Impact of extracapsular cataract extraction surgical instructional video on self-directed learning of surgical skills in a tertiary eye care centre

Introduction

Training and education forms the foundation for sustaining the patient-centred, evidence-based healthcare system we have, and attaining competency in psychomotor skills is pivotal to being a competent ophthalmologist. With the advent of modern technology, the traditional apprenticeship model of attaining surgical competency is rightly challenged, improved on and supplemented with digital media strategies. Video-based teaching of clinical skills has been found to be more time effective and cost-effective in terms of reducing workloads of the trainer as well as on faculty resources.¹

With the introduction of modern phacoemulsification, the art of performing a good ECCE surgery is increasingly lost. There are many videos detailing surgical tips and highlighting pitfalls to avoid for phacoemulsification but few with regard to ECCE surgery. ECCE remains an excellent surgical technique to fall back on should difficulties be encountered during phacoemulsification.²

There are specific requirements at our centre before a patient ‘qualifies’ for ECCE over phacoemulsification including a dense, brunescent cataract with poor visual acuity. This leads to limited numbers of ECCE cases being listed for surgery. Together with larger intakes of residents, the number of ECCE cases a resident performs is few and far between. With each surgery, one learns from the specific mistakes made, how to manage these mistakes and avoid them from occurring in the first place. With such limited cases available, it takes a long time to achieve surgical competency by keeping strictly to such a model for learning.

Surgical videos allow for better visualisation of the limited surgical field and removes ‘missed opportunities’ from the equation when learning from a specific case. We aim to come up with an ECCE instructional video detailing the steps, surgical tips and pitfalls to avoid during surgery. The video also serves as a platform that ensures a certain standard of teaching is achieved instead of the varying instructions from different tutors.

Here, we describe the impact of an ECCE surgical instructional video on self-directed learning of surgical skills.

Methods

Year 1 ophthalmology residents who have completed the basic microsurgical course as well as supervised wet-lab training were involved in the evaluation of the ECCE surgical instructional video. The residents were assigned to watch the surgical instructional video as a group. They were also given structured worksheets to focus their attention on specific areas of the video content. All participants rated the usefulness of the surgical video and the worksheet using a 4-point Likert scale. After the video, a focus group discussion was held to clarify any steps as well as to gather feedback.

This study was conducted in adherence to the tenets of the Declaration of Helsinki.

Instructional video

We developed a 10 min ECCE instructional video (online supplementary video 1) showing the following segments (table 1).

Table 1: Summary of surgical instructional video.

Demonstration of surgery	Summary of extracapsular cataract extraction video Subtitles to highlight key steps
Individual segments with explanation and tips	Subtitles of surgical tips Voice over highlighting important aspects
Photos and short videos showing instrument handling	Holding the colibri Holding the blade Right cutting blade, left cutting blade, hand movement when cutting cornea Holding the Simcoe/irrigation and aspiration port Holding and insertion of the intraocular lens Holding the needle holder, hand movement when suturing the corneal wound

Discussion

Video-based teaching for clinical skills is widely accepted across various disciplines including medicine,³ nursing and dentistry.

Jumping straight into live demonstrations can result in confusion if one is not equipped with a good understanding of basic concepts. In addition, watching different mentors perform live surgery adds to the variability by the subtle individual preferences each mentor brings to the surgical table. Variability of learning experience arising from differing tutor exposures and teaching styles is eliminated with use of a surgical instructional video. It allows for a more standardised and efficient means of passing on valuable surgical pearls of wisdom which would only benefit a handful based on the traditional apprenticeship model of learning. Having the ability to replay the video allows for learning at each individual’s pace as well, enhancing the ability to learn a skill in a shorter time.⁴

Watching live surgeries faces challenges of suboptimal visualisation of the procedure arising from space constraints from the limited operating field, detailed and fast-paced nature of the surgery and competition from having multiple residents being attached to the tutor. While the quality of the video will pale in comparison to looking through the surgical microscope, the video offers magnified and unimpaired visualisation of each surgical step. Although stereoscopic visualisation is lost, the ability to replay and reflect over each step compensates for this. Residents generally felt that the video was able to highlight insights which would normally be glossed over in a live surgery.

The use of subtitles and having a voice over was another feature appreciated by the residents. The voice over was carefully scripted to follow the video closely and to highlight more important aspects. In addition, the subtitles were summarised key points of the shown segment. This helped to emphasise important points and take home messages.⁵

While use of a surgical instructional video has clear benefits, residents felt that it cannot replace watching live surgeries or the microsurgical course in terms of psychomotor skill learning. Face-to-face encounter with the tutor and individual pointing out of key steps to the surgery was still fundamental to learning of a surgical skill. Having the surgical video on hand, however, serves to reinforce key steps and increase confidence and understanding on the part of residents.

The use of the surgical instructional video also reduces stress on tutors as residents go into the operating theatre armed with a clear understanding of the surgery and nuances which usually come only with experience. Importantly, tutors will also have a clear idea of what learning experience the residents have been through and can thus focus on reducing the learning curve when the residents begin the live surgery.

Conclusions

The surgical instructional video was created to facilitate learning of ECCE. While it does not substitute live surgical experience, the outcomes were very positive and highlight the effectiveness of the use of multimedia in attaining surgical competency in an ophthalmology training programme.

The surgical instructional video in this study is available for use by interested parties and can be found at the following link: https://www.dropbox.com/s/zwwylupfg0yp7dj/ECCE.mov?dl=0.