ophthalmology-off-the-grid
Ophthalmology off the Grid
Episode 66

The Sport of Surgery

Host Gary Wörtz, MD, talks with Ashley Brissette, MD, MSc, FRCSC, and John Hovanesian, MD, about what physicians can do to keep their minds and bodies in peak condition for performing surgery.

Speaker 1: Welcome to another episode of Ophthalmology off the Grid.

Today, host Dr. Gary Wörtz talks with Drs. Ashley Brissette and John Hovanesian about how physicians can keep their minds and bodies in shape for performing surgery.

Dr. Brissette is a cornea and cataract specialist and is an assistant professor of ophthalmology at NewYork Presbyterian/Weill Cornell Medical Center. Today, she discusses ergonomics and how surgeons can improve their positioning to avoid injury.

Later, we hear from Dr. Hovanesian, who practices at Harvard Eye Associates in Southern California and is on faculty at the UCLA Jules Stein Eye Institute. He weighs in on preparing for surgery in the context of being an athlete and the types of physical and mental habits that make a great surgeon.

Coming up, on Off the Grid.

Speaker 1: Ophthalmology off the Grid is an independent podcast produced by Bryn Mawr Communications and supported by advertising from Alcon. For a full listing of podcasts for eye care professionals, go to eyetube.net/podcasts.

Gary Wörtz, MD: Welcome to another very special edition of Ophthalmology Off the Grid. This is Dr. Gary Wörtz, and today I have a good friend with me, Dr. Ashley Brissette. Ashley is an assistant professor of ophthalmology at Weill Cornell Medicine, New York Presbyterian Hospital, and she is a cornea and cataract specialist. Beyond that, she is a good friend to me and, I think, everyone in ophthalmology. Ashley, I just want to thank you so much for taking a little bit of time to talk to me today about a topic I think we're both passionate about, and that's keeping our bodies and minds ready for surgery and avoiding injury. So, tell me a little bit about your practice, and then maybe we'll get a little bit into more the meat of the discussion.

Ashley Brissette, MD: Yeah, absolutely. Thank you so much for having me. It's so fun to be a part of this, and I know everybody refers to you as the podfather of ophthalmology, so it's awesome for me to get to be a part of this finally. Ergonomics, it kind of started for me as a little bit selfish, to be honest, because as I was a resident and I was learning how to operate, I found that at the end of an OR day, my neck would be sore, I was having this funny wrist pain as I was learning how to do phaco. It kind of started out where I was thinking, “We train for so long to be able to provide this service for our patients, that it would really be a shame if our work was limited by the very profession that we trained to do.”

That's kind of how I started to get interested in this, and then the more that I talked about it with other surgeons, I found that a lot of people have discomfort after a long day in clinic or the OR, and a lot of it just really has to do with our positioning at the operating microscope and just the nature of our professions.

Gary: Well, I think something that we do, and it's probably maladaptive, I think what we do is, perhaps, we just try to go as quickly as we can. Whatever position the patient is in, we try to adapt to their position, and we sort of put ourselves last when it comes to ergonomics. Because we think, "Well, the patient may have kyphosis, and they may have a weird neck situation, or they may have a large body habitus," and you're sort of operating in an awkward position. Why do we do that? Do you think it just comes from residency, when we're just sort of made to work hard and not think about longevity? We're thinking about just getting the task done? Why don't we spend more time thinking about this?

Ashley: Yeah, I think there's a few reasons. I think first and foremost, the nature of our professions and why we all go into this is that we want to be able to help people. And so, I've found myself, even when I see patients, if I'm positioning them so that I can examine them, I used to say "Is this an okay position for you? Is this height okay?" Because I want to make it a pleasant experience for them, and they're trusting me to examine them and to offer my opinion. So, I think that plays into it. And then the second thing, we're just not really properly trained how to position. We get so much training in ophthalmology, but to have the formal training to really learn how to optimize our work environments is something that we're lacking.

And that's what started me down this path of doing some research in this area and ways that we can help our residents and fellows and then even people well into their careers that might be experiencing some discomfort. How can we learn to better create our environments so that it's healthy, not only for our patients, but also for ourselves?

Gary: So, I have a friend, Nathan Steinle—shout-out to Nathan—is a retina specialist in Santa Barbara and a dear friend. He actually was one year behind me in training, and we were pretty much best friends throughout residency. His wife is a dental hygienist, and what's really interesting is, for dental hygienists, they have entire courses on the proper way to hold instruments and ergonomics. I thought that made a lot of sense, because they're dealing with their hands, and they're performing tasks all day long. Why don't we have that in ophthalmology, or in surgical training in general?

