This article is more than 5 years old. Information may no longer be current.
Pearls for residents, fellows as surgical training gets underway
Reading, practicing basic techniques and following a mentor are the first steps to take.
During medical school there is relatively little exposure to ophthalmology, and only about 2% of all residency positions are devoted to our field. Training in ophthalmology is different from other specialties in so many ways, from the surgical instruments and techniques to the diagnostic and therapeutic technologies. Probably the most challenging part of ophthalmology residency or fellowship is brevity of the training.
Just think how much has changed in ophthalmology in the past decade or two. Now surgeons in training must learn everything that I learned in 2000 when I finished my training, plus all of the new advances that have occurred in the past 16 years. And they must do this in the same number of years that I did, which is quite a challenge. Here are my pearls for the new ophthalmology residents and fellows who are starting their training this month.
Read to acquire knowledge
Every year the Basic and Clinical Science books from the American Academy of Ophthalmology seem to get thicker with more pages to read. Spending time every night reading is an important part of acquiring the knowledge needed to be a good ophthalmologist. This is not easy because you will likely be involved in clinical activities from the early morning until the evening every day, and when you are on call, this can even extend into the night.
Image: Devgan U
Another excellent way to learn is to correlate your reading with the patients you saw earlier in the day. If you see a patient with a complex disease such as Vogt-Koyanagi-Harada (VKH) syndrome, reading about the details of the disease that same day will help cement it in your knowledge base. Teaching the basics of VKH to a medical student on your team will further help you to understand and retain the facts. When it is time to take your oral exam for board certification, questions about VKH can be answered by thinking back to your patient encounter from years prior.
The first time you read through the Basic Science books, they will seem very detailed and thorough, but as you acquire knowledge, you will see that they are in fact just overviews of the subspecialties. What amounts to just a few pages in the Basic Science book may be a summary of a more specific 1,000-page book. While reading can be done on your own even after you finish your residency or fellowship program, learning one-on-one with a surgeon mentor is most easily done while still in training.
Learn by doing
Ophthalmology encompasses the medical and surgical aspects of ocular care. Surgical procedures, both in the clinic and the operating room, are best learned under the direct supervision and mentoring of a senior colleague. The attending surgeon provides a safety net so that in the event of a complication a successful outcome can usually be delivered. Remember that ocular tissue is delicate and sometimes unforgiving and that we must be true to our Hippocratic Oath of first doing no harm. Strictly adhering to established policies and procedures can help prevent errors and complications that could be sight-threatening to our patients. Emulate your mentors initially, and then once you develop your skills and surgical judgment, you can evolve your own style.
In the operating room, start by doing parts of cases of the more senior surgeons. Assisting on cases is a great learning experience, but actually doing parts of the procedure is better. Cataract surgery is the most commonly performed procedure, and it is useful to learn ocular surgery techniques that can then be applied to many other subspecialties of ophthalmology. Even if you decide to do vitreoretinal surgery exclusively, understanding how to pivot in the incisions and not distort the wounds in cataract surgery will help you become a better retinal surgeon. For cataract surgery, each step tends to build on the previous so that a poorly constructed initial incision can make the entire surgery difficult. For this reason, it may be best to start with the end of the surgery such as closing the wound, then move to doing the viscoelastic removal, and then in future cases perhaps the lens insertion.
Repetition and practice in a wet lab
There is no substitute for practice, practice and more practice. In order to be able to properly place a 10-0 nylon suture in a corneal incision, the maneuver must be practiced hundreds of times. Failure to practice in advance of coming to the operating room will reduce your ability to learn the nuances of the technique. While practicing in the wet lab is not the same as actually doing surgery in the operating room, it is good for building basic skills and dexterity. You have only a few years to learn surgical skills from your mentors in the one-on-one setting. After graduation from your program, you will not have the benefit of an experienced surgeon sitting next to you, offering advice and assistance.
Ophthalmic surgeons must also be adept at using both hands relatively equally, particularly when it comes to intraocular surgery. Increasing the dexterity of the non-dominant hand takes time and effort and can be done at home as well. Brushing your teeth, eating or shaving with your non-dominant hand will seem odd and cumbersome at first but will become second nature after a few years.
Be your own toughest critic
Probably the most important aspect of your surgical training is to be your own toughest critic. After each surgery or procedure, ask yourself, “What could I have done better?” Video record your surgeries and watch them at home with a critical eye. Make a list of things that you did well and steps that need improvement. Aim to hone your surgical skills on each and every case. Your goal is not merely to have a graduation certificate to hang on your wall. Rather, your goal is to squeeze every drop of knowledge, experience and learning out of every patient encounter during your residency or fellowship. You will then spend the rest of your career further advancing your skills in the pursuit of optimal patient care.
- For more information:
- Uday Devgan, MD, is in private practice at Devgan Eye Surgery, Chief of Ophthalmology at Olive View UCLA Medical Center and Clinical Professor of Ophthalmology at the Jules Stein Eye Institute, UCLA School of Medicine. He can be reached at 11600 Wilshire Blvd. #200, Los Angeles, CA 90025; email: devgan@gmail.com; website: www.DevganEye.com.
Disclosure: Devgan reports no relevant financial disclosures.