Closing the Mentorship Distance

Success in reducing the global burden of cataract-related blindness will depend on increasing the supply of skilled cataract surgeons practising in low- and middle-income countries. Live distance surgical mentorship appears to offer a safe, effective, economical, and eco-friendly approach to meeting the latter need.

Kevin M Barber MD is president of Advanced Centers for Eyecare (ACE) Global, a non-profit organisation aiming to eradicate cataract blindness in the developing world by teaching, training, and mentoring ophthalmic surgeons. Fellows become eligible for distance mentorship only after completing wet lab and simulator training and demonstrating competency in the operating room while working under the guidance of an in-person mentor.

ACE Global has focused its efforts in Honduras, where distance mentoring happens with a high-quality 3D visualisation system to livestream the surgery and a teleconferencing platform for communication between the mentor and mentee.

“With this set-up, the mentor shares the surgical microscope view and can see the mentee’s hands and the screen on the phaco machine. The mentor can communicate verbally with the operating surgeon who wears headphones and visually with hand gestures or drawings displayed on a tablet next to the operating surgeon,” Dr Barber explained. “However, distance mentorship can also be done with a lower cost set-up, substituting an action or cell phone camera and webcam for the 3D visualisation system.”

Findings in a prospective, investigator-masked case series showed distance surgical mentorship improved both skill and efficiency of young surgeons.¹ Mentees in the project were four Honduran ophthalmologists, of whom three had recently completed residency training and the fourth expressed a need for improving phacoemulsification surgical skills. They received live, remote expert guidance during 25 cases. Changes in performance over time were assessed by comparing outcomes data from three randomly selected cases completed early during the mentorship programme versus three randomly selected cases performed towards its end.

The analyses showed statistically significant improvements in both median Ophthalmology Surgical Competency Assessment Rubric (OSCAR) score and case duration over time. Improvements were also seen in the odds of major complications and self-rated competence, although the changes were not statistically significant.

Mentoring with lower tech equipment

At Aravind Eye Hospital in Pondicherry, India, distance mentoring of junior surgeons for performing manual small incision cataract surgery (MSICS) was introduced out of necessity during the COVID-19 pandemic and continues today. Illustrating Dr Barber’s comment about not needing sophisticated technology, the Aravind set-up uses the GoPro sports action camera for recording coupled with a GoPro Operations Live on Facebook (GOLF) to link the mentor and mentee.

“Although the distance mentorship is done using a closed-circuit system that is limited to doctors working at Aravind Eye Hospital, the same set-up could be implemented for remote mentoring and live streaming in surgical fields, which are done under a microscope,” Rengaraj Venkatesh MD said.

Currently, all residents and fellows at Aravind Eye Hospital receive one month of mandatory MSICS training provided by an in-person senior ophthalmologist. Thereafter, they progress to a one-month step-up training period where they independently perform one case per day for another 25 cases.

“Junior residents and fellows who have performed fewer than 200 MSICS cases are encouraged to continue operating using the distance mentoring set-up with a dedicated senior medical officer monitoring their surgeries. With this approach, when a junior resident encounters some difficulty, the medical officer can type comments to provide guidance or encourage the resident to call for help,” Dr Venkatesh explained. “Additionally, we use the recorded videos for 30-minute, end-of-day online teaching discussions focused on highlighting mistakes and improving surgical techniques.”

Anecdotally, participation in the distance mentoring opportunity has helped reduce complication rates and improve surgical outcomes for beginners. Now, a study is about to launch, designed to formally document whether this remote mentoring accelerates the surgical learning curve and reduces complication rates for junior surgeons, Dr Venkatesh said.

In the study, residents entering their step-up training are randomised to complete it with or without remote monitoring. Researchers will analyse changes in OSCAR scores for the two groups as the primary outcome.

Attracting more mentors

By eliminating the need for travel, distance surgical mentorship avoids the accompanying ecologic footprint and has time and cost-saving benefits that could lead more ophthalmologists to volunteer their services. Dr Barber said there are some unique considerations for distance mentoring.

“There is a need to be more specific with verbiage and to tweak one’s teaching skills in certain ways when mentoring remotely,” he noted. “All new mentors are required to observe sessions conducted by experienced mentors and be observed by an experienced mentor during their first mentoring session.”

Drs Barber and Venkatesh spoke at ASCRS 2024 in Boston, US.

Kevin M Barber MD is in private practice at Central Florida Eye Specialists, Deland, Florida, US, and President of ACE Global. kbarber@acecaresglobal.org

Rengaraj Venkatesh MD is the Chief Medical Officer of Aravind Eye Hospital, Pondicherry, India. venkatesh@aravind.org

1. Barber KM, O’Connor S, Ponce J, et al. “Distance surgical mentorship in cataract phacoemulsification using a 3D visualization system,” Intl J Surgical Education (IJSED). Published online 14 May 2022.