CATARACT SURGERY

Following a few simple rules and helping to build confidence in the trainee cataract surgeon goes a long way in helping young ophthalmologists become competent in basic phacoemulsification techniques, according to Paul Ursell MBBS, MD, FRCOphth. “In terms of teaching and learning a skill such as cataract surgery, you want to achieve two things: you want to avoid errors and when you do it right, you want to be able to repeat that over and over again so that the success rate improves. Repetition helps to build confidence in the trainee surgeon and prepares them for moving on to the next stage of their training and tackling more complicated steps in cataract surgery,†he said. Dr Ursell, a consultant ophthalmic surgeon at Epsom and St Helier University Hospitals Trust in the UK, said that it was important to remember that surgical skills are not an innate gift but are rather the fruit of countless hours of practice and repetition.

“This is something that we have seen in the United Kingdom with the scandal involving the high mortality rate of babies who underwent heart surgery at the Bristol Royal Infirmary and is now coming out in cataract surgery as well. Basically, the recommendation is now made that children’s heart surgery be carried out only in highly specialist centres which perform lots of cases, because the more cases you do, the better the surgery will be. This holds true for cataract surgery as well. We see that surgeons who are doing a lot of cataracts every year will have a lower posterior capsule rupture rate than a surgeon who is only doing a few,†he said.

Mastering the skill
Dr Ursell stressed that repetition is essential in mastering any physical skill, whether it is football, golf or cataract surgery. “Repetition brings confidence because you learn to repeat the same manoeuvre over and over again. David Beckham had probably kicked more footballs by the time he was 15 than most of us have kicked by the time we are 90 years old, which goes some way to explaining why he is such a good footballer. The common denominator about the world’s best sportspeople is that usually they are mentally very strong and they just do nothing else but practise their particular sport. And in some respects that is what you need to be as a cataract surgeon – it is repetition and doing it at a high level repeatedly,†he said. Dr Ursell said that every trainee surgeon will traverse four key stages in the learning process.

“This is true whether you are learning how to hit a golf ball or perform a correct capsulorhexis. You start off being incompetent, you can’t do it, and you end up being competent and you can do it. At the start you have unconscious incompetence – you think you can do it and you do not realise how bad you are. Then you start doing it and you go from unconscious incompetence to conscious incompetence as you realise how bad you are at doing something. That is a good thing, because self-awareness is a big part of this evolution,†he said. As the surgeon starts practising the manoeuvre he may become good at the task but still has to think about it, said Dr Ursell.

“This is the conscious competence phase. After the task has been performed a few hundred times, the surgeon progresses to the unconscious competence stage where they don’t even need to think about it,†he added.

Build trust and confidence
Nurturing confidence in the trainee surgeon by creating a positive environment in which to learn is a vital component of successful training, emphasises Dr Ursell. “In the old days, medical school training could be very intimidating, with the resident pretty much inconspicuous and scared. Intimidation is not really a very good way of learning and it is certainly a very poor way of learning a stressful, physical skill like cataract surgery. So we have got to try to get away from that. We need to build trust and confidence without making the trainee over confident,†he said. By using modular training, building slowly, and applying Pendleton’s rules for positive feedback and encouragement for the learner, the teacher is helping to create the right environment for the resident to make progress, concluded Dr Ursell.

“We need to take the concepts of repetition, training, complexity of the patient and self-confidence and put all these things together in order to correctly teach cataract surgery. Trainees need to practise the basic skills, and only perform surgery on cases that are within their skill set – so no patients with small pupils, pseudoexfoliation syndrome or weak zonules. We need to titrate the ability of the surgeon against the complexity of the case. Although we tend to focus on the surgeon and the trainee, we must never forget that it is really all about the patients and protecting them. Never forget that the most important person in the operating room is the patient,†he concluded.

• A related EuroTimes podcast interview with Dr Ursell is available at: http://www.eurotimes.org/podcast.asp