The consultant-trainee paradox in simulation: A question of validity, not inherent skill

Dear Editor, We read with interest the editorial by Kaur and Pandav and their observations on the study by El Salloukh et al. examining the effects of distraction on cataract surgery performance using a simulator and the observation that senior consultants performed worse than trainees under specific conditions on the EyeSi simulator platform.[1,2] While such findings are provocative, their interpretation must be grounded in a clear understanding of the validity framework that underpins simulation-based assessment. Face validity: Face validity measures how realistically a simulator replicates live surgery. The editorial rightly notes tactile and contextual limitations in some systems, but newer high-fidelity platforms demonstrate strong face validity. EyeSi, HelpMeSee, and other surgical simulators are designed to mimic core steps of cataract surgery, such as capsulorhexis, nucleus sculpting, and phacoemulsification. These systems offer high face validity because they replicate the visual and mechanical elements of surgery, particularly for novice learners. However, face validity is inherently subjective and does not imply accuracy in assessing real-world expertise. Nair et al.[3] in their study on the face and content validity of the HelpMeSee simulator found that 92% of experts rated its tissue behavior “realistic” and 88% endorsed its anatomical accuracy. Hutter et al.[4] reported that the HelpMeeSee simulator achieved “near-physiological haptic feedback” during nucleus delivery in MSICS, critical for expert engagement. Given that the EyeSi simulator does not have real-time tactile feedback, the findings by El Salloukh likely reflect simulator-specific face validity gaps, not inherent flaws in simulation. It is quite possible that consultants struggled where tactile fidelity was inadequate, while trainees, lacking real-world reference, adapted more easily. Content validity: This addresses whether a simulator comprehensively includes the skills and tasks it purports to train. Many simulators have been designed primarily to teach foundational surgical steps and improve hand-eye coordination, which are particularly relevant in the early stages of training. As Kaur and Pandav have rightly pointed out, studies by Feudner et al. and McCannel et al.[5,6] demonstrated improved capsulorrhexis and surgical skills among residents following EyeSi simulation training, underscoring strong content validity in early surgical learning contexts. Construct validity: This, we believe, is the most crucial parameter when considering studies comparing senior and junior surgeons. It refers to the ability of a tool to distinguish between individuals with differing levels of the targeted ability. EyeSi has shown reasonable construct validity in multiple studies by differentiating novices from experienced surgeons.[7] However, construct validity does not imply perfect correlation across all levels of experience or in all simulated tasks. In fact, certain simulation modules may emphasize precision over adaptability or familiarity with specific interface mechanics rather than true surgical dexterity; inadvertently favoring those with more recent exposure to the tool or structured simulation environments—often trainees rather than consultants. Senior surgeons bring nuanced intraoperative decision-making, anticipation of complications, and context-dependent adaptability – skills that surgical simulators are currently limited in evaluating. The divergence in performance, as noted by El Salloukh et al.,[2] may reflect not a lack of skill, but rather a misalignment between what the simulator measures and the broader expertise of experienced surgeons. Distraction tasks in the study may further skew these outcomes, particularly if such distractions are more relevant to procedural precision than higher-order cognitive surgical decision-making. We believe the consultant-trainee discrepancy is not evidence against simulation but a call for Simulator-specific validity testing: Face/content validity must be assessed during design, not post hoc.[8] Stratified metrics: Scoring systems should reward expert priorities, not just trainee-focused efficiency. Hybrid assessment: Combine simulator scores with live-surgery evaluations for holistic competency mapping.[9] We thank the authors for their insightful editorial, and we commend the ongoing efforts to incorporate simulation in ophthalmic training. However, caution must be exercised when extrapolating simulator-based performance to infer real-world surgical competence, particularly for experienced surgeons. It would be equally unwise to dismiss simulation training altogether. Robust evidence supports its role in reducing complication rates among trainees and improving early surgical skills. Simulators offer a risk-free, reproducible, and resource-efficient environment for learning and assessment – particularly in the foundational stages of training. As simulation technology evolves, it will likely become more sophisticated in capturing higher-order skills and decision-making. Rather than viewing simulation as a replacement or as a threat to traditional expertise, we must embrace it as a valuable adjunct – one that complements but does not substitute the richness of real-world surgical experience. Financial support and sponsorship: Akshay Gopinathan Nair has received lecture fees from Sun Pharma Ltd., Carl Zeiss Meditec Ltd., and currently serves as a consultant for HMS Vision Pvt. Ltd. Van Charles Lansingh and Nicoletta Fynn-Thompson are employees of HelpMeSee. There are no other financial interests for any of the other authors. Conflicts of interest: There are no conflicts of interest.