Surgeons share best practices for managing challenging situations, handling stress

Learning to deal with complicated cases and difficult situations, whether predictable or completely unexpected, is an important part of the skill set of a surgeon.

The needed tools are not only surgical techniques and knowledge but also emotional regulation, stress management strategies, and the ability to communicate effectively and empathetically with patients and their families.

“Every surgeon knows that complications are an inevitable part of their profession because no matter how good a surgery is, there are always unanticipated problems and difficulties,” Healio | OSN Associate Medical Editor William B. Trattler, MD, said.

Being prepared, prioritizing patients and building authentic trust-based connections with them are key factors in managing complications effectively, reducing their negative consequences and emotional impact.

“What patients get the most frustrated about is lack of communication and just not understanding what’s happening and then feeling like they are abandoned,” Healio | OSN Cataract Surgery Board Member Zaina Al-Mohtaseb, MD, said.

Set expectations, prepare for surgery

The No. 1 priority before any surgery is to set expectations for patients, according to Al-Mohtaseb.

“I tell everybody all the risks of cataract surgery, and if I know that it is going to be a more complex surgery, due to whatever pathology or abnormality in their eye, I tell them the specific risks and discuss all the potential complications,” she said.

No. 2 is preparation for surgery. She always goes over her cases in preparation for the next day, and if there is a complex case, she thinks step by step what she is going to do and what extra equipment she is going to need.

“If a patient is likely to have problems with pupil dilation, I know I am going to need a dilation ring or iris hooks. If I think that there’s a zonular loss issue, I’ll need capsular tension rings. I make a list and send it to our surgery center,” Al-Mohtaseb said.

Deepinder K. Dhaliwal, MD, LAc, agreed that “preparing the patient and preparing yourself” are the two most important steps to take preoperatively when a challenging case is planned for surgery. She watches videos of similar cases to learn how other surgeons have tackled them and even calls her colleagues all over the world.

“We have such an amazing network of surgeons we can rely on,” Dhaliwal said. “I talk to them, go over certain steps, do a lot of homework. With my residents and fellows, we sit down and discuss step by step what might happen and what we are going to do.”

Often, she brings patients back a second time and tells them what she thought about their case and the best way to handle it.

“I am totally up front with them. I don’t hide the problems but tell them how I am going to handle them. They usually appreciate this, but if they feel they want a second opinion, if they don’t feel I am the right person for the surgery, I am OK with that too,” she said.

Healio | OSN Section Editor Uday Devgan, MD, writes down what he calls “a game plan,” with his step-by-step strategy, contingency plans and all the supplies he wants to have available in the operating room.

“I tape this piece of paper to the wall next to where I am sitting, so whatever happens, no panic: I have the game plan where I have made notes of all the worst-case scenarios and already know what I am going to do,” he said.

Stay positive, know limits

Dagny Zhu, MD, said that it is important to discuss with patients all the risks and challenges but to also stay positive and point out that all precautions will be taken to make sure that everything goes well.

“Make them feel we are teaming up against their difficult eye,” she said.

She reaches out to colleagues and mentors for their advice and videos.

“We have also plenty of online resources to watch how other surgeons approached complicated cases,” Zhu said.

If a surgeon, particularly at the beginning of their career, perceives that a case might be too difficult to handle, there is nothing wrong in referring a patient to a more experienced colleague.

“It’s important to know when to say no. If it’s not within your comfort level, refer it out to a colleague you trust,” Zhu said.

“You must always look inside yourself and think: ‘Am I the best person to do this case right now?’” Dhaliwal said. “We cannot keep doing just the easy cases, but we must learn to judge if we are prepared for the next step.”

Knowing one’s limits and accepting them is important for a physician’s well-being as well as for the sake of the patient, Devgan said.

“Let’s say there’s a patient with no capsule support who might also need a full pars plana vitrectomy. I refer the case to the retina surgeon, who can, at the same time, suture the lens to the sclera for me,” he said. “Always put the patient’s interest first.”

Be ready, act appropriately

Controlling stress in demanding situations and thinking clearly are critical to getting the best results with surgery.

“We can learn a lot from elite athletes when it comes to managing stress,” Trattler said. “Take LeBron James, for example — he helped lead Miami to two NBA championships. While he does not make every shot, he never lets a missed shot shake his confidence. He stays focused and continues to play at a high level, relying on his skills and mental resilience even when his shots are not falling.”

Surgery is a similar game in which not everything can always be controlled and not everything can always be fixed. Issues can develop, such as a small capsule tear that changes significantly how the surgery will unfold, some cortex that is difficult to remove or pupils that suddenly constrict.

