NO SUPERVISION

“The cataract team convened last week and reviewed Leigh Spielberg’s application,” read the email, “and it was determined that he may perform unsupervised cataract surgery in the Rotterdam Eye Hospital.”

There were no exclamation points in the email, but I read it as though its contents were front-page news. Unsupervised cataract surgery! From beginning to end! I couldn’t believe it. What a rush.

But what now? The Rotterdam Eye Hospital has a huge department dedicated solely to cataract surgery, performing approximately 7,000 phacos per year. But it isn’t designed to channel eligible patients to residents with surgery privileges. We have to do it ourselves. I was in the middle of an intense vitreoretinal surgery rotation, and I rarely saw patients with uncomplicated cataract.
How would I ever fill my surgical schedule?

The advice I received from several surgeons was: “Do yourself a favour and make it all as easy as possible. Only select the simplest cases for your first solo surgeries.” Logical enough, but finding these patients was tricky.

I scheduled myself into the cataract clinic on my post-call days off. Eligible patients would appear by the dozens, I thought, and I’d be on my way. Not exactly. The most difficult post-trauma, uveitic, highly myopic and surgical mishap eyes populate our cataract clinic, referred by other subspecialties and general ophthalmologists.

I needed a new plan. I paid a visit to the surgical planning department, through which all patients’ dossiers passed, and explained my situation. Maybe they could contact me when standard cases were booked into the OR.

“Should we only call you if we have nun-nuns?” asked Jolien, a planner.

“Sorry, but did you say nun-nuns?” I asked.

“Yes, nun-nuns,” she replied. “Patients with neither ocular nor systemic risk factors. Both boxes are checked as ‘none’ on the surgical request document. We call them none/nones.”

“Um, yes, that would be great, thanks,” I replied, as I gave her my phone number.

This didn’t work out too well either. Most doctors seemed to want to keep these uncomplicated cases for their own surgical programs. As it turned out, the best way to get referrals was to ask my fellow residents who don’t yet operate independently.

In an act of desperation, I sent a WhatsApp text to the whole group: “If anyone has an over-busy clinic with calm & friendly cataract patients they’d like me to take off their hands, call me! It’s a win-win situation for you & me!”

My phone started ringing off the hook. Chang, Michelle and Angela, three incredibly enthusiastic and helpful young residents, sent me one patient after the other. Within no time, a dozen patients had appointments with me.

Despite my trainee status, they were generally enthusiastic to be operated on by me. Maybe the fact that they were “referred” to me for their operation by my colleagues lent me some stature in the eyes of the patients. However, this made it all deceptively easy and somewhat dangerous. I tried to keep in mind what I had been advised, to only schedule the simplest cases.

Dr Manzulli, a cataract specialist, was my advisor during this process. “I just screened a perfect patient, but her pupil was too small, so I referred her to you instead,” I said to him one afternoon.

“Velle, juste pute ina soma iris hookse anda no problem!” he replied, his Italian accent making it all sound so simple. I had some experience placing iris hooks, but that was a few standard deviations outside of my comfort zone. His synthesis of near-comical enthusiasm and complete confidence in my skills was very comforting. But I suspected that he was overestimating me, which was both flattering and unnerving.

Perfect guidance

Nevertheless, his guidance was perfect. Before long, I had all my operating schedules filled with patients. I had selected each patient’s lens power, and double-checked all the details. But as the date of my first procedures neared, my heart occasionally skipped a beat and seemed to jump into my throat. What had I gotten myself into?

I would be sitting in the driver’s seat with no real back-up. An uncomplicated phaco is like cruising down the highway on a clear day, all smooth riding and sunny skies. But what if an iris decided to take an extraocular detour? I hadn’t had any significant complications, which gave me the feeling that I wasn’t prepared to solve them if they occurred.

I didn’t sleep well the night before the first session. I dreamt that all my patients were scattered at random throughout the hospital, and I had to locate them while all the building’s toilets overflowed. It was pure chaos and I hadn’t yet begun.

To be continued…