I am now most of the way through my ST3 year working in Plymouth, within the Peninsula Deanery. Before the start of the year, I was approached by one of my consultants who asked if I would like to carry out my next year of cataract surgery training at Newmedica, an independent sector provider (ISP) in Plymouth.
I jumped at the chance, and as this is reasonably new territory for NHS trainees, I was keen to share my experience and thoughts so far, as ISPs will likely play a larger role in trainees’ surgical development as time goes on.
Cataract surgery training was a new role for the relatively fresh establishment which had only opened its doors a year before. I knew that trainees were beginning to train in the independent sector elsewhere in the country, but it hadn’t yet been done in the Peninsula Deanery. Being the first in my region to train in the independent sector was an exciting prospect. At the beginning of the year, there was a slight delay while we finalised all the necessary checks and paperwork. Initially we had to get the go ahead from the hospital’s chief medical officer and I needed to ensure my indemnity provider was aware of my new, additional workplace. After a few more forms were signed by relevant supervisors – Operational framework for governance of doctors in training and Registration form for doctors in training – I was good to go.
As we know, the NHS built up a significant backlog of cataracts during the Covid-19 pandemic. The diminished capacity in theatres for ‘non-urgent’ surgeries exacerbated the already lengthy waiting lists, necessitating the delivery of more efficient and larger-volume cataract surgery lists to alleviate them. Although ISPs such as Newmedica do take on complex cases, the business model relies on high-flow cataract surgery, meaning that a lot of the more straightforward cases are being completed there. Of course, anyone needing a general anaesthetic, or those patients where the operation is expected to be particularly challenging, will still be done in the NHS hospital setting.
Although the independent sector has undeniably contributed to reducing cataract waiting times, these high-volume operating lists being populated with numerous cases also serve as ideal training opportunities. A large proportion of cataract lists in hospitals are increasingly filled with more complex cataracts, which can be far from suitable for the budding ST1 or 2 looking to hone their surgical skills! I have often been on operating lists in the past with just one suitable cataract for a junior trainee, which I found was hardly fertile ground for growth and learning skills, both of which require repetition and exposure. In 2022, the Royal College of Ophthalmologists (RCOphth) published a blueprint for cataract surgery training at ISPs. This stated that independent sector providers must be able to train NHS ophthalmic trainees on at least 11% of whole cases within two years in each region. The background to this blueprint highlighted concerns that far fewer trainees had completed 50 cataract surgery cases by the end of ST2 in 2022 compared with 2019 [1].
Prior to this placement, I was fortunate enough to have a good number of full cases under my belt, but these were all done under sub-tenons anaesthesia. Clearly, the topical anaesthetic technique was going to need some adjustment on my part. My consultant rightly asked me to take a step back and he suggested that I learn the new techniques in a modular fashion, working from the end of the case, forwards. In my first week, I spent the afternoon as a scrub nurse and familiarised myself with the theatre flow and patient journey through the department. The following week, I practised only the draping and draped every patient that came through on the list. Although my instinct was to dive straight back in with full phacos where I’d left off in ST2, focusing on these steps was essential and gave me the confidence to make minor adjustments before putting everything together for my first topical case.
"In my opinion, ST3 has proven to be the ideal stage in my training for this placement, and I believe it’s best suited for trainees who have already gained proficiency in handling complete cases before starting the placement"
One of the initial observations while working at this ISP was the enhanced flow and effectively designed Newmedica building. The ground floor is used for clinics and laser suites whilst the theatres and offices are found on the first floor. The patient experience is prioritised, with a seat in the waiting area in a relaxed room with lots of natural light and some chilled music playing in the background. The patient is greeted on arrival and checked in before dilating drops are given by the nursing staff. The surgeon then comes out to greet the patient, the eye is marked and then the consent forms and biometry are double checked. The patient is brought through and introduced to the theatre team whilst a lens is taken from the store rack on the way through. The patient is then seated as the surgeon scrubs and the preoperative checks are completed. Once the operation is finished, one scrub nurse swaps over with the other who is ready to go with the next case. The patient is then taken outside for a cup of tea and is given the postoperative instructions via a video which is displayed on a tablet. There is a separate entrance and exit from the theatre, giving a flowing, rotational design to the patient pathway. The patients arrive in staggered 20-minute slots, meaning that often they aren’t in the building for much longer than an hour.
