Lessons for Future Attendings
Answers to questions about managing surgical complications and teaching trainees.
“I’ve failed over and over and over again in my life, and that is why I succeed.”
With graduation rapidly approaching, I (JS) asked two senior fellows (NP and NY) for their most pressing questions as they enter their lives as attendings, in terms of avoiding complications and dealing with trainees. Here are the questions they came up with, along with my answers.
What do you do to try to avoid complications on certain types of cases?
When I was a fellow attending a vitreoretinal training course in Boston, Donald J. D’Amico, MD, of Cornell University, gave a talk on complications that has stuck with me. To paraphrase his words, “For any eye case, the biggest complication you can have is to operate on the wrong eye.” When you are a junior attending, this seems like an impossibility, but as you get busier and are trying to hold excessive information and external distractions in your head, the chance of this devastating complication rises. So, always check the patient and check the site.
Next, understand the goals of the case, and understand that these goals differ tremendously depending on the pathology. For a rhegmatogenous retinal detachment, the objective is to seal the breaks and, if necessary, place a tamponade. For a membrane peel for a symptomatic epiretinal membrane, the goal is to relieve foveal traction. For a diabetic vitreous hemorrhage, the goals are to clear the hemorrhage and prevent future complications of diabetic retinopathy. Reiterating these goals in your head while scrubbing will help keep you clear-headed and pointed in your surgical decision-making. If you can stay focused and directed in your maneuvers, you will reduce unnecessary steps and operative time, dramatically lowering your chance of a complication.
Finally, remember the pledge, Primum non nocere—First, do no harm. The complications that surgeons regret the most are the avoidable ones, and those usually come from trying to do something good in a situation that is not amenable to improvement. For example, if the view deteriorates in a case due to corneal edema, peeling membranes close to the fovea without adequate visualization represents a risk-benefit ratio that is not in the patient’s best interests. Take a deep breath and avoid—to borrow a phrase from the poker world—going on tilt. Quitting while you are still behind is sometimes the best thing you can do for your patient to preserve options for the future.
What is your stepwise approach to peeling near the macula to avoid complications?
The most important factors in safe macular peeling are good visualization and minimizing untoward movement. Good visualization comes from optimizing your viewing system (indirect vs contact lens), ensuring that there is no media opacity in the anterior chamber or vitreous cavity (eg, residual vital dye swirling around that was not cleared completely prior to peeling), obtaining good focus on the target tissue, and lighting appropriately with the fellow hand when using a light pipe.
Early career surgeons often light inadequately out of fear of coming too close to the retina, and certainly going excessively close increases the risk of iatrogenic damage from direct contact or phototoxicity. However, there is a sweet spot between two extremes, and even a couple millimeters of advancement of the light pipe can make a huge difference in ensuring safe peeling.
Patient movement can be minimized by reducing sedation of the semi-awake patient prior to peeling. I often wake the patient up prior to the peel to avoid the scary-but-all-too-possible scenario of the patient waking up mid-peel and moving his or her head.
How much surgery do you allow fellows to perform? Is it based on a certain timepoint in their training?
The first priority for any attending surgeon in the OR is getting the best possible outcome for the patient. If that can be achieved while supervising a trustworthy and capable fellow surgeon, then the fellow may operate.
Every fellow surgeon is different in his or her progression. Some fellows are ready to peel membranes within a month in the OR, and others need more time to get comfortable with visualization of the retina. Visualization is again a huge key because, if the attending can see, they will feel more comfortable and be more willing to allow the fellow to operate. If I cannot see sufficiently to ensure a safe patient outcome, then a switch of positions at the microscope is inevitable.
What do you do if a patient refuses to have a trainee participate in surgery?
This is the question that I asked my attendings as I left fellowship 4 years ago, and it is a situation that thankfully comes up infrequently. Most patients understand that at teaching institutions we have a dual responsibility to take the best care of our patients and to teach the next generation of surgeons for the benefit of everyone. Every once in a while, a patient specifies that he or she does not want a trainee involved in surgery. In those instances, I explain that surgery is generally a two-person operation with a capable assistant making certain maneuvers during surgery (eg, scleral depression) much easier and more effective. If a patient insists, I obey his or her wishes that I perform the critical portions of the procedure (eg, macular peeling) with the understanding that other portions of the procedure will require both the attending and fellow surgeon. I have never had a patient refuse to have a trainee at the side scope for a surgery.
When there is a surgical complication, how do you address it with the patient and family?
