Playing music in the operating has been shown to benefit both patients and doctors. What are surgeons listening to? And why? EuroTimes Content Editor Aidan Hanratty reports
Spotify’s playlist for surgeons
Cataract surgery can be a stressful experience. Many people have hang-ups about their eyes, and the idea of a surgeon, no matter how capable they may be, poking around in the ocular region may set even the calmest individual on edge. Music can therefore play an important part in the process.
One study followed 141 patients undergoing cataract surgery under local anaesthetic, with subjects being given earphones playing binaural beat music, plain music or nothing at all (control). Blood pressure and heart rate were measured before and 20 minutes into the operation, while anxiety was assessed throughout using The State-Trait Anxiety Inventory (STAI). Both musical groups saw significant reductions in STAI scores and in blood pressure compared with the control group, while only the binaural beat group saw a significant reduction in heart rate.
Cardiothoracic surgeon Mehmet Oz MD has been experimenting with music since the 1990s, with patients being given headphones as they went under. He told Billboard: “To deal with the root cause of pain, you need to numb the area locally, which is hard to do because I’m working on your heart. The bone that I break is not easy to make immediately better…
“We thought: ‘If I can get you to be calm about the pain you’re having then you won’t need to take as many pain pills. If I can get you to meditate through your pain, or if I can use your subconscious to convince you that you’re not really feeling the pain as much as you think you are…’ That’s like when you’re playing in the middle of a game, and you sprain something, you don’t even notice it.”
This corresponds with both the prospective study above and what one skin cancer surgeon told The Guardian. “All the surgery I do now is local anaesthetic surgery on people’s faces. The main function for me is to get a patient, who is awake, to relax when I am about to put a knife into their face,” said Gabriel Weston, in a piece that asked doctors if they played music in theatre. Most said yes, but the styles they listened to varied.
Studies have shown that music can aid task completion, and indeed Dr Weston said that: “In planned operations, there are long stretches where you are doing something you have done many times, but it still requires meticulousness, and music is good for this.” As far as what type of music can help, it’s generally best to listen to music that you know, as new and unfamiliar music can demand your attention, as you listen closer in order to hear what’s coming next.
Spotify recently teamed up with healthcare app Figure 1 to find out what doctors were listening to. In short? Everything. Tastes ranged from hard rock to radio pop, classical to hip-hop. One ophthalmologist’s choice was jazz. Asked if there was a point where they turned off the music, they simply replied: “Never.”
EuroTimes Content Editor Aidan Hanratty follows in the footsteps of Thomas Edison, Benjamin Franklin and Leonardo da Vinci
Leonardo da Vinci’s 16th-Century to-do list
As an ophthalmologist, do you use to-do lists? They’re a handy way to keep on top of your business, from such mundane things as buying toilet roll or milk to more important matters like noting which eye you’ll be operating on. It’s not a new phenomenon. Benjamin Franklin famously kept to a 13-point self-improvement plan that he carried out on a weekly basis four times a year. Themes included temperance, frugality and resolve.
Thomas Edison kept lists of ideas and plans throughout his life, in particular a five-page list of “Things doing and to be done”. These included what may seem like standard inventions now but were not exactly household items in 1888. “Artificial Silk”; “Silver wire wood cutting system”‘; “Red Lead pencils equal to graphite”.
None of this compares to the wildly ambitious to-do list of Leonardo Da Vinci from the 1490s. The Renaissance polymath sought to learn as much as possible about a host of tasks. Da Vinci kept a book hanging from his belt at all times, in which he would jot ideas or thoughts as they came to him.
A list of the artist’s, translated by NPR’s Robert Krulwich from a book by Toby Lester (Da Vinci’s Ghost: Genius, Obsession, and How Leonardo Created the World in His Own Image), contains references to a number of experts in other fields, which shows a humility alongside that hunger; acknowledging one’s own shortcomings is important when it comes to making headway into new territories.
As well as intending to calculate the measurements of Milan and several noteworthy buildings in the city, he expressed an interest in learning about how to square a triangle, how people travelled on ice in Flanders (ice skating? general travel?), how to repair locks and mills on canals and more.
