Novice Cataract Surgeons May Be Prone to Complications During Independent Practice

By Marilynn Larkin

February 13, 2017

NEW YORK (Reuters Health) - First-year cataract surgeons are nine times more likely to have high complication rates than more experienced surgeons, suggesting better training and monitoring may be needed, researchers in Canada say.

Dr. Robert Campbell of Queen's University in Kingston, Canada, told Reuters Health, "Cataract surgery is a highly technically challenging procedure to learn, and even tiny missteps can mean the difference between success and serious complications. As a result, despite years and years of dedicated training, not all graduates appear equally ready for the challenges of independent practice."

"In our study, while the majority of new surgeons had excellent outcomes, some had much higher complication rates than surgeons at later career stages," he said by email.

Dr. Campbell and colleagues compiled records of all patients 66 or older who underwent cataract surgery in Ontario, Canada from 1997 to 2013, and assessed outcomes for operations performed by 144 surgeons who were just starting their practice during that period. They looked at four serious complications: posterior capsule rupture, dropped lens fragments, retinal detachment and suspected endophthalmitis.

Among more than 1.4 million cataract operations, 9,932 (0.7%) resulted in one of the serious adverse events, the authors reported online January 24 in Ophthalmology.

Specifically, 6,588 (0.5%) patients had a posterior capsule rupture; 1,648 (0.1%) had a dropped lens fragment; 294 (0.02%) had a retinal detachment; and 1,402 (0.1%) had suspected endophthalmitis.

After adjustment for potential confounders at the patient, surgeon, and institutional levels, surgeons in their first year of independent practice were more than nine times as likely to have high complication rates (two percent or higher) as surgeons in their 10th year (odds ratio, 9.3).

Each additional year of practice was associated with a 10% decrease in the risk of patients experiencing an adverse surgical event (OR, 0.90).

"The need to train new surgeons is an absolutely essential part of a sustainable healthcare system," Dr. Campbell said. "However, our study suggests that ongoing innovations may be needed both in surgical training and early career monitoring and mentoring processes to ensure we provide the highest quality of care."

"Although we used cataract surgery as a model for this study, many other areas of surgery place similarly intense demands on trainees and the outcomes we observed may be reflective of issues facing many technically challenging surgical fields," he said.

Queen's University is the first institution in Canada to transition all of its postgraduate residency programs to a competency-based medical education framework, Dr. Campbell noted. "This approach incorporates greater use of surgical simulation and clearly defined learning outcomes to help ensure that trainees have mastered all of the skills that are expected of them."

"The new educational paradigm also includes the development of a more comprehensive and objective assessment system and specific attention to the transition to independent practice," he added. "It's our view that these initiatives will improve the educational outcomes of residents at Queen's and beyond as this new approach spreads."

Ophthalmologist Dr. Bradford Tannen of the Icahn School of Medicine at Mount Sinai in New York City told Reuters Health, "First, it is important to emphasize that modern cataract surgery is an exceptionally safe and effective procedure with outstanding quality of life gains across the more than 3 million cases done in the United States annually."

"Hospitals and academic medical centers like New York Eye and Ear of Mount Sinai are dedicated to educating and training new surgeons at the highest level and to rigorous, continuous performance evaluation of practicing surgeons at all stages of their careers to ensure safety and the best outcomes for our patients," he said by email. "This important study suggests that we need to continue to assess our initiatives to support, develop and provide resources to newly minted surgeons in their post-graduate years," he concluded.


Ophthalmology 2017.