New M.D.

The Three Charges of Residency

By Lauren Eckstein, M.D.

A detailed understanding of the philosophical and technical foundations for both the mundane procedures as well as the sophisticated techniques we routinely practice critically impacts our ability to deliver excellent surgical outcomes and to generate happy patients.

It is not sufficient to be merely skillful or proficient at cataract removal by phacoemulsification. To be truly expert — to adapt effortlessly to unanticipated or unique situations — we must also fully comprehend the mechanics of fluidics, the detailed phaco instrument settings and the dynamic interplay between the two. Anything less and we will be incapable of troubleshooting unexpected intraoperative behaviors, such as an unusually shallow chamber, or successfully managing surgical complications like vitreous loss. Failure to master this knowledge not only compromises patient safety, but also reduces us to little more than skilled technicians. The long-term success of an ophthalmic surgeon rests in part on our exquisite understanding of these fundamental principles. Therefore, the first charge of residency is to instill a rich and detailed expertise.

Skill Should Beget Confidence

Yet even this level of mastery is not itself sufficient indoctrination to ensure the ascendancy of the surgeon in the years beyond residency. Physicians in training must also develop a sense of empowerment. They must come to believe that they are the most qualified and suitable person to render a given task — from performing a laser procedure, to operating. Many residents believe a priori that they are the most qualified surgeons available as a default function of their seniority; alternatively, their early enthusiasm to operate may blind them to the contrary reality. But these are at best hedges, conditions unique to residency.

In the years following, as physicians enter the community and compete in the marketplace, they will probably encounter patients who may be ‘doctor-shopping,’ They are also likely to experience job fatigue, whereby the formerly unique becomes the mundane. Through these humbling experiences, they will come to understand that they are neither the most senior nor the most experienced surgeon.

They must nevertheless press on, confident that they are qualified to perform the task before them — anything less results in hesitation, equivocation and impaired surgical outcomes. Therefore, the second charge of residency is to nurture a resilient sense of confidence.

Commit to Lifelong Learning

Finally, we must prepare our residents to be competitive at all stages of their careers — equipped with tools and philosophies (in addition to formal knowledge) that will facilitate their success, not only in the years immediately following residency but also in the decades beyond. As technology advances and surgical techniques evolve, it is essential to bestow upon residents a skill set that enables and encourages adaptation to this changing clinical landscape. This may not be accomplished by strict didactic teaching alone, as these lessons will doubtless someday become outmoded or obsolete. Rather, it is achieved by engendering a sense of curiosity and a commitment to lifelong learning.

Training must not end at the conclusion of residency. Indeed, at some point following graduation we will each face a situation or attempt a surgery for which we have not explicitly trained during residency. Success will be achieved not by the dogmatic commitment to antiquated methodologies, but rather by the reasoned application of newly acquired learning and the careful practice of newly mastered skills. Therefore, the third and final charge of residency is to engender a lasting commitment to scholarship.

These are profoundly difficult tasks, but no other aspect of resident education is more critical to ensuring the long-term success of physicians and surgeons. It is imperative that lack of experience must neither be a surrogate for lack of knowledge nor a pretext for lack of confidence. Indeed, as we negotiate the many challenges that will confront us throughout our careers, empowered by these philosophical precepts, experience becomes just one of many important players. But it must remain only a minor character in the foundation of conviction. OM