Surgical skills empowerment of ophthalmology residents in India – Are they future-ready?

“Transformation is a journey without a final destination.” – Marilyn Ferguson

Just like the magical metamorphosis of a caterpillar into a butterfly, ophthalmology residents undergo a staged transformation. Rapid evolutionary change is the only constant in a budding ophthalmologist’s life. The residents are expected to believe in the process with a positive mindset, smoothly glide through the journey, and evolve into skilled, confident, and independent surgeons. The ophthalmology residency programs in India have been designed to provide a balance between clinical and surgical skills along with adequate background theoretical knowledge. While didactic teaching and acquisition of clinical skills seem adequate across the country, gross variations in the quality and quantity of surgical learning opportunities remain an area of concern.

How Much is Enough?

“Sometimes less is more and sometimes more is less.”

The constant debate that persists is between the power of observation versus immersive hands-on experience. A generous mentor or a senior surgeon passing on the tricks of the trade selflessly to a resident is an asset, and the resident must observe every move of the mentor and pay attention to the minute details. In little details, lie precious lessons. At the same time, learning from one’s own experiences remains unparalleled. There must be an ideal balance between these two processes for maximum learning.

Indian residency programs are highly oriented towards knowledge empowerment, with surgical training often taking a backseat. The new National Medical Commission (NMC) competency-based curriculum for a master’s degree in ophthalmology does list the essential surgical skills but stops short of prescribing minimum required numbers.^[1] [Table 1] The All India Ophthalmological Society Ophthalmology Residency Curriculum lays elaborate guidelines for surgical training but does not state the desirable numbers.^[2] However, in the United States and the United Kingdom, quantification of surgical training is given significant importance, and for a resident to be qualified, a minimum number of 86 and 350 cataract surgeries respectively, as the primary surgeon is required.^[3,4] Singh et al. believe that greater practical training, brings in a sense of better judgment and ability to handle complications.^[5] However, the ideal number of surgeries to help make a resident confident, skillful, comfortable with handling complications with efficiency and appropriate speed and optimal outcome remains variable based on an individual learning curve and the mode of training. A didactic module providing adequate background knowledge, curriculum-based wet lab exposure to develop microsurgical and tissue-handling skills, staged rubric-based supervised surgical training, regular video recording of partially supervised and unsupervised resident surgeries and posthoc discussion and analysis leading to constant improvement are believed to be the best approach for optimal training.^[6–8]

Table 1: Ophthalmology residency surgical training mandates in the National Medical Commission competency-based curriculum

The COVID-19 Setback

A study conducted to assess the effect of the lockdown on ophthalmic training programs across India stated that out of the 716 trainees, 81% felt a negative impact on their training due to the pandemic with a 50% drop in their surgical exposure.^[9] The authors of this study conducted a second phase of the survey carried out in 2022 after the pandemic, which is being brought to you in this issue of the Indian Journal of Ophthalmology.^[10] In this survey, 740 residents participated across India. It found that only 40% were independently performing cataract surgery and 14% were comfortable with phacoemulsification. However, it is impressive to see that 97% of this sub-set were trained to perform manual small incision cataract surgery (MSICS), which enables them to provide optimal eye care with minimal infrastructure and investment. The study also highlights the non-availability of training aids to at least 47% of the respondents. In times like the pandemic where there was a striking dip in the number of surgeries being performed, the residents’ surgical skills wouldn’t be compromised if high-quality training aids were to be part of the training program. A survey conducted in the pre-COVID times by the Academic Research Committee of the All-India Ophthalmology Society also showed that observed and assisted cataract surgeries were more prevalent in ophthalmology residency programs in India, with a predominance of SICS training and low sub-specialty exposure.^[11] These figures highlight the dire need for a standardized ophthalmology residency curriculum in India with quantification of a minimum desirable number of surgical opportunities.

What Can We Do?

The Accreditation Council for Graduate Medical Education (ACGME) guidelines^[3] can be made the basis for developing the ideal system customized for the Indian scenario. These guidelines should be ideally utilized symmetrically (irrespective of the formal curriculum that is followed), nationwide with a deep understanding of the requirements and expectations of an evolving ophthalmologist:

1. The importance and need for simulation training should be well understood and adopted by all the training institutes.
2. Formal curriculum-based wet lab training should be made available to the residents either as institution-based facilities or shared regional hubs
3. Competency-based surgical training curriculum with Rubric-based supervised training and posthoc discussion, with minimum numbers pegged in.
4. National Ophthalmology Residency Resource Centres with emphasis on video-assisted surgical teaching.
5. Honest inter-departmental discussions about the progress of each resident and appropriate tailored training.
6. Promoting regular outreach eye care activities in underserved areas enables the trainees to develop independent thinking, management skills, and surgical skills while providing much-needed eye care services to the patients.
7. Embracing the Halstedian concept of “See one, do one, teach one” with the senior residents involved in training the third and second-year residents and they all training the first year resident^[12,13]
8. Focus on surgical skills ranging from extracapsular cataract extraction, MSICS to phacoemulsification, to prepare the residents for diverse practice scenarios.
9. Optimal ocular surface, cornea, glaucoma, retina, oculoplasty, and squint subspecialty surgical exposure is needed to be a good comprehensive ophthalmologist
10. Global interactions and exchange programs to help provide a broader perspective.

While maintaining optimal background knowledge, a precise surgical skill set, and a high level of competency, the residents must adopt the step-wise training approach.^[2–4] It is important to understand and respect each phase of training and the lessons one is supposed to learn and imbibe during the journey. The metamorphosis might seem slow and tedious; however, the residents must trust the process and their trainers duly. Eventually, the outcome is impacted by aptitude and attitude maintained throughout the journey and the ability to embrace the transformation.

“Only those who will risk going too far can possibly find out how far one can go.” – T. S. Elliot