Learning to Be A Surgeon: Tips for Ophthalmology Residents

The eye is such a delicate and intricate organ. Cutting it open, rearranging its parts, and restoring vision seems like an impossible proposition. But that gross oversimplification is exactly what ophthalmologists are able to do.

Surgery is a special and central part of ophthalmology. The field offers a huge breadth of procedures, all contained within one (or two) orbit. Knowing when and how to use this surgical skill can immediately change a patient’s life. As a surgeon, the first time a postoperative patient is overwhelmed by the positive impact you have had is a memorable experience—and it never gets old. The promise of learning these skills and feeling such gratification encourages many medical students to pursue ophthalmology.

But what makes a good eye surgeon? Medical school does not provide substantial exposure to microsurgery. As a student, it can be hard to see what is going on under the microscope, and the scale of structures and movements are too small to appreciate without firsthand experience. Residency interviews do not delve into surgical competence. (As an aside, I did play the board game Operation and was asked to pick up a marker with two other markers during my interview process, but I do not think those are specific predictors of skillful surgeons.) These are not oversights. Instead, everyone is capable of becoming a surgeon. That truth arises from the fact that surgery is not just hand-eye coordination. Cognitive and emotional factors heavily influence how successful a surgeon is, and nurturing these characteristics in oneself is critical.

When embarking on a surgical career, there are certainly practices and habits that can smooth the trajectory of one’s own surgical learning and required growth.

Eye surgery is not just the physical act. The preparation prior to a case is equally important. Ultimately what distinguishes a good surgeon is how she reacts to unforeseen events. In stressful situations, everyone falls back on what they have thought about and done previously. That is why examining cases before the operating room with an eye for possible complications is so crucial.

Identifying patients that are at high risk for complications and thinking through how you might respond to that event makes you much more likely to act appropriately in the moment. At first this seems arduous and impossibly broad. However, just as faculty mentors are invaluable in the operating room, they can also provide excellent guidance on how to prepare for cases.

Mental preparation also helps to reduce stress, particularly when someone is learning a new skill. Confidence that you know the next steps, the appropriate instruments, and the responses to complications allows you to execute with focus and calm. This leads to better performance when you are asked to be the primary surgeon and more of those opportunities being passed your way.

Inevitably, you will hear about a trainee who had “great hands.” Usually this is someone who graduated a while ago and is benefiting from the elevating effect of time passing. In reality, everyone goes through periods of rapid growth and frustrating struggles as they learn to be a surgeon.

Completely eliminating the mistakes and stumbles is impossible, but repetition and practice allow you to accelerate through these periods. Residency applicants fixate on cataract numbers as a proxy for overall surgical exposure. While these are fine numbers to examine, they are notoriously inaccurate and do not represent the full spectrum of opportunities to practice. Wet labs provide excellent surgical training. There are all sorts of knocks against the different feel and behavior of animal eyes, but imprinting the steps, instruments, and landmarks in your brain in a low stress, controlled environment positions you to maximize your cases in the real operating room.

When preceptors see that you have a good grasp of the basics, they are less quick to switch you out of the operating chair. Similarly, surgical opportunities are also more available to those that are willing to put in the effort to make them happen. When you are learning to operate, your thresholds for too early, or too late, or too busy ought to be very high. Some of the most productive teaching cases happen at night or on weekends when there are fewer time pressures and more latitude for residents to take the lead. It is no surprise, but maximizing practice in all of its forms is essential to accelerating the surgical learning process.

Inevitably, you will spend time in the operating room watching others. This can be tedious, but engaging in active observation can make these experiences valuable. Ask yourself why each step was completed in the way it was. Reviewing those rationales will help your own surgical decision making, and identifying when you are not sure why a step was performed in a particular manner allows you to ask intelligent, productive questions.

Watching a more skilled surgeon encounter and overcome complex pathology or unexpected complications is the best way to prepare yourself. These cases are uncommon, which means that spending time watching routine surgeries is part of the process. But the yield from watching or assisting during a complex surgery is huge.

Fortunately, the operating rooms of the future will likely be more conducive to observing microsurgery. Technology is advancing quickly, allowing for three dimensional and virtual displays. These improvements will make the nuances of intraocular surgery more readily visible. The educational value of watching someone skilled at the craft you are trying to perfect is unparalleled and will only increase as the technology evolves.

Sports analogies abound in medicine, and “watching game film” is particularly relevant in learning to be a surgeon. While operating, our focus is often so intense that we miss things happening all around the surgical field. Sometimes, it’s hard to pay attention even to what our own second hand is doing. This tunnel vision makes reviewing surgical videos crucial.

The fact that most surgeries in ophthalmology happen under the microscope means that almost everything can be recorded. Re-watching these videos, even if the case went as expected and particularly when a complication arose, is critical to learning. It is not unusual to be totally surprised by what the video shows. There are simply too many events happening at once to keep track of them all in the operating room.

Developing these habits early on is important because learning continues throughout a career. Entirely new techniques, instruments, or surgeries will appear long after you have left residency, and the process of learning that starts as a postgraduate student will repeat again and again. It is important to reflect on the good and the bad from every case so that productive habits are encouraged and improvements are made.

For many, developing into a surgeon is central to becoming an ophthalmologist. Learning the knowledge and skills is not easy or trivial, but that process is something that all trainees go through. And there are effective ways to maximize your growth. A huge amount of surgery depends on mental and emotional preparation. Those that are prepared are more likely to succeed.

As with learning anything new, repetition is key to making gains. Prioritizing opportunities to practice is crucial to accelerating your learning, as is watching and learning from experts. Even when a surgery is over and has gone well, an imperative step remains. Reviewing a case and learning from the good as well as the bad solidifies gains and prepares you to become a life-long learner.

Everyone is capable of becoming a surgeon, and those who apply themselves in all aspects of the process can become incredibly skilled and impactful.