“Being ready, watching for signs of things not going as expected, is critical. Then, be ready to act appropriately,” Trattler said. “There are situations that occur during surgery that are beyond anyone’s control and depend on the patient’s anatomy and on how their eye responds to surgery. The key is to not let stress interfere with your performance. Stay calm and concentrate on resolving the situation effectively.”

“Being prepared and staying alert for early signs that something isn’t going as expected are essential,” he said. “Some situations during surgery are simply beyond our control — they depend on the patient’s unique anatomy and how their eye responds in the moment. The key is to stay composed, not let stress compromise your performance and focus on finding the best way to manage the challenge at hand.”

“Stop, take a deep breath, do what you can to stabilize the eye and take the time to think,” Zhu said. “The worst thing you can do is immediately pull out of the eye, allowing the chamber to shallow and the vitreous to come forward. Almost always the answer is to fill the eye with viscoelastic to make sure it is stable and then pull out and think.”

One step at a time

Al-Mohtaseb suggests taking a breath and thinking over what to do. Speaking calmly and slowly is also important to avoid transmitting tension to the patient and staff.

“Remember that the patient is awake. Remember that the scrub techs, the nurses, they all would be negatively affected by your tension,” she said. “No matter what you are feeling inside, you have to practice not to show it to everyone around you because the less stress there is in the environment, the more positive the response goes.”

“Complex cases are just a series of simple steps,” Dhaliwal said. “I love that saying, and that’s the way I like to think when I deal with difficult cases or unexpected complications.”

She recommends staying in the moment and focusing on each step individually to perform it in the best possible way.

“Compartmentalizing” is what Devgan calls this ability to focus only on the task at hand.

“It’s a learned skill that comes with time and age. It’s the ability to stay calm, stay logical and have good backup plans,” he said.

It is also important to bear in mind that not every complication needs to be fixed immediately or be fixed by the initial surgeon.

“Let’s say you are dealing with a very difficult cataract,” Devgan said. “Somehow you manage to get it out, but the capsule is damaged, and you don’t know how to implant the lens. It’s perfectly OK to stop, leave the eye aphakic, finish this surgery, and come back in a week or a month to implant the lens.”

This happened to Trattler with an advanced cataract in an elderly patient in whom a significant tear in the capsule occurred. Part of the nucleus fell into the back of the eye, and at that point he decided to stop the surgery.

“I placed a suture to secure the eye, and then I referred the patient to our retina specialist,” Trattler said. “The retina specialist observed the patient for about 5 weeks because there was significant corneal edema, and the eye pressure remained in a normal range. Once the corneal edema resolved, the retina specialist calmly and beautifully removed the rest of the cataract from the vitreous cavity and implanted an anterior chamber IOL. I recently saw the patient — she’s about 2 years out from surgery — and she has 20/30 uncorrected vision in that eye and a very healthy-appearing cornea.”

Communicate bad news empathically

The most challenging part of having a complication is dealing with the patients and their families afterward, according to Zhu.

She is immediately open and truthful with her patients, brings them out to the postop area and invites their family right away to explain what happened and what is needed to fix the problem, offering realistic hope.

“I focus on the solutions and on the path forward without dwelling too much on what happened. If you are positive and have a plan, the patient also stays positive,” she said.

It is mandatory to plan the second surgery, if needed, quickly and efficiently. Equally important is to stay in close contact with the patient either personally or through a dedicated patient counselor.

“I have patient counselors in my practice, and they communicate with the patient and their families personally through their own cell phone, day to day, and never miss a call,” Zhu said.

Trattler provides his own cell number and communicates via text messages.

“I like to be the point person to answer questions, to help reduce anxiety, to make sure they remember the right drops. They know to contact me if any new symptom develops,” he said.

“I never want a patient to feel abandoned,” Dhaliwal said. “I let them know that we are going to be together on the recovery journey, even if I have to refer them to another specialist. If I can look in the mirror and say I did the best job I could do in this case, then I give myself grace. You have to be kind to yourself, knowing that you are only human and that the only way to avoid complications is never to operate.”

Fortunately, most complications have a fix, and patients and their families must be reassured that everything will be done to have the best possible outcome.

“The most important thing is to make them feel that you’re a team and together you’re going to get through this,” Al-Mohtaseb said.

Dealing with angry patients

In Al-Mohtaseb’s experience, if patients feel like the surgeon cares, they are usually understanding. However, everyone will have to deal with an angry patient at some point.

“It’s hard because I really care,” she said. “Those are the situations that affect me the most, the ones I take to heart when I feel I have done my best in everything. But sometimes there comes a point where you just have to accept that there is nothing else you can do to make that patient happy.”

Understandably, patients are upset when their expectations are not met. Therefore, setting the most realistic expectations is as important as delivering the highest level of care, Devgan said.

