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Cadaveric simulation improves ophthalmology resident confidence and preparedness for emergent ophthalmic procedures

Published:March 16, 2021DOI:https://doi.org/10.1016/j.jcjo.2021.02.015
      Simulation-based training programs have become an essential tool in medical education.
      • Blackmore C
      • Austin J
      • Lopushinsky SR
      • Donnon T.
      Effects of postgraduate medical education “Boot Camps” on clinical skills, knowledge, and confidence: a meta-analysis.
      Surgical simulation on platforms, including the Eyesi, which are now widely adopted throughout ophthalmology training, reduces intraoperative complication rates.
      • Rogers G
      • Oetting TA
      • Lee AG.
      Impact of a structured surgical curriculum on ophthalmic resident cataract surgery complication rates.
      Even virtual training utilizing computer graphics and surgical models, which may be lacking in qualities provided by real-life scenarios or cadavers, helps trainees perform faster and with fewer errors compared with trainees who went without virtual training.
      • Grantcharov TP
      • Kristiansen VB
      • Bendix J
      • Bardram L
      • Rosenberg J
      • Funch-Jensen P.
      Randomized clinical trial of virtual reality simulation for laparoscopic skills training.
      The majority of ophthalmology residents complete a preliminary medicine or transitional year internship and therefore enter postgraduate year 2 (PGY-2) with limited surgical experience. Additionally, some ophthalmology residents struggle to acquire all of the necessary surgical skills for comprehensive surgical competence by graduation.
      • Gedde SJ
      • Volpe NJ
      • Feuer WJ
      • Binenbaum G.
      Ophthalmology resident surgical competence: a survey of program directors.
      Residents often perform emergency procedures outside of clinic and may not be adequately prepared despite the use of virtual intraocular simulators and surgical curricula focusing on cataract surgery.
      • Rogers G
      • Oetting TA
      • Lee AG.
      Impact of a structured surgical curriculum on ophthalmic resident cataract surgery complication rates.
      Lack of confidence regarding urgent surgical procedures may magnify stress and anxiety for residents when on-call and impact patient outcomes.
      While boot camps, in-training surgical courses, and simulations have been shown to improve postgraduate medical trainees' clinical skills, knowledge, and confidence, they are not commonly utilized within ophthalmology education.
      • Blackmore C
      • Austin J
      • Lopushinsky SR
      • Donnon T.
      Effects of postgraduate medical education “Boot Camps” on clinical skills, knowledge, and confidence: a meta-analysis.
      We designed a 1-day procedural simulation program, entitled Ophthalmology Olympics, consisting of didactics and a skills check-off, utilizing cadaver heads to improve resident confidence and preparedness for acute ophthalmology procedures often performed outside of routine clinic visits.
      This study is Institutional Review Board approved, Health Insurance Portability and Accountability Act compliant, and adheres to the Declaration of Helinski. A procedural simulation course for ophthalmology residents and medical students was conducted annually. Trainees completed pre- and post-course surveys. Six procedures most commonly performed by ophthalmology trainees on an urgent basis were selected: retrobulbar injection, vitreous tap/inject, anterior chamber paracentesis, eyelid margin laceration repair, temporary tarsorrhaphy, and lateral canthotomy/cantholysis.
      Ophthalmology Olympics included didactic sessions: faculty presented each procedure, described the clinical background (when to perform, how to evaluate patients prior to procedure, etc.), and described procedures step-by-step. Students were given several hours to practice in the cadaver laboratory with faculty supervision as well as near-peer teaching from upper-level residents and fellows. Vitreous tap/inject and anterior chamber paracentesis were performed on donor human eyes secured in a model head. All other procedures were performed on formalin-fixed cadaver heads. For the skills check-off portion, trainees were divided into teams and given 12 minutes to perform each skill. Grading was performed by faculty, with a set point–based scoring system. A rubric was provided to each faculty scorer and included points for each step of the procedure. Real-time feedback and performance-based teaching were incorporated into the end of each round. PGY2-3 residents competed in the skills check-off while PGY4s played a coaching role and provided assistance when needed.
      Participants filled out pre- and post-course questionnaires to evaluate confidence level and prior familiarity with each skill. Participants were asked how the Olympics impacted their confidence performing procedures, procedural knowledge, familiarity with anatomy, team building, morale, and decreasing anxiety.
      Statistical analysis was performed using IBM SPSS, version 22.
