Surgical Learning: A Survey to Evaluate How Ophthalmologists Learn New Surgical Techniques

Abstract

Purpose:

To evaluate ophthalmologists’ attitudes and approaches to learning new surgical techniques.

Methods:

This cross-sectional, prospective study distributed an anonymous, voluntary web-based survey via email to surgeons of the Royal Australian and New Zealand College of Ophthalmologists (RANZCO). The survey collected data on demographics, fellowship training, practice location, the number of trainee surgeons supervised, the impact of Coronavirus disease 2019, resources for surgical learning, and perceived barriers to learning and adopting new techniques. Multiple-choice, scaled response, and open-ended questions were used in the survey.

Results:

Seventy-five surveys were completed (7.1% of 1050 members). Multivariable analysis demonstrated that the number of new surgical techniques adopted over the preceding 5 years was associated with the number of trainee surgeons supervised (P = 0.003); membership of the New Zealand branch of RANZCO (P = 0.021); self-reported interest in innovation (P = 0.043); and inversely associated with the age of the surgeon (P = 0.002). YouTube was the most frequently used resource. It was used by 96% of respondents and rated the most useful resource by 95.8% of respondents. The two most frequent barriers to learning and adopting new surgical techniques were fear of adverse outcomes (90.7%) and having an existing technique with good outcomes (90.7%).

Conclusions:

This is the first study exploring how ophthalmologists learn new surgical techniques. The widespread use of YouTube for surgical learning highlights the opportunity for postgraduate colleges to create or post quality-controlled online video resources for their members.

INTRODUCTION

Surgeons are required to remain up-to-date with technological advancements and surgical techniques.1 Reviewing current practices and learning and adopting new surgical techniques are essential components of continuous professional development, a requirement of all health professionals, including ophthalmologists.2,3

Several authors have investigated contemporary surgical education.4,5,6,7,8,9,10 These studies focused on one e-learning modality and its effectiveness, resources for learning a specific procedure or exam preparation, and general knowledge for undergraduate students or surgeons in training. One study noted that YouTube was the most frequently used educational video source for surgical preparation by trainees in a general surgical department.4 However, little is known about the resources fully qualified ophthalmic surgeons use to learn new surgical techniques.

This cross-sectional prospective study aims to identify how ophthalmologists in Australasia learn new surgical techniques and assess how learning is influenced by the practice setting, supervision of trainee surgeons, fellowship (subspecialist) training, self-reported interest in surgical innovation, and self-reported confidence to perform new surgical techniques. Potential barriers to learning new surgical techniques and the impact of the Coronavirus disease 2019 (COVID-19) pandemic were also assessed.

METHODS

An anonymous voluntary web-based survey was used to evaluate how the surgeons in the Royal Australian and New Zealand College of Ophthalmologists (RANZCO) learn new surgical techniques. The pilot survey was reviewed by two independent ophthalmologists based in Australasia. Their feedback on completion time, technical functionality, and question clarity was evaluated and incorporated to refine the structure of the survey and enhance its usability.

The survey was approved by the Auckland Health Research Ethics Committee [AH24539] and RANZCO. In February 2023, RANZCO ophthalmologists were invited to complete the survey via email. Participation was voluntary, and all responses were anonymous. The survey remained open for 6 weeks.

The survey [Appendix 1] was completed by participants online using Google Forms (Google, California, USA). Demographic data collected included the number of years practicing as an ophthalmologist, fellowship training, location of practice, the number of trainee surgeons supervised, and the impact of COVID-19 on their practice. Specific information was sought on self-reported interest in innovation, the most frequently used resources for surgical learning, and the perceived barriers to learning new surgical techniques. Multiple-choice, scaled response, and open-ended questions were used in the survey.

This study utilized an exploratory and qualitative design. Statistical analyses, including Spearman correlation, Fisher’s exact test, and Poisson regression, were performed using IBM SPSS software version 29.0 (SPSS, Inc., Chicago, IL, USA). A Poisson regression model was employed as the primary outcome variable, “number of new surgical techniques adopted in the last 5 years”, followed a Poisson distribution rather than a normal distribution. This model also facilitated multivariable analysis, allowing for the evaluation of individual variables while controlling for potential confounders. All statistical results were reviewed by a statistician. Statistical significance was defined as P < 0.05, and results are reported as mean ± standard deviation.