He also wrote on his list, simply: “Draw Milan.” It brings to mind a short story by Jorge Luis Borges entitled On Exactitude in Science. A simple paragraph, it imagines a fictitious empire where cartographers draw up a map that matches the realm in size. Perhaps I’m jumping to conclusions. Maybe Da Vinci merely intended to paint a view of the city. Regardless of the size of his drawing, one can imagine the intensity of purpose that would have gone into such a task.
A 2009 study found that care teams often used a vague to-do list or “signout” sheet, which could feature specific directions for patient care as well as more vague notes or suggestions. The study created a hierarchical model of tasks based on these forms that provided insight into the nature of clinical tasks and the management thereof.
Working with this knowledge, it suggested how such to-do lists could be integrated with a patient’s electronic health record in order to enhance work flow as a kind of Plan B to such a muddied approach. Further studies are under way at present that expand on such models while taking into account patient concerns over privacy.
Perhaps if Da Vinci were alive today he would be able to suggest a manner in which the quest for efficiency and fears over personal privacy could be reconciled. For now, that task is left for us mere mortals to complete.
Our new EuroTimes blogger Aidan Hanratty explains why even the best physicians can suffer from exhaustion and a lack of motivation
Are you suffering from burnout? It can happen to the best and brightest of us. Tiredness, frustration, a lack of concentration, poor performance at work – these are just some of the signs that you may be in a rut. David Ballard PsyD of the American Psychological Association describes job burnout as “an extended period of time where someone experiences exhaustion and a lack of interest in things, resulting in a decline in their job performance”.
Graham Greene’s A Burnt-Out Case predates the first use of the term in psychology, telling the story of a dissatisfied architect who travels to a leper colony in the Congo to find purpose. “Leprosy cases whose disease has been arrested and cured only after the loss of fingers or toes are known as burnt-out cases,” wrote Greene in his journal In Search of a Character. He used this in parallel with the mentally exhausted and disinterested architect, who is fortunate enough to be in a position to drop everything and get away in the hopes of returning afresh.
That’s not so easy for doctors, whose patients don’t stop needing help. Writing in the Huffington Post, Melinda Hakim examines some of the reasons doctors in particular are facing burnout. Key factors include an inordinate amount of time spent on paperwork (as opposed to treating patients); rising overheads; debt following long years of training; an imbalance between hours worked and money received.
Studies have shown that ophthalmologists are among the most satisfied with their chosen field, but they may also feel forced to hide problems with mental health. Every specialty faces issues with waiting lists, and ophthalmology is no different – this can have a draining effect, leaving physicians with a feeling of helplessness.
Among other things, the Mayo Clinic recommends that anyone suffering from burnout manage their stressors, and adjust their attitude. These are easier said than done, especially if those stressors come from management or general dissatisfaction with the state of the health service.
There are no simple answers to the dilemma of burnout, and Hakim does not attempt to provide any. Instead she points out how important it is that the field of medicine can continue to attract the brightest minds. “We must all reach out to doctors and do everything in our power to demonstrate that we value our country’s physicians before it’s too late.”
The architect of Greene’s novel meets an unfortunate end; hopefully the same will not be said of the medical profession.
- Aidan Hanratty is Content Editor for EuroTimes
Studies have shown that up to 80% of medical information provided by healthcare practitioners is forgotten immediately, reports Dr Leigh Spielberg.
I recently received the following text message from a good friend: “Hi Leigh, quick question: my aunt went to her ophthalmologist hospital because she was seeing floaters in her right eye. She said the diagnosis is a retinal detachment and that she should ignore it. Her next appointment: 6 months from now. Does this make sense?”
Whoa, wait a minute. Any ophthalmologist would recognise that something was amiss. But where, between diagnosis and this text message, had the mistake occurred? Time to investigate.
I assumed that the ophthalmologist had made the correct diagnosis. I was certain that my friend hadn’t made the mistake; he was just the messenger and I was convinced that the patient was doing her best to relay the information she had received from her doctor. I thus suspected a communication breakdown between doctor and patient.