Ashley: Yeah, I completely agree with you. And so, I did some research at my alma mater in Canada, a place called Queens University, that I started when I did my master’s degree and then continued where I work currently at Weill Cornell in New York. And what we did is we created an online ergonomics module for, really, residents and fellows, but anyone can access it. It should be available in the next few months online, where people can actually go into a simulated scenario in the operating room or in the clinic and learn how to properly position. It's a really interactive module for that education. Because, we just found in looking at the curriculum across the country that that's really lacking, and I think unless you seek it out, that you're probably missing that. And I think if you're seeking it out, it's because you're already experiencing pain or discomfort. So, we want to try and get to the point where that's not happening.

And our work environments, I mean, there's specific risk factors that I think are found in ophthalmology, and when we were looking at this and the research we found that there were really three main things, which is pretty similar actually, to a lot of microscope-bound physicians, dental hygienists, laparoscopic surgeons, etc. Specific for ophthalmology, we found that, one, sometimes it's just awkward positioning, as we've discussed, due to the patient's body habitus or just the equipment that we're using, it can be kind of awkward. And then, as you mentioned before, the repetition of tasks, especially if we're doing something like cataract surgery, where we're doing multiple surgeries in a row in the same position, that repetition, it's almost like a repetitive strain injury.

And then lastly, what we refer to as this forced manipulation. So often we grip the instruments really tightly. We're working in very small spaces under very stressful conditions. I think all those three risk factors are really what plays into this being a profession where we’re prone to developing discomfort. In the studies that we looked at, we found that in a range of studies, about 50-80% of ophthalmologists had back or neck or wrist discomfort in their profession. And what was really surprising is, we found that 9% of surgeons at some point had to quit operating due to chronic discomfort. And so again, I just think we train for so long to be able to provide this service and to be able to work, that we want it to prevent it from getting to that point where you're not able to operate any more.

Gary: Ashley, I'm asking this selfishly. This is part of the reason I love this podcast, because I get to ask everyone the questions I want. I'm a bigger guy, I'm 6'2", and I probably look more like an orthopod than a guy who should be doing eye surgery. You know, for me, I'm trying to get my legs under the table, for example, and I operate temporally, which I think most of us, sort of the newer generation of surgeons, operate temporally. But, it can be a real struggle for me to get my legs under the table and also have the oculars at the appropriate height so that everything's in focus. I've sort of figured out some tips and tricks to do that, but for a long time, I would end a case with my right leg—If I'm operating on a right eye, sitting on the right side—my right leg will be sort of pinned up underneath the bed. And, it wouldn't be infrequently that my leg would be either numb or starting to feel a little almost like paresthesia at the end of the case, just because I'm trying to wedge myself into this situation.

I think, also, there's something that needs to be done to create this surgical cockpit, so that we can actually align the bed height and the chair and have the right size or space underneath the bed that allows us to get into a comfortable situation, almost like a luxury car. But, do you find surgeons on both ends of the size spectrum have different challenges? Because, I find that for myself.

Ashley: Yeah, absolutely. We see that a lot as well, especially in trainees, where you might have two surgeons of completely different body habitus that are switching between the primary microscope. That can be really challenging, because if you're operating with someone and assisting them and going back and forth, that size disparity can pose some challenges. You don't want to slow down the case by repositioning everything all of the time. So, I definitely have heard that before. And even me, sometimes just the way that the bed is set up or the patient's body habitus, you're really contorting yourself into different positions to make it so that the eye is at a plain field so that you can operate. So, I've definitely been there myself, and I've heard this a lot.

One thing that I usually recommend to people is to consider having an ergonomics assessment of the workplace, or just get somebody to take photos of you. Because, sometimes you might not even know that you're in an awkward position, because we're so focused on the task at hand. And then, if you look at those photos afterward, or even just a quick video of the way that you're positioned, you might see places in the environment where you can make adjustments. I think it's really important to just take the one minute or less that it would take at the beginning of each case to set it up appropriately for yourself, rather than just trying to rush into the next case, because, I think longevity wise, your body will thank you, not even in terms of years of your career, but even toward the end of the day.

I think that plays a lot into, because this is a repetitive injury, that you really need to be performing regular exercise, stretching, or resistance training, especially after these long OR days, or even a long day in the clinic. And I know, Gary, that you're really into exercise as well, and I just think that that's something that also needs to be instilled into everybody, that we have to maintain ourselves as healthy individuals—mind, body, everything—so that we can provide that service back to our patients.

