A Broadly Applicable Surgical Teaching Method: Evaluation of a Stepwise Introduction to Cataract Surgery

ORIGINAL REPORTS

A Broadly Applicable Surgical Teaching Method: Evaluation of a Stepwise Introduction to Cataract Surgery Carolyn E. Kloek, MD,* Sheila Borboli-Gerogiannis, MD,* Kenneth Chang, MD,* Mark Kuperwaser, MD,† Lori R. Newman, MEd,‡ Anne Marie Lane, MPH,* and John I. Loewenstein, MD* Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts; †Department of Ophthalmology, Beth Israel Deaconess Medical Center, Boston, Massachusetts; and ‡Shapiro Institute for Medical Education and Research, Harvard Medical School, Boston, Massachusetts *

OBJECTIVE: Although cataract surgery is one of the most

commonly performed surgeries in the country, it is a microsurgical procedure that is difficult to learn and to teach. This study aims to assess the effectiveness of a new method for introducing postgraduate year (PGY)-3 ophthalmology residents to cataract surgery. SETTING:

Hospital-based

ophthalmology

residency

program. DESIGN: Retrospective cohort study. PARTICIPANTS: PGY-3 and PGY-4 residents of the

Harvard Medical School Ophthalmology Residency from graduating years 2010 to 2012. RESULTS: In July 2009, a new method of teaching PGY-3 ophthalmology residents cataract surgery was introduced, which was termed “the stepwise introduction to cataract surgery.” This curriculum aimed to train residents to perform steps of cataract surgery by deliberately practicing each of the steps of surgery under a structured curriculum with faculty feedback. Assessment methods included surveys administered to the PGY-4 residents who graduated before the implementation of these measures (n ¼ 7), the residents who participated in the first and second years of the new curriculum (n ¼ 16), faculty who teach PGY-4 residents cataract surgery (n ¼ 8), and review of resident Accreditation Council for Graduate Medical Education surgical logs. Resident survey response rate was 100%. Residents who participated in the new curriculum performed more of each step of cataract surgery in the operating room, spent more time practicing each step of cataract surgery on a

Correspondence: Inquiries to Carolyn Elenora Kloek, MD, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, 243 Charles St, Boston, MA 02114; e-mail: [email protected]

cataract surgery simulator during the PGY-3 year, and performed more primary cataract surgeries during the PGY-3 year than those who did not. Faculty survey response rate was 63%. Faculty noted an increase in resident preparedness following implementation of the new curriculum. There was no statistical difference between the precurriculum and postcurriculum groups in the percentage turnover of cataracts for the first 2 cataract surgery rotations of the PGY-4 year of training. CONCLUSIONS: The introduction of cataract surgery to

PGY-3 residents in an organized, stepwise manner improved resident preparedness for the PGY-4 year of residency. This surgical teaching method can be easily applied to other surgical specialties. ( J Surg 71:169-175. C J 2014 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: surgical curriculum, deliberate practice,

medical education, procedural training, cataract, cataract surgery COMPETENCIES: Patient Care, Medical Knowledge, Practice-Based Learning and Improvement

INTRODUCTION Learning a surgical procedure is challenging, requiring trainees to assimilate both technical and cognitive skills as they prepare to perform the procedure.1 Studies have shown the benefit of surgical curricula in improving resident preparedness for surgical procedures and decreasing intraoperative complication rates.2-5 A key component of surgical curricula is the preoperative training for the learner before performing an entire procedure on a patient. This preoperative training teaches the cognitive

Journal of Surgical Education  & 2014 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2013.07.007

