The transition from operating under the guidance of expert faculty in an academic setting to operating “on your own” in practice is an important opportunity to develop your surgical confidence, hone your surgical skill set and judgment, and begin building your practice in a new community. It is also one of the most stressful aspects of the early career period. In this article, I discuss some pearls from my experience building a surgical practice—first in academics, and subsequently in a private retina-only practice setting.
Preparing to Operate Solo
Select your initial cases carefully and focus on bread-and-butter procedures with clear surgical indications—such as primary rhegmatogenous retinal detachments, vitreous hemorrhages, or macular holes. Avoid operating on patients with 20/25 or 20/30 vision due to epiretinal membranes, as these can often be safely observed or deferred for a few months until intervention is clearly warranted.
Prior to operating in a new facility, visit the operating room (OR). Make sure you know where the locker room is, where the OR is, and how to log into their medical records system. Load your settings into the microscope and the vitrectomy machine, and meet the OR staff. Some practices and/or ORs require you to assist another surgeon or receive proctoring before your first solo cases, which can be helpful for navigating these logistical details. The less frazzled you are about all the little things, the more relaxed and focused you can be on the surgery.
Develop a preoperative surgical preparation routine. The day before surgery, I review each case, including the diagnosis and indication for surgery, laterality, and key clinical details such as hyaloid status and lens status (phakic or pseudophakic). I briefly mentally run through my surgical plan and jot down all the surgical equipment I may need, which I hand to the OR staff so they can have everything available and avoid delays during surgery. During my first year or so in practice, the day before surgery I would visualize myself going through the steps for each case, pausing to consider potential challenges I might encounter and how to handle these. While I rarely do the visualization exercise today, I still find it a useful strategy before unusual cases or ones where I’m trying a new technique. There is something meditative about having a routine.
Finally, do not hesitate to ask for help. Call colleagues or watch surgical videos if needed prior to performing new, complex, or challenging cases. Your practice setting may even allow an assistant surgeon to join for a new or complex case early on. On occasion, you may even scrub out and “phone a friend” to talk through an intraoperative challenge and how best to manage it.
Building a Surgical Referral Base
The adage “available, affable, and able” applies. Referral patterns can take time to change, but in my experience the best way to break those patterns is to be available for urgent surgical referrals. A senior general ophthalmologist in town may have been sending all his macular degeneration patients to another doctor for decades, but if you’re the one who has taken good care of his last few Friday night macula-on detachments, those patterns will shift. Be available to see and manage those late afternoon detachment referrals. Get the cases scheduled in a timely manner, even if it means going to the hospital and doing the case at night or over the weekend.
In addition to sending a letter, call or text the referring doctor to thank them for the referral, and update them on how you’re managing the patient. And of course, be excellent surgically. Go the extra mile to do whatever, in your hands, has the best outcomes with a single surgery.
Dealing With Complications and Growing as a Surgeon
Complications happen to every surgeon. They can either be discouraging or serve as valuable opportunities for growth and improvement—and they do become easier to manage with time and experience.
First and foremost, prepare before the surgery so that you can anticipate intraoperative challenges or complications, identify them early on, and manage them appropriately. Do not shy away from facing the complication and the patient, being honest, and taking the right next steps to take care of the patient. These are the patients that are hardest to face in the clinic, but the ones who need the most attention.
Take care of yourself. Maintain a community of retina colleagues and mentors you can turn to for case discussions, debriefing, and support.
Continue to grow as a surgeon. If your operating room has recording equipment, consider videotaping your cases. Review your surgical videos, particularly those involving complications or suboptimal outcomes. You may identify technical adjustments to improve future performance, or you may confirm that the outcome was unavoidable. When possible, ask a colleague to review the footage and provide feedback. Either way, video review offers a valuable opportunity to critically evaluate your technique and identify areas for improvement.
Track your outcomes, especially for common procedures such as primary rhegmatogenous retinal detachment repair and macular hole surgery. When performing a high volume of cases, it is difficult to know whether your single-surgery reattachment rate is 75% or 95% without objective data. Outcome tracking enables you to compare your performance against published benchmarks and strive for continuous improvement. Moreover, maintaining a record of your results across hundreds of cases can offer reassurance and perspective, especially when dealing with the emotional impact of a recent complication or suboptimal result. RP
