Open Journal of Ophthalmology, 2013, 3, 61-67
http://dx.doi.org/10.4236/ojoph.2013.33015 Published Online August 2013 (http://www.scirp.org/journal/ojoph) 61
Application of Pedagogical Perspectives in the Teaching
and Training of New Cataract Surgeons—A
Literature-Based Essay
Björn Johansson
Department of Ophthalmology, Linköping University Hospital, Linköping, Sweden.
Received May 14th, 2013; revised June 15th, 2013; accepted July 15th, 2013
Copyright © 2013 Björn Johansson. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Cataract is the most common cause of visual impairment that can be effectively treated by surgery and cataract surgery
is the most commonly performed surgical procedure in the world. With modern cataract operation techniques, patients
expect excellent results. Teaching and training of new surgeons involve both pedagogical and ethical challenges for
teachers and trainees, and also may pose a potential risk to patients. This literature-based essay aims to describe how
behavioristic, cognitiv e and con ceptu al learning perspectives can be recogn ized during the trainee surg eon’s progress. It
also describes how teacher-pupil relationships may vary during the training process. Finally it presents the concept of
situational tutorship, where the teacher adapts to the stages that the trainee passes through with increasing experience.
Teaching and trainee surgeons who are aware of pedagogical concepts such as teacher-pupil relationships and tutoring
strategies may use this knowledge to optimize the learning process. Further research is needed to clarify how using this
knowledge may affect the training of new cataract surgeons.
Keywords: Cataract Surgery; Teaching; Training; Learning
1. Introduction
Modern cataract surgery is carried out through a micro-
scope with 7 - 10× magnification. Dexterity is necessary
as the surgeon’s hands and feet are constantly active
during surgery (Figure 1).
Developments in surgical technology and techniques
have improved outcomes in terms of quality of vision
and life, and increased safety has led to widened indica-
tions and more operations performed [1]. Hence, in de-
veloped societies patients expect their cataract operation
to be painless and quick, with excellent outcome after a
short period of recovery. Patients and health care systems
also demand good accessibility. Surgeons therefore need
to be trained in order to meet continuously growing de-
mands and expectations. However, when an operation is
performed by a trainee surgeon or a less experienced
independent surgeon, there is a greater risk of surgical
complications [2]. Complex ethical issues thus arise
when teaching new surgeons, as Bernstein & Knifed
point out regarding neurosurgery [3]. These issues are
further emphasized by the fact that cataract surgery in
almost 100% of cases is carried out nowadays under lo-
cal anesthesia with ligh t or no sedation , allowing patien ts
to be aware of surrounding activities and conversations
during their operation. An ethical dilemma arises when,
in order to make cataract surgery accessible to future
(and larger numbers of) patients, and with present meth-
ods for education of new surgeons, certain patients will
undergo surgery under conditions that in many ways
must be considered to be “high-risk environments”. For
example, when the operation is performed by a surgeon
with limited or no experience, assisted by a teaching
surgeon who will try to communicate this to the trainee
surgeon and staff in a way that causes as little alarm as
possible is judged to be necessary. Several authors have
discussed how to optimize training of surgeons in order
to address these ethical issues and decrease the risk of
complications [4-9].
As Henderson and Ali summarize, the trainees must
master cognitive knowledge at the same time as they
need to develop a spatial familiarity with the three-di-
mensional surgical anatomy of the eye, coupled with
sufficient technical dexterity to execute surgical ma-
ne u v ers within a small space limited by sensitive structu r e s

Application of Pedagogical Perspectives in the Teaching and Training of New Cataract Surgeons—A
Literature-Based Essay
62
Figure 1. Surgeon’s position during modern cataract sur-
gery is shown with one instrument in each hand, manipu-
lating the intraocular tissues through incisions < 1 mm - 2.5
mm (inset top left). Left foot pedal controls the microscope
zoom, focus and position in three dimensions; right foot
pedal controls the phacoemulsification machine.
[7]. Most literature on training cataract surgeons deals
with the structural framework of training. Tests, surgical
training facilities such as simulators and wet labs, and
methods such as the delivery of graded responsibility and
modular surgery have been described [4,5,7]. The peda-
gogical perspectives that can be applied by the teaching
surgeon during the various phases are not discussed to
the same extent.
The aim of this paper is to problematize the process of
education and training of new surgeons, and by means of
a literature search explore how awareness of different
learning perspectives, teacher-student relationship mod-
els, and possible pedagogical approaches can be of value
in this process.