169

skills required for that procedure, the basic skills of the procedure, and provides the chance for the learner to practice in a safe, risk-free environment.2-4,6-10 The progression of skill level from novice to expert across a variety of fields, including chess masters, musicians, pilots, and surgeons, has been studied by Ericsson. His research shows that individuals achieve expertise in a given skill not simply from the amount of practice, but from deliberate practice, which he defines as practice that is highly concentrated, specifically designed to improve performance, and pushes an individual to the limit of his or her current abilities. Furthermore, Ericsson states that it is the deliberate practice of specific training tasks with coaching and feedback that allows a learner to progress from novice to expert.11,12 Cataract surgery is one of the most commonly performed surgical procedures in the United States. Despite the prevalence of this procedure, cataract surgery is difficult to learn and teach. This microscopic procedure requires the learner to maneuver both hands in a 3 to 4 mm space while both the feet are working different equipment related to the procedure. There is no margin for error; a small movement of intraocular instruments anteriorly can injure the cornea and an equally small movement of instruments posteriorly can violate the important barrier between the posterior and anterior segments of the eye. To add to these challenges, patients are awake and often alert during the procedure. Given these complexities, trainees must be prepared for the operating room (OR) before performing the procedure on a patient. Ophthalmology residency is of 36-months duration (postgraduate year [PGY]-2 through PGY-4). Traditionally, the bulk of cataract surgery training takes place in the final, PGY-4 year of training. Before 2009, Harvard Medical School (HMS) PGY-3 ophthalmology residents primarily assisted in cataract surgery cases. Faculty who taught PGY-3 residents cataract surgery “backed residents into cases” in which residents were introduced to cataract surgery in a graduated manner by performing the last components of a cataract surgery before moving onto the middle and finally the beginning of the surgery.2,13,14 This model of introducing cataract surgery to residents offers the potential of improved patient safety as surgical errors later in the case are more straightforward to address than errors earlier in the case.13,14 However, with this model, we observed that PGY-4 residents would often start the more intense, high-volume cataract surgery experience of the PGY-4 year in need of additional training in basic steps of cataract surgery. We were concerned that lack of a comprehensive approach to training as a PGY-3 resident could affect the number of surgeries and overall educational experience that a resident was able to obtain during the PGY-4 year. The use of Ericsson’s theory of deliberate practice to teach capsulorhexis to PGY-3 residents, a critical yet technically challenging step of cataract surgery in which 170

the resident makes a continuous, curvilinear opening in the anterior capsule of the lens, has previously been described as one of several components of an ophthalmology surgical curriculum that resulted in reduction of sentinel event complications in cataract surgery performed by PGY-4 ophthalmology residents.2,9 We hypothesized that employing deliberate practice by modifying the focus of cataract surgery training for the PGY-3 year so that the residents could deliberately practice all steps of cataract surgery, in order of difficulty, would result in better preparedness for the higher volume and increased surgical skill level required of a PGY-4 resident as well as increased rate of turnover of attending cases to residents in the first 2 cataract surgery rotations of the PGY-4 year.

METHODS In July 2009, a component was added to the existing HMS Ophthalmology Residency surgical curriculum for PGY-3 residents, termed the stepwise introduction to cataract surgery. The goal of the new curriculum was to improve the PGY-3 training experience for performing cataract surgery steps. There were 2 primary elements in the new curriculum, which included the following: (1) using a cataract surgery simulator to perform cataract surgery steps and (2) deliberately practicing a series of steps of cataract surgery in the OR with attending supervision and feedback.

Cataract Surgery Simulator The HMS Ophthalmology Residency obtained an EyeSi cataract surgery simulator at the beginning of the 2009 to 2010 academic year. The EyeSi cataract surgery simulator, which gives the learner feedback while performing a simulated task, has been validated as a training model for procedures concerning the capsulorhexis and has been shown to lessen intraoperative complication rates.15-17 The cataract surgery simulator was placed in the wet laboratory training facility at the Massachusetts Eye and Ear Infirmary, and residents were given unrestricted access to the simulator. Four critical steps of cataract surgery were available for simulated practice including capsulorhexis, hydrodissection, sculpting, and quadrant removal. OR Experience In July 2009, a new clinical rotation was created for PGY-3 residents in which they were assigned to work with 2 cataract surgeons. The faculty supervising this newly created clinical rotation, as well as other cataract surgery instructors

