CATARACT / IOL |
Evaluating continuing surgical competence by John Polansky, M.D. |
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Dr.
John Polansky I. Howard Fine, M.D., Column Editor |
 Several years ago, I. Howard Fine, M.D., came to me with the
request that I observe him at surgery for the purpose of evaluating surgical
competence. Early in his career he had the experience of assisting at
surgery with senior ophthalmologists in our community. At that time,
all major eye cases were done in the hospital, and hospital bylaws required
that a second ophthalmologist assist. He observed a great variation in
skill levels. As time went on, he noted deterioration in some of the
senior sur- geons’ skills. It was certainly difficult for the younger doctor,
who had been asked to assist, to truthfully criticize the senior doctor.
However, if complication rates are increasing and preventable events
are occurring, it is important that the surgeon know that. Dr. Fine resolved
that when he reached senior status that he would do things differently. Changes in hospital bylaws, evolution in insurance reimbursement patterns,
and the need for greater surgeon efficiency have affected the practice of
medicine such that today ophthalmologists rarely assist one another. Hence,
if you want to be observed doing surgery by another surgeon, you have to
ask. Thus, Dr. Fine decided to involve me in the process of evaluating his
surgical skills. This has become an ongoing process repeated every year or so. Over the years
I have refined the criteria that I use to judge his skill level and developed
a system that allows a numerical score to be assigned to a group of surgeries.
At the present time, I’m restricting my observations to the events
in the operating room. I’m making no observations or judgments regarding
pre-op issues or post-op care. For evaluation of cataract surgeries, I’ve used a 10-point scale to
be applied to each step in his cataract procedure. Ten points are given if
the step is performed as perfectly as can be done. The steps that I specifically
evaluate and grade are as follows: 1) The performance of the paracentesis.
Dr. Fine uses two as he usually performs bimanual micro incision phacoemulsification
with separation of the irrigating chopper in one hand and the unguarded phaco
needle in the other. 2) The continuous curvilinear capsulorrhexis. 3) The
hydrodissection and hydrodelineation. 4) The phacoemulsification portion.
5) The irrigation and aspiration process if it is performed. 6) The temporal
clear corneal incision performance. 7) The intraocular lens (IOL) insertion
and position. 8) The degree and precision of the overlap of the anterior
capsulorrhexis on the optic of the IOL. 9) The removal of the viscoelastic
material. 10) The sealing of the temporal incision. 11) The sealing of the
left paracentesis. 12) The sealing of the right paracentesis. If all 12 steps have been performed as perfectly as they could have been
done, the score for each step would be 10 and the total for the 12 steps
would be 120. I then divide the total scores for each case by 12 for the
score for that procedure. If 10 cases were performed and evaluated, I would
add the score for each case and divide by 10. This would give an average
score for all 10 cases observed in that session.
Each year by doing this same analysis, I can see if there is any significant
deterioration in any of the basic phacoemulsification and IOL implant skills
required to perform excellent cataract surgery.
Trends can be quantified. I always write a formal summary letter to Dr. Fine
when I complete the statistical analysis. The surgeon being evaluated can
thus compare his performance over time and have an additional tool to help
him determine the difficult task of when or if he should stop performing
surgery.
This method of surgical evaluation is simple to do and has the advantage
of providing a numerical record from which one can easily spot trends. It
does require a trusted colleague who is willing to be candid and a senior
surgeon who is willing to be evaluated in a specific and detailed way. As
we all grow older, it is nice to know that something more objective than
our gut feelings can be utilized to answer the tough question of when to
stop doing intraocular surgery.
When should an ophthalmologist stop doing intraocular surgery? Certainly
in the face of declining skills or failing to be able to learn new and proven
better techniques, one should consider voluntarily stopping or referring
difficult cases to those better skilled to handle them. More routine cases
may be fine to do and very competently done. At some point the surgeon may wonder if his or her skills are changing. That
is where an objective evaluation may be helpful. Finding a trusted colleague,
although he may be a competitor, who is willing to be objective and candid,
may be a challenge in many communities. Hopefully enough well-trained younger surgeons with a strong sense of ethics
would develop strong relationships with their senior colleagues to permit
such evaluations to occur. If this process is begun earlier in one’s
senior status rather than after board reviews by local or state authorities,
it may ultimately serve the senior surgeon and the community well.
I am 65 years old and feel as though I still have very good surgical skills.
I am fortunate to have a wonderfully skilled younger associate who can perform
what I have described above for me. I look forward to beginning this process.
As the examinee, it will afford me the opportunity to be objectively evaluated
and possibly refine what I do. It will also guide me in a more objective
and hopefully less threatening way as to when it is time to stop intraocular
surgery. As the examiner, I have always learned a lot by observing other
surgeons. I look forward to continuing to serve in that capacity and hope
it will be helpful for my colleagues. Contact information |
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