2. Materials and Methods
Apart from own experience, personal communication and
basic literature and papers within the field of pedagogical
science and learning this essay is based upon a literature
search performed using the National Library of Medicine
PubMed (www.pubmed.gov) and the Education Re-
sources Information Center (ERIC) databases. Search
terms were “cataract surgery, microsurgery, surgery, lea-
rning, teaching, training, learning perspectives”. Search
results were reviewed and articles not relevant to the
topic “surgical teaching” were excluded.
3. Learning Perspectives and Cataract
Surgery Training
Different learning perspectives can readily be identified
within the process of training cataract surgeons. The be-
havioristic persp ective is ev ident as regard s the surgeon’s
ability to memorize and perform a predefined set of sur-
gical maneuvers, which are repeated under supervision
and refined by immediate negativ e and positive feedback
from the supervisor [10]. Internal feedback is also im-
portant: It is not difficult to imagine the frustration, dis-
appointment or even dread that the trainee surgeon ex-
periences when realizing—either by own observation or
information from the teaching surgeon—that a complica-
tion is imminent or has occurred. On the other hand, a
surgical step successfully completed evokes a positive
feeling. A cognitive perspective is also important. For
example, the inner process of reflecting upon how surgical
maneuvering must adjust to the anatomical relations in
each specific case enables the surgeon, as experience
increases during training, to anticipate and prevent com-
plications [11]. During later stages of training, when the
trainee surgeon operates on conscious patients and inter-
acts with them as part of a surgical team, the contextual
learning perspective is evident as well [12]. A schematic
outline of the various steps in a training program for
cataract surgery is shown in Table 1.
4. Teacher-Student Relationships and
Cataract Surgery Training
Selecting who is to enter the training program (Table 1) is
sometimes the responsibility of the teaching surgeon, but
trainee surgeons can also be chosen by clinic executives
upon request (or without it) by an individual wishing to be
trained as a surgeon. In some—but not all—countries,
training in cataract surgery is a part of a general curricu-
lum for specialist training. The risk of nepotism should
not be ove rlooked if the teach ing surgeo n has infl uence on
the selection. On the other hand, Gagliardi et al. found that
an existing relationship appeared to be a key enabler of
mentorship [13]. Selection mechanisms where the teach-
ing surgeon has less influence might increase the risk of
enrolling less determined or even less suitable candidates.
When researching relationships between students pro-
ducing scientific texts and their supervisors, Dysthe iden-
tified three basic models [14]. 1) In the teaching model, a

Application of Pedagogical Perspectives in the Teaching and Training of New Cataract Surgeons—A
Literature-Based Essay
63
Table 1. Contents of the various stages of a cataract surgeon’s training program.
Stage of training program Content
Evaluation/Selection of trainees
Acquisition of theoretical knowledge Clinical knowledge Complicating factors Patient selection criteria Surgical techniques
Handling of equipment and instruments
Motor skill training without patient presence “Dry” use of equipment (microscope,
instruments, and machinery) Wet lab training
Simulator training
Clinical training with patient presence
Observation of tutor performing surgery Step-wise execution of
different surgical elements Selection of patients Complete surgery
performed by trainee, tutor present Complete surgery
performed by t rainee, tutor present only wh e n requested by trainee
Independent surgery
Stepwise increasing numbers of operations performed per
working period Stepwi se increasing expected deg ree of
surgical difficulty Continuing but decre as i n g
need for consultation in difficult situations
traditional teacher-pupil relationship with obvious hier-
archical construction, the teacher has knowledge of the
requirements for a successful project and the methods to
attain the set goal, and conveys this knowledge to the
student in a one-way communication. Being instrumental
in the selection process puts the teaching surgeon in a
higher hierarchical position and can lead to accentuation
of the teacher-pupil relationship, at least at the beginning
of the training program. 2) In the partnership model, tutor
and student approach their task (e.g. trai ning of the st udent
in gene ral, o r a specifi c su rgical case) as a joi nt project. 3)
The apprenticeship model has been well-known in the
surgical field since William Halsted refined the concept of
how surgeons are trained through first observing how the
tutor performs a task and then performing the task in the
presence of the supervising tutor [15]. As in the teaching
model, a strict hierarchy between the tutor and the trainee
surgeon is obvious in the training situation, although in
other aspects there ma y be a collegial, peer relati onship. In
the medical field, the Halstedian approach is sometimes
referred to as “see one, do one, teach one”. Not only does
this expression mirror the fact that resource limitations
force teaching to be done within a limited time frame, but
it also reflects the accepted view that learning is achieved
on a deeper level when performing a task instead of ob-
serving, and even m ore so when the student in turn teaches
others how to perform the task.
