Proficiency-Based Training for Phacoemulsification

Princeton Lee

Research Fellow

RCSI & ICOAlcon Education Night 27/02/2009

Peyton’s Learning Circle

Unconsciously

Incompetent

Consciously

Competent

Consciously

Incompetent

Unconsciously

Competent

Awareness

LearningExperience

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 CurriculumAcquisition 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 CurriculumAcquisition 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

Attentionalresources

NoviceSurgeon

MasterSurgeon

Psychomotorperformance

Depth & Spatialjudgment

Operative JudgmentAnd Decision making

ComprehendingInstruction

Gaining additionalKnowledge

Gallagher et al. Annals of Surgery 2005;241(2):364-72

Hypothetical Attentional Resource Benefits of PBP Training

Attentional Capacity Threshold

Attentionalresources

NoviceSurgeon

MasterSurgeon

Psychomotorperformance

Depth & Spatialjudgment

Operative JudgmentAnd Decision making

ComprehendingInstruction

Gaining additionalKnowledge

Gallagher et al. Annals of Surgery 2005;241(2):364-72

Pre-trainedNovice Surgeon

Individual Variability in Automation Process

Gallagher et al. Annals of Surgery 2005;241(2):364-72

Gifted Surgeon

Average Surgeon

Below AverageSurgeon

Experience

Att

enti

on

al R

eso

urc

es

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. 2009

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 profi

ciency 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

Circularity 2 points Size 2 points Centering 2 points Time 2 points Tissue Protection 2 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)

+0.33

(-2.33 to +4.00)

Resident +3.33

(+1.33 to +6.67)

+0.00

(-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 TrialObjective assessment

Of perceptual, visual-spatial,And psychomotor abilities

Didactic Training

Randomization

VR Training untilPerformance criterion

reached

VideotapedPhacoemulsification

procedure

VideotapedPhacoemulsification

procedure

Normal Training

Videotaped performanceobjectively assessed

Videotaped performanceobjectively assessed

VideotapedPhacoemulsification

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