Rule No. 1 is to be honest and up-front. Finish the surgery and then broach the discussion with the patient after the drapes are removed. I would not recommend overwhelming patients with details with anesthesia still on board or in the immediate postoperative period, but I would state that something unplanned occured while being as reassuring as possible. (This obviously depends on the nature of the complication.)
With the patient’s permission, I would recommend spending more time talking to the family member or members in the waiting room. I usually explain more details to the family and indicate that we will speak more about it the next day during the postoperative appointment.
When a patient hears that a complication has occurred, the most important thing is to translate in layman’s terms what that means regarding recovery time, visual prognosis, etc. Keep open lines of communication; exchanging phone numbers and documenting this exchange is a great way to achieve this.
As painful as it may be to see your complications (more on this below), commit to seeing the patient as often as needed in the postoperative period, and be patient with questions and concerns that arise.
How do you move on psychologically as a surgeon after a complication?
An attending surgeon in medical school once told me that the best surgeons are not those who have the best hands but those who handle complications with the most grace. The first thing to do is to put things into perspective: Is the complication permanently visually disabling? Striking the crystalline lens during vitrectomy is not ideal, but the patient can still have excellent visual potential in the long term after removal of a cataract and placement of an IOL. Extrafoveal iatrogenic damage during macular peeling is similarly suboptimal, but it may result in no impactful symptoms for a high-functioning patient, depending on location and degree of injury. On the other hand, direct injury to the fovea or optic nerve is a completely different story that should elicit a different reaction.
Regardless of the severity of the complication, it is normal for the surgeon to feel guilt. We all chose medicine as a field to help people and not cause harm, so it can be damaging to your self-image to experience a visually compromising complication. You need to process these emotions, swallow your ego, and accept that part of being human is making mistakes.
This process, however, comes after you fulfill your role as captain of the ship and take care of your patients. This means finishing the case even if there was a complication during it, getting a sip of water, and taking care of the other patients you have on your OR schedule. As mentioned above, support the patient and family after the surgery with open lines of communication, honesty, and optimism (when appropriate).
After this is done, I find that the most helpful way to move on psychologically is to try to understand why the complication happened so that I can prevent it from happening again. Recorded surgical video can be critical to review to see what exactly happened. Do not be afraid to use your support group of friendly fellow surgeons. Besides offering sympathy and a true understanding of what you are feeling, they can offer insights into their own experiences and help debrief in a HIPAA-compliant “Morbidity and Mortality” fashion after the fact.
Finally, stay balanced. Even on the days you have complications, do your wellness rituals. Whether that includes exercise, meditation, playing a musical instrument, or painting, remember that if you do not first take care of your psyche you will not be prepared to get back on the bike and try again the next day.
How do you, as the primary surgeon, maintain or boost confidence in a trainee experiencing complications?
As the attending, you have to acknowledge what just happened, but, as with your conversation with the patient, immediately after the event is not the best time to dive into the nitty-gritty. Give your fellow time to process, and always emphasize that any complications that occur on your watch are ultimately your responsibility as the attending.
Every trainee is a little different in how he or she processes events. Depending on the complication, some will be ready to operate again right away, whereas others may need a couple of cases to gather their wits. Respect those differences, and do not force trainees out of their comfort zones too soon.
The best thing you can do as the attending is to have a short memory for your fellows’ mistakes. (This is probably a good thing to have for life in general!) For example, if a fellow once hit the crystalline lens with the cutter with you or with another attending, never say “Be careful! Remember, you hit the lens that other time.” Be positive and supportive and let the fellow understand that you are there to guide and protect him or her from complications as much as possible.
As a senior attending once told me, “The only way to avoid complications is not to operate.” Complications are part and parcel of what we do as surgeons on a daily basis. Let your fellows understand that they exist, that we do everything in our power to minimize them, and that, when they do happen, we use them as learning experiences to continue to improve.
Nimesh Patel, MD
• Fellow in Vitreoretinal Surgery and Chief Resident, Bascom Palmer Eye Institute, Miami
• Financial Disclosure: None
Jayanth Sridhar, MD
• Assistant Professor of Clinical Ophthalmology, Bascom Palmer Eye Institute, Miami
• Financial disclosure: Consultant (Alcon, Alimera Sciences, Oxurion, Regeneron)
Nicolas Yannuzzi, MD
• Fellow in Vitreoretinal Surgery and Chief Resident, Bascom Palmer Eye Institute, Miami
• Financial disclosure: Advisory board (Genentech, Novartis)