The complex effect of taking a role as supervisor
vis-à-vis a colleague or a peer (who in some aspects or
fields m ay have a sup erior pos ition) has been discusse d by
Denicolo [16]. As the specific relations above, as outlined
by Dyst he, can be rather diffe rent fr om oth er rela tions a nd
context between training and t eaching surgeon, power and
responsibilities need to be balanced properly with regard
to the surgical training situation. One of Denicolo’s in-
formants points out the potential difficulty in delivering
critical feedback accurately to a peer.
The influence on the learning process exerted by the
roles and relationships between teaching and trainee sur-
geons is not a common topic in literature. Memon &
Memon made a distinction between the roles of trainer
and mentor, respectively, and identified a lack of formal
mentorship programs and learner-support in surgical
training [17]. A mentor should not only act as a surgical
teacher, but according to Kay and Hinds also be “prepared
to think about the broader aspects of people development
and the factors that influence them in their daily work and
choice of careers” [18]. Gagliardi et al. [13] investigated
how mentorship format, delivery, and content influenced
participation in and the impact of two programs for
training specific surgical measures for breast cancer and
rectal cancer. Their qualitative approach identified barri-
ers, such as scheduling and financing, but also found that a
key enabler was a pre-existing relation ship between men-
tor and mentee.
Learning perspectives and tutor-trainee relationship
change and overlap as the trainee surgeon progresses
through the different phases towards independence in
surgery, as outlined in Table 1. These changes can be ins-
tant, e.g. due to how an operation is prog ressing, or more
long-term as the trainee acquires deeper knowledge and
develops increased professional independence. It is im-
portant to realize that these changes are not a one-way
continuous develop ment, but instead th ere is commonly a
mix, or a back-and-forth movement, between different
perspectives and relationships. The teaching surgeon
needs to be aware of when the trainee surgeon’s situation
changes, and adapt the pedagogical framework accord-
ingly in order to opt imize the learning . The next paragraph
discusses how vari ous pers pectives com e into play in di ff-
erent phases and situations during the training program.
Initially the teacher-pupil relationship as described by

Application of Pedagogical Perspectives in the Teaching and Training of New Cataract Surgeons—A
Literature-Based Essay
64
Dysthe is readily recognized, especially if the teaching
surgeon is involv ed in the selection of new trainees [14].
This relationship can easily co ntinue into the next phase,
the acquisition of theoretical knowledge, when the tea-
ching surgeon gives advice about suitable sources of
knowledge—books, clinical guidelines and preferred prac-
tice pattern documents, user manuals, web-based sources,
or courses. Although strategies and protoc ols for assessing
that the trainee surgeon attains the learning objectives of
this second phase have been described, systematic ap-
proaches for this purpose are not generally implemented
[5]. Instead, the training and teaching surgeon may
commonly come to an agreement about when the learning
goals have been achieved. This is also applicable to the
third phase, when the trainee surgeon practices technical
skills without patients present. Depending on the trainee
surgeon’s progress, the relationship with the teaching
surgeon may take the form of partnership but a teaching
model may also be necessary depending on how much
guidance the trainee surgeon needs during these earlier
phases. Duri ng the fourt h phase, the app renticeship model
for supervising comes into play, as the trainee surgeon
first observes how the teaching surgeon performs the
different parts of the operation, and with time progres-
sively applies acquired theoretical and practical knowl-
edge by performing increasingly complete, complex and
competent surgical maneuvers on patients’ eyes [14].
5. Merging of Motor Skills Training and
Contextual Learning
As the surgical training program progresses (Table 1),
the teaching surgeon’s role becomes increasingly impor-
tant for the final result. When, in the fourth phase, the
surgical maneuvers are executed by the trainee surgeon
on the eyes of real patients, the teacher needs to be alert
and clear when instructing or correcting the trainee. The
patient should be informed of the progress of the surgery
without being worried by the teacher-trainee communi-
cation. A common approach is modular training, where
the trainee surgeon in the first cases only performs the
simpler steps while the teacher carries out the more com-
plicated parts [4]. As the trainee becomes comfortable
with the easier steps, the more difficult parts are succes-
sively introduced. Here it is easy to recognize the three
major stages of the motor skill theory suggested by Fitts
et al., with an initial cognitive phase, where the trainee
surgeon reads, listens, watches images, video recordings,
and live surgery and forms a mental picture of the per-
formance of the procedure before starting to execute un-
der close supervision—with more or less difficulty—
more and more of the full procedure [19]. With practice
and feedback from the supervisor the trainee surgeon
enters the second stage of the motor skill theory, where
the discrete components of the procedure are connected
into a smooth chain of su rgical events th at constitu tes the
complete operation, with fewer and fewer interruptions.