I will say, one more thing about positioning is that I'm excited about some of these newer technologies that are coming out. Some of the heads-up technology or the 3-D projection, where you might not be leaning forward looking into a microscope, but instead maybe leaning back in the chair a little bit more. I think that's kind of exciting from an ergonomics perspective, too. So, I'm interested to see where that goes in terms of new technology.

Gary: Well, you read my mind in terms of where I was going. Because, not only do we need to do a better job of positioning ourselves or being mindful of our ergonomics, but at some level, we're limited by the technology that we have at our disposal. And so, like I said before, sometimes we're sort of having to wedge ourselves into the situation. But these newer technologies that I think most of the companies now are coming out with, I know True Vision has a product, Zeiss just came out with a digital microscope with a similar type of feel, and I think some others are potentially working on similar technologies. What I like about that is you have a new variable. So, you may still have to worry about your legs under the bed and those sorts of things, but now you're free to basically put your head and lean back and sit where you want.

You think about buying a new microscope as sort of a "How much is this going to cost me?" But, you might want to think about it in a different way, like, if I get the right microscope or the right platform, how much is this going to allow me to maybe add cases to the end of the day, when before I needed to limit the amount, or years to my productive life? I think that's an investment question that's very different than the cost question that we've typically had, don't you think?

Ashley: I think so too. And I think people are becoming more cognizant of that as well, rather than thinking about our bottom line, it's thinking about our well-being as the surgeon. So, I'm really excited to see where industry continues to grow, and as we continue to ask those questions and build and work with industry, I just think it is going to be for the better of everybody. I'm really excited about those new technologies. I know we have Ingenuity at Cornell, and I've used it for some of my anterior segment cases. Our retina surgeons were using it for a really long time, and they were just saying incredible things about it. So, we've just started to employ it for anterior segment, and I've really seen a difference in terms of positioning, especially for longer, say, corneal or conjunctival procedures.

And then also, in terms of teaching and just being, exactly as you said, if you're a taller male operating with somebody who maybe has a different body habitus, being able to switch back and forth between the primary surgeon and the assistant has been really easy, even if they're of two different sizes. So again, I just think it's going to be great to see where we grow with this in industry.

Gary: Let's talk a little bit about something you mentioned earlier, which is exercise, stretching, actually taking care of your body. I mentioned this earlier article in CRST a few months ago about, I think the title is “Cardio and Cataract Surgery," which is kind of catchy. But really, the point of it was, 4 or 5 years ago, I started having lower back pain and neck pain, and I wasn't doing near the volume I'm doing now. But, it was for all the reasons we said. It was me basically just trying to work my way through the day as fast as I can and not trying to take care of myself until I ran into a little bit of a problem. It wasn't severe, but I could tell it was coming. I actually started doing more whole-body exercises, slowly but surely, working into squats and dead lifts with moderate weight, not crazy weight, and trying to make sure the form is really, really good. Because sometimes, if you're not careful, you can injure yourself with those kinds of things.

But, I have actually found that strength training and also yoga are two things that—and yoga, I think, is kind of obvious—most people would say that make sense. But, I have really found that strength training those muscles to actually be stronger so that I can sit up straight and my postural muscles are better, that's helped me so much. I have zero neck and back pain since I've been doing this, and I really am a big fan of it. Have you found any of that in your research to be helpful?

Ashley: Oh, absolutely. I think we really underestimate the strength that is required to maintain a static position. If you think about holding your shoulders up for 5 hours, which if you think, the cumulative time of an entire OR might be that you're in that position, you need an incredible amount of strength for that. So, I completely agree with you that not only the cardiovascular training just for total body health, but the strength training and the stretching is such an important component of limiting any kind of strain or discomfort that you might get just as the nature of this profession is. So, I completely agree with what you're saying, and I've found that in myself as well. I try to encourage that in our trainees at Cornell. I mean, I know it can feel so overwhelming sometimes, when you have a busy practice and other things going on in life, to incorporate exercise.

But, not just for the health reasons that we all know we should be exercising already, but I think to also think about it in terms of preventing injury in the future is incredibly important. So, I completely agree with you. I have a number of exercises that I give out to our trainees, and that will be included in that online module about ergonomics that I'm happy to share with you and the people listening as well, that were developed by a physiotherapist.

Gary: Give me a rundown of what some of those are, if you don't mind.