I asked my friend to request a copy of the clinic report, which stated what I had expected: a posterior vitreous detachment. As is common in these situations, the patient had probably heard her doctor say that the vitreous had detached from the retina. However, this is a common source of confusion: I have noticed that the juxtaposition of “detached” and “retina” in the same sentence is often incorrectly recalled. In fact, this is a common reason that patients come to our clinic for second opinions.
To avoid this confusion, I’ll say, “The gel in the eye has contracted, which is a normal occurrence, and it has freed itself from its connections at the back of the eye.” If patients ask about their retina, I’ll clearly state, “Your retina is not detached. This is a benign condition,” after which I explain that the patient must remain alert for flashes and new floaters.
Studies have shown that up to 80% of medical information provided by healthcare practitioners is forgotten immediately, and that the greater the amount of information presented, the lower the proportion correctly recalled. Furthermore, almost half of the information that is remembered is incorrect. Thus, my motto is “Keep it Simple.”
Telling a patient that cataract surgery will occur under “topical anesthesia” often falls on deaf ears. Instead, I’ll say “eye-drop anesthesia, using the same drops I used today to measure your eye pressure.” If my patient has diabetes, I refer to my medical retina colleagues as diabetic eye specialists. Glaucoma colleagues are eye-pressure specialists. Of course, if a patient has had glaucoma for 25 years it’s a different story, but for new patients, simplicity and clarity are paramount.
Admittedly, as a retinal surgeon, I have it easy. My diagnoses are mostly simple to understand (retina is on or off; bleeding is present or absent) and vitreoretinal treatment adherence usually involves only a few weeks of eye drops. Conversely, our glaucoma colleagues understand that good communication is highly correlated with better patient adherence.
My goal is to allow the patient to remember their diagnosis and treatment for as long as necessary and then, hopefully, let it all fade into the past.
I suspect that most ophthalmologists don’t read the Financial Times (FT). This is probably because its core content concerns the world of industry and commerce rather than eye surgery.
If you hold shares in one of the ophthalmological market leaders, then the FT should be required reading. If not, it is unlikely to be one of your go-to newspapers.
But every now and then, the paper publishes an article that is of universal interest, so it is worth keeping an eye on.
I recommend that all eye surgeons, regardless of age or experience, should read this excellent article by Lucy Kellaway which is syndicated in The Irish Times.
Kellaway is an Associate Editor and management columnist of the FT and for the past 15 years her weekly Monday column has poked fun at management fads and jargon and celebrated the ups and downs of office life.
In her “Just Say No” article, she argues that the great challenge is to spot when to stop saying no and start saying yes.
” I say yes to things I a) have to do; b) want to do or c) ought to do,” says Kellaway.
So, if you’re a busy ophthalmologist, when should you say no? You have a duty of care to your patients, so you are unlikely to say No to them, unless you have a very good reason. There are a lot of things you want to do, but you can only do these things within the constraints of your daily and weekly schedule. There are many things you ought to do, but again, can you find the time to do these things outside of your normal operating hours?
This is a topic addressed by my colleague Dr Leigh Spielberg in his excellent EuroTimes column. In an article he wrote three years ago, he looked at the pressures of having to say ‘no’ in a busy operating theatre.
He concluded the article stating:
“Time-management, multi-tasking, and delegating responsibility become the keys to success, and it takes quite a while to learn it all.”
Words to the wise!
Ophthalmologists take risks every day, not only in surgery, but also at home and at play, says Dr Leigh Spielberg
What is an acceptable level of risk? By which I mean, what is the risk-benefit trade off for a particular situation. That seems to be the primary question in my life these days, wherever I am and whatever I’m doing. The question poses itself when I’m in the clinic. It’s in the back of my mind in the operating room. It is a recurring theme when I’m at home with my kids. It pops into my mind when I’m doing any of my hobbies.
