New education method or tool
Open Access

Cataract-Surgery Informal Feedback for Trainees (C-SIFT)

Matthew Fenech[1], Adesuwa Garrick[2]

Institution: 1. St Helens and Knowsley NHS Trust, 2. Southport and Ormkirk NHS Trust
Corresponding Author: Mrs Adesuwa Garrick ([email protected])
Categories: Learning Outcomes/Competency, Teachers/Trainers (including Faculty Development), Teaching and Learning, Postgraduate (including Speciality Training), Undergraduate/Graduate
Published Date: 08/10/2020


Introduction: Ophthalmology is a medical and surgical specialty. Feedback is regarded as a comparison between trainees’ observed performance and a standard. It should be used by both the trainer and trainee to assess surgical skills, to improve surgical learning curves and identify areas that affect trainee’s surgical outcomes.


Method: Post-operatively, the trainee is asked to rate his or her performance as “Good” or “could do better” for each of the key steps in cataract surgery. This is done on a table drawn on a board within the operating theatre. The trainer then assesses the way the trainee has judged his or her own performance and gives feedback accordingly on each step. On attempting a second case the trainee is able to build on the performance of the previous case and the table is repeated once more post-operatively.


Result: This method has proven to be engaging, quick and reliable. Most of all it is reproducible and can be adapted to any surgical environment. From a trainees point of view it allows him or her to assess their own capabilities, criticize their own performance and visualize what can improve. From a trainer’s point of view, this method helps assess the trainee’s insight and allows for an informal constructive criticism of each surgical step. With a visual representation of their performance on the board, the trainee may use this as a roadmap of where to improve on the next attempt.


Conclusion: C-SIFT Tool is trainee driven, orderly and consistent. It enables a bird’s eye view of the trainee’s performance instead of focusing on the negatives. Once the method of feedback is established with the trainee, there will no debate as to how, where or when to commence feedback as this is done immediately after every case.


Keywords: Cataract surgery; Ophthalmology; training; Feedback; reflection; Insight


Ophthalmology is a medical and surgical specialty, posing a unique challenge to trainees and trainers alike. Feedback is unique to different specialties, as each requires its own method and approach.


Mastering a surgical skill is fundamental to any surgical training program, where the acquisition of surgical competence must be closely paired with the ability to grasp key concepts and develop robust professional attitude (Saleh et al., 2007). Constructive and formative feedback is essential in ensuring surgical heights are pursued and reached.


Historically, the recognition and acquisition of feedback within the medical sector has always proven to be both poor and challenging (Kamali and Illing, 2018; Vab Der Veur, 1978). Feedback is regarded as a comparison between a trainee’s observed performance and a standard, usually given with the intent of improving the trainee’s performance (Saedon et al., 2012; van de Ridder et al., 2008). Feedback should be used by both the trainer and trainee to assess surgical skills, to improve surgical learning curves and most of all, identify areas that affect trainee’s ’ surgical outcomes (Cremers et al., 2005).


In this paper, we will discuss how feedback can be provided in ophthalmology and discuss the strategies already available.


Why is feedback important?

There is a great paucity within the literature on the impact feedback can have on a surgical trainee’s development and well-being (Kamali and Illing, 2018), even more so in the field of ophthalmology. This is surprising, when one considers that feedback has a powerful impact on a trainee’s development, than prior cognitive ability (Hattie and Timperley, 2007; Kamali and Illing, 2018).


Both positive and negative feedback can enhance the learning process. Positive feedback is more likely to result in an attitude that is conducive to learning (Kamali and Illing, 2018). Positive feedback tends to be supportive and constructive, with the ultimate aim of improving the well-being and performance of the trainee (Kamali and Illing, 2018). Intra-operative positive feedback also helps relax the trainee. Trainees tend to feel reassured and confident in continuing despite making errors, something that is not commonly seen when negative feedback is given (Zahid, Hong and Young, 2017). Positive feedback also helps strengthen the relationship between trainee and trainer, enhancing both the collegial and educational aspect to learning (Hoffman et al., 2015).


