Dr Akshay Narayan MBBS BSc
Foundation Year 2 Doctor, Aberdeen Royal Infirmary, NHS Grampian
Introduction
The decision to pursue a career in medicine is a reflection of one’s commitment to lifelong learning. From the moment one steps through the lecture theatre doors all the way to when he/she hangs up their stethoscope for the final time, the medic embarks on a lifelong journey of education and self-improvement. Although there is a constant emphasis on learning, the learning environment constantly evolves. Pre-clinical students by and large are taught through a combination of lecture-based and small-group theoretical and practical teaching. As these students progress to become clinical students, the main focus of their learning shifts from the lecture theatre to the clinical environment (hospitals, clinics and GP surgeries). As ophthalmology is a unique blend of medicine and surgery, clinical medical students and junior doctors may find themselves in a clinical setting that they may not be accustomed to – the operating theatre.
Benefits of learning in the operating theatre
Even during their dedicated clinical ophthalmology placement, most of the teaching on the specialty is delivered to medical students in the outpatient setting. For junior doctors in their foundation years interested in increasing their exposure to the specialty, jobs in ophthalmology are few and far between and taking time out of one’s busy rota to attend ophthalmology theatre in their free time may seem like an onerous ask. Although time in the operating theatre may be fleeting it does offer the following benefits:
Stimulation
Each of us is unique with regards to the way we learn best. Some of us are visual learners whilst others are auditory and furthermore. The operating theatre is vastly different to the ward and clinic and you may find that your learning experience in it may be more stimulating and enriching compared to the other settings.
Variety
When we are exposed to the same learning environment countless times, learning fatigue can set in and we may become numb to the skills and knowledge that the clinicians are imparting to us. A change of scenery would be beneficial to revitalise our learning needs and the operating theatre may offer just that.
Teamwork
It is undeniable that division of labour is the cornerstone of a good clinical team and in no setting is it more evident than in the operating theatre. Each individual from the scrub nurse to the primary surgeon has an important role to fulfill and being in the operating theatre gets you front row seats to witness this.
Career planning
Although ophthalmology is a surgical specialty, the types of surgeries performed by ophthalmologists is unique compared to the other surgical specialties. For example, the emphasis is on microsurgery where millimetres matter as opposed to large incisions. By attending theatre, medical students and junior doctors interested in surgery can then make an informed decision about whether this is the surgical specialty best in alignment with their interests and capabilities
Challenges encountered in the operating theatre
Given the numerous benefits of being in the operating theatre, it may seem like a no-brainer to get involved in a cataract surgery list. However, there are several hurdles that medical students and junior doctors may encounter in the operating theatre when they first engage with it:
Lack of clear lead educator
In most settings within the clinical context, there is a clear individual entrusted with the responsibility of teaching medical students and/or junior doctors and medical education is their priority. However, within the operating theatre, this may not be so clear-cut. Although the primary surgeon is likely to be the person best positioned to teach, their foremost duty is understandably to operative performance and patient care and teaching is more of a secondary responsibility.
Relevance to learning outcomes
The main objective of the ophthalmology placement in medical school is to ensure that students are able to take a thorough history and perform a comprehensive examination to assess vision. Students are not expected to display knowledge of various steps of cataract surgery or common post-operative complications. Hence, the main focus of learning within the operating theatre – the practical skills required to perform intraocular surgery – may not be directly relevant to medical students or junior doctors.