In the clinic, I can usually manage the question quite well. Most of the surgical indications are fortunately quite straightforward, so the risk of operating is usually clearly outweighed by the expected benefits. But what about vitreous floaters in a middle-aged phakic patient with -5D myopia? Is the decision to operate too risky? Who’s to say?
Similarly, in the operating room, almost every step of a vitrectomy is the result of calculating the risk. How closely should I shave the vitreous in this eye to make sure enough is removed but not so much that I risk an iatrogenic retinal tear. How much peripheral laser do I apply? Just a little, to absolutely minimise the risk of macular pucker, or a bit more, to allow me to sleep better tonight, knowing that a micro-tear won’t end up as a retinal detachment. Do I suture the sclerotomies, with the knowledge that sutures can irritate for days to weeks, or do I risk the potentially dangerous but very unlikely postoperative hypotony?
METAL OR PLASTIC?
The risk-benefit calculations continue at home too. Do I allow my little chefs-in-the-making use a metal knife to slice a banana for breakfast? Or do I insist on them using a plastic kid’s knife, which is perfectly safe but results in a banana that is mashed rather than sliced? Can Philippa (5 years old) and Raphael be trusted with metal scissors (currently: no! But when does the answer change to: yes)? Ocular trauma, whether personal or professional, gives me nightmares. And, on a less serious and dangerous note, can I accept the risk of them dropping my (wife’s) iPad while they watch a video that keeps them busy long enough to allow me to finish writing this blog?
My hobbies all pose some level of risk. Do I always have to protect my big camera and its fancy lenses if it not only decreases the chance of an expensive fall but also the chance of capturing that perfect shot? A nasty fall off my mountain bike could result in a broken hand or wrist, with serious implications for my operating future. But riding ultra-cautiously somewhat defeats the purpose of riding at all. Is riding a motorcycle an acceptable risk for someone with a wife and two young children? Clearly, not if it’s rush h hour and raining? But what if I only ride down country roads on sunny Sunday afternoons?
I’ve made it to where I am now, so I guess I’ll continue as I’ve done since day one.
Dr Manish Mahabir, winner of last year's prize, reflects on his achievement
The 11th September 2016 was an auspicious day for me.
I was in Copenhagen, Denmark at the XXXIV Congress of the ESCRS to receive the John Henahan prize for Young Opthalmologists.
I wore a white linen kurta-pyjama with a brown stole. The prize giving ceremony was held in a grand hall which was well-lighted and packed with people. After all the Video Awards had been presented , which seemed like infinity, my name was announced for the prize.
My heart skipped a beat. I walked on the dais with folded hands and received the prize amidst a roar of clappings. A woman came up to me and said that she was so happy to see me in a traditional Indian dress. It was a matter of pride for all the Indians.
So what has winning the prize meant for me?
It has helped me grow as a person. It has validated my faith in my ability to create value through my writings. The prize sitting on my desk reminds me to look upon myself as a global citizen and aim for loftier goals in life. It has strengthened my resolve to work at an international level, in a multi-cultural environment.
Due to my busy schedule, I hardly get time to visit my parents. They never get to see my (smiling) patients. The picture of me holding an international prize with the president of the ESCRS , Professor David Spalton, is something they hold on to.
They feel happy that all the sacrifices they have made have borne fruit. It gives immense pleasure to my teachers when they see their teachings being echoed in my words and their student achieving great success.
There is no better time to publish and manifest the unlimited potential already within us
Since I won the prize, many of my colleagues have been inspired to write. They have read my essay “Why Should I Publish” and discussed its unconventional style with me. As they say in the movie Kung Fu Panda, there is no secret ingredient…It’s just you!
The process of entering the competition, writing the essay and then winning the John Henahan Prize has been profound and even soul-stirring. It makes you think and study, understand the profession and society and even re-discover yourself.
The journey is thoroughly enjoyable and rewarding in itself. If you win, a prestigious international prize and will add five stars to your résumé. You will love the attention and accolades that come with it. The EuroTimes editorial staff and the staff of ESCRS is full of amazing people. They will go to great length to make you feel comfortable as well as special. Winning the prize will open new doors and mark the beginning of a new journey.