Statistically significant results identified in the univariate analysis were further analyzed with multivariable analysis. Backward selection was performed, sequentially removing variables that did not meet statistical significance.

Spearman correlation analyses were used to test hypotheses for the linkage of categorical variables. Fisher’s exact tests assessed the statistical correlation between categorical variables.

RESULTS

There were 75 completed surveys, i.e., 7.1% of 1050 RANZCO ophthalmologists [Table 1]. The majority of respondents were from Australia (69%, n = 52), male (69%, n = 52), over the age of 50 (56%, n = 42), and located in urban centers (71.3%, n = 53). There was a complete overlap between the branch of RANZCO and the country of practice for all the respondents; therefore, the variable “country of practice” was removed from subsequent analysis.

Table 1.

Demographics of survey respondents (n=75)

	n (%)
RANZCO branch
Australia	52 (69.3)
NZ	23 (30.7)
Gender
Male	52 (69)
Female	23 (31)
Age group
31–40	9 (12)
41–50	24 (32)
51–60	21 (28)
61–70	17 (22.7)
>70	4 (5.3)
Practice location
Urban public	48 (64)*
Urban private	59 (78.7)*
Rural public	15 (20)*
Rural private	28 (37.3)*
Academic appointment
Yes	31 (41.3)
No	44 (58.7)
Type of work
General and subspecialty	62 (83)
General only	9 (12)
Subspecialty only	4 (5.3)
Mean years as specialist (mean±SD)	18.11±11.50
Mean number of subspecialist group part of (mean±SD)	1.99±1.17

*Percentages sum to more than 100% as respondents could choose more than one option. SD: Standard deviation, RANZCO: Royal Australian and New Zealand College of Ophthalmologists, NZ: New Zealand

The respondents’ mean number of ophthalmology colleagues at their current place(s) of work was 16.48 ± 19.52 (range, 1–100). The mean number of trainee surgeons supervised by respondents was 5.57 ± 7.90 (range, 0–35). The mean number of registrars supervised, with a minimum of 12 weeks of contact, in the preceding 3 years was 11.16 ± 8.52 (range, 0–45).

94.7% (n = 71) of respondents had fellowship (subspecialty) training [Table 2].

Table 2.

Fellowship experience of 71 respondents out of 75 (n=71)

	n (%)*
Fellowship region
Europe	51 (71.8)
Australia	28 (39.4)
North America	12 (16.9)
NZ	9 (12.7)
Asia	4 (5.6)
Fellowship hospital types
Secondary	13 (18.3)
Tertiary	45 (63.4)
Quaternary	44 (62)
Fellowship subspecialty
Anterior segment	25 (35.2)
Oculoplastics	23 (32.4)
General	18 (25.4)
Glaucoma	14 (19.7)
Vitreoretinal	11 (15.5)
Paediatric	10 (14.1)
Medical retina	9 (12.7)
Uveitis	5 (7)
Neuro-ophthalmology	2 (2.8)
Oncology	2 (2.8)
Mean number of fellowships (mean±SD)	1.85±0.88
Mean duration of fellowship months (mean±SD)	22.92±10.58

*Percentages sum to more than 100% as respondents could choose more than one option. SD: Standard deviation, NZ: New Zealand

The mean number of new surgical techniques adopted during the previous 5 years was 2.55 ± 2.27 (range, 0–10).

The self-reported attitude to learning new surgical techniques followed a normal distribution [Figure 1a]. Overall, 38.7% (n = 29) of respondents reported they were a “somewhat adopter” or “early adopter and innovative”, with a similar proportion of ophthalmologists from New Zealand (39.1%, n = 9) and Australia (38.4%, n = 20).

Figure 1.

