Professor Andrew Chang teaching at the Sydney Eye Hospital's Eye Schools.
Future plumbers, builders, and carpenters learn their trade through apprenticeships, combining hands-on experience with guided instruction. While at first glance, these trades seem far removed from ophthalmology, the training of ophthalmic surgeons has traditionally followed this very same model, with their practical experience in the operating room forming the foundation and development of their skills and education.
However, with the rapid advancement of technology to perform surgery efficiently in teaching public hospitals, there has been a growing need for a more structured, standardised training model in surgical training. In NSW, where up to 50% of Australia’s ophthalmologists are trained, a change in surgical education has emerged.
In the past, surgical training for ophthalmology registrars took place primarily in the operating room of a hospital, under the supervision of an experienced surgeon. In the case of a cataract operation, where there may have been 10 steps involved, registrars would begin by performing the last few, if not final, steps. As they grew in competence and confidence, they would progressively take on more steps of the procedure, therefore having more responsibility.
Learning on the job was also supplemented with more didactic ‘Eye School’ lectures at Sydney Eye Hospital, after business hours, once a week.
Rethinking Registrar Training
This apprenticeship model may have been effective up to a certain point, but it failed to consider the rapid pace of technological advancement, with its expanding range of products and procedures. And it didn’t address the challenges of finding time and resources for training in hospitals already stretched by higher patient volume and long waiting lists. Add to that, more prosaic difficulties such as dealing with traffic after a long shift in the outer suburbs of Sydney or being placed on regional rural rotations around the state. Eye School attendance became more challenging to attend and learn as a group.
Dr Iain Dunlop, Chair of the Sight for Life Foundation, explained: “Surgical training has always been an apprenticeship model that has had many benefits… [but] it can be difficult to keep up with technology, both in terms of expense and complexity. There’s a real pressure on the amount of teaching time that’s available… so to stay abreast of technology, we needed a surgical skills laboratory… to give ophthalmology trainees wet lab experience and specimen experience with the technology to develop skills.”
In 2008, Professor Frank Billson, as Director of the Sight for Life Foundation, established a theatre and training laboratory for the ophthalmology registrar training programme.
What we’re doing… is trying to make sure that everybody is at a threshold level of competence… Once trainees are competent in the fundamentals of microsurgery, next we push for excellence
Mandatory Simulator Training
A significant advance in the surgical training programme came with the acquisition of the Eyesi (Haag-Streit) surgical simulator, which was acquired by the Sight for Life Foundation in 2012. A virtual reality simulator, it can be equipped to safely practise cataract, vitreoretinal, and retinal ‘surgeries’ that range from basic to entire surgical procedures and troubleshooting. While the use of the simulator was initially voluntary, it is now a mandatory training component, with registrars being required to tick off basic microsurgical skills in the first few months of their first year. There are now three simulators, located at Sydney Eye Hospital (at the Sight for Life Foundation), Westmead Hospital, and the Prince of Wales Hospital.
The result is that instead of a registrar’s first incision being on a live patient, they will have experienced and learned many ‘first’ incisions on the simulator. The initial steps are closely supervised by a trainer who can give feedback on technique, but ultimately it is an independent way to practise procedures. Registrars now need to complete 80 hours on the simulator before being permitted to move on to human tissue and live patients. This simulation training helps to standardise the training process, allowing registrars to familiarise themselves with instruments, and develop both hand-eye coordination and confidence, all without putting unnecessary risk on patients and stress on the registrars themselves.
“From a training perspective, competence is really important,” said Professor Mitchell Lawlor, Chair of the Delivery and Development Committee, the main Education Committee for the Royal Australian and New Zealand College of Ophthalmologists (RANZCO). “The nice thing about simulation is that it really brings everyone up to a very similar standard before they start.”
Professorial Senior Registrar at Sydney Eye Hospital, Dr Alice Dutton agreed. “The Eyesi simulator has significantly improved the experience of learning cataract surgery as the modules guide you through increasingly complex surgical situations. [It] enables competence and confidence prior to becoming a primary surgeon in the operating theatre, projecting trainees up the steep microsurgical learning curve and ultimately lowering the rates of surgical complications for junior trainees.
