April 2012




Cataract tips from the teachers

Treading too lightly


Sherleen Chen, M.D.

Assistant professor of ophthalmology Harvard Medical School Director of Cataract and Comprehensive Ophthalmology Massachusetts Eye and Ear Infirmary

Roberto Pineda, M.D. Assistant professor of ophthalmology Harvard Medical School Director of Refractive Surgery Massachusetts Eye and Ear Infirmary

Sometimes when beginning something new, there is a tendency to be overly cautious. This may create ineffectiveness or even make achieving goals more difficult. Such is the situation that can occur with beginning phaco surgeons, who may be too timid and slow with their instrumentation, resulting in inefficient phaco-emulsification, with the potential for additional collateral damage. This month, three faculty members share their experience in helping early phaco surgeons progress past their timid tendencies to become safer and more effective cataract surgeons.

Sherleen Chen, M.D., and Roberto Pineda, M.D.



Natalie Afshari, M.D.

Director, Cornea and Refractive Surgery Fellowship Program Assistant professor, Department of Ophthalmology Duke University, Durham, N.C.

There are several ways to help the overly timid resident gain confidence in learning cataract surgery.First, you need to make sure that the groundwork has been set prior to stepping into the OR.This can be done by ensuring proper wet lab practice has been accomplished (ideally with you at the resident's side), by reviewing cataract videos and discussing them with the resident, or by having the resident discuss with you the steps of the surgery, including how to manage any common difficulties.

When you are comfortable that the basic pre-surgical training and preparation have been undertaken, it's very important to make the OR environment as comfortable as possible for the resident.The timid resident is already quite nervous and anxious, and anything that you can do to ease the tension will help. Start by ensuring the surgical scheduling is set to allow sufficient time so the resident doesn't feel rushed or hurried.Also, consider having the timid resident start by only doing a few steps of the surgery at firsthe or she may gain much-needed confidence by only having a small portion of the surgery to focus on and master.

At the time of surgery, establishing a calm OR atmosphere is crucial. Take a few moments to again review the surgical steps prior to beginning. During the surgery itself, remain calm, cool, and collected. Don't try to convert residents to your technique even if it's more efficientallow them to proceed in the way they are most comfortable. As residents gain more experience and are less timid, specific teaching on techniques is more appropriate and better received. Be supportive and affirmative, and avoid criticism or negative feedback during the surgery. While critical evaluation of surgical technique is important, for the timid resident this may be more effective if undertaken while reviewing videos or discussing performance after the surgery.

By ensuring proper preparation, maintaining a calm and comfortable OR environment, and giving positive feedback intraoperatively, timid residents can gain the confidence needed to improve their OR skills.

Douglas M. Blackmon, M.D.

Assistant professor, Department of Ophthalmology Emory University, Atlanta Director, Corneal and Refractive Surgery Veterans Affairs Medical Center, Atlanta

I teach a lot of residents in the operating room, so I encounter a variety of personalities. Some residents appear confident and have steady hands, some actually may be aggressive or seem hurried. However, it is common to have young surgeons at the other end of the spectrum be tentative, whether trying to avoid missteps or complications, or maybe because of their inexperience.

Surgeons, among other things, need to be confident in their abilities, acknowledge potential limitations, and be efficient. Being timid interferes with all of those characteristics. To overcome this potential obstacle to successful surgery, you must identify its cause.

Most often, being timid is simply due to inexperience. To avoid its interfering with successful surgery, the resident should start preparing well in advance. Residents should: 1) Read books and watch videos to understand the procedure and the instruments involved. 2) Familiarize themselves with upcoming patients by reviewing their charts. 3) Discuss and listen to fellow residents and other surgeons talk about their surgeries. 4) Talk to the actual attending surgeon they will be working with, if possible. Residents can become unnerved by the attending suddenly changing the surgical technique that was planned. Changing from a block to a topical case or using unfamiliar instruments will prevent residents from being as comfortable as they would like to be. Residents need to trust their attending, just as the attending needs to trust the residents. Trying to interpret what one is trying to say to the other intraoperatively can readily lead to problems, quickly worsening any apprehensions.

Working in the wet lab is critical, but often limited in some of its benefits, such as creation of the capsulorhexis. Its greatest help is simply getting residents comfortable with the microscope, gaining dexterity with the instruments, and suturing the wounds. I find residents who have these basic fundamentals may be timid initially, but they rapidly improve as they see the good outcomes and success in their preparation. Some residents may not have faith in their hands, from lack of coordination, a tremor, or a variety of other possibilities. The following formula I came across in Malcolm Gladwell's Outliers says it best: Achievement = Talent + Preparation No matter your level of innate skills or talent, you will always improve your achievements by putting in extra preparation. Even the great ones will be greater with continued practice.

Susannah Rowe, M.D., M.P.H.

Faculty, Department of Ophthalmology Boston University

Teaching the overly timid resident can be as challenging as teaching the overly aggressive resident. Some residents are so tentative they can barely get through a case; others freeze suddenly at critical junctures. A few seem so worried about their abilities that they duck surgical opportunities altogether. The key is to gently nudge the resident forward along the surgical learning curve at a pace that develops skills without endangering patients. Earning your timid resident's trust is essential. All residents need to know that you understand what they are ready for and have realistic expectations, that you can get them out of trouble, and that you will keep the patient safe. Timid residents also need to know that you understand their fears.

Some causes of excessive timidity include: 1. Not understanding the procedure: These residents appear overly passive as they wait for instructions. Ask them to watch more surgery and narrate each step in advance, including which instruments will be called for.

2. Feeling physically uncomfortable or unable to see well: Spend as much time as necessary setting up the microscope, pedals, stretcher, and chair before the case. Check in often throughout surgery, making adjustments as needed.

3. Unrealistic expectations: When residents expect too little or too much from themselves, they can lose confidence and become hesitant to try new maneuvers. Honest, timely feedback and clear expectations foster confidence and more realistic goals. 4. A bad experience: Almost every resident loses confidence after a complication. Residents must have opportunities to review the complication in detail with non-judgmental, experienced teacher-surgeons and peers, so they can understand what went wrong and how to prevent it from happening again. If the patient has suffered significant harm, the resident may need additional assistance dealing with that. 5. A slow learning curve: Some residents are appropriately timid because they have underdeveloped surgical skills. They should be directed to wet labs, surgical simulators, and suture practice sessions. Opportunities in the OR should be tailored to their abilities and may need to be curtailed until their skills improve. As with all residents, small successes build confidence and should be celebrated.

With appropriate mentoring, most residents can learn to overcome these challenges. A dedicated surgical instructor who is aware of these issues will help overly timid residents develop into skillful, confident, independent surgeons.

Editors' note: Drs. Afshari, Blackmon, and Rowe have no financial interests related to this article.

Contact information

Afshari: natalie.afshari@duke.edu
Blackmon: dmblackmon@me.com
Rowe: susannah.rowe@bmc.org

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