Letters to the Editor

Further prospective studies are required to corroborate these findings.

ACKNOWLEDGEMENTS The authors would like to acknowledge Vision Australia and Data Services Section of the Department of Social Services, notably Ms Allison Cattle, for their assistance in providing the supplied data. Shaun R Parsons MBBS BPharm,1 Justin C Sherwin MBBS(Hons) MPhil2 and Anthony J Hall MD FRANZCO1 1 Department of Ophthalmology, Alfred Health, 2Royal Victorian Eye and Ear Hospital, Melbourne, Victoria, Australia Received 29 September 2015; accepted 4 October 2015.

REFERENCES 1. Attebo K, Mitchell P, Smith W. Visual acuity and the causes of visual loss in Australia. The Blue Mountains Eye Study. Ophthalmology 1996; 103: 357–64. 2. Pascolini D, Mariotti SP. Global estimates of visual impairment: 2010. Br J Ophthalmol 2012; 96: 614–8. 3. Rosenfeld PJ, Brown DM, Heier JS, et al. Ranibizumab for neovascular age-related macular degeneration. N Engl J Med 2006; 355: 1419–31. 4. Mitchell P, Bressler N, Doan QV, et al. Estimated cases of blindness and visual impairment from neovascular agerelated macular degeneration avoided in Australia by ranibizumab treatment. PLoS One 2014; 9: e101072. 5. Australian Bureau of Statistics. Australian Demographic Statistics, Dec 2014. Australian Bureau of Statistics, 2015. Accessed August 2015. Available from: http://[email protected]/mf/3101.0

Teaching cataract surgery to trainees in the operating theatre With over 180 000 cataract operations occurring per year in Australia alone,1 mastering this procedure makes up a large portion of the surgical training of ophthalmology trainees in this country. Many techniques have been utilized to teach phacoemulsification including wet lab and simulation; however, a significantly large amount of learning occurs in the operating theatre itself, where trainees are supervised by their senior colleagues. Techniques outlining the best way to teach manual surgical skills are scarce in the literature, even less of these specifically for ophthalmic micro-surgery. Only one paper from the United Kingdom has previously looked at teaching methods for phacoemulsification exclusively.2 There is an obvious steep learning curve for trainees, who experience far greater numbers of complications including vitreous loss than more experienced consultants.3 Conflict of interest: None. Funding sources: None.

A popular technique recommended by a number of clinical teaching bodies is the ‘Four step method’ described by Walker and Peyton in 1998. The steps of demonstration, deconstruction, comprehension and performance offer a framework for teaching manual skills.4 This method is recommended by a number of Australian state government healthcare networks in their ‘Superguide: A guide to supervising doctors in training’5; however, anecdotally this resource is not widely known about or used by teaching ophthalmologists. We conducted a survey to explore the techniques used by consultants at The Royal Victorian Eye and Ear Hospital (RVEEH) in Melbourne, Australia, to teach cataract surgery (phacoemulsification) to trainees in the operating theatre, and to see how their practices aligned with the available literature on teaching surgical skills. The questions asked were:


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Do you use the ‘four-step method’ (Demonstration, Deconstruction, Comprehension, Performance)? Do you teach the end of the procedure first? Do you teach the easiest part of the operation first? Do you break down the procedure into its component parts? Do you teach heuristics? (‘tips’ or ‘rules of thumb’) Do you use ‘stop and swap’? (trainee stops when having difficulty, swaps with consultant who completes this component, and then swaps back with trainee who continues) Do you use any other techniques?

There were 52 out of 104 consultants who responded to the survey. Among the responders, 18 reported that they did not teach phacoemulsification. Of the remaining 34 consultants, approximately 80–90% used each of the first five abovementioned techniques (four-step method, end of the procedure first, easiest part first, component parts and using heuristics). The most popular method was ‘stop and swap’, utilized by 34/35 consultants. This method allows consultants to take over when a trainee experiences difficulty, complete that particular component, and swap back for the trainee to continue. To our knowledge, this ‘stop and swap’ technique has not previously been described in the literature, but is evidently very popular in our sample group and offers an alternative to a consultant taking over and finishing the procedure. Our results showed that consultants at RVEEH use a number of different techniques when teaching phacoemulsification to trainees in the operating theatre. These were consistent with current medical educational principles for teaching clinical skills, including the ‘fourstep method’ and starting with the end of the procedure first. This survey also showed popularity of a highly utilized but not previously described technique, ‘stop and swap.’ Making resources like the ‘Superguide: A guide to supervising doctors in training’ more easily accessible, and © 2015 Royal Australian and New Zealand College of Ophthalmologists

Letters to the Editor further research into this area, will be important in streamlining the teaching of this important skill.

Rebecca N Haward MBBS 1 and Diane L Webster FRANZCO PhD1,2 1 Royal Victorian Eye and Ear Hospital, and 2University of Melbourne, Melbourne, Australia Received 6 May 2015; accepted 16 May 2015.

REFERENCES 1. Centre for Eye Research Australia: Cataract 2014 [Internet] Accessed 12 Nov 2014. Available from http://

© 2015 Royal Australian and New Zealand College of Ophthalmologists

223 2. Alexander P, Matheson D, Baxter J, Tint NL. UK national cataract training survey. J Cataract Refract Surg 2012; 38: 533–8. 3. Randleman JB, Wolfe JD, Woodward M, Lynn MJ, Cherwek DH, Srivastava SK. The resident surgeon phacoemulsification learning curve. Arch Ophthalmol 2007; 125: 1215–9. 4. Walker M, Peyton JWR. Teaching in theatre. In: Peyton JWR, ed. Teaching and Learning in Medical Practice. Rickmansworth, UK: Manti-core Europe Limited, 1998; 171–80. 5. Clinical Education and Training Institute. The Superguide: A Handbook on Supervising Doctors in Training, 2nd edn. Sydney: HETI, 2012.

Teaching cataract surgery to trainees in the operating theatre.

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