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Teaching Moments

How can you get the most out of your training?

Sorcha Ni Dhubhghaill

Posted: Monday, July 3, 2017

We’re pretty much just treading water here’ you can hear yourself think, as your eyes dart over a surgical list that’s more overbooked than the bathroom stalls at a music festival. Patients are trickling through at a glacial pace, and the day ward is a nightmare.
You were behind schedule pretty much from the start, and it’s only been getting worse ever since. While it’s not spoken about, you can feel the pressure mounting in the operating theatre. Nobody wants to run into overtime.
People have other appointments, things to do, or perhaps even plans for tonight. Your phone tells you it’s nice and sunny out, but you’ll have to take its word for it.
You feel an inkling to ask a question, but you quickly dismiss it as a bad plan. The message to you as a trainee 
in ophthalmology is clear: ‘Keep the 
list moving, write the notes, finish 
the discharge letters, and let’s all get home on time.’
This is not a ‘teaching moment’, and to ask the whole team to grind to a halt just so that you can learn some steps does not seem like a reasonable request.
The best days for surgical training 
are when all cases are straightforward, there’s been absolutely no overbooking and no urgent meetings for your supervisor to get to on time. In other words, days that are in the best of cases exceedingly rare, and for many of us completely fictional.

ASSERTIVENESS
So what do you do? Do you beat 
yourself up for not pressing the matter? Perhaps you should pass by the bookstore for the latest tome on assertiveness? Perhaps I’m projecting, but I’ve had my fair share of days like these. They were some of my worst 
days as a surgical trainee and I 
would often blame myself for 
not stepping up.
Now, I’m glad I didn’t. Yes, we all want to get from here to there in as little time as possible. But making a stand and demanding to be taught is not the way 
to do that.
Your supervisor has not forgotten that you want to be a surgeon. Like you, they are scrambling to make the clinic run as smoothly as possible. And even when it does run smoothly, there may be genuine reasons why this is not the ideal moment for teaching.
The point is that your relationship with your teacher is more valuable than any question you might have in that moment. Trying to force the issue can create a negative atmosphere in the operating room.
When pressure rises, keeping your head down and soldiering on is always going to be your best bet.

COMMITMENT
So, how can I show my trainer that I am committed to surgery?
In most of the basic ophthalmology training schemes in Europe, real hands-on surgical training is more of a ‘privilege’ than a ‘right’. Consequently, you can’t always expect to get loads of it. In many schemes, the number of candidates for surgical training outnumber the available trainee positions, and surgeons can be very selective in whom they wish to train.
It’s a competitive environment from the very start. Sure, you have the degree and the grades and you really want to become a surgeon. But so does everybody else. The chances are that a surgeon looking for new trainees will be looking elsewhere for things that set you apart from the other candidates. So take courses and attend wetlabs. In other words, invest in yourself.
Wetlab training is the first concrete step to surgery. Attending the wetlabs at national and international conferences can be quite expensive, but not only will it kick-start your manual skills, it can also bulk up your CV and provide certifications to show your commitment.
Use your own time to read up on as many aspects of surgery as you can. The ESCRS provides online didactic courses that you can take from your own home. I have mine running in the background when I cook and that works well for me.

TAKING THE NEXT STEP
How can I create more ‘teaching moments’?
You have done your preparation, you have followed the courses, and watched the videos. How can you take the next step to actual surgery?
Take the time to talk to your trainer at the beginning of your rotation with them. Be clear about what you want to learn and how you hope to learn it. Be honest about the experience you have and what you can do competently.
See if there is a particular part of the week where you can have time reserved just for you to learn. Small scraps of surgery here and there will never build mastery. The best-case scenario is to organise a weekly moment for training, even if they are only very small steps. This creates a very relaxed atmosphere and will help ease the natural anxiety and any associated hand tremors.
How do you make the most of your operating theatre time?
Know your microscope, instruments and phaco machine backwards and forwards and have everything set up before you scrub in.
Set your chair up to a comfortable height. A mentor of mine once told me that they could tell a bad trainee by the amount of fidgeting and manipulation of the microscope they needed after scrubbing in.

SKILL LEVEL
When you are given your chance, prepare a case that matches your skill level. Select a calm and co-operative patient with normal eyelids who dilates well. Think about what type of anaesthesia would be best. It can be stressful to jump straight into topical anaesthesia, so consider a block with a longer-acting agent.
Prepare a mental checklist of all of the steps of the surgery you are going to do. Most trainers teach the last steps of the surgery first and then build on that. It’s worth focusing on a single manoeuvre and repeat it over and over rather than trying to attack a full case.
Every trainee should keep records of their cases, refractive results and complications. Recording videos of your complications as well as your successes can be invaluable feedback.
Surgical training is not a commitment that should be taken lightly. As a trainer, I not only offer my own time – and time in the surgical theatre – for the benefit of the trainee. There is also an implicit commitment that makes me responsible for the complications of the people I train, even after they have completed their training.
On the other hand, seeing a trainee complete their first case can be one of the more rewarding experiences in hospital medicine.

Sorcha Ni Dhubhghaill is an anterior segment surgeon and guest lecturer at Antwerp University Hospital in Belgium.
Dr Ni Dhubhghaill won the John Henahan Writing Prize at the XXX Congress of the ESCRS in Milan, Italy

nidhubhs@gmail.com