Negative feedback, depending on how it is delivered, can have a powerful effect on the trainee’s self-confidence, self-direction and self-discipline. It may undermine the overall performance and belief (Kluger and DeNisi, 1996). Furthermore, research has shown that trainees with a low self-esteem are more likely to react poorly to negative feedback. This results in suppressed motivation to complete and excel in subsequent tasks, believing that feedback is due to a lack of ability rather than trial and effort (Brockner, Derr and Laing, 1987; Kernis, Brockner and Frankel, 1989; Moreland and Sweeney, 1984). Trainees may lose interest, with some describing a “fear” for theatre and a lack of self-worth. Negative feedback may also heavily impact learning, in and out of the surgical setting, decreasing performance and devaluing the trainer/trainee relationship.


Effective Feedback needs to be provided by trained trainers. Supportive trainers may encourage the trainee to leave their comfort zone, enabling them to perform more complex operations than they previously thought with the aim of furthering their surgical development (Kamali and Illing, 2018). Ultimately, certain learning events within the confines of an operating theatre and surgical setting require constructive criticism and corrective feedback (Kamali and Illing, 2018).


Feedback models

Unless the trainee accepts feedback, it cannot be effective. Both the recipient and provider should agree on the purpose and content of the feedback (McKinley, Williams and Stephenson, 2010). The Pendleton feedback model aims to identify the strengths of the trainee and build on them, further focusing on how performance may be improved from that point. This approach focuses on the trainee’s opinion first, assesses the positives before the negatives and targets specific behaviors rather than general comments. Although useful, this approach tends to result in a lack of insightful thought due to its rigid nature (McKinley, Williams and Stephenson, 2010). The “agenda-led model” is a modification of the Pendleton feedback and it gives importance to identifying the trainee’s learning objectives.


Formative feedback measures assists the trainee in identifying their strengths and weaknesses, allowing them to focus on skills that need further development and refinement (McKinley, Williams and Stephenson, 2010). No matter what assessment tool is implemented, distinct objectives may be clearly identified amongst them all, namely (Green et al., 2017):


  • The desire to minimize subjectivity
  • The importance of clearly defining the skills that must be obtained at each level of proficiency
  • The necessity for clearly identifying objectives expected of the trainee, in order to obtain competency at each level
  • The drive towards self-assessment


Formative assessments also help the faculty recognize suboptimal performance. They are often objective and transparent, allowing consistent assessment free of inter and intra-assessor variability. The Keele skills curriculum model is designed for formative and summative assessments of clinical procedural skills. The Leicester clinical procedural skills assessment tool is another tool designed for the formative and summative assessment of clinical procedural skills, helping teachers to systematically identify strengths and weaknesses amongst trainees. Unfortunately, such tools do not help pupils identify the specific interventions required to address their weaknesses. The modified LCAT approach aims in doing just that (McKinley, Williams and Stephenson, 2010).


Unfortunately, the above measures cannot be applied to all specialties. Although they form an integral part of the personal development plans established between trainee and trainer, they do not provide an adequate assessment tool for immediate feedback to the trainee following cataract surgery. In anesthesia, the LOAF and BREAD educational checklists are commonly applied to tackle this issue. The acronyms refer to the key factors required for a learning brief to be provided at the start of the operative list and the feedback provided at the end of the list respectively (Maclennan, 2020)


  • LOAF:
    • Learning objectives
    • Assessment
    • Feedback
  • BREAD:
    • Best practice
    • Reflection
    • Educational agreement
    • Assessment
    • Debrief

Such models can be applied to ophthalmology, especially in the surgical setting. Prior to any surgical list, learning objectives must be agreed on and ultimately, a trainee must be receptive to any intraoperative and postoperative feedback. Furthermore, the trainee must be capable of reflecting on the feedback received during and after the surgical procedure. The trainee must also feel comfortable enough to discuss how the educational environment could have been improved. Similarly, time should be allocated, during the theatre list, for the trainee and trainer to discuss feedback. This will include what the trainee did right and what could be improved. As well as feedback, the ultimate aim includes   reflecting on the practice which enables the formation of an action plan to support the trainee in developing further.