Self-reported attitude to learning new surgical techniques (a) Self-reported confidence level to perform new surgical techniques (b)

Regarding confidence level, 82.6% of respondents felt somewhat confident or very confident in teaching themselves and performing a new surgical technique [Figure 1b]. A higher proportion of ophthalmologists from the New Zealand branch reported being “somewhat” or “very confident” compared to their Australian colleagues (95.7% and 76.9%, respectively).

The most used resource for learning new surgical techniques within the previous 5 years was YouTube (96%), followed by journal articles (88%) and in-person conferences (88%) [Figure 2a]. LinkedIn™ (18.7%) was the least used learning resource, followed by the RANZCO website (34.7%). Many ophthalmologists reported LinkedIn™, the RANZCO website, and textbooks as “not useful at all” compared to other resources [Figure 2b].

Figure 2.

Resources used by respondents to learn new surgical techniques (a), Usefulness of different resources in learning new surgical techniques (b), Barriers to learning and implementing new surgical techniques (c), Relevance of each barrier to learning and implementing new surgical techniques (d), Percentages sum to >100% as respondents could choose multiple options

Of the 72 respondents who used YouTube to learn new surgical techniques, 95.8% (n = 69) found it “somewhat”, “moderately”, or “very useful” [Figure 2b]. The ophthalmologists’ age was not significantly correlated to using YouTube (P = 0.084, Fisher’s exact test). However, all respondents aged 31–40 (n = 9) and half of those aged 70 or older (n = 2) reported YouTube to be very useful.

Of the 46 respondents who used educational institutions’ online resources (i.e., other than the RANZCO website) and the 66 respondents who used journal articles, 95.7% (n = 44) and 95.5% (n = 63), respectively, reported these resources as useful.

In-person courses/workshops were useful for 94.8% (n = 55) of the 58 respondents who used them. Hands-on teaching from another specialist was useful for 93% of respondents, mainly those aged 31–40 (n = 9) and 51–60 (n = 12).

For simulation-based technologies or wet laboratories, of the 36 respondents who had used them, 91.7% (n = 33) of the respondents reported them to be useful.

In the comments, “mini-fellowships” (short-term observerships or operating under the direct supervision of another surgeon, n = 19) and a dedicated online platform to discuss surgical techniques with experts (n = 7) were reported as valuable methods of learning new surgical techniques. Seven respondents reported the usefulness of training from industry representatives for device-related surgical techniques.

The most commonly identified barriers to learning and implementing new surgical techniques were “fear of adverse outcomes” and “already having a technique that gives good results” (90.7% each, n = 68).

The “fear of the initial learning curve” was highest in the 31–40-year-old group (88.9%, n = 9) and was significantly associated with the self-reported attitude to learning new techniques (Fisher’s exact test, P = 0.040). Respondents who identified themselves as “early adopters and innovative” were least impacted by the fear of the initial learning curve (i.e., 50%, n = 4 reported this as irrelevant).

The barrier of “already having a technique that has good results” was irrelevant for 25% of the respondents (n = 4) who identified themselves as “early adopters and innovative” compared to 14.3% (n = 3) of “somewhat early adopter” and 6.9% (n = 2) of “neutral” respondents. At the same time, it was relevant for all (n = 17) of the “somewhat conservative” or “conservative” respondents.

Simulation-based technologies or wet laboratories were not used by 49% (n = 39) of the respondents, with 37 reporting the lack of these facilities in their local area.

Other barriers reported included higher costs of new technologies, poor access to new devices, inadequate patient numbers, poor access to observing other surgeons, reduced/limited theatre access, only having access to industry representatives with limited knowledge, and difficulty keeping up with rapid technological advances.

Most respondents (65.3%, n = 49) had an opportunity to discuss new surgical techniques with their colleagues of the same subspeciality at monthly or more frequent intervals.

Before the COVID-19 pandemic, the average number of conferences or symposia attended by the respondents was 2.81 ± 1.147 per year (range, 1–6). No statistically significant relationship existed between the number of conferences or symposia attended per year and the number of new surgical techniques adopted in the last 5 years.