After spending a few weeks relearning the steps of cataract surgery in a modular approach, I felt prepared to start handling complete cases on my own. Initially, the afternoon session, typically accommodating 12 patients when only the consultant operates, was reduced to eight. We alternated between patients, doing four operations each to start with. I would discharge the patient I’d just operated on whilst my consultant brought the next patient into the operating theatre. This worked very well and increased my confidence utilising new techniques learnt through my surgical experience. After a few additional weeks, the consultant granted me permission to manage the afternoon list independently, unless there was a particularly challenging cataract or an ‘only eye’ patient.
At first, the majority of patients scheduled for my Monday afternoon lists tended to be more straightforward, however, we gradually introduced some complexity incorporating some shallow angles and small pupils. The latter often requiring dilating devices to gradually build up my confidence with new skills including use of the Malyugin ring and I-Ring pupil expanders.
A few of my usual techniques needed some adjustment to align with the standard operating instrument list. For example, I learnt to use a coaxial Irrigation / Aspiration (I/A) probe at Newmedica, whereas at my previous trust I had been taught the bimanual technique. Also, rather than using an microvitreoretinal (MVR) for the side port, I used the keratome for both the main incision and the side port – the latter technique requiring only partial insertion to create a smaller incision for the paracentesis. The surgical packs don’t have a cystotome as standard either, so I’ve learnt to use the capsulorrhexis forceps to make an initial break in the capsular bag before continuing with the capsulorrhexis from there. Adapting to these changes required some initial discomfort, yet upon reflection, they’ve enhanced my efficiency as a cataract surgeon and equipped me with invaluable skills to carry forward in my future career.
The Newmedica centre in Plymouth is only a stone’s throw from the newly built Royal Eye Infirmary (REI) where I work for the remainder of the week. This proximity has been an excellent bonus for me as travel between the two buildings is no more than a five-minute walk. This works well when incorporated into my timetable, which often has me working a clinic at the REI in the morning, before finishing the working day at Newmedica in the afternoon. The team at Newmedica have been very welcoming, with each member exuding a great deal of pride in their work. This warmth has made operating there a real pleasure, and despite only working there once a week, I still feel a valued member of the team.
Working in the independent sector has been an experience that I would whole-heartedly recommend to other trainees who get the opportunity, and not only because of the prospect of increasing surgical numbers. This placement has also provided valuable lessons on enhancing efficiency, both in the flow of cataract theatre lists, but also my own surgical technique.
For those who get the opportunity, my advice would be to have a discussion with your surgical supervisor at the beginning of the placement, as this will allow you to establish how to best utilise your time and identify early on skills and surgical techniques you wish to develop. Learning these skills step by step in a modular fashion was crucial to ensure I wasn’t overloading the amount I could learn and develop each week. It is vital that all relevant forms are signed off early and that your indemnity provider is aware of your additional workplace to avoid any potential delays in getting started. I’d also recommend reading the RCOphth blueprint [1] for cataract training in the independent sector for more advice and suggested timelines. And lastly, I would really recommend taking time to appreciate how patient flow and surgical technique can be optimised in these high flow cataract lists which will no doubt be a cornerstone of our future careers as cataract surgeons.
Reference
1. Blueprint for Cataract Training in the Independent Sector (2022). Royal College of Ophthalmologists.
https://www.rcophth.ac.uk/wp-content/
uploads/2022/10/Blueprint-for
-cataract-training-2022_v2.pdf
[Link last accessed April 2024].
Declaration of competing interests: None declared.
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