There is no better time to publish and manifest the unlimited potential already within us.
For information and to enter the 2017 John Henahan writing prize for Young Ophthalmologists visit: http://www.escrs.org/lisbon2017/henahan-prize.asp
Streamlining a process eliminates the confusion involved with extraneous tasks and concerns
I couldn’t believe it. An elderly patient who I had seen in the clinic an hour or two earlier was walking into my operating room, a relieved smile on his face. This patient, who I knew to suffer from vascular dementia that led to extreme agitation when he was confronted with stressful situations, was the picture of calm, despite his very recent diagnosis of endophthalmitis. Here he was, about to receive a vitreous tap and intravitreal antibiotics under local anesthesia, and there was nothing about his demeanor to suggest that anything had progressed anything less than perfectly since I had planned his surgery.
We had worked long & hard for this moment. What caught me by surprise when I started working as a full-time university staff ophthalmologist is the amount time and energy that needs to be devoted to coordinating logistical processes.
As a resident and fellow in another institution, I took the organisational aspect of the whole process for granted. That’s the way I’ve always known it, so it must have always been that way. And anyway, I had other things to worry about, like learning how to be an ophthalmologist and a retinal surgeon.
But once I graduated from training, started working elsewhere and inherited another system, I started looking critically at the organization in which I work. Identifying and eliminating inefficiencies became a top priority of mine. This is in part because a more efficient system is a safer system. Streamlining a process eliminates the confusion involved with extraneous tasks and concerns so that the focus can be placed on what’s important. But also because it’s more pleasant for everyone involved.
A more efficient system is a safer system
I have been concentrating on what happens from the moment I plan a surgical procedure to the moment the patient leaves the operating room. A clear, concise, 1-page surgical planning document has, I think, helped everyone involved know what’s going on (What’s the diagnosis? What’s our plan? What do we need to carry it out? Vision blue? ILM blue? Membrane blue?) and how we’re going to achieve it. My colleagues in the planning department have received clarified instructions on how to plan procedures, with unambiguous documents and materials lists for each specific operation.
The nurses in the operating room greatly appreciate this simplification. Everything moves more quickly, despite less effort being expended.
I’ve had a lot of help. My colleague, Thierry Derveaux, returned from his phaco fellowship full of insight into how a well-run and highly professional clinic works, along with the energy and motivation to make it happen. The resident currently rotating through the operating room, Geraldine Accou, is highly organised, well-prepared. As we say in NY, she gets the job done. No procrastination, no forgetting, no nonsense.
Ever since I spent many of my first days in the university hospital working until 7pm, either supervising the clinic or operating, two of my (many) goals have been the following: first, to finish the workday earlier. Second, to see more patients every day. My goals have seemed to many to be mutually exclusive. I disagree.
Dr Leigh Spielberg is a vitreoretinal and cataract surgeon at Ghent University Hospital in Belgium
A cocktail party or wedding is not necessarily the best opportunity to dispense medical advice
“So you’re an eye surgeon?” is a frequent question that we are often asked in social situations. It opens a conversation that is generally quite standard, but occasionally takes an interesting turn.
Usually, the question that follows is, “So why do you still wear glasses? I thought all eye doctors would definitely get their eyes lasered? Do you not trust the procedure? I guess you’ve seen all the ways it can go wrong, huh? Do you think I should get my eyes lasered? I’ve always wanted to get my eyes lasered, because I’m tired of dealing with contact lenses and I don’t look good with glasses. But I’m too scared! I can’t imagine a laser shooting my eyeball while I’m awake. There’s no way I could keep my eyes open for that long. But so many of my friends have had it done, so it can’t be that bad. Who’s a good surgeon? I’d only want the best to treat my eyes. Do you do laser surgery?”
I frequently can’t even get a word in, so I’ll just stand and listen, to see whether this new person delivering this monologue is actually interested in hearing my opinion on refractive laser surgery, which is very positive, or is instead simply interested in discussing it without forming any conclusions. But I don’t find a cocktail party or wedding to necessarily be the best moment to dispense medical advice. And anyway, refractive surgery isn’t my field of expertise.