58.7% (n = 44) of respondents reported that the COVID-19 pandemic had a neutral impact on their surgical learning. Thirty-six percent (n = 27) reported a negative impact due to fewer conferences attended, fewer face-to-face discussions with colleagues, and restricted access to operating theatre time. Five percent (n = 4) reported a positive impact on their learning due to having more time to acquire new skills and greater availability of online resources.

Univariate Poisson regression analysis identified eleven variables as statistically significant to the higher number of new surgical techniques adopted in the last 5 years: lower number of years as a specialist (P < 0.001), younger age (P = 0.001), practicing in an urban public setting (P = 0.001), having more frequent discussion opportunities with colleagues (P = 0.004), having supervised more trainee surgeons in the last 3 years (P = 0.005), being in the New Zealand branch of RANZCO (P = 0.007), having an academic appointment (P = 0.028), supervising more trainee surgeons at work (P = 0.029), a more innovative attitude to learning new techniques (P = 0.016), a higher level of confidence in adopting new techniques (P = 0.021), and the COVID-19 pandemic having a positive impact on surgical learning (P = 0.005) [Table 3].

Table 3.

Poisson log-linear regression analysis – univariate and multivariable results for the number of new surgical techniques adopted

Variable	Wald χ2 (df)	P
Univariable analysis
Demographics
Younger specialist years	χ2 (1)=17.53	<0.001
Younger age category	χ2 (4)=23.30	0.001
Practicing in an urban public setting	χ2 (1)=10.50	0.001
More frequent discussion opportunities with colleagues	χ2 (1)=8.07	0.004
Higher number of trainee surgeons supervised in the last 3 years	χ2 (1)=7.99	0.005
Being in the NZ branch of RANZCO	χ2 (1)=7.38	0.007
Having an academic appointment	χ2 (1)=4.85	0.028
Higher number of trainee surgeons at work	χ2 (1)=4.75	0.029
Being part of more number of subspecialist groups	χ2 (1)=1.96	0.162
Higher number of total ophthalmologists at work	χ2 (1)=1.86	0.173
Practicing in an urban private setting	χ2 (1)=1.03	0.311
Practicing in a rural public setting	χ2 (1)=0.05	0.828
Practicing in a rural private setting	χ2 (1)=1.93	0.165
Higher number of conferences attended on average per year prior to COVID-19	χ2 (1)=0.83	0.362
More percentage of subspecialty work on average (rather than general)	χ2 (1)=0.61	0.435
Male gender	χ2 (1)=0.008	0.928
Fellowship
Region	χ2 (5)=10.78†	0.056
Hospital type	χ2 (3)=3.85†	0.278
Subspecialty	χ2 (8)=9.35†	0.314
Number of fellowships completed	χ2 (1)=0.17	0.678
Duration of fellowship	χ2 (1)=0.007	0.933
Self-reported
More innovative attitude to learning new techniques	χ2 (1)=5.85	0.016
Higher level of confidence in self-learning and performing new techniques	χ2 (1)=5.32	0.021
COVID-19 pandemic
Positive impact on learning	χ2 (1)=7.83	0.005
Multivariable analysis
Younger age category	χ2 (4)=17.30	0.002
Higher number of trainee surgeons supervised in the last 3 years	χ2 (1)=6.57	0.003
Being in the NZ branch of RANZCO	χ2 (1)=5.73	0.021
More innovative attitude to learning new surgical techniques	χ2(1)=4.39	0.043

^†Significance test from the omnibus model test including one variable for each response as respondents could choose more than one option. RANZCO: Royal Australian and New Zealand College of Ophthalmologists, COVID-19: Coronavirus disease 2019, NZ: New Zealand

In the multivariable analysis, the self-reported confidence level correlated with the self-reported attitude toward learning new surgical techniques (correlation coefficient 0.45, P < 0.001) and caused multicollinearity problems. Therefore, the self-reported confidence variable was removed from the final multivariable analysis.

Younger age, supervising more trainee surgeons, being based in New Zealand, and having a tendency toward early adoption and innovation were positively associated with adopting a greater number of new surgical techniques [Table 3]. Each is explored in more detail below.

