Hands Off “Hands-On” Training

“The past is a foreign country; they do things differently there.” That certainly goes for cataract surgery and training – but the old ways of learning weren’t all bad, and maybe we can still learn from those far-off times today. Conversely, we shouldn’t be shy of sharing our experience with those countries who have fewer resources than we do, and who might benefit from assistance with skills acquisition.

Yesterday

My own training has been somewhat haphazard – that’s simply the way it was 50 years ago. Consider how I began: in January 1964, soon after qualifying, I turned up at a very busy “eye camp” in a rural area of Pakistan after driving across Europe and Asia in a Land Rover. I brought enthusiasm, but precious little experience. And that could have been a problem, because at that time – and in that part of Pakistan – specialist medical care was virtually non-existent outside Karachi or Lahore, so the hospital was obliged to tackle everything other than neurosurgery or thoracic surgery. But my mentor, Ronnie Holland – a legend who had been running the   hospital for 25 years – wasn’t worried; he just gave me some basic instruction, and set me to work on hernias, scrotal swellings, piles and bladder stones. And within weeks of that, Ronnie decided I should also learn cataract surgery!  This was after all an “eye camp,” but over the years it had also tackled other chronic surgical problems.

My cataract training procedure went like this: Monday – watch Ronnie perform intra-capsular extractions; Tuesday – start hands-on training for each step of the cataract procedure; Wednesday – do complete procedures independently (but under Ronnie’s supervision); Thursday – do everything other than complicated cases and “only eyes” while Ronnie goes off to deal with the outpatients! Remember, there were no operating microscopes or videos to review your work in those days, so my ability to observe Ronnie’s technique was relatively limited – it really was a case of learning by doing.

Even in the UK, I tended to learn my surgery in a hands-on, serendipitous way. For example, in 1972, I had to stand in for the consultant who was training me after he fell ill. Before his absence, he’d started using the new iris clip intraocular lenses, which could be inserted following intracapsular cataract extraction, and had become very enthusiastic about them. After consulting my colleagues, I decided this was a reasonable approach for uni-ocular cataract patients. I proceeded with this new technique, using loupes, without any supervision (there wasn’t anybody available to supervise me). When the consultant had fully recovered, I reverted to being his trainee, and eventually we jointly published one of the earliest reports on intraocular lens implants (1).

This experience in somewhat “off-the-cuff” adoption of new techniques was immensely helpful towards the end of the 1970s, when ophthalmic surgery changed rapidly. Operating microscopes were supplanting binocular loupes for intraocular surgery; intraocular lens implants were increasingly common; and extra-capsular extraction was beginning to take over from intra-capsular as the standard procedure. Again, like most other young consultants at the time, I had to more or less teach myself these new procedures. But it also became clear that the “teach-yourself” approach had limits. For example, in the 1990s, I tried to pick up phacoemulsification through attending courses, studying videos and observing procedures undertaken by one of my skilled ex-trainees. That wasn’t quite enough to guarantee good results when I started using the technique, and I had a couple of dreadful outcomes as a result of my inadequate phaco experience. Similarly, in 1999, having seen a marvelous video of small-incision sutureless cataract surgery (SICS), I was convinced that I could quickly teach myself this technique. In fact, I consistently failed to deliver the nucleus properly until a more experienced African surgeon kindly showed me where I was going wrong.

Today

Nowadays things are – or should be – totally different. Access to “wet lab” facilities gives trainees the chance to develop their skills before being exposed to real patients, and the development of teaching attachments for operating microscopes allows the trainer and the trainee to see exactly what each one is doing. This permits efficient, low-risk training, which is good for everyone, the surgeons and especially the patients. It also has a “fast-to-fail” advantage, in that early exposure to the demands of the various techniques enables trainees who lack the required dexterity to change career early on.

Nevertheless, the modern system is by no means perfect, and over the years I have observed that in some countries it is possible for trainees to finish formal training without being ready to perform cataract surgery. One key weakness of the current system, in my opinion, is our failure to assess the vision and the manual dexterity of potential trainees. I have had two postgraduate trainees who I am sure had no stereopsis: they constantly failed to appreciate how deep their instruments had penetrated into the eye. Consequently, I counseled them both to concentrate on medical ophthalmology. One took my advice, but the other did not and continued to struggle – and, unfortunately, also continued to produce sub-optimal outcomes. On another occasion, I noticed that a trainee of mine seemed to have great difficulty discerning the finer details of his procedures. On investigation, I discovered that he was highly myopic – his best corrected visual acuity was 6/12. I had been unaware of this, because he had been using extended-wear soft contact lenses. Fortunately, he soon realized that his surgical ambitions needed to be reconsidered.

As a result of these kinds of experience, I suggested at a committee meeting that all potential trainees should have their stereopsis and corrected visual acuity measured. Much to my surprise, I was told by a very senior colleague that this would be discriminatory! It is an unfortunate attitude – I believe it’s far better to counsel struggling trainees at the beginning of their career, rather than to watch them go through years of training only to have their ambitions frustrated.