Whilst it may be challenging to adapt the BREAD model after each and every surgical procedure performed by the trainee, adequate assessment tools may be implemented in order to help facilitate the delivery of effective, constructive and formative feedback.

Our approach to intra-operative feedback

Surgical time for trainees has been impacted by the change in the training structure coupled with the ever-growing financial pressures which push for increased surgical numbers. This has ultimately led to the need for achieving surgical proficiency in less time (Golnik et al., 2004; Leach, 2001; Lee and Volpe, 2004; Mills and Mannis, 2004) In order to provide effective feedback assessment tools need to be practiced that are quick, provide insight and stimulates the trainee to maintain a passion to improve (Moorthy et al., 2003; Skidmore, 1997).


We describe below an assessment tool that is quick and easy to perform, enabling the trainee to assess their performance. Furthermore, this too gives the trainer indirect access to the trainee’s insight.  The assessment tool consists of a table drawn on a board in the operating theatre, breaking down the surgery into 10 key steps; draping, wound construction, capsulorhexis, hydrodissection, grooving, divide and conquer, quadrant removal, irrigation and aspiration, IOL insertion and wound closure/hydration (Table 1).


Table 1: C-SIFT Tool as used in the Operating Theatre.

Main Steps in straight forward cataract surgery


Could be improved







Wound construction












Divide and Conquer



Quadrant Removal



Irrigation and Aspiration



IOL insertion



Wound closure/hydration




After each hands-on surgical case, the trainee (trainer may be writing up the surgical notes) is given a chance to tick the sections in which they have ‘Done well’ in and those areas they feel they ‘could do better’. We refer to this assessment method as the Cataract-Surgery Informal Feedback for Trainees (C-SIFT).  


For each step, multiple facets may be discussed, with the following points proving the be particularly effective:

  • Draping:
    • Adequate orientation?
    • Adequate lash cover?
    • Adequate face fitting?
    • Adequate nasal exposure?
  • Wound construction:
    • Adequate side port location?
    • Adequate main wound position?
    • Adequate wound construction – 3-step technique followed?
  • Capsulorrhexis:
    • Adequate capsule exposure? Vision blue/Intracameral phenylephrine required?
    • Adequate positioning?
    • Adequate size?
    • Adequate continuous curvilinear technique?
  • Hydrodissection/Hydrodelineation:
    • Adequate control?
    • Adequate mobilisation of the lens?
    • Adjustment made for the nature of the cataract?
  • Grooving:
    • Adequate depth?
    • Adequate width?
    • Adequate power used?
  • Divide and Conquer:
    • Adequate cracking?
    • Adequate positioning of the phaco probe and 2nd instrument?
    • Adequate insight on the stress put onto the posterior capsule?
  • Quadrant removal:
    • Adequate positioning of the phaco probe?
    • Adequate protection of the corneal endothelium?
    • Adequate protection of the posterior capsule?
  • Irrigation and aspiration:
    • Adequate respect for the anterior capsule?
  • IOL insertion:
    • Adequate filling of the bag with visco-elastic?
    • Adequate IOL positioning?
  • Wound closure/hydration:
    • Adequate assessment for any wound leaks?
    • Adequate assessment for suture requirement?

Benefits of C-SIFT tool for the trainee and trainer

Trainee perspective: This approach ensures immediate reflection. The trainee is able to assess what they have done correctly, what they have excelled in and what could be improved.  Identifying weak areas will:


  • ensure the next case runs smoothly
  • Assists the trainee to identify what adjustment is needed.
  • How these adjustments have impacted surgical outcomes.


Following a challenging case, it is important for the trainee to ‘get back on the horse’ as quickly as possible and put that feedback into practice. This will facilitate a steeper learning curve and quicker adjustment to surgical technique. Our assessment tool is quick, targeted and most importantly informal. It is designed to allow the trainee to learn with every surgical case. It is not targeted to assess a change in practice over time but a means of dissecting each and every case, pin pointing how things could have been performed better in order to achieve a more streamlined and smoother surgical outcome on the next attempt. This method allows the trainee to self-evaluate straight away, giving them a chance to improve at the next attempt.


