Appendix

Despite all of these facts, you must:

•Pay very close attention to the case the entire time, no matter how boring and repetitious it gets.

•Remain very patient3 and not immediately voice every suggestion that your brain flashes up, even if the suggestion would surely improve the efficiency of the surgical maneuver in question and reduce the time of the operation.

•Resist, at least temporarily, the temptation to tell the fellow to switch places so that you can demonstrate how it’s done.

•Use encouraging words for things well done and suggest corrective actions as need be, finding a balance between the two since.

–Too much or undeserved praise unnecessarily boosts the fellow’s ego, which can lead to overconfidence (see Sect. 4.7).

–A nonstop flow of commands to do something differently kills the fellow’s initiative and indeed thinking.

•Make a decision every time you notice the fellow is struggling, whether you are going to:

–Let him find the answer himself (this is the ideal option as long as it does not risk a significant complication).

–Suggest the solution (a solution) if the fellow does not seem to find it.

–Take it over if the maneuver is too difficult for his level or if you yourself cannot determine what the next step should be.

•Switch places if the situation in the eye threatens with a major complication so that you demonstrate what needs to be done.

•Be ready to answer any and all questions the fellow has; in fact, you must encourage him to keep asking questions, no matter how trivial they may seem to be.

Pearl

This is what I tell my fellows, at the very beginning of the training process, and repeatedly prior to the operation: You can ask any question at any time, whether you are doing the case or I am. There is no such thing as a stupid question, only a stupid person who does have a question but does not voice it.

During an operation or the training process in general, you may come across something that needs an extensive discussion; it may turn out to be a positive or, more commonly, a negative feedback. Do not spare the time; sit down with the fellow in private – never shame him in front of others, whether it is a patient, a nurse, a colleague, or a visitor. Go over the issue in detail. Find a solution together with the fellow: not merely suggesting one but arriving at it together.

3 Even though virtually every maneuver will take longer for the fellow to complete than for you, you have to dedicate sufficient time to allow him to actually do it. Observing is passive knowledge, doing it is active; we all know from every walk of life (just think about learning a language) that the active knowledge is many times more important and useful.

Being the “surgical coach” has much higher stakes than coaching in sports, even if there are many similarities. In your case somebody’s sight can be ruined or another person’s professional goals dashed if you do not act properly, and if you are not willing to do the training properly, get out of this business (see

Sect. 3.5).

Pearl

Never lose sight of the fact that some time ago you were a beginner surgeon yourself. You also struggled with what you perform so (seemingly) effortlessly today, so always act toward your fellow the way you wished your mentor would have acted toward you back then.

Part 2. Important Personal Experiences

As we look back at our lives, both personal and professional, we all remember events that had a profound effect on us and shaped us, turning us into what we became. Below is a collection of events that had a major impact on my own professional life.

A Person, Not a Diagnosis

As a medical student, I once woke up with terrible pain in my right shoulder and soon realized that I was unable to lift my arm above the horizontal. My father, who was the chairman of the Radiology Department at the same university, took me to the Neurosurgery Department.

I spent the next two weeks there as a patient. I was a “VIP” because of the family connection, because I was a medical student just before graduation, and because I had known my treating physicians for a long time. Yet during all that time nobody ever spoke to me about the diagnosis, the potential consequences, the medications I had to take, and the prognosis, not even the diagnostic procedures I was facing (the latter is a less pressing issue in the era of CT and MRI, but back then pneumoencephalography [see http://www.ncbi. nlm.nih.gov/pmc/articles/PMC494289/] was just one of the horrors a patient had to face). And because none of my physicians talked to me, I did not dare asking questions myself.

The bottom line

That was when I made the conscious decision that if I ever become a physician, I will be a doctor, a doctor to whom the patient is not a case, an organ, a tissue, a condition, but a person. With time, I went one step further and have practiced what is described in Chap. 5: I counsel, the patient decides.