In the autonomous third phase, the surgery is performed
more and more automatically without the need for the
surgeon to consciously focus on every movement in de-
tail. The motor skills increase by repeating movements
and evaluating their outcomes according to Schmidt’s
schema theory of discrete motor skill learning, in which
specific muscle commands aimed to produce a specified
response from a defined starting point give sensory con-
sequences (in cataract surgery mainly through visual and ,
to some extent, proprioceptive feedback), and a response
outcome that is recognized and compared with the in-
tended response [20]. In this process, structured feedback
from the supervisor has been found to be important [21].
This should be kept in mind when implementing virtual
reality methods for surgical training of motor skills, as
has been suggested in the field of cataract surgery as well
as other surgical specialities [22,23]. As mentioned ear-
lier, structured forms for staging the training cataract
surgeon’s technical skills have been described [5]. Such
forms do not appear to be commonly implemented amo-
ng Swedish teaching cataract surgeons (personal com-
munication). When the surgical skills acquired by the
trainee surgeon during the first three training phases
(Table 1) are to be applied on a real patient, a whole new
set of contextual capabilities and skills will be necessary.
The trainee surgeon must focus not only on the specific
surgical maneuvers, but also monitor and respond ade-
quately to input from the patient as well as the teaching
surgeon and operation room staff (Figure 2). The teach-
ing surgeon must not only assess the surgical movements
and their outcomes but also pay attention to the contex-
tual learning perspective. Care must be taken to provide
feedback and information in a manner that does not make
the patient worried. A British teaching cataract surgeon
anecdotally instructed a trainee surgeon to immediately
stop the surgery at the moment the teacher uttered the
word “Excellent!” Coded messages, or silent communi-
cation with signs, are probably commonly used by
teaching surgeons with the aim to minimize untoward
anxiety and tension in the patient. The learning process is
inhibited if the tension level of the trainee surgeon in-
creases too much so also from a learning perspective it is
important that the teaching surgeon’s feedback be con-
veyed in a constructive, calm, and neutral manner [24].
6. Adapting to Stages and Situations as the
Trainee Surgeon Develops
After stating the importance of effective mentoring in the
development of surgeons at various levels, Memon &
Memon highlighted the absence of true structure and

Application of Pedagogical Perspectives in the Teaching and Training of New Cataract Surgeons—A
Literature-Based Essay 65
Figure 2. Schematic drawing of the contextual situation in
the operation room, at the stage where trainee surgeon is
performing the operation with teaching surgeon present.
Assistant nurse, trainee surgeon and teaching surgeon are
sterile. Scrub nurse is not sterile and may leave/enter the
room upon request or stay during the whole procedure.
Patient is awake and aware. Black single-lined arrows de-
note communication with information and instructions,
double-lined arrows denote orders. Continuous arrows in-
dicate communication open (not necessarily understandable)
to the patient. Dotted arrows indicate that the communica-
tion is constructed, or “censored”, aimed at providing pa-
tient information on a “need to know basis” and at the same
time concealing information that would cause patient con-
cern or anxiety.
incentives for mentorship in training of surgeons [17].
How the teaching surgeon can optimize mentorship by
navigating through the various learning perspectives and
types of teacher-student relationship while the trainee
surgeon gathers increased knowledge, skill and experi-
ence has indeed not been a common topic in the medical
literature. This lack of attention to developmental stages
in higher education has also been addressed by Gardner
[25].
