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Rules of engagement for the premium surgeon
These five rules will help the surgeon stay on track during 'routine' procedures.
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Rules of engagement, or ROE, are rules followed by either military forces or individuals that define the circumstances, degree and manner in which the use of force, or actions that might be construed as provocative, may be applied. ROE do not normally dictate how a result is to be achieved but will indicate what measures may be unacceptable. Every day, premium surgeons face their own rules of engagement, which can be humbling to heroic to making all the difference in a patient’s outcome. Below, I give my personal ROE for the premium surgeon:
1. Nothing in eye surgery is ever routine.
2. Murphy, from Murphy’s law, is never asleep.
3. What happens in the OR stays in the OR.
4. There is always more than one way to skin a cat.
5. If all else fails ... .
1. Nothing in eye surgery is ever routine.
How many times has a premium surgeon entered the OR on a perfectly efficient day, not expecting any unusual circumstances in a “routine” cataract surgery (no prior trauma, pseudoexfoliation, prostate medication use, prior retinal surgery, prior refractive surgery and/or essentially emmetropic history), and then — the unexpected, for example, sudden head movement from a cough or disorientation from mild intravenous sedation, and that “routine” becomes quite “unroutine” in a matter of seconds. Of course, many of us have encountered a variety of “silly” or “esoteric” circumstances when ROE No. 2 suddenly comes into play.
2. Murphy is never asleep.
Murphy’s law is a well-known adage that basically states, “Anything that can go wrong, will go wrong.” My perfect example is that of the monocular patient who is about to undergo “routine” cataract surgery and decides to remind his/her premium surgeon in the preoperative area that he/she will be operating on the only seeing or potentially-seeing eye (like the premium surgeon did not already know that). I personally always remind the patient to never wake up Murphy until Murphy needs to be awakened, which in our premium surgeon world is essentially never. And unfortunately, when Murphy awakens, ROE No. 3 may now potentially become a reality.
3. What happens in the OR stays in the OR.
This rule, in my opinion, is probably the most controversial and can result in many excellent or serious consequences from either a patient outcome or malpractice liability. All of us premium surgeons took that infamous Hippocratic Oath in medical school, which basically upholds specific ethical standards to the way we practice our specific medical/surgical specialty. And every surgical situation has its unique interpretation and approach in case that “unroutine” event happens in the OR. By definition, medical malpractice in its simplest interpretation of the law is when a physician performs an act of negligence that results in a bad outcome. I am not a lawyer and always encourage professional legal counsel in all situations in which malpractice may be a possibility. My best example is the “unroutine anterior vitrectomy” in planned “routine” cataract surgery is not necessarily negligence and most likely is the standard of care for handling vitreous in the anterior chamber. Furthermore, if a patient ends up with a good visual outcome, what happened in the OR not only was the right thing to perform in such a situation but does not need to be broadcasted to those such as a receptionist/billing specialist, for example, who has no medical and/or surgical training to give an opinion to a patient when they are coding and/or documenting the procedure performed. In other words, what stays in the OR should remain in the OR among the professionals who perform the same surgical procedures of the same specialty of that premium surgeon. Of course, the rules of engagement, especially in a “unroutine” situation, could lead to my fourth rule as follows.
4. There is more than one way to skin a cat.
Personally, my spouse and I own two Devon Rex hypoallergenic cats so I can breathe and live and enjoy their presence every day, and in no way do I ever want to skin a cat. But the famous phrase suggests there are more ways than one to perform a specific surgical maneuver or procedure. The best example I encounter every cataract surgical day is the small pupil case with or without a prior history of trauma, prior surgery and/or prostate medicine use. All premium surgeons have the responsibility to approach these cases in more than one way in a variety of patients, from use of pupil expansion devices such as the APX pupil expander (APX Ophthalmology), the Malyugin ring (MicroSurgical Technology) — now in a 2.0 version for microincision cataract surgery but still expands to a 6.25-mm pupil opening — and/or the use of intracameral Omidria (Omeros), which is an excellent combination of phenylephrine and ketorolac as an FDA-approved continuous irrigation to maintain pupil size throughout a cataract procedure. Remember, as a premium surgeon, you can always default to rule No. 5.
5. If all else fails ... .
As we all learn the hard way, heroics are sometimes necessary in emergency situations such as ocular trauma, but in many elective premium surgeries, we should ethically be more selective in whether we should proceed to do a complex case or refer it to a specialist with greater experience. At the same time, a premium surgeon can never reach premium status without experience. My advice is to always do the proper due diligence before performing your first surgery of any kind or a complex case in which you have great experience already. My suggestions is to spend a day with a surgeon you trust, reach out to websites such as Healio.com/OSN with great surgical videos to review, and speak with your peers and colleagues about the intricacies and pearls needed to successfully reach that premium surgeon status. If all else fails, I hope you use these rules of engagement every day in your practice and OR setting.
- For more information:
- Mitchell A. Jackson, MD, can be reached at Jacksoneye, 300 N. Milwaukee Ave., Suite L, Lake Villa, IL 60046; email: mjlaserdoc@msn.com.
Disclosure: Jackson reports he is a consultant for APX Ophthalmology and Omeros.