The Welcome Message

The first day I showed up for work at the university hospital, the chairman of ophthalmology took me to a ward where a middle-aged female ophthalmologist (Dr. S.) was in charge. The chairman asked her to take me under her wings and train me as best as possible. I had never met Dr. S. before; her first words to me were an instruction to “go and fetch Mr. X.” I concluded Mr. X had to be a patient so I went to the nurse and asked her where I could find him and then took the patient to the exam room.

Dr. S. told me to take the (direct) ophthalmoscope and describe the macula. I replied that this is an impossible task; the only time I had the direct ophthalmoscope in my hand was 2 years earlier as a medical student, and even then for 1 min only. I, as my fellow students, was very happy to catch sight of the disc – no hope for the macula. Dr. S. told me to move over to the desk and write in the chart what she dictates. I tried my best, but she used technical words I was unable to understand. When she finished, she told me, in an icy voice and in front of the patient: “You see, I can dictate half a page about something you are unable to even see.”

The bottom line

Do not expect that all your colleagues have the same interest as you do in advancing your career.

Vision or the Removal of the IOFB?

Within weeks into my residency, a young male patient arrived with a small IOFB lodged into the posterior retina. Amazingly, he had full vision and no VH. As usual, it was the chief of the department who removed the IOFB, using a large external electromagnet; for some reason the procedure was not done under general anesthesia. All 17 ophthalmologists of the department were present when the extraction took place, and everybody was visibly relieved when the IOFB finally “jumped out of the eye”; some of my colleagues even clapped their hands. Nobody seemed to be bothered by the scream of the patient: “I can’t see anymore.” I asked an experienced “attending” what may have happened and was told that the patient probably suffered a VH – this before the age of vitrectomy. (Eventually, the eye became blind and phthisical and was enucleated.)

In the late afternoon hours that day I went to the chief’s office and told him what I could not understand: we seem to be so happy that the IOFB was successfully removed, even though the patient just lost vision. The chief stood up behind his desk, pointed at me, and in a very threatening voice asked a question: “who are you to question what we have been doing for a hundred years?”

The bottom line

That was the moment when I decided that from now on, I will question everything, irrespective of who says or does it. (As a corollary: decades later I heard a lecture about 4,444 IOFB operations with a “99% success rate.” The answer to my question [“what is the definition of success?”] confirmed my suspicion: success is defined by IOFB removal. The study did not even look at visual outcomes.)

It’s Not My Business

While on duty at the hospital, I had a patient who was in a car accident. His facial bones were broken and his right hand in a cast, although he had only corneal erosions as globe injury. I asked him what happened, and he told me that he likes to keep his hand rested on the middle of the steering wheel, and when the airbag deployed, it threw his hand against his face.

Years later I was riding in a taxi and noticed that the driver also kept his hand in the middle of the steering wheel. After some hesitation I told him the story of my patient; I said I knew it was not my business how he drives, but my consciousness would not be at peace if I had not informed him about the danger.

He immediately took his hand off the steering wheel and thanked me.

The bottom line

It is your business to inform; whether the other party accepts it or not is not your worry anymore, but you at least did what you could.

Blame Yourself, Not the Nurse

I once had to operate with a very inexperienced nurse. I had the probe in my hand, operating on an eye with an EMP; there was no PVD and the detachment was very difficult. I was working under the contact lens, which kept sliding off the cornea, and I had to ask the nurse numerous times to adjust the lens. I got very frustrated and eventually decided to adjust the contact lens without asking the nurse or pulling the probe out of the eye first (a big no-no!). Much to my horror, I accidentally bumped the probe into the posterior retina, causing a tear – just a mm from the fovea. There was no long-term consequence, fortunately – but I will never forget the sinking feeling I had at the moment when I discovered the tear and its proximity to the fovea.

The bottom line

Never keep instruments in the vitreous cavity if your attention is focused elsewhere. I faced the same scenario multiple times after this experience but would not even contemplate repeating that stupidity.