Trainer’s perspective: This tool is useful for all surgical trainees who find a surgical step challenging. It enables the trainer focus on a particular step and discusses, in fine detail, techniques on how to improve. The sandwich technique of feedback starts with a positive reinforcement, followed by a negative aspect to the surgical steps performed, ultimately ending with a positive aspect (Brown, Rangachari and Melia, 2017). Trainees with no insight may not hear the negative feedback in the middle or not understand the gravity as it is quickly followed by positive tones. However, with our C-SIFT tool, the order in which feedback is given follows the surgical steps. The trainee/trainer discussion of every surgical step is a mixture of feedback and reflection. For trainees, with limited insight, this is an effortless way of commencing them on the journey of improving their insight. In cases were the trainer had to take over surgery from the trainee or cases that the trainer found challenging/complicated, the trainer may also reflect on their own performance elaborating on what they did well and what they could have done better. This opens up an avenue to foster trust between the trainee and trainer. The trainee is indirectly been told that reflection never ceases no matter how experienced the surgeon is.


The benefit of the C-SIFT tool lies in its simplicity. The trainer is able to quickly and effectively disseminate information on the areas that require improvement and offer praise to the trainee in areas of improvement. This will allow the trainee to examine his or her own insight into their surgical skills at every step. Whilst the trainee may feel that he or she was performing well in some fields but in actual fact was underperforming, the same rings true vice versa. This sort of feedback is both formative and constructive. The trainee will be able to act on the fields that were not up to standard. Similarly, the areas where the trainee felt he or she fell short but were actually deemed sufficient by the trainer may give the trainee further confidence their ability.


Underpinning our approach is a framework conceptualized by Egan (Egan, 1998). It gives the trainee time to proceed from one step of the process to another. There may be times when a step back is taken as new insight is obtained. This method encourages trainees to reflect and build on their insight, which is essential for continual development (Klaber, Mellon and Melville, 2010). Feedback is crucial in developing and maintaining such insight.


The relationship between feedback and the desired outcome is not always straightforward (McKinley, Williams and Stephenson, 2010; Saedon et al., 2012). Good feedback may lead to increased motivation and confidence in trainees. Furthermore, negative feedback should not aim to demotivate or demoralize a trainee.  There is a need to match the expectations of the learner with those of the trainer, trainers that are skilled in giving feedback (McKinley et al., 2010).


C-SIFT Tool is trainee driven, orderly and consistent. It enables a bird’s eye view of the trainee’s performance instead of focusing on the negatives. Once the method of feedback is established with the trainee, there will no debate as to how, where or when to commence feedback as this is done immediately after every case.


All institutions should have skills assessment criteria (McKinley, Williams and Stephenson, 2010). If these criteria are valid, they will represent what a student is expected to achieve. They also identify the likely range of deficiencies in the student’s skills (Saleh et al., 2007). As eluded to earlier, no single method can single handedly, adequately or comprehensively assess the surgical skills of a resident in training. Direct observation with objective analysis of surgical technique and proper immediate feedback after each case are help towards instilling immediate positive reinforcement as well as indicating where things can be improved (Cremers et al., 2005).


Ultimately, high quality training in any field needs a strong ethos of supervision and feedback (Klaber, Mellon and Melville, 2010).

Take Home Messages

  • Drive to match expectations of the learner with those of the trainer.
  • Feedback helps to improve surgical learning curve.
  • Trainee perspective:  C-SIFT allows for an assessment of personal capabilities.
  • Trainer perspective: C-SIFT helps assess the trainee’s insight, allowing for informal constructive criticism of each surgical step.
  • Sets the tone for immediate feedback after every case.

Notes On Contributors

Matthew Fenech is an Ophthalmology specialist trainee in the Mersey Deanery. Prior to starting his training program, he completed an MSc in clinical ophthalmology where he obtained a distinction and was nominated for the Dean's List award. He has a keen interest in anterior segment and teaching.


Mrs Adesuwa Garrick is a Consultant Ophthalmologist with a special interest in glaucoma and cataract surgery. She completed her specialist training in the Mersey region ending with a one-year glaucoma fellowship. She holds a PGCert in WPB assessments. 




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