PART 4 | SUBSPECIALTY SERIES

Ensuring a Smooth Transition for Your New Subspecialist

Two surgeons describe how they introduced and integrated their subspecialties

By Virginia Pickles, Contributing Editor

In the final article of this series, a retina specialist and an oculoplastics surgeon describe how they collaborated with management and staff of the ophthalmic ASCs they joined to successfully integrate their subspecialties. They share practical tips that helped ease the transition for them and their new colleagues.

Meet the Surgeons

After 15 years in practice, retina specialist Nancy M. Holekamp, MD, had operated in every setting in which retina surgeries are performed: the outpatient surgery center of a large hospital, the main operating room of a mid-size community hospital, and a freestanding ambulatory surgery center that performed both ophthalmic and non-ophthalmic procedures.

With vitreoretinal surgical techniques becoming more elegant and streamlined at a rapid pace, Dr. Holekamp recognized the advantages of operating in an ASC. However, as part owner of an ophthalmic ASC serving 13 other surgeons, she was finding it difficult to schedule time there.

After exploring other opportunities in the area, she joined the Pepose Vision Institute in St. Louis, which, until her arrival, had focused only on anterior segment surgeries. That was 5 years ago, and Dr. Holekamp has never regretted her decision. Not only has she found operating in this setting more efficient with less administrative tasks and paperwork than in most hospitals, she also feels she can deliver better patient care at the ASC.

Charles Anthony II, MD, came to the same conclusions about the advantages of operating in an ASC. “During my training, I had operated in seven or eight different settings, involving both hospitals and ambulatory surgery centers, and I felt that operating in an ASC would be less stressful with fewer layers of bureaucracy,” he says. “In addition, you have much more flexibility and control over your schedule in an ASC.”

After completing a fellowship in oculofacial plastic surgery last year, Dr. Anthony joined The Eye Associates in Bradenton, Fla., an ASC focused primarily on cataract surgery.

Both surgeons say another key benefit to operating in an ASC is the convenience — to patients as well as physicians — of having a surgery center adjacent to where they practice.

“One of the most remarkable things,” Dr. Holekamp says, “is that I can see a patient with an emergency macula-on retinal detachment in my clinic, call the OR to add on a case, and within a matter of hours, I can be operating on that eye. Nowhere else in St. Louis — and I would venture to say very few places in the country — can someone walk into a building with a retinal detachment and walk out that same day with that retina repaired. That is great care.”

Achieving and maintaining the highest level of care requires that surgeons and staff function as a team, and being the first surgeon of your subspecialty to operate in a particular ASC requires meticulous attention to detail and thorough, advance planning.

Patient Flow and Scheduling

Although Dr. Anthony wasn’t the first oculoplastic surgeon to operate in the ASC at The Eye Associates, he joined the practice after the previous surgeon had left, so he knew it would be important to reacquaint the staff with the unique needs of his subspecialty, as well as apprise them of his preferences.

“During my initial tour of the ASC, I took note of how many pre-op and post-op beds were available to help predict patient flow, which is an important consideration,” Dr. Anthony says. “The majority of their cases were cataract surgeries, which are relatively uniform in terms of time required. In oculoplastics, I perform a variety of surgeries, which can take from 15 minutes to 2 hours or more, so it was crucial to discuss this and devise a way to block the proper amount of time per case and organize the day to maximize efficiency and minimize wait times for patients.”

Similarly, Dr. Holekamp says good communication with the ASC staff is essential to efficient patient flow and minimal patient wait times. “I give the scheduling staff realistic estimates of how long each case will take, they create a schedule, and then I review it,” Dr. Holekamp says. “That way, we’re all on the same page. At an ASC, the patient flow is easier to control than at a larger hospital.”

Equipment and Instrument Acquisition

About 3 months before Dr. Holekamp began operating at the Pepose Vision Institute, she and her scrub nurse, Laurie Richards, who has extensive experience in vitreoretinal surgery and had been working with Dr. Holekamp for 17 years, pored over catalogs and viewed equipment at the annual meeting of the American Academy of Ophthalmology. Their shopping list included major items — a vitrectomy machine, a laser, and a cryotherapy machine — but even seemingly mundane instruments take on added importance when starting from scratch.