Ashley: Yeah, so there's one called the broomstick stretch, which is, if you have like a broomstick, or you can do it with an exercise band or even just anything like that, what you want to do is rotate it from right in front of you to overhead to behind your back, and just to really be releasing a lot of that forward kind of positioning that we get into at the microscope as we're operating, and to stretch in more of a backward position to counter all that forward positioning. There's some scapular retraction exercises that you can do as well to strengthen those back muscles exactly as you were describing, where the strength training comes into play. Other stretches like that that really counter those forward positioning, I think, can be beneficial.

Gary: What about stress? That's something I think we don't talk a lot about, because I think we all try to pretend that we don't encounter stress, and stress is something for other people. But, I'll give you a little background. My partner had an injury and was out of commission for a little while, and I went from being a busy surgeon to being kind of like a super-busy surgeon with a double workload. I was really feeling the stress. Exercise is a great stress release, so I kind of use that also, but I think when I walk into the operating room, I kind of feel like I need to be almost like a race car driver or someone who's ready just to perform. That means, not just is my body ready, but it's, have I had enough sleep last night? Am I hydrated? Have I meditated or prayed or gotten myself into the proper mental space to be able to accomplish the task in front of me? Do you have anything in your world that helps you get in the right mindset to be the best version of yourself when you sit down to operate?

Ashley: Yeah, I love that you've brought this up. I think this is something that sometimes people are afraid to talk about. But, our jobs are stressful, and not just in terms of the time commitment, but also in terms of the almost emotional work that's required of it as well. I don't know if you agree with that.

Gary: Yes, definitely.

Ashley: But yeah, I'm a very empathetic person, and I take a lot of what my patients tell me and what I discuss with them, whether it's about their personal lives or their families or things that they're going through with their health, and I take that home. I always think about my patients as I get home, and I think about things they told me about their family members, maybe, who are ill. I think that we underestimate how much that plays into our emotional states as well. We spend so much time at work and so much time taking care of other people that we need to also recharge ourselves. So, I love that you brought this up. I agree with you. I think the importance of mental health is important.

I really think that talking with, whether it's friends, a therapist, can be extremely helpful for managing some of those emotions. Our jobs are difficult, and what we see day to day, a lot of people don't necessarily deal with. So, I think it's nice having an outlet for being able to talk about that, either with people who understand or someone that can help guide you through that. I think meditation can be really important as well, and like you said, prayer too. It's just having that sense of community that you know you have an outlet for. So, I think that just helps day to day for everything. I think as well for the operating room, I specifically have a few weird things that I do ritualistically that I think kind of help.

Gary: Like OCD?

Ashley: Oh, yeah, like I don't drink coffee the days that I operate, so that's like my thing. So, I don't do that. I like to have music playing in the background, so I have a few little things that I like to set up the morning of. I get there early to make sure that the environment is good, that I've said hello to the nurses, I double-check my lenses for the day. So, I just have kind of a few ritualistic things that really help me set the stage for that being a good day. But, other than that, I completely agree with you that I think talking and meditation, seeing friends, therapy, prayer, whatever you want to do, is completely necessary. Because, we've talked a lot already in this podcast about the body component of it, so that you're healthy, so that you can provide the service, but you also need the health of mind and the peace of mind to be a good caregiver as well. So, I think it's important.

Gary: You know, you mentioned something about music, and I almost cannot operate without music.

Ashley: I'm the same way. I wouldn't be able to tell you what song was just playing as I was operating, but I just need that background. That's so funny.

Gary: So, I'll just share my playlists that are kind of my go-to playlists. It depends on the mood I'm in, but Pandora has a few great radio stations. One is called Laid Back Beach Music.

Ashley: I love that.

Gary: It's sort of a weird mix of like Bob Marley and Zac Brown Band and Jack Johnson. That's really good. There's a great one that's basically of the decades '60s,'70s, and '80s. My cataract patient population usually was somewhere in their youth during that timeframe, and so those songs, the patients sort of relate to and like. Also on Pandora, the Eagles radio is fantastic. And that's a decade and genre of music I kind of missed. I was a little bit past that when I was growing up, but I've really, really loved the Eagles and the music that the Eagles, sort of that genre of music. It's relaxing without putting you to sleep. And I'll also mention, if you're getting a little sleepy in the OR, and you may disagree, but the Milli Vanilli playlist is actually amazing, because it hits that segment from the late '80s to early '90s that is sort of like a microcosm of awesome pop music. I don't care who sang it, but I like to listen to it.