      Data were collected over a 3-year period. Participants included visiting medical students, interns, and ophthalmology residents. There were 12-14 trainees who participated in Olympics each year. A total of n = 36 and n = 34 participants completed the pre-survey and post-survey, respectively. This represented 3 medical students, 4 PGY-1 trainees, 11 PGY-2s, 8 PGY-3s, and 10 PGY-4s. Survey response rate was 100%. Among the participants, 100% of lower-level trainees, including medical students, PGY-1s, and PGY-2s (n = 17) had never performed any of the 6 procedures independently, and only 4 had observed any of the procedures (Fig. 1).
      Fig 1
      Fig. 1Prior experiences observing or performing each procedure. Survey question: Have you observed or assisted with this procedure? 1 = no, 2 = observed only, 3 = assisted once, 4 = assisted multiple times.
      Average pre-course comfort level on a scale of 1–4 ranged from 1.75–2.33 (Table 1). Average anxiety on a 0–4 scale with 0 = no anxiety and 4 = severe anxiety was 2.14. Three trainees rated their anxiety performing acute procedural skills as a 4/severe.
      Table 1Average pre- and post-Olympics comfort level performing each skill on a 1–4 scale with 1 = not comfortable at all, 2 = somewhat comfortable if I had assistance, 3 = moderately comfortable, could perform independently, 4 = very comfortable to perform independently.
      ProcedureAverage Comfort Level Pre-courseAverage Comfort Level Post-coursep
      Lateral canthotomy/cantholysis2.112.94<0.01
      Temporary tarsorrhaphy2.313.2<0.01
      Eyelid margin laceration2.312.890.01
      Retrobulbar injection2.833.10.14
      Vitreous tap and inject2.523.10.01
      AC paracentesis2.533.180.01
      Significant p-values (less than 0.05) were bolded to highlight the statistical significance.
      Average comfort level increased from pre- to post-Olympics in each procedure. This increase was statistically significant for all procedures except retrobulbar injection (Table 1).
      When asked to rate the utility of skills learned for performing procedures while on-call on a scale of 1–5 with 1 = not useful at all and 5 = extremely useful, the average response was 4.57. The majority of participants (62%) reported that the skills learned during the course would be “extremely useful,” whereas 32% found these skills “very useful.” When asked to rate the utility of Olympics in increasing confidence performing procedures, procedural knowledge, familiarity with anatomy, team building, and morale, and decreasing anxiety, all categories received a score between 4 and 5.
      Formal cadaver-based surgical simulation enables trainees to prepare for emergent ophthalmic procedures in an educational environment. Hands-on training significantly enhanced resident confidence level related to performing 6 essential ophthalmology procedures frequently performed on-call and outside of the routine clinic setting. Lower level trainees reported minimal prior experiences observing, assisting, or performing all six procedures. In all levels of training, post-course confidence level was significantly higher than pre-course, with the largest improvement seen in lower-level trainees.
      Preparation for the operating room in residency often focuses on intraocular training with simulators or skin suturing curricula.
      • Fisher JB
      • Binenbaum G
      • Tapino P
      • Volpe NJ.
      Development and face and content validity of an eye surgical skills assessment test for ophthalmology residents.
      Virtual simulations have become commonplace in ophthalmology, which makes procedures like lateral canthotomy/cantholysis, margin laceration repair, and tarsorrhaphy difficult to practice. Ophthalmology Olympics specifically focuses on a subset of procedures more likely to be performed outside normal clinic hours and for which early exposure, formal teaching, and confidence by frontline trainees may improve prompt, high-quality care. Inconsistent experience with urgent procedural skills often results in anxiety and stress for trainees. Simulation-based programs have been shown to decrease anxiety and increase clinical performance across multiple surgical subspecialties.
      • Bommer C
      • Sullivan S
      • Campbell K
      • et al.
      Pre-simulation orientation for medical trainees: An approach to decrease anxiety and improve confidence and performance.
      Early exposure to these procedures may also improve surgical readiness. Residents requiring intervention to improve surgical skills earlier in training may be identified and proactive measures instituted.
      This structured program has provided our students with early exposure and hands-on training and could be widely adopted or translated into a virtual event. Limitations to this study include the small number of participants as well as the inherent bias of a survey design. Additionally, as Olympics is an annual event, resident confidence may increase year to year. Future studies will be helpful to better understand the long-term impact of such a course.
      Ophthalmology Olympics is a training course focusing on acute ophthalmologic procedures that are often overlooked in surgical training. Early exposure to surgical procedures decreases resident anxiety and increases surgical confidence.

      Footnotes and Disclosure

      The authors have no proprietary or commercial interest in any materials discussed in this article.

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