“And if the patients are upset or angry, you should continue to make them feel that, whatever happens, you will be here right next to them,” he said.

When complications lead to litigation, the emotional impact can be potentially devastating.

Many of these cases are dropped, some are settled and some go to trial, but surgeons should not live their life being worried about medical legal cases, Trattler said.

“Instead, we should just do everything we can to take the very best care of our patients. Often, that works out best for everybody,” he said.

Stress relievers

There are no protocols that suggest how surgeons can learn to live with the high amount of stress that is inherent to their profession, but everyone develops their own “survival strategies.”

“What helps me the most is to know that I am not alone,” Zhu said. “I have a tight-knit group of people, like mentors and colleagues I can share my experiences and worries with. And it is also important to have someone to talk to outside of the field. For me, it’s my husband.”

She feels lucky to be, by nature, a stress-free person who lives day to day without worrying about what is going to happen next.

“I do whatever I need to do on that day and look forward to something nice at the end of it, like sitting on the couch and watching a movie with my husband,” Zhu said.

Dhaliwal also shares her burdens with colleagues, family and friends and cultivates mindfulness through yoga and meditation.

“I also do some stretching and breathing in between cases and review my notes,” she said.

Trattler recommends eating well, sleeping well and staying physically active.

“I go to the gym and take fitness classes with my wife, Jennifer Loh, MD. Stress impacts the cardiovascular system, so you need to stay fit,” he said.

Al-Mohtaseb said she has learned a lot about maintaining balance from being a working mother. She also does meditation to calm the fight or flight response, but her more congenial way of dealing with life challenges is through analytical thinking.

“If I feel I am getting stressed, I try to rationally understand the reasons why things happen, why people are acting the way they do, and it helps me,” she said. “It’s a kind of psychological distancing that regulates the physical impact of emotions such as fear, frustration or surprise.”

Worst nightmare

What are the most feared complications and worst nightmares of surgeons? The one Devgan worries about the most is endophthalmitis, which has an incidence of about one in 2,000 surgeries and is therefore likely to happen at some point in the life of high-volume surgeons.

“We have come a long way in reducing that risk by using intracameral antibiotics, and I am lucky because I have done thousands of cataracts over 25 years, and I’ve had zero endophthalmitis. But that doesn’t mean it can’t happen next week,” he said.

Trattler mentioned three sources of major stress. The first is a posterior capsule tear, which is not infrequent. The second is suprachoroidal hemorrhage during intraocular surgery, which is rare but potentially devastating. The third is a postoperative retinal detachment, a well-known risk after cataract surgery.

“Thankfully, there are treatments for all three complications, but those are the things I think about a lot before, during and after surgery,” he said.

For Dhaliwal, as for every cornea specialist, the nightmare would be an expulsive hemorrhage during penetrating keratoplasty, which can result in total loss of vision.

“To prevent those cases, we administer intravenous mannitol preoperatively and make sure that the patient is under deep akinetic anesthesia,” she said. “When I am open sky, I let everybody in the room know that this is the most challenging time of surgery and maximum preparedness is needed because we must be as quick as possible.”

The worst complications are those that occur in patients who are undergoing refractive lens exchange because they have healthy eyes and high expectations and pay out of pocket, according to Zhu.

“I am thinking of complications where there is no easy fix, like a suprachoroidal hemorrhage,” she said. “You are doing your routine procedure, and all of a sudden there is bleeding in the back of the eye. You have to stop. You can’t put the lens in, you can’t finish the case, and then you have to close the eye to make sure intraocular contents don’t come out. I think that’s the worst nightmare scenario for most cataract surgeons.”

What Al-Mohtaseb fears the most is any complication that could result in permanent vision loss for the patient, especially in a monocular patient.

“It could be a really bad retinal detachment, a really bad infection or a really bad hemorrhage, which can happen with any surgical technique,” she said. “More often than not, you can fix complications, but if you can’t and the outcome is bad for the patient, regardless of what the cause is, that would keep me up at night, for sure.”

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For more information:

Zaina Al-Mohtaseb, MD, of Whitsett Vision Group in Houston, can be reached at zaina1225@gmail.com.

Uday Devgan, MD, of Devgan Eye Surgery in Los Angeles, can be reached at devgan@gmail.com; website: www.CataractCoach.com.

Deepinder K. Dhaliwal, MD, LAc, of UPMC Vision Institute in Pittsburgh, can be reached at dhaliwaldk@upmc.edu.

William B. Trattler, MD, of the Center for Excellence in Eye Care in Miami, can be reached at wtrattler@gmail.com.

Dagny Zhu, MD, of NVISION in Rowland Heights, California, can be reached at dagny.zhu@nvisioncenters.com.