Response to: Comments on 'Confidence of ophthalmology trainees in the management of posterior capsule rupture and vitreous loss'

Sir,

We are grateful to Bishop and Spencer,¹ of the Royal College of Ophthalmologists’ Training Committee and Curriculum Sub-Committee, for their thoughtful comments regarding our study.² We acknowledge that OSATS represent a form of competency-based assessment, but there is still scope for these tools to become a ‘tick-box’ exercise.

In our experience, trainees are often assessed on uncomplicated cases, partly due to low complication rates but also because of a fear of receiving poor evaluation if, for example, posterior capsule rupture has occurred—even if the subsequent management of this is deemed satisfactory. This is an unfortunate consequence of the quite generic current format of assessments, with cataract surgery being assessed as a whole, rather than in more discrete components. It may be preferable to introduce more specific assessments for distinct aspects of cataract surgery, for example, ‘managing posterior capsule rupture’ or ‘managing zonular dialysis’. This more targeted form of assessment would avoid trainees selectively seeking assessment on uncomplicated cases that have gone well. Trainees would likely need to seek assessment in simulated scenarios, assuming that the rate of such complications is too low to guarantee adequate exposure during the course of training. This would avoid the situation of trainees completing their training with admirably low complication rates, but with proportionally low experience of managing complex scenarios, which they will be required to handle independently as Consultants.

We are pleased to note that as of 12 September 2016 (5 months after our study was published online) there has been official notification from the RCOphth that the UK ophthalmic specialist training curriculum has been modified to tackle some of these issues.³ There is now an ‘Entrustable Professional Activity (EPA1)’ assessment, whereby senior trainees must demonstrate that they can manage an entire operating list of cataracts. This is in addition to the standard OSATS, rather than a replacement. We welcome this development, which is certainly an improvement upon the previous system of assessing single cases, and will hopefully increase the likelihood of trainees being assessed in more complicated scenarios.

Accepting the value of simulation and an enhanced programme of competency-based assessments, we suggest that stating a numerical minimum requirement of cases (regardless of the number chosen) is superfluous and potentially falsely reassuring. Whereas one trainee may attain a high level of competence and confidence after completing a relatively low number of challenging cases, others may still be deficient in managing difficulties after many more uncomplicated cases. We acknowledge that numerical minimum requirements are provided for other subspecialty procedures, and this is appropriate for general ophthalmology training because further subspecialist experience is usually gained during fellowships before taking up a substantive consultant post. However, cataract surgery continues to be performed by most ophthalmologists, regardless of subspecialty or fellowship, and we should therefore be confident that all trainees are adequately trained and practised in the management of complications by the culmination of the training programme.