Eyeworld

September 2011 difficult and critical steps, e.g., cap- sulorhexis or nucleus removal, are only attempted when the other steps have been successfully performed on a number of cases. This method al- lows the resident to build confi- dence in his/her skills. Have the resident practice working under the microscope and become familiar with the surgical instruments. This gives the preceptor an opportunity to observe the resident's skill level, identify weaknesses, and intervene to correct technique errors. Using this approach, there is a clear under- standing of what the expectations are of the resident for each case. Over a relatively short period of time, residents are able to perform entire cases by building every week on skills acquired during the previ- ous weeks. This has the advantage of putting less pressure on the attend- ings to turn over entire cases and re- duces the burden on the operating room schedule. All parties leave sat- isfied. 3. Communication: Instill in the residents the notion that treat- ing cataracts is not a procedure per- formed exclusively in the operating room. Engage them in surgical plan- ning, biometry evaluation, and IOL selection. Discuss phacoemulsifica- tion machine parameters and rea- sons for modifications, the preferred technique, instruments, and method of nucleus disassembly. Following each case, discuss with the residents in a calm and friendly setting tech- nique errors, intraoperative events, errors in recognition, or other obser- vations you made in regard to their performance. 4. Simulation: Use a wet lab if available. It is a stress-free environ- ment where techniques can be demonstrated and the resident can practice on pig eyes steps such as wound creation and suturing. If the eyes are in good condition with a clear cornea, capsulorhexis and nu- cleus removal can be practiced. A surgical simulator is particularly helpful, especially for certain steps, e.g., capsulorhexis. The software al- lows performance measures to be evaluated. Encourage the residents to use it as much as possible prior to attempting this step in the operating room. Scott H. Greenstein, M.D., F.A.C.S., Massachusetts Eye & Ear Infirmary, Harvard Medical School For anyone teaching either a resi- dent or another practitioner a new surgical procedure, there are several key points to bear in mind. Some may seem obvious, but unless you find yourself in the gratifying posi- tion of teaching surgery (which I do after 20 years of private practice), these may not all be apparent. 1. Scrutinize every step: As a teacher, you cannot look away from the microscope for even a second. The 20 major steps of cataract sur- gery have multiple technical and judgment components. 2. Prevent complications: Know when to switch seats and take over. While it may be useful in horseback riding to get back in the saddle after a fall, we cannot afford to let the procedure progress to a point where it becomes irretrievable. 3. "The enemy of good is per- fect" does not apply to cataract surgery: Our patients expect perfec- tion today, and the results of the trainee must equal that of the at- tending. 4. Repetition is good and es- sential: Try to have the resident do multiple consecutive cases, early on in training emphasizing certain as- pects of the procedure (such as inci- sion creation or capsulorhexis). 5. Ask the resident for his/her opinion: For example, "Do you think we need to use trypan blue?," "Do we need iris hooks?," "Are we looking at cortex or capsule?," "Do we need a suture?" 6. Don't go after a tiny piece of residual, far-peripheral cortex. 7. Be patient at all times: While you may have performed ten thousand of these as an attending, the resident has done maybe a dozen or two. Never lose your cool. This sets a good example for the resi- dent to maintain composure and logical thinking if a complication does arise. 8. Communicate: Do this in soft tones, respectful of the patient who may be able to understand the nature of what is being said. Try to give a full commentary on every step you go through on the first case of the day, before the resident starts. General anesthesia cases obviously enable maximum verbal input. 9. Utilize positive reinforce- ment: In many ways, you are acting as a coach. 10. Instill confidence: "You can do this." 11. Avoid all distractions in the room: Pagers should be given to the circulating nurse, rather than being worn by the resident. There should be no unnecessary conversa- tions in the room. Music should be played at low volume and only if the trainee agrees to this. 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Experience The Benefits of Excellence The Scanmate DGH 8000 d Cataract continued from page 71

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