After adjusting for the other three variables, younger age was correlated with more new surgical techniques adopted (P = 0.002) [Table 4]. This association was supported by results of pairwise comparisons [Table 5], with statistically significant differences between the 31 and 40 age groups and all other age groups (P = 0.023, P = 0.001, P < 0.001, and P = 0.037, respectively). No significant differences existed between the 41–50, 51–60, 61–70, and >70 age groups.

Table 4.

Model-estimated mean number of total new surgical techniques adopted by age group and branch of Royal Australian and New Zealand College of Ophthalmologists

	Mean±SD	95% CI (lower, upper)
Age group
31–40	4.48±1.17	3.30–6.09
41–50	2.81±1.14	2.17–3.64
51–60	2.28±1.15	1.72–3.02
61–70	1.84±1.23	1.24–2.74
>70	1.76±1.52	0.77–4.01
Branch of RANZCO
NZ	3.00±1.17	2.23–4.06
Australia	2.03±1.13	1.61–2.57

RANZCO: Royal Australian and New Zealand College of Ophthalmologists, CI: Confidence interval, SD: Standard deviation, NZ: New Zealand

Table 5.

Pairwise comparisons of estimated means of total number of new techniques adopted in the last 5 years across different age groups

Age group	Compared age group	P	Ratio of means	Percentage change	95% CI for percentage change (lower, upper)
31–40	41–50	0.023	1.59	59.4	6.6–138.5
	51–60	0.001	1.97	1.97	30.5–196.5
	61–70	<0.001	2.43	2.43	46.4–304.7
	>70	0.037	2.55	2.55	5.65–516.6
41–50	51–60	0.28	1.23	23.4	−15.7–80.4
	61–70	0.073	1.53	52.7	−3.8–142.1
	>70	0.28	1.60	60.2	−31.5–274.7
51–60	61–70	0.40	1.24	23.7	−24.8–103.6
	>70	0.56	1.30	29.8	−46.1–212.4
61–70	>70	0.92	1.05	4.92	−57.3–157.8

CI: Confidence interval

RANZCO ophthalmologists in New Zealand had a higher model-estimated mean number of total new surgical techniques adopted in the last 5 years (3.00 ± 1.17) compared to Australian colleagues (2.03 ± 1.13). Pairwise comparison analysis showed a ratio of means of 1.47 and a percentage change of 47.7% (95% confidence interval [CI]: 6%–105%).

A higher number of new surgical techniques were adopted by respondents who had supervised more registrars in the previous 3 years (P = 0.003). For every additional registrar, there was a 2.5% increase (B = 0.025) in the total number of new surgical techniques adopted (95% CI: 0.9%–4.2%).

More new surgical techniques were learned and implemented by those who identified themselves as early adopters and innovators (P = 0.043). For every additional one-point increase on the scale of self-reported attitude to learning new techniques (range, 1–5), there was a 15.1% increase (B = 0.151) in the total number of new surgical techniques adopted (95% CI: 0.5%–34.8%).

Spearman coefficient analysis did not identify any statistically significant correlation between the self-reported attitude to learning and implementing new surgical techniques and factors such as the ophthalmologists’ gender, age group, years of experience as a subspecialist, number and duration of subspecialist fellowships completed, percentage of subspecialty work in day-to-day practice, membership of multiple subspecialist groups, number of trainees supervised, or respondents’ academic appointments.

DISCUSSION

As with advances in technology, learning methods have also evolved.5,11 In the current study, ophthalmologists of all age groups reported that YouTube was the most used (96%, n = 72) and most beneficial (95.8%, n = 69) resource for their surgical learning. Of note, all respondents aged 31–40 reported YouTube as “very useful”. These findings are consistent with other studies that evaluated the use of video modalities, particularly YouTube, for surgical preparation or learning.4 The advantages of YouTube for surgical learning include free access, wide-ranging content, accessibility from almost all devices, time efficiency, and independent learning.12

As highlighted by several studies, the primary disadvantage of YouTube videos is the high variability in quality and credibility.7,13,14,15,16,17 Viewers must exercise discretion when deciding whether to learn from a video, as the techniques demonstrated are not always evidence-based or reflective of best practices. The platform enables one-way content uploading, offering no opportunities for feedback or discussion with professionals in the field. Misinterpretation of steps can result in improper technique adoption. In addition, the applicability and adaptation of these techniques to Australasian healthcare settings are not always proven.13,14,15,16

Many conferences and workshops/courses now offer in-person or online attendance. In this study, respondents preferred in-person over online attendance, likely from greater familiarity with face-to-face learning and the social aspects of attending conferences.