“A particularly useful example is using the Eyesi simulator to practise creating a capsulorrhexis – an essential part of cataract surgery. Practising this procedure hundreds of times in the wet lab before performing it on a patient makes it much easier when the time comes.”
Professor Chang AM, Head of Ophthalmology at Sydney Eye Hospital describes microsurgery as a “fine art” as well as being highly technical. The technical skill required follows the rapidly advancing technology of surgical machines, instrumentation and microscope. The art of surgery develops with experience and mentorship in the operating room.
However, with less time for personal mentorship, which enables techniques to be observed and taught – the emphasis is increasingly on evidence-based approaches and standardised care to achieve more uniform outcomes.
“What we’re doing,” said Prof Lawlor, “is trying to make sure that everybody is at a threshold level of competence so that they do a good job. Once you know people are competent, you can push for excellence as well, but from a surgical training perspective… competence is really important.”
… to stay abreast of technology, we need a surgical skills laboratory… to give you [the] wet lab experience and specimen experience with the technology to develop skills
Learning from COVID-19
Like many other industries, much of the Eye School’s face-to-face learning was delivered remotely during lockdown. While not all aspects of training could be provided virtually, the opportunity to dial into online Eye School lectures and training sessions was – and continues to be – embraced, especially by registrars on call or on rural placements. Additionally, the simulators at Westmead, Prince of Wales, and the Sydney Eye Hospital are now interlinked, allowing registrars to save their progress and continue to practise when they’re at different hospitals.
The Sight for Life skills laboratory has also just completed a major upgrade of its audio-visual and teleconferencing technology to meet the growing demands of this evolving hybrid model. “Having access to online learning has been beneficial,” said Dr Dutton. “As trainees, we rotate through different hospitals throughout Sydney, regional NSW, Hobart, and Darwin. Also, we are often on-call during teaching sessions. The hybrid model allows us to access lectures from any location; we can even rewatch recorded lectures at any time.”
Prof Lawlor agreed the introduction of virtual teaching has had advantages. “There was a range of reasons why attendance was very difficult for the registrars, and then obviously COVID came and so we switched over to virtual teaching and that worked reasonably well. There’s a lot of benefits to that in terms of not needing to be physically located [there]… that means other clinical commitments don’t get in the way (of Eye School) so much.”
Practising this procedure hundreds of times in the wet lab before performing it on a patient makes it much easier when the time comes
An Evolving Offer
The training programme continues to evolve in response to feedback.
“We hold regular surveys for the registrars to provide feedback on both the content and style of teaching,” explained Dr Dutton. “Consultants will also provide feedback, and this is regularly discussed during meetings such as the Registrar Training Committee meeting. This has really helped guide the changes that have been implemented.”
It was due to this feedback that the structure and timing of the Eye School programme was changed early last year; lectures were previously held every Friday afternoon and approximately eight wet lab sessions were spread across Saturdays or weekday evenings throughout the year. Lectures and wet lab sessions have now been condensed into one Friday per month, which includes lectures, wet labs, and live patient teaching. Lectures are still broadcast and recorded for those registrars on regional rural placements or who have clinical duties. “Attendance on a weekday evening or Saturday morning proved challenging,” Dr Dutton remarked, noting that “attendance has improved four to five-fold” since the timetable change.
Creating an Ecosystem
Along with the essential skills and knowledge being acquired at the Eye School are the meaningful connections being built within the ophthalmic community – a community and network that Prof Chang refers to as an “ecosystem”. These relationships are cultivated in the wet lab, as registrars have the opportunity to use cutting-edge surgical machines, engineering, and equipment, and as they receive guidance from the education and training teams of industry companies such as ZEISS and Alcon. It’s a collaborative environment that is nurturing a supportive and close-knit community, which will ultimately contribute to rewarding professional careers, advancing surgical efficiency and safety, and improved patient outcomes.
