Sir,

Modernising Medical Careers will require rapid and effective training of tomorrow's ophthalmologists, but a recent survey showed that only 42% of trainees reach the Royal College's target of 50 completed phacoemulsifications within 2 years.1

We advocate modular phacoemulsification training, in which the procedure is broken down into component modules. The trainee performs a given module, starting with the easiest, for all suitable patients on a list.2 The learning curve for each stage of phacoemulsification is steepest during the first attempts, and modular training allows morale-boosting improvements in speed and proficiency during a single list. As only a single module is learnt at a time, advice from the trainer can be exacting without the SHO being overburdened, and can immediately be implemented during the next case. Additional lists can be devoted to gaining competence in a module that is causing problems.

If offered a single procedure per week, we suggest that trainees experience heightened stress when operating, and may attempt to rush parts of the procedure if a time limit is imposed. By contrast, a modular system allows trainees to perform a single part of each procedure carefully without causing delays. If experiencing difficulties, the trainee can ask the trainer to take over, knowing that they will usually have further opportunities to operate on the same list.

As the speed of performing each module improves, the trainee can perform several modules during each procedure without causing the list to overrun. In our experience, within 10 weeks of modular training, first year SHOs can learn to perform complete phacoemulsification procedures quickly and safely. Over 6 months, two consecutive first-year senior house officers underwent modular training in our DGH. Of 149 phacoemulsification procedures, 34.2% were observed by an SHO, 50.3% part performed by an SHO, and 15.4% performed by an SHO alone (a mean of 3.8 procedures per week). One case performed by an SHO (0.67%) required a suture to ensure wound stability.

We would encourage trainers to consider a modular approach, having found that it allows rapid progress in learning phacoemulsification without compromising efficiency or patient safety.