It Is Not the “Who” but the “What”

I used to work in a country that back then had a totalitarian society and a very rigid hierarchy in medicine. It was in another country, which had a free spirit both within the profession and in general, that I attended the lecture of a Harvard professor (Hp) at the university where I now worked. He was given 45 min to discuss a vision-related basic-science topic, followed by 15 min of questions. All the nobilities of the university were in attendance; being a professor at Harvard deserves that. I was shocked to hear a sentence during the lecture, in which the Hp acknowledged a problem he cannot solve – in that totalitarian country someone of even lesser stature would never admit that a problem for which he has no solution can exist. I was also astonished that the Hp finished on time – in many countries such a title allows you to go overtime.

When the Q&A session started, a very young female colleague from my home country, who also worked at the same university, put up her hand. She did not have a question: in her broken English she explained to the Hp that she may have a solution to his problem. I was watching the facial expression of the Hp as she was talking – from polite it turned to the one when “the lightbulb was just switched on.” The Hp bypassed the university nobilities, came to the young colleague just in front of me, and said the following words: “I think you solved my problem. Would you explain your solution one more time?”

The bottom line

What matters is not the number of stars on your shoulder or the age on your ID card. Your deeds and how you express yourself are all that count.

The IOL vs the Eyeball

I returned home from a long trip late on a Friday afternoon and went straight to the hospital. The nurse informed me about a young female patient who had cataract surgery a week before and now had endophthalmitis. I examined her and immediately offered the possibility of performing vitrectomy, which she, after proper counseling, accepted. During surgery – her eye was full of pus – the original cataract surgeon showed up; he may have been notified by the nurse. He protested when I decided to remove the IOL and the capsule (I deemed it impossible to properly clean the capsular bag): “But then the eye will not have an IOL!” I said only this: “And otherwise there will be no eyeball.”

The patient ended up with full vision and a secondary implant, and I fell out of favor with that phacologist.

The bottom line

Never lose sight of what tissues determine vision and globe integrity: the posterior retina and the ciliary body. The capsule is the attachment to the eye, not the other way around.

Operate When the Anatomy and Function Are Normal?

I remember several patients who were taking immunosuppressive drugs plus systemic steroids for uveitis, but needed PPV because their vitreous was almost totally cloudy. The doses of the systemic medications were temporarily increased prior to surgery so as to reduce the inflammatory reaction the vitrectomy causes. When the patients showed up for the operation, their vitreous cleared up, the macular edema went away, and their vision was full. I was hesitant to go ahead with surgery – one cannot improve vision at that point, only make it worse if a complication occurs. I therefore counseled all of these patients to forego the operation.

Every single patient, independently of all the others, told me that they would risk surgery as long as this gives a chance – not a promise! – that the systemic medications will no longer be needed or can be reduced. They understood and accepted the risks of the operation, but considered the side effects of the systemic drugs too high to keep the ocular inflammation under control. They also realized that once the systemic medications, which could not be maintained at that high dose anyway, are tapered, the ocular complications of the disease will recur.

Fortunately, all of these cases ended up well, but the patients themselves reassured me: even if something goes wrong, they will not blame me.

The bottom line

There is no justification for a physician to consider only the condition of a tissue when treatment decisions are made. There is no alternative to making the decisions together with the patient.

When Your Patient Dies on the Operating Table

I saw a patient who had rather poor vision due to a macular condition. After proper counseling surgery was scheduled; she requested general anesthesia. During the operation I all of a sudden noticed that the color of the fundus is bluish. I immediately warned the (male) anesthesiologist, who was sitting in the far corner of the OR, intensively talking to his new, very pretty female anesthesiologist nurse.

It turned out that the anesthesiologist was focused on the nurse, not on the patient, and let the oxygen tank run empty – back then neither a central oxygen line nor a finger oximetry sensor was available. The resuscitation effort was unsuccessful and the patient died.

The bottom line

For a very long time I could not recover from this tragic event and felt guilty: why did I agree to do the surgery? Slowly I got over it as rational thinking got the better of my emotions, but the event haunts me to this day. The surgeon must always keep in mind the threatening truth in Murphy’s law: If anything can go wrong, it will.