Another weakness of our current system is evident at the other end of the experience spectrum: namely, the issue of elderly surgeons who stubbornly refuse to give up surgery despite having developed a condition, such as a tremor, that could put their patients at risk. This phenomenon – together with evidence that patients treated by younger doctors may have better outcomes than those treated by older doctors (2) – strongly suggests that we need a way of monitoring surgeons towards the end of their careers.

More generally, I believe that we also sometimes fail to give trainees proper “hands-on,” graduated and supervised training. Some wealthier countries may take the view that practical surgery is not an essential part of the postgraduate training program, and is only relevant to a minority of those who complete their formal training. Such a view is understandable in rich countries with an abundance of post-graduates – but in countries with perhaps only one ophthalmologist per million people, all ophthalmology trainees should learn how to do surgery, especially cataract surgery. It’s also worth pointing out that while a postgraduate trainee from a developing country may be delighted to get a scholarship to study in a Western country, the reality is that they are much more likely to get useful and valuable skills if they attend one of the excellent postgraduate training institutes – for example, in India – which are focused on giving “hands-on” SICS training.

Tomorrow

In the developing world, where one might find barely one ophthalmologist per million people, most eye surgery is inevitably cataract surgery. But it’s still not enough to eradicate cataract blindness. What should we do? The obvious solution is to train non-doctors in standard techniques, and the increasing acceptance of this strategy – in Africa, for example – suggests that it will be the future. Indeed, in those countries where there is still a huge backlog of cataract blindness, taking that route is a “no-brainer,” for the following reasons. Firstly, both undergraduate and postgraduate training are much shorter and therefore less costly. Secondly, non-doctors trained in this way are much more likely to remain in rural areas, where they are more needed. Thirdly, being less trained and less qualified, nurse surgeons are more likely to be content with a lower salary scale, and are very much less likely to emigrate. And finally, because their training has been more focused and intensive, their surgical outcomes tend to be as good as, if not better than, those of “fully” trained ophthalmic surgeons. Many African countries accept the role of non-doctors to do lid rotations for trichiasis, but very few actively promote and train nurse cataract surgeons. 

Changing the situation in the developing world, however, may also require wealthier countries to deliver assistance with training programs; local training programs are not always adequate because of the special circumstances of the countries in question. These circumstances include poor salaries for teaching staff, and difficulties in putting aside time for training because of heavy surgical workloads in these countries. Furthermore, in countries where few can afford private fees, the need to supplement salaries through private practice disincentivizes surgeons to train others who will then compete with them in the small private practice market. Hence, outside support aimed at training programs may be essential for some countries.

Unfortunately, not everybody welcomes the advent of nurse surgeons, even in countries where the need is greatest. I have personally been involved in training “nurse cataract surgeons” in Africa, and could see little difference between their skills and those of fully-trained ophthalmologists. Nevertheless, local ophthalmologists were often very unsupportive, and in one case, plainly obstructive. I don’t think that this stems from a wish to maintain high standards – after all, numerous audits have shown that a properly trained nurse cataract surgeon delivers outcomes as good as those of an ophthalmologist. Rather, I think it is more about professional rivalries and preservation of one’s privileged position (and income) after many years of training. One sometimes saw the same friction between ophthalmologists and optometrists in Britain about 30 years ago; today, fortunately, there is much more co-operation. Hopefully, we will see a similar change in attitude in those countries where ophthalmologists are in critically short supply; there is more than enough work for everybody in the developing world, so ophthalmologists have nothing to fear from nurse cataract surgeons.

Not all parts of the developing world have adequate regulation, and, sadly, poor cataract surgery remains a significant cause of blindness in some places. Conversely, in the same countries, we can find hospitals that deliver outstanding work. I suspect that these particularly effective units often owe their success to the qualities of a single individual: charisma and dedication, for example. Such qualities hopefully attract colleagues who either have the same vision or soon acquire it. I remember two particular examples: a Burmese lady who was working single-handedly in a provincial town in Myanmar, and one of my ex-trainees who was working for an NGO in central Africa, also single-handed. Each could do 5,000 cataract operations a year and audit their results. If everyone working in the developing world had the same vision and ethic as these people, the problem of unnecessary cataract blindness would disappear almost overnight. Unfortunately, the norm is to just manage as best as one can in often difficult conditions; it is hard to maintain high levels of concern about the needs of a poor community when your own salary is low and your hospital poorly equipped. But hopefully this situation will change, perhaps via the impact of non-profit organizations; in Pakistan, for example, the Pakistan Institute of Community Ophthalmology, the Leyton Rahmatullah Benevolent Trust and the Al Shifa trust are having a remarkable influence on cataract blindness throughout the country. I believe that particular individuals and groups, by changing local attitudes and training practices, could entirely change tomorrow’s ophthalmology environment in the developing world. Hopefully, one day they will look back on some of today’s practices as if looking at a foreign land!