“When you’re setting up an OR, the equipment you get is very important,” Dr. Holekamp says. “You can’t be in the middle of a case and ask for a subretinal forceps, for example, and not have one. You can’t plan only for the routine cases. You have to anticipate everything that could possibly happen.”

Well before scheduling his first surgery at the ASC at The Eye Associates, Dr. Anthony checked the availability and condition of certain devices that he would need, such as Bovie and Ellman cautery units, suction, and smoke evacuation, and he took stock of the instruments already available, checking them against his list of preferred instruments.

“Before transitioning to the new ASC, I took photos of all of my instrument trays, devices, tips, and other supplies, noting the manufacturers and model numbers for each item,” he says (Figure 1). “They had to order about a quarter of the instruments I use, and having this information simplified the acquisition process.”

Figure 1. Dr. Anthony's instrument tray.

Acclimating Staff

Both Dr. Holekamp and Dr. Anthony were able to use existing staff at their respective ASCs, thus avoiding what can sometimes be a lengthy and tedious hiring process. Joining an established team and teaching them the nuances of a new subspecialty comes with its own challenges, however, and both surgeons proactively took steps to facilitate a smooth transition and establish rapport with staff.

“Well over a month before my first surgery, I went through a dry run with the staff,” Dr. Anthony says. “I followed them through their current process for surgery days and took notes on each person’s responsibilities. I provided them with photocopies of my pre-op and post-op instructions for patients and my usual post-op orders, so they were well prepared. I gave everyone my contact information and reassured them that I would be accessible and available to answer any questions that might arise. For their part, they were quite flexible and able to adjust their routines to accommodate the needs of plastics.”

Dr. Anthony also took steps to help minimize the stress of assisting a new surgeon on unfamiliar procedures. “For the first few operative days, I booked less than half as many patients as I normally would — 3 to 5 cases versus 10 to 15 cases — to allow time to get systems in place and functioning smoothly,” he says. “Beyond that, just being friendly, talking to people, and being approachable can help establish a relaxed but professional atmosphere.”

Some of the relatively minor issues Dr. Anthony and his team encountered early on included how to drape the patient (usually a personal preference), his preferred injection technique, and, specific to oculoplastics, the difference between simply marking the surgical site and actually outlining the tissue to be excised, which is the sole responsibility of the surgeon. “Everything came together,” Dr. Anthony says. “It just took quite a bit longer than it does now.”

Dr. Holekamp says Richards is her secret weapon, so to speak, for teaching staff their roles in retina surgeries. Richards, who trained the ASC staff at the Pepose Vision Institute, also has trained “everyone in the St. Louis area who does retina,” Dr. Holekamp says. “We held meetings. Laurie proctored, observed, and assisted. It’s a process. People need encouragement. They need to be trained, and they need to feel confident, because it’s patient care. You have to deliver your ‘A game’ the first time out, and we did. I also think we were fortunate that the staff was open to change and to learning new skills, with really good esprit de corps.”

Dr. Holekamp maintains privileges at a hospital for complicated cases requiring general anesthesia, but 95% of her cases are performed at the ASC under local anesthesia, and she stresses the importance of the anesthesia team. “You have to know that the anesthesia team serving your ASC is a good group that will accommodate your needs and work with you. Surgeons don’t perform surgery on their own. They need the staff support, and they need the anesthesia support.”

Primary Predictor of a Successful Transition

“It’s all about attitude, and attitude starts at the top with leadership,” Dr. Holekamp says. “The head of the ASC at Pepose Vision Institute is a person who always says, ‘Yes, we can do that.’ She was a nurse early in her career, and she has seen ophthalmology change over the past 30 years. She recognizes that the practice of ophthalmology is constantly evolving, and she is open to change. To her credit, when Dr. Pepose said he wanted to bring in retina, she said, ‘We’ll figure out a way to make it happen.’

“If the leadership says ‘yes’ and is open to change, then everybody else will say ‘yes’ and be open to change — that’s the key.” ■