Reply: The first cut is the deepest: basic surgical training in ophthalmology

Sir,

I read with interest the article by Gibson et al.¹ It is indeed a difficult time for trainees in ophthalmology, specialist registrars (SPRs) and senior house officers (SHOs) alike. As mentioned by Gibson et al,¹ the issues of clinical governance and implementation of the European Working Time Directive have done little to aid in improving surgical training in ophthalmology. Over the past 18–24 months, government initiatives and the introduction of ISTCs have further spiralled surgical training to negligible levels in some units across the UK.

However, it is disappointing that comments made by SHOs were mainly negative. With change come new challenges, and ophthalmology is at the forefront of change. While an SHO in Manchester, during the same period of study as referred to by Gibson et al,¹ intraocular procedures were indeed difficult to come by. Among the six SHOs, all with over 14 months experience in ophthalmology, only two achieved more than two full intraocular procedures per month during an 8-week prospective study of surgical experience. The remaining four achieved just 11 part/full cases between them during the same period. Similar negative comments were made by these SHOs as described by Gibson et al.¹ Interestingly, I also showed during this study that the time taken from the patient entering the theatre to removing the drape did not vary significantly relative to the experience of the surgeon. SHOs, on average, took 36 min, SPRs 35 min, and consultants 34 min. This implies that the grade of surgeon has little impact on the time per patient episode, which is related to multiple other factors relating to efficiency of usage of theatre time. It is therefore wrong to assume that heavily booked lists leave little time for training. In fact, larger lists, if handled efficiently, will allow greater exposure and opportunities for surgery than shorter lists.

Interestingly, after presenting the findings of the above prospective study, several changes were implemented. The department gained awareness of the lack of surgery and actively helped to reverse this trend. Special teaching lists were set up and SHOs were encouraged to approach the team leader and specify which case would be suitable for them on that list. Miraculously, over the next 12 months, all six SHOs had performed over 100 complete cataract procedures!

It is important for trainees to realise that the Royal College of Ophthalmologists has guidelines on basic surgical training. However, in this increasingly difficult time with major changes in medical training, it is important that trainees start to take the initiative and target their own training. Negative comments are unproductive and trainees within departments must look for and aid in instigating change to ensure that the surgeons of tomorrow are trained to the high standard expected by our patients.