In the field of organizational management, Hersey &
Blanchard coined and explored the term “situational
leadership” [26]. According to their theory, a leader’s
behavior can be optimized by adapting to the task-relevant
maturity of the person(s) subordinate to the leader. Al-
though the validity of their theory has been challenged
both theoretically and empirically, it has gained wide-
spread popul arity and a pplication i n various e nvironm ents
[27,28]. When applied to a surgical teaching paradigm
(Figure 3), the task-relevant maturity of the student/
Figure 3. Schematic illustration of teaching concepts adapt-
ed from the situational leadership model. The developmen-
tal stages of the trainee surgeon (D1-D4, single line arrows
and frames) are put into context with the matrix of the in-
structive-directive and supportive teaching concepts (T1-T4,
double line arrows and frames, italics). The beginner
trainee surgeon has a high motivation but a low compe-
tence level (D1). There is no need for the teacher to further
motivate/support at this stage, but the emphasis is instead
on instructive/directive teaching (T1). As difficulties are
encountered, the self-confidence and motivation of the
trainee surgeon decreases (D2), and the teacher needs to use
a more motivating/supportive manner of teaching, while
maintaining the instructive/directive emphasis (S2). Teach-
ing concepts are adjusted analogously through development
stages D3 and D4 (Adapted from Hershey & Blanchard
[26]).
learner can be divided into two factors—task maturity
(capability of performing the operation) and psychologi-
cal maturity (motivation level and confidence level). In
the first maturity or development phase, D1, the learner
has just entered the program, with a low level of compe-
tence but a high de gree of m otivati on and c onfidence . The
next phase, D2, is entered when initial difficulties and
failures may cause severely decreased motivation and
confidence in the learner. Task maturity is still low. As
further exper ienced is gathered, com petence increases, but
in the third stage, D3, motivation and co nfidence are still
on a low level, slowing the further development of the
learner who is reluctant to take on more advanced tasks.
With correct support from the teacher, the learner’s mo-
tivation and confidence may increase, which leads to the
final stage of develo pment, D4, where t he learne r now h as
high competence, motivation and confidence. The various
stages are not passed in a one -way - o nly manner, but there
may be discontinuous leaps and back-and-forth move-
ments.
The teacher needs to assess the trainee surgeon’s level
of development through phases D1-D4 according to the
matrix described above, and be flexible in order to tutor
optimally. As outlined in Figure 3, two fundamental
teaching concepts are applied: instructional/directive and

Application of Pedagogical Perspectives in the Teaching and Training of New Cataract Surgeons—A
Literature-Based Essay
66
Table 2. Learning perspectives, Teacher-learner relationships and situational leadership theory applications through the
different phases of surgical training.
Step in training program Learning perspective(s) Teacher-learner
relationship(s)
Stage(s) according to
situational leadership
theory
Teacher’s approach(es)
according to situational
leadership theory
Evaluation/Selection
of trainees Not applicable Teaching model Not applicable Not applicable
Acquisition of theoretical
knowledge Cognitive Teaching model D1 T1
Practical training without
patient presence Behavioristic, cognitive Master-apprentice model D1-D4 (modular ) T1-T4 (modular)
Clinical training with
patient presence Behavioristic, cognitive, contextual Master-apprentice model, partnership model D1-D4 T1-T4
Independent surgery Contextual, cognitive,
behavioristic Partnership model D4 (D2-D3) T4 (T2-T3)
supportive/contextual. Initially the learner has low com-
petence but high motivation and therefore needs instruc-
tion more than support (T1). In stage D2, there is a need
for both instructive an d supportive tutoring (T2), while as
competence is gained the supportive tutoring is much
more important than instructio ns in stage D3. In the final
stage, D4, the teacher offers less support and fewer in-
structions as the trainee surgeon gains increasing inde-
pendence based on sufficie nt com petence a nd c onfi dence.
In the surgical teaching paradigm, the task of the teacher/
mentor now changes to more organizational supportive
measures, that is, assist in providing suitable working
schedules and finding a new role in the organization
(Figure 3).
7. Summary
The task of educating new cataract surgeons is necessary
but also both ethically and pedagogically challenging. It
is performed under increasingly demanding circum-
stances. In Table 2, the complexity of the learning proc-
ess for a trainee surgeon is evident, culminating as the
training takes place in the operation room with actual
patients. In order to make optimal use of available struc-
tures for education such as literature, on-line resources,
wet-lab facilities, simulators and patient-related activities,
it can be beneficial for the teaching surgeon, the trainee
surgeon and the patients as well that the teaching surgeon
is aware of existing theories and concepts regarding
learning and tutoring. This can improve the teaching
surgeon’s ability to recognize how the situation changes
for the trainee surgeon during the various phases, and
adapt the teaching approach accordingly in order to op-
timize the learning process. Studies concerning how
teaching surgeons make use of various strategies during
the phases that a trainee surgeon passes, and how these
strategies work out, are warranted.
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