Proficiency-Based Training for Phacoemulsification Princeton Lee Research Fellow RCSI & ICO Alcon Education Night 27/02/2009

Peyton’s Learning Circle Unconsciously Incompetent Consciously Competent Consciously Incompetent Unconsciously Competent Awareness Learning Experience Change

Maslows Hierarchy  Physiological  Security  Belonging  Esteem  Cognitive  Self acutalisation  Comfortable  Confident can express themselves  Feel a part of the group  Self confident  Have the ability to master the skills  Supported in achieving potential

Proficiency-Based Training  Training program consists of objectively assessment of technical skills improvement proximate to the learning experience.  Performance metrics should be relevant to the surgical task being trained  Trainees to reach an objectively determined proficiency criterion

Education and Training Curriculum  Education – acquisition of knowledge  Training – acquisition of skill

Template For A Curriculum Acquisition of Knowledge 1. Didactic teaching of relevant knowledge 2. Instruction of the steps of the procedure 3. Defining and illustrate common errors 4. Test of all previous didactic information

Template For A Curriculum Acquisition of Skills 5. Technical skills training on the simulator 6. Provide immediate feedback when an error occurs 7. Provide summative feedback at the completion of a trial 8. Iterate the skills training while providing evidence at the end of each trial of progress with reference to a proficiency performance goal that the trainee is expected to attain.

How does PBP training work?  Improves attention capacity for learning new and complex skills in theatre

Hypothetical Model of Attention Attentional Capacity Threshold Attentional resources Novice Surgeon Master Surgeon Psychomotor performance Depth & Spatial judgment Operative Judgment And Decision making Comprehending Instruction Gaining additional Knowledge Gallagher et al. Annals of Surgery 2005;241(2):364-72

Hypothetical Attentional Resource Benefits of PBP Training Attentional Capacity Threshold Attentional resources Novice Surgeon Master Surgeon Psychomotor performance Depth & Spatial judgment Operative Judgment And Decision making Comprehending Instruction Gaining additional Knowledge Gallagher et al. Annals of Surgery 2005;241(2): Pre-trained Novice Surgeon

Individual Variability in Automation Process Gallagher et al. Annals of Surgery 2005;241(2): Gifted Surgeon Average Surgeon Below Average Surgeon Experience Attentional Resources

Assessment  Based on target achievements rather than number of cases

EYESi Simulator in ICO

Virtual Reality Training Improves Wet-lab Performance of Capsulorhexis: Results of a Randomized, Controlled Study Graefes Arch Clin Exp Ophthalmol Published online: 27 Jan Szurman et al, Germany

Experimental Design  Subjects: 30 medical students and 32 ophthalmology residents.  Assessment Day 1 – perform capsulorhexis on pig’s eye (3 trials)  Randomization for simulator training and control  Simulator training group to reach a pre-set proficiency level  Assessment Day 2 – perform capsulorhexis on pig’s eye (3 trials)

Data Analysis  All (372) procedures were recorded  Scored by a single person who is blinded to the training status  Scoring Criteria – Total 10 marks Circularity2 points Size2 points Centering2 points Time2 points Tissue Protection2 points

Forceps Training Level 1 and 4

Anti-tremor Training Level 1, 3 and 4

Capsulorhexis Simulation Level 1, 2, 5, and 6

Results Level of Improvement Simulator Training Control Student+3.67 (0 to +7.33) (-2.33 to +4.00) Resident+3.33 (+1.33 to +6.67) (-3.67 to +3.33)

VR to OR Clinical Trial for Phacoemulsification Training  Objective: To demonstrate the transfer of skills acquired from training with simulator to operating room performance  A multi-centre clinical trial in Ireland supported by RCSI and ICO

Experimental Design  Prospective, Controlled, Randomized, Blinded Study  Subjects: Ophthalmic surgical trainees who has done less than 100 cases of phacoemulsification

Method of VR to OR Trial Objective assessment Of perceptual, visual-spatial, And psychomotor abilities Didactic Training Randomization VR Training until Performance criterion reached Videotaped Phacoemulsification procedure Videotaped Phacoemulsification procedure Normal Training Videotaped performance objectively assessed Videotaped performance objectively assessed Videotaped Phacoemulsification procedure

Every Subject Will Have  1st month Aptitude test Baseline simulator assessment + Didactic training Submit 3 video recordings of surgery  2nd month Randomization to simulator training or control group  3rd month Repeat simulator assessment Submit 3 video recordings of surgery

Data Collection and Analysis  Video recordings (either modular or complete case) will be assessed by two scorers who are blinded to the surgeons’ training status  3 videos pre and post training each. But only 1 will be randomly selected for scoring  The score of pre and post training video will be analyzed for difference in the experimental and control group  The result is strictly confidential and will not be used to evaluation by the ICO or hospital

Conclusion  Proficiency-based progression training aim to improve: Patient safety Training environment for trainee and trainer Knowledge and skill acquisition Objective feedback and appraisal of surgical skills