I was interested to read the letter from McHugh et al1 expounding the virtues of modular training for phacoemulsification cataract surgery. This approach has been in use in our unit for many years and is a useful one to allow confidence building for junior ophthalmic trainees. It is, however, just one of the of approaches that can be used to facilitate the speeding up of surgical skills' acquisition.2

Reverse chaining is a technique used wherein the trainee takes over towards the end of the operation—the concept being that a more experienced surgeon has successfully completed the initial parts of the process and everything is as it should be. Using phacoemulsification as an example, the trainee may remove viscoelastic at the end of the operation and if successfully completed, perform the next last step (inserting the implant) and removing viscoelastic for the next case.

Another approach is to complete the same part of each operation on the list. For example, performing all six capsulorhexis procedures on a list.

A further suggestion is to limit the time of the trainees' exposure to the surgery, thus removing the pressure of time. I use a 20- to 30-min slot for the trainee who completes what they can in that time. As the weeks go by, as long as they have regular and frequent exposure to the surgery, they will do more and more on each list.

None of this will produce as rapid a progression along the surgical competency pathway as will combining any or all of these approaches with wet lab experience.

There is no practical skill, which is not helped by regular and frequent practise but there are very few surgeons in any specialty who practise their manoeuvres regularly and frequently in a wet lab or skill centre during the early stages of their training.

A further point to make is that each trainee is potentially different from the last. Each will learn best in their own way and a really good trainer will recognize which method of teaching suites which particular trainee and will be able to tailor the method of training, such as those outlined above or the modular approach suggested by McHugh et al,1 and allow each trainee to progress in a structured and facilitative environment.

All of this takes time and must be factored into the fast moving and ever expanding world of clinical service in the NHS.