New M.D.

Every Case Is a Learning Opportunity

By Lauren Eckstein, M.D.

Once a week, the residents at one of our affiliated hospitals gather to discuss any surgical complications or difficult cases they may have encountered during the preceding week.

Cases are discussed in detail – from preoperative assessment and surgical planning to intraoperative events and postoperative management. This supportive forum provides an outstanding opportunity to examine the surgical challenges we are currently confronting, to hear how other residents may have overcome similar difficulties and to learn from our faculty how best to negotiate these obstacles. Without a doubt, this conference provides an indispensable opportunity to critically examine our weaknesses and to leverage the experiences of other physicians to improve our own surgical skills.

No Case Is Ever "Routine"

However, I occasionally encounter a resident who describes an uneventful surgery as, "routine." This is a disturbing statement for a young surgeon. Although a case may have proceeded without complication and the patient may have done well postoperatively, no two cases are identical. Thus, no case is routine. At a minimum, every case presents unique considerations, distinct challenges or novel opportunities for learning; often times, all three.

My mentor, Dr. Uday Devgan, speaks and writes about maximizing the educational benefit to residents in all aspects of their instruction. This philosophy encourages relentless clinical exploration and erudition. It demands a commitment on the part of faculty and residents alike to actively seek new opportunities for learning and to exploit every case to expand their surgical expertise and extend their ophthalmic knowledge. Nowhere is this truer than in the operating theater.

Every surgery is an occasion to improve the welfare of the patient, and also an occasion to advance the skills of the resident surgeon. To realize this objective, it is imperative that we create supportive instructional environments, that we nurture cultures that maximize the opportunities for residents to expand their surgical armamentarium and that we encourage resident exploration. Perhaps this is as simple as changing the position of the corneal incisions during phacoemulsification to mitigate preexisting corneal astigmatism, or as complex as employing a novel pupil-expansion device in a patient with floppy iris syndrome. In all such instances, the patient benefits from improved surgical outcomes, and the resident physician benefits from the acquisition of new skills.

Not so surprisingly, this principle of proactive learning in all cases demands a commitment by both attending surgeons and residents. As we advance in our careers and gain greater surgical experience, we each develop preferred surgical methodologies. But the opportunity for formal surgical instruction is short and we must not allow ourselves to become complacent, seduced by the familiar and the routine. Rather, we must seek new challenges and capitalize on all available experiences. Our attending physicians are an invaluable resource, and we have an obligation to ourselves and to our patients to acquire as much of their expertise as possible.

My greatest gains in surgical knowledge and skill have come during difficult or complex cases — a sentiment I share with many other physicians. But what is unique for residents during these experiences is that we are generally supported by assistants more practiced than ourselves. What transpired during these cases was an intense discussion wherein my attending and I freely exchanged thoughts and ideas to realize the objective of a safe and successful surgical outcome. In the process, I gained the greater insight of my attending and assimilated wisdom beyond my limited experience. However, what is most challenging, is engendering this dialogue during ‘routine’ cases.

We are all thrilled when a case goes well, but the lack of complications is not satisfaction enough. Indeed, success must also be measured by our acquisition of new knowledge, not merely the reinforcement of our current proficiency. From the perspective of a resident physician, absent new understanding, a successful surgery may still be a failure. OM