Journal of Surgical Education  Volume 71/Number 2  March/April 2014

responsible for the PGY-3 residents, were asked to concentrate on teaching the PGY-3 residents cataract surgery in a stepwise manner. Previous authors have described the process of deconstructing a surgical procedure into defined steps with the goal of providing a structural framework for the OR team and facilitating resident training.4,18,19 For the stepwise introduction to cataract surgery, the procedure was deconstructed into 7 steps and ranked according to difficulty level consistent with the published literature20 and HMS faculty consensus. The steps, in order from least to most difficult, were lens insertion, wound construction, hydrodissection, aspiration of cortex, sculpting and cracking of the lens, quadrant removal of the lens, and capsulorhexis. The cataract surgery instructors were asked to supervise individual residents in the OR performing one of the specific steps of cataract surgery until the trainee achieved a predetermined level of skill and demonstrated the confidence needed to progress to the next surgical step. Residents were expected to perform only 1 of the 7 steps during each surgery, allowing for deliberate practice of that particular skill. The attending surgeon then performed the remainder of the case. Although we did not instruct the faculty how to teach and give the residents feedback, surgical faculty involved in this residency program most commonly adopt the briefing, intraoperative teaching, and debriefing model.21

regarding the importance of the new simulator modules and stepwise training in preparation for the PGY-4 year. The surveys were administered via surveymonkey.com to faculty members who serve as cataract surgery instructors for the PGY-4 year of training (n ¼ 8). Faculty were asked about their impressions of resident preparedness before and after implementation of the stepwise cataract surgery curriculum. They were also asked to rate factors that affect their decision to hand over a cataract surgery to a PGY-4 resident at the beginning of the year. Accreditation Council for Graduate Medical Education (ACGME) surgical logs were reviewed for the graduating classes of 2009 to 2012. Surgical numbers were analyzed, including the number of primary cataract surgeries completed before the PGY-4 year of residency, as well as the number of primary cataract surgeries and number of surgery assists during the first 2 rotations of the PGY-4 year. The percentage turnover for a clinical rotation was calculated by dividing the number of primary resident surgeries by the sum of the primary resident surgeries and assists logged during that rotation. Statistical analyses were performed using nonparametric tests of association as well as the Kruskal-Wallis test for continuous variables and the Fisher exact test for discrete variables. The Spearman correlation coefficient was also used to evaluate associations.

Assessment of Curriculum An exemption was obtained from the Institutional Review Board to study the effectiveness of these curricular changes. The surveys were administered via e-mail to the 2009 to 2010 class of PGY-4 residents who graduated before the implementation of the stepwise introduction to cataract surgery (n ¼ 7) and to the senior residents of the 2010 to 2011 and 2011 to 2012 classes who participated in the new curriculum (n ¼ 16). The residents were asked about the number of cataract surgeries and steps of cataract surgeries performed; the amount of time spent on each simulator training module before the PGY-4 year; their comfort level with each step of cataract surgery at the beginning of the PGY-4 year; and, for the 2 classes who participated in the new curriculum, their attitudes

RESULTS Resident Survey Response The resident survey response rate was 100%. The reported average number of hours spent practicing on the cataract surgery simulator during the PGY-3 year of training was 22.6 for the first year of residents who participated in the curriculum and 23.2 for the second year (Table 1). The resident survey responses showed that residents who participated in the stepwise introduction to cataract surgery performed more of each of the 7 surgical steps than residents who did not participate. The findings were all statistically significant except for hydrodissection (Table 2).

TABLE 1. Average Number of Hours PGY-3 Residents Practiced Cataract Surgery Steps on the Cataract Surgery Simulator After Implementation of the Stepwise Cataract Surgery Curriculum * Postcurriculum Year-1 h of Practice on Simulator Cataract Surgery Steps Capsulorhexis Hydrodissection Sculpt and crack Quadrant removal Total number of hours

Postcurriculum Year-2 h of Practice on Simulator

Mean

SD

Range

Mean

SD

Range

10.2 4.1 4.2 4.1 22.6

7.4 5.4 4.4 4.4 20.1

2-20 0-15 0-10 0-10 5-50

12.7 3.4 3.7 3.4 23.2

9.9 3.1 3.2 3.2 16.8

0-25 0-10 0-10 0-10 0-50

* Given that the HMS ophthalmology residency did not have a cataract surgery simulator before the initiation of the curriculum, there are no precurriculum data to report.