“I do a different type of laser surgery, a type that I hope you never have to undergo,” I’ll say, referring to retinal lasers in the context of a retinal tear or a vitrectomy for retinal detachment.
PLEASE PASS ME THE WINE
Another route of inquiry involves the details of how eye surgery is performed, which to most people, especially the young, is unbearably grisly. “How do you take the eye out to operate on it? Do you remove it completely, or just pull it out of the patient’s head so that you can get behind it? When you make holes in the eye, how come everything inside doesn’t just leak right out? And how do you see what you’re doing? It’s all so small! What if your hand trembles? Eye surgeons must have really steady hands.”
I tell them that we use microscopes that make the eye look the size of a large dinner plate. Seeing everything is no problem at all. I suppose most eye surgeons were born with reasonably tremor-free fine motor coordination. But tremor also something that simply wanes with experience, confidence and a relaxed state of mind.
The eye fascinates most people, and is right up there with the heart as an organ that captures peoples’ imagination. And yet it remains a mystery for most people, something that they prefer to think about in more abstract terms.
“The eye is a beautiful thing,” I’ll sometimes say to end this line of conversation on an uplifting note. “So, do you have any interesting vacations planned? And can you please pass me the wine?”
Dr Leigh Spielberg is a vitreoretinal and cataract surgeon at Ghent University Hospital in Belgium
Another year is almost over and a new one will soon begin
Wikipaedia defines Ephemerality (from Greek εφήμερος – ephemeros, literally “lasting only one day“[) as the concept of things being transitory, existing only briefly. The term ephemeral is frequently used to describe objects found in nature, although it can describe a wide range of things, including human artifacts intentionally made to last for only a temporary period.
Ephemeral can also be used as an adjective to refer to a fast-deteriorating importance or temporary nature of an object to a person.
William Dean Howells (March 1, 1837 – May 11, 1920) was an American realist novelist, literary critic, and playwright, particularly known for his tenure as editor of The Atlantic Monthly as well as his own prolific writings, including the Christmas story Christmas Every Day, and the novels The Rise of Silas Lapham and A Traveler from Altruria.
His work can be read in The Complete Works of William Dean Howells which includes the following musing: “…I am impatient of the antiquated and ignorant prejudice which classes the magazines as ephemeral. They are ephemeral in form, but in substance they are not ephemeral…”
This was written long before the development of the internet which has completely transformed the nature of magazine publishing. While many of the readers of EuroTimes may keep the printed magazine in their offices for months, even years, they will eventually have to free up space and reluctantly dispose of their back issues.
And one day, they may regret this act when a colleague says: “Did you read the article in EuroTimes which talks about the downturn in LASIK procedures?”. The answer is no because that issue of the magazine has been binned.
But there is redemption. Howard Larkin’s article in December/January EuroTimes points out that global LASIK volume peaked at about 3.8 million procedures in 2007, and has struggled to break 3.6 million since.
In the USA, volume peaked at 1.4 million procedures in 2000, and has bumped along around 600,000 for the last five years, according to Market Scope data presented by Richard L Lindstrom MD at the 2016 ASCRS•ASOA Symposium & Congress in New Orleans, USA.
“We are in a no-growth market globally and in the USA. The question is, why is that?” asked Dr Lindstrom, founder of Minnesota Eye Consultants in Bloomington, Minnesota, USA.
To find out the answer to this question you can read the latest issue of EuroTimes but you can also go online and find the article at http://www.eurotimes.org/lasik-growth.
But you want to research further, so you can then another article from November EuroTimes http://www.eurotimes.org/lasik-studies, which is also written by Howard Larkin.
And the more you surf www.eurotimes.org , the more you will learn about LASIK and patient satisfaction.
Another year is almost over and a new one will soon begin and I wish all of our readers a happy and successful 2017.
* Colin Kerr is Executive Editor of EuroTimes, the award-winning news magazine of the ESCRS.