Most respondents (67.4%, 29 of 43) who had learnt new surgical techniques from another specialist or subspecialist considered this to be “very useful”. However, only 57.3% (n = 43) of respondents had learned new surgical techniques this way. This could be due to a lack of time during usual working hours. Many ophthalmologists employ time outside working hours or during conference attendance for self-education purposes.

The RANZCO website was used by 34.7% of the surveyed ophthalmologists (n = 26) for surgical learning. This could present an opportunity for postgraduate surgical colleges such as RANZCO to develop and present high-quality, peer-reviewed content for their fellows.

The most frequently reported barriers to learning and adopting new surgical techniques were “fear of adverse outcomes”, “already having a technique that gives good results”, “fear of the initial learning curve”, and “lack of evidence on efficacy and outcome”. The potential benefits of new techniques, such as lower surgery cost, greater surgical efficiency, faster patient recovery, or fewer complications, must be weighed against the potential for uncertain or poorer outcomes or the risk of more adverse events that can occur during the initial learning curve.18

Many studies confirm that simulation-based learning can assist surgeons in overcoming the initial learning curve and facilitate those returning to practice after a significant career break.19,20,21,22,23 About 91.6% of ophthalmologists in the current study stated simulation-based technologies such as the EyeSi surgical simulator (VRMagic Holding AG, Mannheim, Germany) or wet labs were useful. The primary limiting factor was the unavailability of these facilities in their local centres (49%). Due to the substantial cost of these simulators/wet laboratories, access is more difficult for surgeons in provincial areas with constrained resources.10

In this study, the younger surgeon’s age was associated with a greater number of new surgical techniques adopted in the previous 5-year period. Many RANZCO graduates relocate to different centres to broaden their practice and learn new surgical techniques. Although none reported feeling “very confident”, 88.9% of the respondents in the age group 31–40 years felt somewhat confident in teaching themselves and performing new techniques.

Affiliation with the New Zealand branch of RANZCO was associated with a greater adoption of new surgical techniques. The reason for this is unclear, as self-reported rates of early adoption and innovation were comparable between the two branches (39.1% in New Zealand vs. 38.4% in Australia).

Several factors may explain the positive correlation between a greater number of trainees supervised and the higher number of new techniques adopted. The surgical instruction of trainees provides greater opportunities for feedback on surgical decision-making and techniques. The cross-pollination of ideas and techniques is another benefit from trainees working in various training locations and working with multiple surgeons. The same relationship was not observed for respondents in academic positions, possibly due to surgical teaching not being a component of many academic positions.

As anticipated, when respondents rated themselves as an “early adopter and innovative”, the more new surgical techniques they adopted in the previous 5-year period. Creativity and innovation can drive surgical learning, improve efficiency, and increase productivity.24 Eight respondents identified themselves as “early adopters and innovators”. The “fear of the initial learning curve” was not a barrier for half of these surgeons. Two of these surgeons did not regard “already having a technique that gives good results” as a barrier to learning new surgical techniques. While the number of early adopters and innovators was small, it aligns with the authors’ experience that among surgeons, “early adopters and innovators” are a small but often influential minority.

