The robot never doubts itself nor has ego issues. Both can, however, happen to the VR surgeon; there are certain things that he must subconsciously keep in mind while other things need conscious reevaluation on a regular basis. Why the surgeon should periodically face himself in the mirror is best discussed before the need to turn to a psychiatrist emerges.

11.1Self-Confidence Versus Overconfidence

Without proper belief in his own capabilities, the VR surgeon may be overcome or even paralyzed by the task ahead. Conversely, a complete lack of self-doubt can lead him to readily undertake jobs that he is yet unqualified for and then blame somebody else (or the circumstances1) when something does go wrong.

It is not easy to find the right balance between these two opposing extremes, yet this is one of the key ingredients in being a VR surgeon who can justifiably feel as satisfied with himself as his patients can with him. Those who during the training do not neglect the “only gradually” rule (see Sect. 2.2) have a higher chance of finding the right balance.

11.2A Series of “Bad-Luck Cases”

No surgeon, and certainly no VR surgeon, has a 100% success rate. Even if he always does a superb, error-free job, nature interferes: the human body does not accept part of what took place during surgery and surely not all the time. If eyes

1 The nurse gave him the wrong instrument, the vitrectomy machine was not set correctly, the retina was unexpectedly “weak” etc.

F. Kuhn, Vitreoretinal Surgery: Strategies and Tactics,

DOI 10.1007/978-3-319-19479-0_11

with poor outcome cluster,2 it is not necessarily his fault, yet he eventually feels guilty and starts to doubt himself: maybe he has indeed erred.

As an example, Fig. 11.1 shows several possible outcomes in a person presenting with an EMP. In extremely rare instances, the patient may even die during surgery (see the Appendix, Part 2), and compared to this event the original scar on the macula is so insignificant that the surgeon seriously blames himself for offering/ indicating vitrectomy in the first place.

Fig. 11.1 Possible outcomes after PPV for macular pucker. Not all potential options are shown here; see the text for details. Preop preoperatively, intraop intraoperatively, postop postoperatively, * compared to before the initial surgery

Occasionally an intraor postoperative complication occurs and makes the patient’s final vision worse than the preoperative one (or at least prevent improvement). If there is an accumulation of such failures in a short period of time, however unrelated they are, it naturally suggests to the surgeon that he is at fault.

It must be understood that such a series of unexpected failures can and do occur. The surgeon must thoroughly examine each such occurrence (see below, Sect. 11.3) and objectively determine whether he is guilty.3 If he is not, then, and only then, should he move on (without losing confidence, see above,

Sect. 11.1).

2When you flip a coin, it is either head (H) or tail (T). If you flip it 10 times, you do not always end up with 5 Hs and 5 Ts; neither will the order be a neat H/T/H/T, but something random like T/T/T/ H/H. Similarly, you may have 30 cases with no complication, and then all of a sudden in the next two cases the very same complication occurs. It is only natural to start blaming yourself: surely, this is not a chance event.

3Doing something he should not have or not doing something he should have.

Q&A

QHow should the surgeon deal with his own feeling of guilt due to a significant complication that is his fault?

AThere are several ways a surgeon can react to a significant complication he caused. Not feeling guilty at all and not contemplating what happened and why is the worst possible scenario. Feeling guilty to the point of being paralyzed by the event and considering giving up surgery all together (lack of selfconfidence) is also a misguided response, unless such cases regularly occur. Initially feeling guilty and giving serious consideration to why the complication occurred and how it can be avoided next time is the optimal response.

11.3Self-Examination

It is very useful if the surgeon periodically analyzes his results.4 Such a statistical analysis provides feedback mostly on the strategic level (see Table 3.1).

A great opportunity for the surgeon to review his intraoperative activities (tissue tactics) is to record all his operations and dedicate time to actually watch them (see Table 2.2 and Sect. 12.4), especially if this can be done at a later date (when the memory is not so fresh) and by watching multiple tapes one after another.5 Reviewing unedited videos is an indispensable teaching tool even for the experienced surgeon.

•Every surgeon6 has a mental image of how he does certain maneuvers.

•When facing the mirror, which is what the videotape provides, there may come a shock, showing that the memory is selective and pliable.7

–What the surgeon thinks he has been doing and what he actually does, whether it concerns the surgical technique or the number of attempts to achieve a certain goal, can be vastly different. Watching the videotape and thereby realizing the difference between the mental image and reality8 helps reconcile the conflict and improve performing the maneuver in question.9

4Even better if he has a resident or colleague who does it for him so that the review is absolutely unbiased.

5Conversely, it is very misleading to watch your own edited videotapes (or ones shown at scientific meetings). These are sterilized to the point of uselessness: they never show complications or failures; every maneuver is immediately successful and all attempts work effortlessly. Nothing is further from real life.

6Except the very beginner who, understandably, focuses too closely on the “tree branch,” not the tree, much less the forest.

7This is not a conscious process to artificially improve the surgeon’s image of himself; it is identical to what happens when eyewitnesses try to remember an event. Even though they all saw the same thing, their brain makes them recall very different things.

8The surgeon is convinced that when he says: “I always do it this way and it always works,” it is true. However, the recording may show that he does not always do it that way and it does not always work.

9In the classic joke, the surgeon has three wishes. First, that he has as much money as his colleagues think he has. Second, that he had as many girlfriends as his wife thinks he had. Third, that he is as good a surgeon as he claims he is.

11.4My Way

As mentioned in the Preface, the surgeon should develop his own, individualized way of performing VR surgery, whether this relates to strategic or tactical questions. The “doing things my way” philosophy, however, must never mean rigidity: as a result of technological advances and the self-examination process, the actual execution of the my-way technique should undergo a perpetual change, a constant strive for improvement.