April 2009




Evaluating continuing surgical competence

by John Polansky, M.D.


Dr. John Polansky is a spectacular ophthalmologist who has practiced in my community for over 30 years. He has been a good friend and a good colleague. He is what people refer to as a friendly competitor. Because of his special interest in medical ethics, I’ve chosen him as the one that I wanted to evaluate my own surgical competence. The need, I think, for ophthalmologists to retire at the top of their game rather than on the decline is obvious in that patients are very much at risk if anything other than that occurs. It is for that reason that I asked him many years ago to annually evaluate my surgical skills, as I reached the status of the senior surgeon. Dr. Polansky has long been a leader in ophthalmology in Oregon. He is a past president of the Oregon Academy of Ophthalmology, a long standing member of the Executive Committee of the Oregon Academy of Ophthalmology, a member of the ASCRS Clinical Committee for Comprehensive Ophthalmology , and a fabulous practitioner. I know that this month’s column will give all ophthalmologists food for thought.

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

Polansky: johndpolansky@yahoo.com

Evaluating continuing surgical competence Evaluating continuing surgical competence
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