Unwritten code of conduct
As with any clinical setting, there are specific protocols and codes of conduct that individuals in the operating theatre are expected to abide by. For example, the importance of maintaining sterility, specific sequence of actions to be taken from the start to the end of the procedure etc. However, these are not necessarily made clear to medical students and/or junior doctors but there is still an expectation to abide by them. Hence, the fear of infringing on these ‘rules’ may be prominent for some individuals
Lack of familiarity with the surgical tools and equipment
As I have mentioned previously, ophthalmology is unique amongst surgical specialties. Apart from the microscopic nature of the surgeries performed, the surgical instruments, types of surgical knots, length of procedures etc. are also vastly different. For example, medical students may never have seen an operating microscope before. Hence, medical students and junior doctors may find it challenging to reconcile with the ‘foreign’ nature of the types of surgeries and manner in which they are performed
Making the most of theatre time
Although awareness of these challenges associated with the operating theatre can be off-putting, it is this same awareness that will then galvanise you to take the necessary steps to mitigate them and make the most of your time in theatre. The following steps can be taken to ensure that your time within theatre can be enriching and fulfilling:
Be enthusiastic
At the risk of sounding cliched, enthusiasm is a hugely useful attribute and goes a long way in medicine. By turning up to the pre-operative assessment early and staying for multiple cases, your eagerness to learn will only put you in good stead amongst the other team members. As most ocular surgery is elective and rarely lasts more than an hour and a half, spending time in theatre does not take up the better part of a day
Build rapport with your consultant
The consultant ophthalmologist is the main individual spearheading the team in the operating theatre, so it pays dividends to have a good working relationship with them. By being enthusiastic and inquisitive in clinic with them, they are more likely to offer you opportunities in theatre
Check the theatre list the day before
Although ophthalmology may seem like a niche specialty, there are several subspecialties within it and the surgeries undertaken by each subspecialty are vastly different. Cataract surgery in the front of the eye is vastly different to vitreoretinal surgery. Hence, being aware of the theatre list you will be participating in, you can read the relevant anatomy, physiology and pathology beforehand to make the most of your time.
Follow the patients pre- and post-operatively
Given the elective nature of ophthalmology and that they are predominantly day cases, this will be challenging. However, if you are able to fit in the time to read the case notes of the patient pre-operatively, that will give you a good understanding of their past medical history and indication for surgery. Furthermore, if you do see the patients at their first post-operative visit, you can finally appreciate the truly life-changing impact of eye surgery
Acquisition of practical skills in ophthalmology
Regardless of how enthusiastic or well-informed you are about the patient, indication for the surgery or the steps involved, having the expectation that you may get to be more involved than scrubbing up and watching the surgery through the operating microscope is futile. Given the highly specialized and high-risk nature of the surgeries, it is unlikely that you will be able to learn and perform the practical steps of the surgeries. However if you are keen to learn and practice the microsurgical techniques involved in ophthalmic surgery, the following options may be worth considering:
Introduction to Ophthalmic Surgery Course
This is a 1-day course delivered by the Royal College of Ophthalmologists in London. This course gives non-ophthalmology trainees such as medical students and Foundation Doctors the unique opportunity to learn the fundamentals of ophthalmic surgery. Although the course does have a hefty price tag, it gives candidates a rare insight into the theory and practice of eye surgery and has generally been well-received
EyeSi Ophthalmic Surgical Simulator
The EyeSi Surgical Simulator is a virtual reality simulator for intraocular surgical training. Through a sequence of numerous modules, one is able to learn the various steps of cataract surgery in a safe manner. During the Introduction to Ophthalmic Surgery Course, candidates are given the chance to use the EyeSi Simulator for 15 minutes and subsequently they can book sessions to use the EyeSi at the Royal College
Although the course is expensive, it is hugely enlightening learning experience that offers you the rare opportunity to learn and practice the fundamentals of eye surgery that may not otherwise be possible. It is important to note the course is very popular and you will need to book early to obtain a place
Conclusion
Ophthalmology offers a unique balance of medicine and surgery and although it may be tempting to shy away from the operating theatre in favour of the wards and clinic, the benefits of spending time in it far outweigh the disadvantages. Although there are some challenges of delivering teaching in the operating room due to its inherent design and structure, these can often be overcome by being proactive and enthusiastic. If after attending theatre you are keen to learn and practice the fundamentals of ocular surgery, the Introduction to Ophthalmic Surgery Course and the EyeSi Ophthalmic Surgical Simulator are useful resources to consider.