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The Physician's PERSPECTIVE sometimes they pay off big time. However, there is always risk associ- ated with being aggressive, and sometimes in the financial world, you pay the price dearly. The same situation exists for trainees who are overly aggressive when performing cataract surgery. Sometimes they get away with it and everything turns out great, which unfortunately rein- forces that they should continue to do it that way, until one day it com- pletely backfires and there is a huge complication. The best thing to do is to iden- tify the problem early on. It is infi- nitely easier to change behavior before it becomes a habit, and it is much harder to deal with a resident who has gotten away with being ag- gressive for much of his/her train- ing. Aggressive residents come in two different types: those who have a heavy hand and just "don't know their own strength" and those who perform daring and dangerous ma- neuvers inside the eye. For residents who merely seem aggressive because of a heavy hand, I remind them that ocular tissues are delicate. Pushing too hard when making a scleral groove can damage the ciliary body; pushing posteriorly too hard when trying to crack the nucleus can rupture the posterior capsule; and forcing instruments too hard through the main incision can strip Descemet's membrane. If a sim- ple talking to is not effective, a few hours in the wet lab to show them how ocular tissue can behave rea- sonably with a gentle but firm hand generally does the trick. The resident who does daring acrobatics during cataract surgery is a different story. This resident has to be distinguished from a resident early in training who is simply un- aware that the phaco tip shouldn't be chasing a nuclear fragment deep into the bag, or that he is unknow- ingly phacoing up against the en- dothelium. The aggressive resident will purposely do such maneuvers in the name of "efficiency." To that res- ident, I say that cataract surgery is not a race. There is no reason to risk the patient's outcome for a few min- utes less of operating time. With this resident, I will observe carefully for an entire case to see if the perceived aggressiveness is a continuing pat- tern or just a fluke. If it's a pattern, I will walk though every step at which an aggressive maneuver can be made, such as not regrabbing the capsulorhexis when it would be helpful, risking the tear going radial; using excessive phaco power for a soft lens; and chasing and phacoing nuclear fragments in dangerous places. We'll discuss what can hap- pen in the worst-case scenarios. If aggressive maneuvers are still subse- quently being made in the eye, I make the resident stop, and we dis- cuss right then and there the possi- ble ramifications of the maneuvers he or she is doing. Ultimately, if an aggressive resi- dent chooses to ignore the teach- ings, actions to protect the patient need to be employed, such as sus- pending operating privileges until less aggressive actions can be demonstrated in a practice model setting. I've never had to go this far, and I hope never to have to. EW Editors' note: Drs. Jeng, Oetting, and Pyfer have no financial interests related to this article. Contact information Jeng: jengb@vision.ucsf.edu Oetting: 319-384-9958, thomas-oetting@uiowa.edu Pyfer: mfpyfer@gmail.com Stephen S. Lane, MD ASSOCIATED EYE CARE STILLWATER, MN In today''s d s economic clima onomic cllimate... EyeWorld @EWNews Keep up on the latest in ophthalmology! Follow EyeWorld on Twitter at twitter.com/EWNews I trust my business to ASOA. The American Society of Ophthalmic Administrators— the fastest, most reliable, and accurate resource for ophthalmic practice staff. Sign your staff up for a free-trial membership! Call ASOA at 703-788-5777 or email ASOA@asoa.org www.ASOA.org