Cataract skills: how do we judge competency?

Abstract

The practice of medicine is undergoing continual change. For trainees, the transition from a Halstedian apprenticeship to competence-based models of surgical training and assessment has been accelerated by European Working Time Directives, public/regulatory expectations and funding pressures.For qualified practitioners, revalidation will demand evidence of practice to a good standard. To successfully revalidate, ophthalmologists are expected to demonstrate competence if they undertake ( phacoemulsification) cataract surgery, the commonest operation in the UK 1 .We pose two key questions: what are reasonable minima for (1) the number of operations before trainees can operate independently in a safe and timely manner (acquisition of competency) and (2) for consultants to maintain competency?Like our colleagues in other specialties, the Ophthalmic Specialty Training syllabus parallels the UK Intercollegiate Surgical Curriculum Programme, with objective checklists and global rating scales that qualitatively assess operative skills. One example is the Objective Structured Assessment of Technical skills, originally developed by general surgeons and now validated across various surgical disciplines including ophthalmology.Our focus on operative numbers is due to the delicate 4 μm window of error that phacoemulsification surgeons must contend with. Furthermore, in other specialties (e.g. ENT, plastics, maxillofacial surgery) microsurgery is deemed a higher surgical, non-core skill, whereas ophthalmic trainees are assessed from the very first year. To achieve Certificate of Completion of Training, plastic surgery trainees must perform at least 22 microvascular anastomoses. In comparison, the seven-year UK ophthalmology training programme specifies at least 350 full cataract operations. Three-year US residencies require 86 and in Australia '50 intraocular procedures' are expected after two years of a five-year traineeship. Actual (median) cumulative totals are 500-600 for the UK 2 versus 100 for the USA. 3 With moves towards competence-based curricula, the intensity of hands-on surgical training may have a bearing on how rapidly trainees acquire operating skills, which is more relevant in US residencies where trainees usually gain surgical experience in their senior years. Trainees improve significantly to approach the benchmark of a published ophthalmologist's (longest) average operating time of 26.8 min after the 120th case. 4 Posterior capsular rupture (PCR) is the commonest complication of phacoemulsification. Widely used as a surgical quality benchmark; it is a likely key quality indicator for revalidation. 1 PCR rates range from >5% for junior trainees 5 to <1.5% for independent surgeons, with less variation in complications between seniors. 1 UK trainees' logbook reviews demonstrate significant decreases in complication rates with increasing experience. 6 One review of 680 trainee operations over four years saw vitreous loss rate halved from 5.1% to 1.9% after the first 80 cases, correlating with significant falls ...

Cataract skills: how do we judge competency?

“…The approach suggested by Ho and Claoue 1 of using the rate of posterior capsule rupture (PCR) during cataract surgery as a surrogate marker for competency in cataract surgery for surgeons who are not in training programmes is a reasonable one. The occurrence of PCR considerably increases the likelihood of further complications and a poorer than expected visual outcome.…”

Cost-Effective Ophthalmic Surgical Wetlab Using the Porcine Orbit with a Simple Dissection Protocol

“…Ophthalmic surgery is a very delicate procedure [1] with safety margin for error as small as 4 microns for phacoemulsification [2]. Manual dexterity, tissue handling and surgical precision are key to achieving desired outcomes [3].…”

A practical guide to monitoring for adverse drug reactions during antihypertensive drug therapy

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