Journal of Surgical Education  Volume 71/Number 2  March/April 2014

171

TABLE 2. Number of Cataract Surgery Steps and Primary Cataract Surgeries Performed in the Operating Room During the PGY-3 Year Before and After the Implementation of the Stepwise Introduction to Cataract Surgery Curriculum Number Performed Cataract Surgery Steps Wound construction Capsulorhexis Hydrodissection Sculpt and crack Quadrant removal Irrigation and aspiration (I/A) Lens insertion Primary cataract surgeries† †

Precurriculum

Postcurriculum Year-1

Postcurriculum Year-2

p Value*

3.7 3 7.1 1.6 2 9.6 15.5 1.7

21.8 10.6 12.1 8.3 11.4 18.1 30.6 7.6

29.2 19.4 19.1 15.3 15.3 19.9 30.2 15

0.0003 0.001 0.11 0.0006 0.0003 0.04 0.01 0.0004

*Comparison of precurriculum group to postcurriculum group, years 1 and 2 combined. Primary Cataract Surgery ¼ resident performed 450% of the critical components of the case.

Residents who participated in the new curriculum felt more comfortable performing each of the cataract surgery steps, aside from capsulorhexis, than residents who did not participate (Fig. 1). Although the second class of residents who participated in the curriculum performed more of each of the cataract surgery steps than the first class, the second group of residents felt less comfortable with each of these steps at the beginning of the PGY-4 year. These differences were not statistically significant aside from the steps of quadrant removal (p ¼ 0.01) and cortical aspiration (p ¼ 0.02). Faculty Survey Response The faculty survey response rate was 63%. Of the responding faculty, 60% felt the precurriculum class of residents was only moderately prepared for PGY-4 cataract surgery

training experiences whereas the 2 classes of residents who did participate in the curriculum were very prepared (Fig. 2). Faculty members noted that common factors in deciding whether to hand over a cataract surgery case to a trainee were resident skill level, anticipated complexity of the case, and patient personality. Resident Surgical Log Review Review of resident ACGME surgical logs revealed that before the stepwise introduction to cataract surgery was implemented, senior residents in the precurriculum group had performed on an average 1.7 primary cataract surgeries before PGY-4 year. After implementation of the curricular changes, this number increased to 7.6 and 15 average 70% Prior to Introduction of Step-Wise Curriculum

60%

Post Introduction of Step-Wise Curriculum

50% 40% 30% 20% 10% 0%

FIGURE 1. PGY-4 resident comfort with cataract surgery steps during the first 10 cases of the academic year before and after the implementation of the stepwise introduction to cataract surgery curriculum. Rated on a 1 to 5 Likert Scale, 1 ¼ poor comfort; 5 ¼ comfortable and confident. 172

FIGURE 2. Cataract surgery instructors' assessment of level of resident preparedness for the cataract surgery training experience of the PGY-4 year before and after implementation of the stepwise introduction to cataract surgery curriculum.

Journal of Surgical Education  Volume 71/Number 2  March/April 2014

TABLE 3. Average Percentage Turnover* of Primary Cataract Surgeries during the First 2 Operative Rotations of the PGY-4 Year of Residency Before and After the Implementation of the Stepwise Introduction to Cataract Surgery Curriculum Rotation no. 1 % Turnover* Rotation no. 2 % Turnover*

Precurriculum (%)

Postcurriculum Year-1 (%)

Postcurriculum Year-2 (%)

p Value

46

46

61

0.53

56

56

57

0.97

*Percentage turnover for a clinical rotation was calculated by dividing the number of primary resident surgeries by the sum of the primary resident surgeries and assists logged during that rotation.