Ashley: You're sticking by your word. It's so funny, I go back and forth. Because, sometimes I play what I want to hear, but what I want to hear isn't necessarily what everyone in the OR wants to hear. I play a lot of this...I have this one on Apple Music called Chill Mix, a lot of those, kind of like, synth pop progressive stuff of my millennial generation, I guess you could call it, and, I have a playlist called Music to Operate To, which has a bunch of music like that. But, sometimes the nurses want to hear certain things, and so it's so funny, Blake Williamson, who I know is a good friend of yours as well, once told me that he just kind of wants to keep his team happy. So, whatever his team wants to hear, he'll play for them, whether it's country or pop or anything. So, I'm pretty open to that as well, but I agree with you. Sometimes just having that background music, it just kind of makes the day go so smoothly. So, I love to play music in the OR as well.

Gary: It does. One other thing I'm going to mention, and I don't know how you feel about this, but a habit I got into a few years ago was actually walking around, when I'm done with surgery, at the end of every day, I go up to every employee at my surgery center, and I just thank them for helping me. I go up to the front desk, I go to the guys who are mopping the floors, Tony and Brian, I talk to the techs, the nurses, everyone, and I just thank them. It kind of gets routine, perhaps, but it's an exercise in gratitude that I feel like when I leave, I know that every person that helped me that day, I was able to tell them thank you. And it allows me sort of like to mentally shift gears, of like, okay, this task has been completed. I've shown everyone appreciation, and now I'm going to shift gears into the next thing.

Ashley: Yeah, I really love that, that's something that I think I'm going to take away even just from our discussion today. I think that's so important, that gratitude for the team and for having a shared goal. Because, at the end of the day it's all about the patient and their experience, and I'm always blown away when they say to me, even from the check-in person to getting in the cab at the end of the day, it was just a great experience. And, all of those people play a role in that, not necessarily just us. So, I love what you just said, I think that's wonderful.

Gary: Well, Ashley, I can’t wait to hear more about this online ergonomics module. When it comes out, will you come back potentially and give us a little bit of an update, even if it’s a quick one? Because, I'd love to share this with the masses.

Ashley: Yeah, I'm so excited for this. This has been a work in progress for a really long time, and so it's just kind of something that I'm so excited to finally have out there, and, I think, to continue this discussion, because I know we have a shared interest in not just ergonomics, but exercise and health and wellness. I just love that that conversation is becoming more common in ophthalmology. So, thank you so much for having the space to talk about that, and I really appreciate it, and I'm happy to come back any time.

Gary: Thanks, Ashley.

Speaker 1: Next, Drs. Wörtz and Hovanesian dig into the concept of “preserving the surgical athlete” and the physical and mental toughness required to get into the right state of mind for surgery.

Gary: Welcome to another segment of Ophthalmology Off the Grid. Today I'm talking to my good friend, Dr. John Hovanesian, who, as most of us know, is in clinical practice at Harvard Eye Associates in Southern California and is on clinical faculty at UCLA Jules Stein Eye Institute. So, John, thanks so much for taking some time to discuss what I think is going to be a really, really important topic, which is preserving the surgical athlete. It's something that you wrote about that really resonated with me. So, thank you for coming and talking to us about that.

John Hovanesian, MD: My pleasure, Gary.

Gary: So when you wrote the article, which was actually in Ocular Surgery News, I think it was a month or so ago, not very long ago, I read this, and like I said, it really struck a chord with me. Because, I've said for a while that I think that cataract surgery in particular is probably the closest thing we have in medicine to a sport or a performance art, because, what we are doing is highly technical, it requires a high degree of skill, and we're constantly trying to refine our technique and skill to come up with better outcomes, which would be analogous to winning or having a higher batting percentage. When you wrote this, what was going through your mind when you were sort of taking on this concept of surgical athlete, or maybe even surgery as an athletic event?

John: Yeah, I first heard of the term surgical athlete from Steven Dell, and it resonated with me because it occured to me that although we're sitting down when we do the surgery, there really is an awful lot going on. Not to say that other forms of surgery don't require meticulous attention, but when we operate, we're using both hands, both feet, and both eyes, and of course our brain, most importantly, to do a surgery that requires forces, fluid forces that are not really intuitive. They're learned skills. It's a very unforgiving surgery as well. When bad things start to happen in cataract surgery, they can escalate into worse, and so it takes not only our physicality, but our mentality and our state of mind to perform this surgery, this intense surgery that has such implications for our patients. So, in a way, we are playing a very high-stakes game like an athlete.