As with advances in technology, learning methods have evolved.5,11 With prolonged periods of restrictions and reduced operative volumes, the COVID-19 pandemic accelerated the integration of virtual learning into surgical education. Innovative solutions, such as interactive online modules, virtual simulators, and live-streamed surgical procedures, addressed educational gaps during restricted clinical access.25,26,27,28 Many workshops and conferences adopted virtual platforms, thereby increasing the use of virtual learning resources. While these adaptations ensured the continuation of surgical education, they also presented challenges, mainly on decreased hands-on experience and potential impacts on surgical competency.28,29,30 In this study, most ophthalmologists have accessed online resources to learn surgical techniques in the last 5 years. This corresponds to the period since the onset of the COVID-19 pandemic. The majority (64%, n = 48) of ophthalmologists reported that COVID-19 pandemic restrictions had a “neutral” or “positive” impact on their surgical learning. The more positive the reported impact of the COVID-19 pandemic was on the ophthalmologists’ surgical learning, the greater the number of new techniques adopted.

There are several limitations to the current study. As with all surveys, responses are subject to response and recall biases. The response rate in this study was 7.1% of RANZCO Fellows, which may impact the generalizability of the findings. Despite this, the sample included a range of subspecialty fellowship training, and most respondents reported engaging in both general and subspecialty work in their routine practice–aligning with the typical practice patterns of RANZCO Fellows in Australasia. In addition, self-selection bias may have influenced the results, as those with a greater interest in innovation and surgical education were potentially more likely to participate. However, the responses demonstrated variability, ranging from conservative to early adopter and innovative, with the majority reporting a neutral stance. Furthermore, the resources listed in the survey may not have captured all modalities available for learning new surgical techniques. To mitigate this limitation, respondents were invited to provide open-ended comments to identify additional valuable resources.

With the increasing popularity of online resources for surgical learning-particularly video content-postgraduate surgical colleges could develop greater resources for their members. Examples are libraries of “approved” surgical videos and educational content, online forums, and matching expert surgeons with other surgeons seeking tuition.

This study describes a cohort of ophthalmologists representing a wide cross-section of age groups, fellowship experience, practice settings, and self-reported characteristics of early adoption and innovation. Most respondents reported utilizing online resources to learn new surgical techniques, with YouTube being the most frequently used and considered the most helpful. Supervising more trainee surgeons, being a member of the New Zealand Branch of RANZCO, younger surgeon age, and being a self-reported “early adopter and innovator” were associated with a higher number of new surgical techniques learned and adopted.

Conflicts of interest

There are no conflicts of interest.

Appendix 1: Surgical Technique Learning

1. Please read the participant information above. Do you consent to participating in this survey study? * Mark only one oval.

Yes Skip to question 2

No

Demographic information of Opthalmologists

2. Gender *

Mark only one oval.

Female

Male

Gender diverse

Decline to answer

Other:

3. Age *

Mark only one oval.

31-35 46-50 61-65

36-40 51-55 66-70

41-45 56-60 >70

4. Which branch of RANZCO are you a member of? *

Mark only one oval.

Australia

New Zealand

5. Are you currently practicing as an Ophthalmologist? *

Mark only one oval.

Yes, in Australia

Yes, in New Zealand

Yes, elsewhere in the world

No, not currently practicing Other:

Other

6. In what year was your first consultant post? *

______________________________________________

7. How many sub-specialist groups do you belong to? *

Examples include RANZCO, ANZSOPS, ANZGS. Please answer as a number.

______________________________________________

8. How many conferences/symposia did you attend on average per year, prior to COVID? * This includes both national and international events

Mark only one oval.

0 5 10

1 6 10-15

2 7 15-20

3 8 20+

4 9

9. What type of practice do you work in? *

Tick all options that apply.

Tick all that apply.

□ Urban - Public

□ Urban - Private

□ Rural - Public

□ Rural - Private

10. In a typical week, what percentage of your time would you spend doing subspecialty work? (%) *

Scale in percentage (eg. 3 means 30% specialist work, 70% general ophthalmology. Please select 0 if your work involves general ophthalmology only, 100% if it is subspecialty work only)

Mark only one oval.

0 4 8

1 5 9

2 6 10

3 7

11. How many ophthalmologists are there at the practice(s) you work in? *

Total number of ophthalmologists, including yourself, combined between all the centers chosen above.

______________________________________________

12. How many registrars are there at the current practice(s) you work in? *

The total number of registrars (training, non-training)

______________________________________________

13. How many registrars or fellows have you supervised clinically in the last 3 years? *

Please only count those that had minimum of 12 weeks and day-to-day contact in clinical setting. Students/visiting doctors are excluded.

