Surgical training: See one, do one, teach one?

Though always discussed in a tongue-in-cheek fashion, the old adage "see one, do one, teach one" is essentially the closest thing most ophthalmology residency programs have to a surgical training curriculum.

In the past, completion of these three steps assumed surgical competency. In today's world, however, this isn't very realistic, and the surgical training of residents has become rather challenging. Patient expectations are higher than ever-they want the very best hands to perform their cataract surgery.

Many consider it unethical to have a resident perform the surgery if the patient believes the attending physician will be doing it. The dominance of local anesthesia makes it difficult for an attending physician to turn over a case or to instruct the resident openly during the surgery.

So what is the solution? I've used sheep eyes to practice repairing globe lacerations and to review the steps of cataract extraction, but I don't find them useful for actually getting comfortable with phacoemulsification. The corneas of sheep eyes too easily become edematous, the capsules are too thick, and the lenses are too soft. Very little about it feels like real cataract surgery to me.

Alternatively, we could use sound exclusion headphones for patients during surgery so that they cannot hear the attending instructing (or yelling at) the resident. But many surgeons and anesthesiologists feel that they need to be able to communicate with a patient immediately at all times during the case. (Even having a foot pedal available to cut the music off the moment the doctor needs to communicate with the patient isn't good enough.)

New technology

A vendor's display at a recent cataract course offered an intriguing potential solution to the dilemma of resident surgical training: virtual reality surgical simulation. The "promised land" is the Star Trek holodeck where things get so "real" that holographic bullets can kill you if a homicidal maniac hacks into the system. We're not quite there yet in the world of eye surgery simulators, but the cataract course provided the opportunity to test drive a promising vitreoretinal surgery simulator currently on the market.

It was very cool. A binocular viewer attached to a computer console hovers over a mannequin-like "patient." The "patient" has an "eye" with pre-made ports for inserting instruments (basically a small track ball with holes in it). Whatever you put in the eye, you "see" stereoscopically through the viewer over an image of the optic nerve and macula. All instruments, once inside the eye, are controlled by the surgeon's hands and via foot pedals. Tasks range from simply piercing colored balls throughout the vitreous to epiretinal membrane stripping.

After playing with the system for a while, I became curious about how much the whole thing might cost. The company representative's six-figure response was not surprising, but I couldn't help wondering if all his company's hard work might be in vain. Why would an institution pay that much money for something that didn't provide enough of the surgical training that is actually needed?

For example, the simulator offers no tactile feedback (that is, you feel no resistance from the tissues you're manipulating). You don't have to make or close any incisions. You never have to struggle to insert the instruments. Once inside the eye, you always seem to have a perfect view. The representative mentioned that experienced retinal surgeons (which I certainly am not) have been very impressed with the authenticity of the program and that he had indeed sold one simulator to a residency program in the United States already.