Tell me about your typical day of surgery. How is it structured, and how do you plan ahead to best utilize your time?

 Dr. Blessing: I have two full operating days at the ASC each week. We start at 8 AM, and usually end around 3:30 PM. I usually do anywhere from 8 to 12 cases per day. Obviously, that number depends on how long the cases are, because I do a mix of complex and simple cases.

Everything’s booked out at least four to six weeks in advance. I get a few emergency cases, but honestly, because I’m in an academic satellite, a lot of the emergency stuff goes to Miami, so I usually don’t have to worry much about coordinating or adding on emergency cases at the ASC.

There are guidelines that my schedulers follow. We try to do the longest cases first. So if I’m doing a three-hour full cosmetic case, that’s what I’ll start my day with. We also tend to do general anesthesia cases first, just because we don’t want to do a general at 3 PM and then have the staff recovering those patients after we would normally be finished. Otherwise, we structure the schedule based on patient preference. If there’s a patient that’s diabetic and they want to go early in the morning because it’ll be easier for them to manage their blood sugars, then we try to accommodate that. But generally, what works best for me is to do longer cases first and then all my really quick cases in the afternoon.

When it comes to your ASC, is there anything about the facility layout or equipment that enables you to work through cases faster or more efficiently?

 Dr. Blessing: Our ambulatory surgical center is on the smaller side—we only have three operating rooms, and then preop and postop are in the same adjacent room. But that can be an advantage over operating at the hospital in Miami. In Miami, patients have to show up and check in, then they wait in a waiting area. Next, they get moved to a second waiting area, then they are moved to a holding area before they go to the operating room. Our patients basically come from the waiting area into preop and then go straight back to the operating room, so they only go through three doors and everything’s very close together. We don’t spend a lot of time shuffling patients around.

I do occasionally run two rooms and it can be extremely helpful if I’ve got really fast cases, but I don’t need to routinely do that. We’ve started planning one Friday a month where I’m the only surgeon operating in the facility, so we’ll have two operating rooms available. We’ll intentionally schedule a lot of shorter cases on that Friday to maximize the rooms. That way, the turnover time between cases is essentially eliminated and I can spend all my time operating instead of waiting for patients to move in and out of the rooms.

From a scheduling standpoint, that’s helpful for the ASC. I’m not as fast as a cataract surgeon, so if I can pack a lot of 10- to 15-minute cases in on my two-room Friday, I can do longer cases on the other days, when there are other surgeons operating at the ASC. If I’m next door to a cataract surgeon who is running two rooms, the staff is really focused on keeping the flow going for him because he’s doing 30 cases, whereas I might only be doing eight. When I’m in an operating room next to a cataract surgeon, it’s easier on the ASC staff if I do longer cases that take hours instead of minutes.

Are there any specific processes or tools that you use that contribute to surgical efficiency?

 Dr. Blessing: I feel like my workflow in the operating room helps to facilitate me being more efficient. One thing I like to do is give my local anesthetic with epinephrine plenty of time to work. We will do a cursory timeout, do a basic prep with alcohol swabs followed by any necessary lid markings (such as for blepharoplasty) and I will inject local anesthetic before the patient is prepped with betadine for surgery and draped. While the staff preps and drapes, I finish up computer work and scrub. Injecting the local anesthetic ahead of time makes it so that when I actually cut, I don’t get as much bleeding. That helps cases move more efficiently, because the more time I spend during a surgery cauterizing and stopping bleeding, the slower my case goes.

I also regularly use monopolar cautery to cut, which also makes you more efficient moving throughout basic soft tissue cases.

Another tool I couldn’t do without are my Designs for Vision loupes. I use the titanium framed Yeoman loupes with 2.5x magnification and, most importantly, an attached UltraMini HDi headlight. The combination of magnification, lighting, and loupe-afforded ergonomics ensures that I can always see what I am doing from a comfortable and safe position.

Can you tell me a little more about how your staff contributes to surgical efficiency?

 Dr. Blessing: I have a couple of senior scrub techs and circulators who have been around oculoplastics for a long time. When I first showed up, I did things a little different than my predecessor and it took them some time to get accustomed to it. But I’m pretty predictable, so now, when they see certain things on the schedule, they know what I need and can anticipate what I’m going to ask for.

I try to be very routine about things, so they’re comfortable knowing what to expect when I’m operating. If I want to change something, I will talk to them about it ahead of time. I won’t show up on a surgery day and say, “I’m gonna do this differently.” It’s more like while we’re doing a case I will tell my scrub tech, “You know, the next time we do this I want to try doing XYZ.” Then we’ll talk about it for a while before we change anything.

Is there anything in particular that you do to ensure the best possible outcome while also maximizing patient safety?

 Dr. Blessing: I do a lot of bilateral surgery, and sometimes I’ll be doing something slightly different to one side or the other, so we will verify that. If I know that I’m tightening a muscle 8 mm on one side and 10 mm on the other side, we will verify that. My scrub tech will write it down and I sometimes will write numbers like that on the patient’s forehead to remind me. Also, because I use a lot of cautery, we always make sure that the oxygen is turned off before I start cutting to reduce the risk of a fire.

What about when you run into complications? How do you react when problems arise that threaten to throw your surgery day off track?

 Dr. Blessing: The nice thing about soft tissue surgery versus cataract surgery is that, if you’re doing cataract surgery and you drop a lens, that’s a big deal because the cataract surgeon may have to get a retina surgeon to help them get the lens out of the back of the eye. For me, usually if something’s going wrong, it’s an anesthesia issue where the patient can’t get comfortable, or I’m spending a lot of extra time controlling bleeding. I work with great anesthesiologists and CRNAs and we can adjust. I give patients adequate local anesthesia so that they don’t have a ton of discomfort.

But really, it’s having tricks in my toolbox to deal with whatever is going on. If a patient’s extra sensitive when I’m removing fat from their lower lids, then instead of using the cautery I will just clamp the fat and excise it with scissors and cauterize it. It’s about being able to adjust to whatever the patient or the procedure is giving you in that moment.

The nice thing is, those issues tend to arise during the longer cases that are scheduled for the beginning of the day. If an early case runs a little bit longer, then I know that the cases that follow should be shorter. So if I can shave off a few minutes here and there over the subsequent few cases, then we usually get right back on track

If you could talk to your younger self, what advice would you give that would make you a better, more efficient oculoplastic surgeon?

 Dr. Blessing: Surgical efficiency starts in the clinic, so when you are talking to patients about the surgeries that you’re proposing, keep in mind how long it should take and do a thorough exam to avoid any surprises later. I’m the one that does all of the patient exams and controls the times that I give to my scheduler, so I’ll tell the scheduler what I’m going to do and how long I think it’s going to take. All of that planning starts in the clinic with what surgery you’re going to do and how you prepare.

Every surgeon is different. I know that the more I operate during the day, the more tired I get. So that’s why I want to have my longer cases earlier. Young surgeons need to find an OR flow that works for them with the resources that they are given, because every ASC is different. Not every ASC can give two rooms, or maybe they want to do their general anesthesia cases starting at noon or something like that because of staffing issues, so surgeons must find a flow that works for them after accounting for what the ASC can provide.

Finally, I think being very thoughtful and developing good habits and a good routine is important. If you’re running behind, don’t rush, just do things in a routine way, in the way that you know, and do them right the first time. I find that doing things faster in an effort to make up time actually ends up slowing you down because when you go too fast you make mistakes. Slow is smooth, smooth is fast. ■