Gary: Well, and something I thought of previously is, when we think about NASCAR or Indy Car racing, those guys and gals are considered athletes because of the way their bodies are performing, and even though they're driving a car, they're very much doing a lot of the same things that we are doing as surgeons. So, to the extent that I think that race car drivers would be considered athletes, and I think they are, I would say that what we do mimics a lot of the same things that they're doing. They're sort of pushing that razor's edge, and we're doing the same thing.

John: Yeah, that's a great analogy. And, like eye surgery, it tends to be fairly unforgiving, when bad things start to happen they can go very bad very fast.

Gary: Yeah, high-stakes.

John: Right.

Gary: Yeah, one thing I've said to some of the residents I interact with from time to time at UK, where I'm on associate faculty, is that there's no limit to the amount the eye can punish you. You think that there's certain limitations to how bad a surgery can go, and it just doesn't seem that that's the case, from personal experience. So, let's talk about preparing for surgery and preparing for our careers as surgeons, sort of in this context of being an athlete. One of the things I really value when I watch sports, I love watching sports, especially college sports, UK basketball and football, I love watching, I love professional sports as well, the players that I think are the best are the ones that are mentally tough. The ones that can shake off a bad shot, whether it's in golf or basketball, and just get right back and just forget that. What do you think is important as a surgeon, psychologically? What do you think makes a great surgeon from a mental toughness standpoint?

John: It is the very same types of skills, isn't it? I think frequently of the advice of the head coach of Notre Dame, Lou Holtz, who was a famed coach for many decades, who used to say that in order to win, you have to pay attention to W-I-N, or What's Important Now. When you're performing a capsulotomy, it really doesn't matter how you plan to disassemble the nucleus of the lens. When you're doing I/A, it doesn't matter what type of injector you're going to use. You need to focus on what's important now. And, he always taught, so did John Wooden at UCLA, that the attitude and effort are what determine your success. There are many things you cannot control, but you can control everything that's within your control and stack the odds in your favor when your mental approach is set up right.

Gary: Well, and that sort of reminds me of the serenity prayer, which I feel like if there's something in my life that I sort of orbit around, it's really this concept of trying to focus on the things I can control. The serenity prayer says, "Lord, give me the strength to change the things I can, the serenity to accept the things I cannot change, and the wisdom to know the difference." And, I think in surgery what we have to do is, we have to say, "Okay, here are the things that are under my control at this moment. I can't focus on maybe the mistake I made previously in this case or a few cases ago. I have to focus on right now, and I have to just focus on the few variables at my disposal to control to sort of move the ball in the right direction."

John: Well said, I agree completely.

Gary: So, before going into surgery, and before preparing for a big day, what are the things that you do? For me personally, I'll kind of give you my pre-game, I think it's important that I'm well rested and that I get a good night's sleep before a big day of surgery. Because, I know the next day I have to be ready to be as sharp for case number 35 or whatever as I am for case number one. If I'm staying up later watching the Late Show or The Tonight Show, that's not going to be a good thing for me the next day. So, for me, making sure that I have adequate rest before a big day of surgery is really key. I feel like that's sort of paying dividends or putting a deposit in the bank for tomorrow. What are some things that you think are important?

John: Sleep is hugely important. Most of us, there are very few of us who can perform at our best on less than 8 hours of sleep. And of course, most of us do with less than that quite regularly because our schedules and all that we have to do just doesn't allow it. But the night before surgery, it's particularly important. I have friends who have young children who get up in the middle of the night, and sometimes they'll sleep in a different bedroom so that their spouse who takes care of the kids at night can manage them, or do whatever they need to do to allow themselves to get rest, because, they're serving not themselves the next day, they're serving every single patient they treat.

I think how you eat matters, what you consume. I'm not a big fan of caffeine any time, and particularly not before surgery. Because, although for some people, we're all different, it helps us to focus better, for many of us, it may give us a little tremor or, in my case, it just elevates my...let's say it lessens my sense of calm if I drink caffeine. I think stretching is tremendously helpful. One of the biggest issues that surgeons run into is a physical one, because you're not in the most physiologic position when you operate, in many cases. You’ve got to stretch or lean or whatever. Having good core strength and good flexibility of your entire body makes a huge difference. I'm a fan of yoga. Even a couple minutes of yoga before you operate does wonderful things both for your body and your mind.

Gary: Yeah, I think that that's sort of like the pre-game. You see athletes stretching, getting ready, and even going through things mentally. You can see them taking shots, like before a basketball game. Sometimes if I've got a tough case, particularly, like if I'm doing a newer technique like a Yamane double needle fixation, or something that I don't do every day, it's something that I might do once a month or once every couple of months, I will try to mentally rehearse the steps of those surgeries. Sometimes, I have a whiteboard in my office, I'll even diagram it out. Because, for me, sort of writing it out and seeing how the play looks helps me when I'm in surgery to remember each one of those important steps, so I don't miss a step.