primary cataract surgeries for the first and second years of residents who participated in the curriculum before the PGY-4 year, respectively (Table 2). Review of resident surgical logs showed that there was no statistical difference between the precurriculum and postcurriculum groups in the percentage of attending cataract surgery turnover to residents for the first 2 cataract surgery rotations of the PGY-4 year of training (p ¼ 0.53 for rotation 1; p ¼ 0.97 for rotation 2) (Table 3). The 16 residents who participated in the stepwise introduction to cataract surgery were asked to rate the educational value of both the cataract surgery simulator and the operative stepwise introduction to cataract surgery on a Likert scale of 1 to 5, with 1 being “least helpful in improving surgical skills” and 5 being “critical to learning and development of surgical skills.” The postcurriculum year-1 group was extremely positive about the new curriculum, rating both the simulator and the OR experience as critical to learning; the average satisfaction rating for the simulator was 5 and for the OR experience was 4.75. The postcurriculum year-2 group was slightly less positive about the new curriculum, with an average rating of 3.75 for the simulator and 4.1 for the operative experience. The number of hours spent practicing on the cataract surgery simulator was similar between the first and second year of residents who participated in the new curriculum. There was no association found between an attending turnover rate of 450% or resident comfort level with surgical steps and number of hours spent on the surgical simulator.

DISCUSSION The stepwise introduction to cataract surgery, a novel cataract surgery curriculum in which cataract surgery is deconstructed into discrete steps and each of these steps is deliberately practiced throughout the PGY-3 year in both a simulated and real surgical environment, improves resident preparedness for the more intense cataract surgery training experience of the PGY-4 year. Our analysis of this curriculum showed that PGY-3 residents performed more of each step of cataract surgery and PGY-4 residents felt more comfortable with each step of cataract surgery as compared with those residents who did not participate in the new

curriculum. Although the curricular initiative described in this report focuses on cataract surgery, we believe the educational concept of deconstructing a surgical procedure into steps and subsequently introducing novice surgeons to the steps of surgery in a hierarchical manner with feedback, is broadly applicable to other surgical specialties. Although the goal of the stepwise introduction to cataract surgery was to increase deliberate practice of the steps of cataract surgery, a secondary benefit was that deliberately practicing cataract surgery steps led to a higher total number of primary cataract surgeries performed during the PGY-3 year of training. We believe this increase occurred as residents were able to assimilate the surgical steps learned and apply these skills more effectively when performing entire cataract surgeries.11,22 Feedback from attending cataract surgeons about the new curriculum has been overwhelmingly positive. A cataract surgery performed by a novice can be lengthy and potentially affect OR flow. Handing over individual steps of cataract surgery to a resident during the PGY-3 year allows the attending to keep operative time to a minimum, and in doing so, lessen OR costs and minimize risk to the patient, while still providing a valuable educational experience for the trainee.7,23-26 The cataract surgery attendings of the more advanced PGY-4 year of residency have also benefited from this curriculum, noting increased preparedness and skill level of the residency classes that participated in the new curriculum. Although residents in the second year of the stepwise curriculum performed more of each of the steps of cataract surgery during the PGY-3 year of training than the first residency class that participated in the curriculum, the second class that participated felt less confident in performing each of these steps at the beginning of the PGY-4 year of training than the first and rated the curriculum as slightly less critical to learning than the postcurriculum year-1 group. A theory to explain this change in resident attitude from the first to the second year of the curriculum is that with implementation of the new curriculum, residents developed a higher expectation of expected performance level at the beginning of senior year between the first and second year of the curriculum. In addition, the postcurriculum year-2 group had exposure to the cataract surgery simulator during their PGY-2 and PGY-3 years of training whereas the simulator was novel to the PGY-3 residents who participated in the first year of the curriculum.

