Competence Beats Confidence and Adopts Simulation Training

If we were to ask you what the Navy SEALS, the creme de la creme of the American special forces, have in common with the song Bootylicious by R&B group Destiny’s Child, you’d think that we’d have gone mad. Well, more mad than usual when it comes to Media MICE but believe it or not these two entities have one thing in common, aside from being from the United States.

According to one of the foremost speakers at the recent European Society of Cataract and Refractive Surgeons (ESCRS) Winter Meeting, both the special ops soldiers and the group that gave rise to Beyonce offer valuable pearls of wisdom for ophthalmologists.

Yes, that might sound somewhat fantastic but this was one of many insightful tidbits we got to hear during a presentation by Dr. David Lockington, PhD, an ophthalmologist based in Glasgow, Scotland, who’s also an honorary clinical science lecturer at the University of Auckland, New Zealand. His work on Digital Dry Labs and Simulator Training To Start Your Surgical Training… A Safer Surgical Experience for All, did exactly what it promised in its name. It provided an overview of training and safety best practices in ophthalmology for beginners and experts alike.

Delicious Bacon Cheeseburger Donuts

Dr. Lockington started his presentation by emphasizing that while doctors aim to do no harm, it’s ultimately an exercise in damage limitation, accidents can and will happen in the course of surgery. The trick is to identify when they are more likely to occur, and he said that to be more aware of this factor it’s equally important for doctors to know when not to operate, wisdom that often comes from bad experiences.

“Here’s an example that comes from Glasgow, it’s a Krispy Kreme bacon cheeseburger, a burger that comes in a donut bun,” Dr. Lockington said, pointing to an illustration on the screen.

My point is that just because you can do something, it doesn’t mean that you should,” Dr. Lockington said.

Dr. Lockington went on to describe one of the major issues in ophthalmology training as he saw it, namely how confidence is valued more highly than competence. He pointed to numerous surveys of prospective doctors that rate confidence as being one of their primary concerns, and argued in turn that this could be dangerous. Instead, the aim should be on competence, to ensure all trainees know exactly what they need to do before they do it, otherwise, there’s a risk to ocular health.

Take the maxim of the American Navy SEALS for example, as Dr. Lockington did during his presentation; ‘Under pressure, you don’t rise to the occasion, you sink to the level of your training. That’s why we train so hard.’

Therefore confidence does not automatically result in competence. However, consistent competence will result in confidence going forward. Dr. Lockington provided a graph that highlighted the efficacy of this approach, which came in four segments; Unconscious incompetence when one is unaware of a skill and one’s lack of proficiency, conscious incompetence, when one is aware of the skill and not proficient, conscious competence, where one is able to use the skill but with effort, and finally unconscious competence, where performing said skill becomes an automatic ability.

You Can Simulate Confidence, not Competence

How does one best train budding young ophthalmologists to adopt this mindset and subsequently reduce the risk of errors happening during surgery? According to Dr. Lockington, the best policy is to embrace simulation technology as it provides a “safer surgical experience for the patient, trainer, and trainee. Many simulation resources exist but there’s a prevailing need for proactive strategies to engage effectively across the UK and Europe.” It was implied that these issues exist in other parts of the world too.

Dr. Lockington said that some of the barriers to engaging with simulation-based training include time concerns, resource costs, training cultures that are intrinsically opposed to simulation, and a poor understanding of the benefits of such training. These issues can be overcome by increasing exposure to simulation-based training techniques and adopting tools, systems, etc, that are at the cutting edge of current development. The best options include micro-surgical techniques, artificial model eyes, and artificial intelligence (AI).

One example of high-tech equipment recommended by Dr. Lockington was the Eyesi Surgical device, a high-end virtual reality simulator for intraocular surgery training that can be equipped with interfaces for cataract and vitreoretinal surgery. It provides an immersive environment for surgical training, and its operating microscope allows trainees to see the virtual surgical field in stereo and high resolution while operating with lifelike surgical instruments. He reported that the Eyesi performed well in several studies, with one from 2020 highlighting that a monthly median duration of actual simulation training reached 1,246.5 minutes was optimum for good results.

Ophthalmology is All About… Jelly?

Of course, to make simulation techniques, devices, etc, work for yourself and your staff, one needs a way of organizing everything in one place, to ensure the training program works smoothly. To that end, Dr. Lockington recommends that you look at log books, specifically “what you did, not what you may need, and use surveys to identify gaps where they exist.” 

He also recommended linking up with organizations like the Royal Australian and New Zealand College of Ophthalmologists (RANZCO) and the United Kingdom & Ireland Society of Cataract and Refractive Surgeons (UKISCRS) to further efforts to adopt and implement simulation technology. He also recommended the ESCRS too, as one would hope.

The Destiny’s Child song that Dr. Lockington referred to at the start of his speech, had a chorus refrain of ‘I don’t think you’re ready for this jelly, I don’t think you’re ready for this jelly…’ Wise words indeed. Of course, they do highlight the attitude that one should adopt in ensuring that prospective ophthalmologists according to our Glasgow-based doctor, and while we’re still not sure what exactly ‘jelly’ is, we can only imagine it refers to full adoption of the competency over confidence mindset and a successful entry into the ophthalmology industry.

Editor’s Note: The 27th ESCRS Winter Meeting was held on 10-12 March 2023 in Vilamoura, Portugal. Reporting for this story took place during the event.

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