John: Sure, reviewing surgery video also helps. YouTube and other instructional videos can just give you a...basically, what it does, you may know the steps very well, but reviewing them gives you a level of comfort that you're not going to be wondering in the middle of the case, it doesn't need to be something you think about so much, it'll happen much more fluidly.

Gary: Well, and another saying that I've heard is that under stress, we sort of revert to our level of our training. We don't tend to perform our best under stress, we tend to revert to our level of training. So, to the extent that you've prepared and you've trained and you've rehearsed something, when the stress occurs in a case, you're going to be much more likely to be successful, I believe.

John: Yeah, that's exactly right.

Gary: Tell me a little bit about your surgical day. Do you have scheduled breaks throughout your surgical day? Personally, if I want to take a break I can, but I hammer it pretty hard. That may be something that's not smart, but I try to start around 7:30, we'll take about a 30-minute break for lunch, and then we'll finish the rest of the cases. Do you think it's important to take maybe some micro-breaks throughout the morning or throughout the day, just as a way to reset or to refocus yourself? Take a drink of water, stretch a little bit? Are those things that maybe we don't do them, I don't know if you do or not, but would that be something that you think would be smart?

John: You bet. We all know ourselves and how we like to function. Personally, I like to maintain a pretty good pace when I'm in surgery. For me, it's a little bit like if you're backpacking. They teach you, take breaks frequently, but not for too long. Because you start to actually tense up, and you start to develop kind of an inflammatory response in your joints and your muscles when you rest them for too long. Your cardiovascular system slows down, it has to work its way back up. And of course, this is a different kind of physiology, it's more mental, but for me, I work out of two operating rooms and move back and forth, and for me, I get into a zone when I start operating, and I can tell you that my cases later in the day always go a little more fluidly than my first cases of the day, because I haven't worked into that pattern.

Having said that though, I have partners and lots of friends who do schedule breaks, because that's what allows them to reset and do their best. So, I think it's a little bit of knowing yourself and trying different things that determines your best path. But know that more important than doing X number of cases in Y amount of time is doing each case well, and prioritizing those kind of breaks when you need to is helpful. For me, I breathe between cases, I sometimes will say a little prayer of thanks for getting myself to where I am in the day, and that I hope things continue to do well. Or the opposite, if I had a tough case, to say, “Okay, the next case is a new one and a new chance to do good for my patient.” And, doing that allows me to focus in the moment and perform, for me, at my best.

Gary: Yeah, I definitely resonate with all of that. One thing you said about sort of staying on pace, and for me, I'm probably a little OCD, I think we all are to some degree when we get to becoming a functioning ophthalmologist, I operate out of two or three rooms, just kind of depending on the day, but I sort of have this mental pace that I feel like, if I can stay on this pace, it's going to be good, it's going to get me through the day. And, I sort of get into this state of flow, where time almost stops, and I'm sort of—you said in the zone, which is kind of the same thing—so, when I'm in the zone, personally, I really don't want to take a break, because I'm feeling so good, things are happening fluidly, they're happening naturally. But if I get out of that zone, sometimes I'll just go to my office, I'll take a nice long sip of water, I'll do some breathing, I'll say a prayer, I'll try to just refocus myself.

Because, I know that the next patient, they deserve my absolute best, and if I'm not there mentally because of something that happened in the previous case, I think it's much better just to take a little break and refocus yourself than to just sort of push through and try to just catch up or get back on time.

John: Particularly after a tough case, I think it's important, because your catecholamines in your body are just surging. Whether you feel it, or whether you've been operating for 20 years or you're in your first year out, getting yourself back to a place where you're at your best means recognizing that and addressing it. All of us know at some level how important the work we're doing is for our patient, and that's why we get those stress mediators flowing in our body. It's natural, and yet we have to cope with that in a way that's going to serve the next patient well.

Gary: Yeah, absolutely. What about reviewing film? That's another thing that I think is really analogous. We have sports teams who are reviewing film, looking at how they performed, looking maybe at how other people performed. How does that work into your strategy for peak performance?