Journal of Surgical Education  Volume 71/Number 2  March/April 2014

173

The number of hours residents spent practicing on the surgical simulator was highly variable with 1 resident in the postcurriculum year-2 indicating no hours of practice on the simulator and another resident in the same year noting 39 hours of practice. Subsequent versions of this curriculum have specified a recommended number of hours of practice on the simulator. Given that 2 interventions were introduced simultaneously, the simulator and the operative experience, it is difficult to assess the isolated effect of each intervention on the residents’ learning. The wide variability in the number of hours residents spent using the cataract surgery simulator coupled with the lack of correlation of hours on the simulator and outcome variables, such as resident comfort with surgical steps and percentage attending turnover, leads us to conjecture that the operative experience may have been more valuable than the simulator. Despite the positive effects of the new curriculum, there was no statistical difference in the percentage of attending turnover of primary cataract surgeries to residents during the first 2 cataract surgery rotations of the PGY-4 year between the precurriculum and postcurriculum groups. The cataract surgery faculty of the PGY-4 year of training indicate that resident skill level is one of several factors that affect their decision to hand over a case to a resident, while other key factors including anticipated complexity of the case and patient personality may create a “ceiling” effect in turning over cases to residents. Regardless of resident skill level, it takes time for an attending to build confidence in a resident’s surgical performance to hand over a case, particularly early in the resident’s surgical training. Finally, these numbers were obtained based on the residents’ self-reported ACGME surgical logs. Resident underreporting of primary cases or assists could affect this data. An important recent addition to this curriculum is that residents are now asked to log each of the steps of cataract surgery that they perform during the PGY-3 year into a cataract surgery step database in addition to logging the primary and assistant cataract surgery cases that are recorded in the ACGME surgical logs. The logging of surgical steps facilitates communication between attending cataract surgeons regarding resident skill level and allows residents to view progress throughout the PGY-3 year even when overall primary cataract surgery volume remains low. As the ACGME milestone project is implemented, monitoring and documenting resident progress in performing surgical steps may be a method of showing increasing competence in surgical performance over the course of the training program.27 This analysis of a new curriculum to introduce novice surgeons to cataract surgery by deliberately practicing surgical steps suggests multiple benefits to the residency training and attending cataract surgical experiences. Limitations to this study are the small sample size and the fact that the study was performed within one residency program; the results of which may not be completely applicable to all 174

residency programs. In addition, the effectiveness of this stepwise approach to teaching cataract surgery using deliberate practice would be best studied in the future with a multicenter, randomized control trial assessing not only the questions addressed in this study, but also whether patient outcomes and complication rates vary before and after the curriculum. Deconstructing a procedure into defined steps and creating a mentored curriculum for novices to deliberately practice and receive feedback about these steps before performing an entire procedure is an educational framework that has potential applicability to other surgical specialties. For example, the decomposition of laparoscopic surgical procedures such as cholecystectomy, inguinal hernia repair, and Nissen fundoplication into steps has previously been described18,19; these defined surgical steps can then be practiced via simulation or as isolated steps in the OR, or both, with attending supervision and feedback to build skill level of the novice surgeon. We encourage other surgical specialties to adopt the “stepwise method” as a means of better preparing residents for performing surgical procedures.

REFERENCES 1. Reznick RK, MacRae H. Teaching surgical skills—

changes in the wind. N Engl J Med. 2006;355 (25):2664-2669. 2. Rogers GM, Oetting TA, Lee AG, et al. Impact of a

structured surgical curriculum on ophthalmic resident cataract surgery complication rates. J Cataract Refract Surg. 2009;35(11):1956-1960. 3. Lee AG, Greenlee E, Oetting TA, et al. The Iowa

ophthalmology wet laboratory curriculum for teaching and assessing cataract surgical competency. Ophthalmology. 2007;114(7):e21-e26. 4. Aggarwal R, Grantcharov TP, Darzi A. Framework for

systematic training and assessment of technical skills. J Am Coll Surg. 2007;204(4):697-705. 5. Surgeons., A.C.o. ACS/APDS Surgical Skills Curricu-

lum for Residents. Available at: 〈www.elearning.facs. org〉; 2012.

6. Grantcharov TP, Reznick RK. Teaching procedural

skills. Br Med J. 2008;336(7653):1129-1131. 7. Wayne DB, Holmboe ES. First do no harm:

preserving patient safety without sacrificing procedural education. J Grad Med Educ. 2010;2 (4):499-501. 8. Norcini JJ, Holmboe E, Hawkins RE. Evaluation

Challenges in the Era of Outcomes-Based Education,

Journal of Surgical Education  Volume 71/Number 2  March/April 2014

in Practical Guide to the Evaluation of Clinical Competence. Mosby Elsevier: Philadelphia, PA. 2008 [p. Chapter 1].

human factors approach to investigating the operating room environment. Minim Invasive Ther Allied Technol. 2001;10(3):7.

