1720: Should you give up operating?

CataractCoach is very popular among young ophthalmologists who are in the earlier stages of learning ophthalmic surgery and I often receive messages from these young doctors. A relatively common sentiment is regarding the difficulty in learning ocular surgery and whether the doctor should give up operating. The learning curve is truly challenging.

This graph shows three paths in becoming a surgeon:

  • The blue line is the young doctor who cannot find the drive to push past the frustration barrier to become an ophthalmic surgeon. As such, this doctor will drop out of medicine, switch to a different medical specialty, or choose to be a medical ophthalmologist who does not perform surgery. Fortunately, this is a rare occurrence.
  • The red line is the surgeon who is able to get past the frustration barrier and become a competent surgeon. But the passion and the drive to be better and better, simply is not there. This doctor will be stuck in this zone of mediocrity forever and will simply do the techniques that were learned back in residency training.
  • The green line is the expert surgeon who has the drive and determination to learn from every single case and consistently evolve surgical techniques over the years. This surgeon embraces the very difficult cases and prepares diligently for them. This surgeon has the passion to be the best and will maintain that passion for decades. This is the true expert.

The frustration barrier is real and this is a very serious topic.

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6 Comments

  1. way too early to give up surgery. you’re still very early in the learning curve. this is part of the process (a painful process at times). things will get better as you get more cases under your belt. practice makes perfect!

  2. I agree with Dr. Devgan’s assessment that with enough dedication and the right mentorship, most people can become competent surgeons. Due to this assumption, most residency programs do not test for or even ask about dexterity when they interview candidates. However, for some people, it may take much more effort than for others.

    Work hard to improve your surgical skills–watch videos, hit the wet lab, and work on practicing common surgical maneuvers even outside the lab, especially with your non-dominant hand. If you are getting very nervous and tend to develop a tremor from the sympathetic discharge, consider the judicious use of a beta-blocker after consulting your physician.

    I think there are circumstances where it may be appropriate to give up surgery. If you have a significant physical limitation such as the lack of stereopsis or dysmetria, or have significant difficulty with other tasks that require dexterity and coordination, or just lack interest in surgery, then you might want to focus on other aspects of ophthalmology where you can excel and best serve your patients.

  3. Go to India and do a few hundred cases. A change of venue may do you much good. Also tour India and have a good time.

  4. Since there are some cases that the fellow is doing are perfect that means they have a potential, all they need is consistency and that comes with practice. Anxiety before OR is like growing pains. The more you go to the OR the less stressful it will be. Initially As mentioned above beta blockers, anxiolytics, meditation can definitely help and as you get more comfortable you can try weaning yourself off it. Going to India can be a game changer where you do surgeries under supervision but no harsh judgement from anyone and the environment is very supportive and conducive for learning. In some of the programs you will be in the OR 4-5 times a week doing 6-8 or even more cases. You will see a great improvement.
    Thinking and analyzing is good in order to learn from each case but too much of it doesn’t help. Too much analysis leads to paralysis😬.

  5. this was sent to me by an anonymous surgeon, so I’ll post it here: (your comments on this are welcome)

    The harsh reality is, we are not all made to be surgeons. I think a bigger problem is selection process for our field. We concentrate on the ability to take a test and make a good score while, instead, we should concentrate on intangibles. These intangibles include but are not limited to manual, dexterity, calm, under pressure, expert decision making. we are not all gifted with manual dexterity, just like we are not all gifted with academic prowess, or the ability to get into medical school even. In my view, we put way too much weight on academia, and not nearly enough on these in intangibles. So the question becomes how do we refine the selection process to quantify these intangibles before they get to that point of wanting to quit. I think it all comes down to mentorship either great or poor. It is the medical schools responsibility to cultivate young doctors, and help them realize whether they are capable of decision-making under pressure, calm under pressure and to find out if they have the hands to do it. The harsh reality is that not all of us do. Medical schools are certainly quick to deal out grades and stratify and quantify medical students in this way, but what they really should be doing is making keen observations of their students and counseling them in the way that they should or should not go. It is a huge problem that most medical schools do not, and what happens on the backend as that young doctors get pot, committed to their education only to find out that they aren’t meant to be a surgeon. The net result is a young doctor hundreds of thousands of dollars in debt scared out of their mind that they will not be able to pay it back or create a life for themselves and their families . This creates problems as well. A young doctor in this position is now forced to make themselves become a surgeon when they know they shouldn’t be or switch fields. The first is a very dangerous prospect and unfortunately this happens way too much and ultimately harms patients. Fast forward to residency. It is the resident staff, the program Director the chairman‘s responsibility to weed out the non-hackers. We are on the other side of the pendulum, where in the past medical training was very malignant and pyramid programs existed. A pyramid program was where six young doctors started knowing that only three were going to graduate. This is a horrible system but what is happening on the other end is that now we have a very soft system where we graduate people who shouldn’t be graduated and people who haven’t met their minimum numbers. This is evidenced by the famous podcast doctor death. I think that the attending physicians, program chairman, and Director should all be held accountable for the people that doctor death harmed.

    To the young doctor, questioning whether they should quit or switch fields from ophthalmology, you have to answer very hard questions to no one but yourself.

    These questions: are am I capable of being a surgeon? This includes, calm under pressure, manual, dexterity, and the ability to make a decision under pressure. Do I have the intestinal fortitude to carry the emotional burden of a surgeon? Am I better suited for something else?

    Only you know the answers to these questions? These are the questions we should be asking ourselves from the beginning of our residency and it is also our mentor’s duty to keep watch and guide us.

    If you don’t know the answer to these questions early in your training, you’re right where you need to be. Fear is natural and healthy for a young surgeon. However, if you are late in your training, and you still don’t know the answer to these questions the hard reality is you may not be suited for this. You don’t want to go home at night knowing that you hurt a patient you don’t wanna go home at night fearing your next day at work.

  6. Tough decision, good advice. With hard work and dedication, it does get better over time. Start slow, perfect your techniques and save harder cases for later after improvements in your techniques.

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