John: Yeah, first of all, filming your surgeries does not need to be either complicated or expensive. There are a number of video capturing devices that will record video to a memory stick that cost under $100, and one that we've used recently is actually made for gamers. It's a video game thing that's meant to capture the video, and it literally has one button and a memory stick you plug in, and it goes in line with your microscope's camera output if you have a camera. So, that allows me to capture every case every day, and they usually get deleted because most of them are uneventful. But, it allows me to go through all of them to see if there was anything that's a pattern. I've found lots of ways that I was really not very efficient in completing surgery, maybe putting more fluid into the eye or more trauma to the eye than I needed to, that I've eliminated. It's made me a better surgeon to review that.

I wrote a blog almost 10 years ago, "Physician, Teach Thyself" was the title of it, or "Doctor, Teach Thyself," and it's all about just that subject, and how much I've gained by doing it.

Gary: We use a similar system, it sounds like. The company that makes the device we use for recording is called Aver Media, and obviously, no financial interest in that. Then, because we've got an older microscope, the highest level output actually is a super video output, and so there are a number of super video to HDMI conversion devices that may cost $50 or so on Amazon. So, you're exactly right. For under, maybe, $200, no matter what microscope you have, you can get the various devices necessary to turn the signal into digital and then record it onto an external device like a memory stick or hard drive. And I agree, I think that not only is recording helpful to you, but you can be a teacher for others if you have an interesting case.

John: You bet. And, those are the perfect kind of cases to review with your referring optometrists. They love to see surgical video. And of course, other physicians, if you do teaching like you do and I do, it's very helpful to have.

Gary: Let's talk about one last thing, and that's the concept of coaching. I don't think we have this as much in ophthalmology. Clearly in sports, there's a defined role of a coach. We are sort of expected to coach ourselves, we're sort of expected to be monitoring our own performance, but sometimes we're not the best arbiters of our own surgical skill. There's an organization called ACES, or they also have a side organization, ABES, American Board of Eye Surgery, and the idea there was, I think, to submit videos, and you would be given some level of critique on your videos. I don't know if it's a pass/fail system, I've been intermittently involved with that organization in the past, but I think the concept is really fantastic, the concept of, we should be doing some level of peer review to our friends, maybe anonymously, perhaps, so that we can get some feedback from other experts on ways we could improve, or maybe areas that are excellent. I think some of that culture, I think, needs to be reinforced in ophthalmology. I think we do a pretty good job, but I think we could do better.

John: We certainly need to check our egos if we want to be good surgeons. Because, we all have something to learn, and at different stages of our career it's different things. I've also found that, interestingly, some of the best coaches are actually not physicians. The reps who sell phaco equipment or make lens implants spend a huge amount of their time watching doctors do surgery, and some of them, these are smart folks, and some of them have seen and heard of things that we never have. I've found just some great advice that has come from industry folks who visit my OR. I ask them, "Hey, what are you seeing other people do? What can I do better?" And very often, they don't want to give you any feedback that's constructive because they don't want to offend you, but if you ask for it, and sometimes you need to ask for it repeatedly, they'll sometimes give you some real pearls that can be helpful to you.

Likewise, talking to your partners or fellow physicians, going to meetings and showing surgical video, and asking for input is enormously helpful. I think most people in our profession are really very interested in helping each other, because they know we face similar challenges, and will give you really valuable insights on how you can do better with your surgery.

Gary: I think that's so important, John. I think, like you said, checking our egos at the door is vitally important. Well, thank you so much for coming on and talking about this. I think this is just a really interesting paradigm that we can look at our profession maybe through a new lens, no pun intended. And again, to go back, I totally agree about the industry reps. I've gotten some of the best tips from industry, just because they see so much, they're seeing so many different surgeons operate, and I sort of call them the honeybees of the OR, because they cross-pollinate really good ideas between different surgery centers. I think they're fantastic, not only for what they do in industry, but the little pearls that they pass along to us.

John, thank you so much, again, for coming on and sharing your insights. I always enjoy our conversations and look forward to seeing you again soon.

John: Gary, you are a real innovator in our field and a real thinker, and covering this kind of topic, I think, is really important, and what you do with your podcast is very educational for me. I listen to it and to a lot of other folks, so thanks for including me.

Speaker 1: Although many physicians may be tempted to put their patients’ comfort before their own, it is crucial that they take care of themselves first to ensure that they are in the best possible shape to do their jobs.

Thank you to Drs. Brissette and Hovanesian for sharing their insights into maintaining optimal health, and thanks to our listeners for tuning in to another episode of Off the Grid. Until next time.

Speaker 1: Ophthalmology off the Grid is an independent podcast produced by Bryn Mawr Communications and supported by advertising from Alcon. For a full listing of podcasts for eye care professionals, go to eyetube.net/podcasts.

8/20/2019 | 47:55

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