______________________________________________

14. Do you hold a university academic appointment? *

Mark only one oval.

Yes

No

15. Did you complete any subspecialist fellowship training? *

Mark only one oval.

Yes Skip to question 16

No

Fellowship Experience

Please provide details of all of your Fellowship training - number of fellowships, type of fellowship (sub-specialty), duration (number of months), location (tertiary vs secondary hospitals), country

16. Number of fellowships completed *

Tick all that apply.

□ 1

□ 2

□ 3

□ 4

□ 5

□ >5

17. Type of fellowships completed *

Tick all that apply.

□ General □ Uveitis and Immunology

□ Paediatrics □ Neuro-Ophthalmology

□ Vitreo-retinal □ Oculoplastics and Orbit

□ Anterior segment □ Ocular oncology

□ Corneal and Refractive □ Other:

□ Glaucoma

18. Total duration of fellowship (in months) *

Please provide total duration of all fellowships in months. Example: ocular oncology 6 months + oculoplastics 6 months = 12 months in total, type in 12.

______________________________________________

19. Location of fellowship (Hospital) *

Please provide which type of hospital/practice each of the fellowship was at - secondary hospital, tertiaı hospital, quaternary hospital.

Tick all that apply.

□ Secondary Hospital

□ Tertiary Hospital

□ Quaternary Hospital

20. Location of fellowship (Region) *

Please tick all the regions you've undertaken the above fellowships

Tick all that apply.

□ Australia □ North America South

□ New Zealand □ America Other:

□ Asia □ Other

□ Europe

Surgical Techniques

21. List the new surgical techniques you have adopted in the last 5 years. *

Include only where significant parts or whole procedures were new

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22. What resources did you use in learning new surgical techniques? And how useful were they? Mark only one oval per row.

	Did not use	Not useful at all	Somewhat useful	Moderately useful	Very useful
Textbooks
Articles/Journals
RANZCO online links/resources
Other educational institution resources online
Online webinars/courses/workshops
In person attendance of courses/seminars
Online conferences/symposia
In person conferences/symposia
YouTube videos
LinkedIn
Hands-on teaching from another specialist
Wet lab/simulator

23. How confident do you usually feel to self-teach and perform a new surgical technique? Mark only one oval.

Do not feel confident at all

Somewhat uncertain

Would feel confident only under supervision/guidance from another colleague

Somewhat confident

Very confident

24. The following are some potential barriers in learning and implementing new surgical techniques. Please grade how relevant each factor is for you.

Mark only one oval per row.

	Not relevant for me	Somewhat relevant	Moderatel y relevant	Very relevant
Inadequate learning resources
Unavailability of surgical instrument(s)
Lack of time to learn and adopt
No access to wet lab/simulator
Fear of initial learning curve
Lack of 1:1 training
Lack of assessment of performance by self or peers
Lack of evidence on efficacy and outcome
Uncertainty in applying to patient
Fear of adverse outcomes
Already having a technique that gives good results

25. If there's any other barrier(s) you have found, please describe below

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26. How often do you get a chance to discuss the new techniques with other colleague(s) of the same * specialty?

Mark only one oval.

Never Monthly

Once a year Fortnightly

Twice a year Weekly or more frequent

Every 3 months

27. How has COVID-19 and the restrictions impacted your learning of new techniques? *

Mark only one oval.

Very negatively impacted

Negatively impacted

Neutral

Positively impacted

Very positively impacted

28. Please provide an explanation of your answer above *

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29. What do you think would be useful to help you learn new surgical techniques? *

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30. How would you describe your affitude towards learning new surgical techniques? * 3 - neutral

Mark only one oval.

Conservative - I tend to use familiar techniques with predictable result

1

2

3

4

5

Early adopter and innovative - I actively seek out new techniques and keen to try them

31. Lastly, do you have any other comments regarding learning of new surgical techniques? If so, please leave them below:

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End of Survey

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Funding Statement

Nil.