9. Oetting T. Teaching the capsulorhexis technique.

19. Cao CG, MacKenzie CL, Ibbotson JA, Turner LJ,

Cataract Refract Surg Today. 2007:46-48. 10. Lee AG, Greenlee E, Oetting TA, et al. Assessing

cataract surgical competency. Ophthalmology. 2007; 114(7):1415-1416. 11. Ericsson KA. The Influence of Experience and Delib-

erate Practice on the Development of Superior Expert Performance, in Cambridge handbook on expertise and expert performance. Cambridge University Press: Cambridge. 685-705. 12. Ericsson KA. Deliberate practice and the acquisition

and maintenance of expert performance in medicine and related domains. Acad Med. 2004;79(suppl 10): S70-S81. 13. Mamalis N. Teaching surgical skills to residents. J

Cataract Refract Surg. 2009;35(11):1847-1848. 14. Gemperli D. Is Backwards Better? Eye World. Avail-

able at: 〈www.eyeworld.org/article-is-backwards-bet ter〉; 2009 [cited 2012 June 8].

15. Belyea DA, Brown SE, Rajjoub LZ. Influence of

Blair NP, Nagy AG. Hierarchical decomposition of laparoscopic procedures. Stud Health Technol Inform. 1999;62:83-89. 20. Dooley IJ, O’Brien PD. Subjective difficulty of each

stage of phacoemulsification cataract surgery performed by basic surgical trainees. J Cataract Refract Surg. 2006;32(4):604-608. 21. Roberts NK, Williams RG, Kim MJ, Dunnington GL.

The briefing, intraoperative teaching, debriefing model for teaching in the operating room. J Am Coll Surg. 2009;208(2):299-303. 22. Peyre SE, Ashley SW. Teaching uncommon and

highly complex operations: maximizing the teaching and learning. J Gastrointest Surg. 2011;15 (10):1724-1725. 23. Hosler MR, Scott IU, Kunselman AR, Wolford KR,

Oltra EZ, Murray WB. Impact of resident participation in cataract surgery on operative time and cost. Ophthalmology. 2012;119(1):95-98.

surgery simulator training on ophthalmology resident phacoemulsification performance. J Cataract Refract Surg. 2011;37(10):1756-1761.

24. Wiggins MN, Warner DB. Resident physician oper-

16. Privett B, Greenlee E, Rogers G, Oetting T. Construct

25. Claesson M, Armitage WJ, Stenevi U. Corneal

validity of a surgical simulator as a valid model for capsulorhexis training. J Cataract Refract Surg. 2010;36 (11):1835-1838.

oedema after cataract surgery: predisposing factors and corneal graft outcome. Acta Ophthalmol. 2009;87(2):154-159.

17. Feudner EM, Engel C, Neuhann IM, Petermeier K,

26. Clark A, Morlet N, Ng JQ, Preen DB, Semmens

Bartz-Schmidt KU, Szurman P. Virtual reality training improves wet-lab performance of capsulorhexis: results of a randomized, controlled study. Graefes Arch Clin Exp Ophthalmol. 2009;247(7):955-963.

JB. Whole population trends in complications of cataract surgery over 22 years in Western Australia. Ophthalmology. 2011;118(6):1055-1061.

18. MacKenzie CL, Ibbotson JA, Cao CGL, Lomax AJ.

Hierarchical decomposition of laparoscopic surgery: a

ative times during cataract surgery. Ophthalmic Surg Lasers Imaging. 2010;41(5):518-522.

27. Nasca TJ, Philibert I, Brigham T, Flynn TC. The next

GME accreditation system—rationale and benefits. N Engl J Med. 2012;366(11):1051-1056.

Journal of Surgical Education  Volume 71/Number 2  March/April 2014

175