for Treatment of Bacterial Keratitis. Am J Ophthalmol. 2016; 16:30516–5. 2. Isenberg SJ, et al. Chemical preparation of the eye in ophthalmic surgery. IV. The antibac- terial effect on the conjunctiva of povidone-io- dine compared with a prophylactic antibiotic. Arch. Ophthalmol. 1985;103:1340–1342. 3. Isenberg SJ, et al. A controlled trial of povi- done-iodine as prophylaxis against ophthalmia neonatorum. New England J. Med. 1995; 332:562–6. 4. Isenberg SJ, et al. A controlled trial of povidone-iodine to treat infectious conjunc- tivitis in children. Am J Ophthalmol. 2002; 134:681–688. Editors' note: Dr. Isenberg has no finan- cial interests related to his comments. Contact information Isenberg: isenberg@ucla.edu Quelling continued from page 34

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