New M.D.

The Making of an Eye Surgeon

By Lauren A. Eckstein, M.D., Ph.D.

A few years ago (while still a resident) I walked into an operating room to begin a case staffed by a new fellow who would be serving as the attending physician for the surgery. Rather than setting up the operating microscope and making other preparations for surgery, the fellow was pacing nervously in the back of the theatre.

When I asked what was troubling him, he explained that he had never operated unattended before. He said that while he knew the surgery well and had performed it many times, he was unaccustomed to working without supervision. Although confident in his abilities, he was nevertheless nervous about operating alone.

In a previous column, I discussed some of the difficulties encountered when starting a new job, often in an unfamiliar city. One of the unique challenges, which is highlighted by the anecdote above, is the transition to independent practice that occurs for all physicians when they complete residency and take their first job or begin fellowship training. This process is especially taxing for surgeons. Prior to graduation, most physicians have had the opportunity to evaluate and medically treat patients with minimal or no attending oversight during evening, weekend or holiday call. And so, this transition may engender only minimal stress or anxiety.

However, due to the educational requirements and patient care stipulations of the Accreditation Council for Graduate Medical Education (ACGME) and other organizations with regulatory oversight, most surgeons have not had a similar experience. Indeed, beyond repair of simple lid lacerations, or removal of a corneal foreign body, at the time that they complete residency few if any ophthalmologists have ever operated without a senior surgeon by their side. How then, do we adequately prepare residents for operating when they finish residency while still respecting the limitations imposed by these external governing bodies?

To be sure, this is a very difficult task, and there may be no definitive, universally applicable answers. Regardless of whether the first time a surgeon operates unsupervised occurs during residency, fellowship or private practice, it must nonetheless occur. As teachers and mentors, we must not try to hasten the approach of this milestone; rather, we must endeavor to ready our pupils for its arrival. New surgeons must be taught to welcome their new freedom rather than face it with trepidation.

Encouraging Independence

Perhaps the most obvious means to engender autonomy is to encourage and even demand regular displays of independent thought — beginning during the earliest stages of training and continuing through to graduation. This process may start with simple decisions, such as allowing a first-year resident to choose which pressure-lowering medication to prescribe to a patient. Through experience and patient follow-up, he or she may witness the consequences of such choices, a process of feedback that may serve to build confidence and an independent spirit.

Concurrent with this maturation, as instructors we must also encourage our residents to routinely question our choices so that they may integrate lessons derived from our greater experience and gain insight from our internal decision-making process. Thus, an intrinsic component in the development of independence is a natural inquisitiveness. Without constant questioning and exploration of ideas, trainees will be incapable of making informed decisions on their own and will instead default to dogmatic clinical and surgical approaches.

As trainees advance and demonstrate ever-greater autonomy and expertise, the breadth of the decisions left to their discretion may reasonably be expanded step-wise. This process naturally culminates in the resident surgeon making insightful decisions about surgical planning (e.g., trabeculectomy vs. Ahmed valve) as well as spontaneous intraoperative choices (e.g., divide-and-conquer vs. stop-and-chop). Ultimately, the attending physician, while present, may contribute only minimally (if at all) to the progress and completion of the surgery.

Through these and other straight-forward actions, we may reliably ready our residents to confidently approach their initial surgical procedures following residency with the understanding that these first unattended surgeries are not also their first independent surgeries. OM