When Should An Attending Take Over Vs. Letting A Resident Continue With The Surgery?

Surgical education has significantly improved over the past 10 years. With the introduction of the outcomes project, advancements in surgical simulation, and emphasis on safety, training in microsurgical procedures has progressed. While complication rates for resident cataract surgeons are low and become lower with experience, there is still an occasion for the attending surgeon to take over as primary surgeon.





Naturally, in any patient encounter, the primary focus must be on the patient; however, this does not necessarily preclude the resident from performing the procedure even when a complication has occurred. During phacoemulsification, it is often challenging to predict a posterior capsular tear prior to its occurrence, but being able to recognize it and manage it are critical components in any surgical curriculum.

In my experience, residency programs differ in culture with regard to the issue of when the attending should take over the case. Typically, in hospitals where residents are the primary physicians (e.g., VA hospitals or county hospitals), the attending physician is less likely to take over as the primary surgeon. I believe that residents must learn how to manage complications and therefore should remain the primary surgeon in the majority of these cases, even if complications occur. However, if the resident is physically, mentally, or emotionally not able to complete the surgery, I think it's reasonable for the attending to take over.

When a resident has very little experience and lacks the dexterity to perform complex surgical maneuvers, it is reasonable for the faculty member to perform these tasks and then return the case to the resident. On rare occasions, it is also reasonable for the attending surgeon to sit as the primary surgeon, just briefly to determine the status of the case (post capsular tear, zonular dialysis, etc.), and then let the resident manage the complication when a plan of action is determined. Finally, the attending should always take over if a resident specifically asks for the attending to complete the surgery.

When the resident is given the opportunity to operate on a case where the patient is scheduled for the attending and the attending will be following the patient post-op, I think it is reasonable for the faculty member to take over the case much sooner. In my opinion, hands-on experience with complication management is critical in surgical education. Therefore, it is essential that residents remain primary surgeons, "find" vitreous, learn to manage complicated cases, disclose the error, and follow the patient post-op with the utmost care.

Vikas Chopra, M.D. Associate residency program director Assistant professor of ophthalmology Doheny Eye Institute Keck School of Medicine University of Southern California, Los Angeles Teaching cataract surgery is different than coaching.

No matter how poorly the players are performing during the game, the coach cannot actually join the game. The coach is limited to providing guidance and support from the sidelines. Cataract teachers, on the other hand, are more like co-pilots. They must observe the resident surgeon operate, but jump in and take over at a critical time that is not too soon but not too late. All of this is certainly easier said than done. During training, it is imperative for the residents to learn not only the proper surgical maneuvers to perform excellent cataract surgery, but also how to properly address unanticipated challenges and to manage complications.

So how does one provide the resident an opportunity to learn, yet prevent the resident from getting into real trouble that could lead to a poor surgical outcome? Both the attending physician and the resident surgeon must understand their personal limitations and tolerances. Before each case, the teaching surgeon must categorize the resident surgeon in one of three categoriesnovice, intermediate, or expertto be able to tackle that particular case. For example, a resident may be becoming an expert in performing divide-and-conquer, but may be a novice in phaco chop; or a resident may be an expert in small incision phacoemulsification, but a novice in converting to extracapsular cataract extraction, if the need arises.

A resident may even conceivably be a novice in performing satisfactory phacoemulsification, but already becoming experienced in managing ruptured posterior capsules from recent iatrogenic complicated cases. Finally, the attending surgeon should discuss the plan of action before an upcoming case with the resident surgeon to make sure their flight plans are aligned. During the case, the resident must be allowed to get into manageable trouble and then be taught how to get out of trouble. For example, a radial tear during capsulorhexis can be managed by residents if they are familiar with the rhexis rescue technique.

A short incision that leads to iris prolapse through the incision presents an excellent opportunity to teach about iris management with viscoelastics, iris hooks, or possibly a Malyugin ring. Thus depending on the complexity in each situation, it may not be necessary to take over, but rather use it as an opportunity to teach from the co-pilot seat to ultimately correct the course.

However, certain situations will demand quick and decisive action by the attending surgeon to assume the pilot seat and take over the case. For example, if a patient is quickly becoming uncooperative, prompt completion of the case is necessary. Another example is a serious sight-threatening complication such as an expulsive suprachoroidal hemorrhage that needs immediate and decisive management.

Therefore, the threshold for assuming control needs to be personalized and will likely vary based on several factors: an individual resident's experience (or lack thereof), the nature of the intraoperative complication, the risk for poor surgical outcome, and ultimately the ability of the teaching surgeon to either co-pilot or assume pilot command to bring the situation to an optimal resolution. The ultimate challenge is not only to make sure that the surgery is performed primarily by the resident surgeon, but that it yields a comparable outcome to a case performed by a more experienced attending surgeon.

Susan M. MacDonald, M.D. Assistant professor Tufts University School of Medicine, Boston Director, comprehensive ophthalmology Lahey Clinic, Burlington, Mass.

Teaching cataract surgery can be a rewarding experience for the teacher as well as the student, yet it has the potential to be stressful and full of anxiety. Developing trust between the resident and attending is critical to keep this a safe, successful, and stress-free experience. The resident must trust the judgment and expertise of the attending, and the attending must trust the skill set and responsiveness of the resident.

When should an attending take over versus letting a trainee continue with the surgery? In the beginning of a resident's surgical experience, I believe it should be happening constantly. I use a stepwise teaching approach that starts during the first year of training. I like to switch back and forth with the resident to safely allow the resident to build successful snippets of surgery. It also allows for demonstration and correction and modification of residents' technique. As the residents master each of these steps, they will progress and have the skills to complete a full case. When an appropriate full case is chosen for a resident, it is understood that the patient's welfare is the first and primary focus.

The resident knows if I am concerned that the patient is at risk, I will take over. This is also for the benefit of the resident, as having a major complication early in one's career can negatively impact learning, creating anxiety and fear that can undermine performance in future cases. If residents are capable and focused I will allow them to problem solve a difficult situation. But allowing residents to proceed with a case when they are having difficulty managing complications serves no purpose. I strongly believe having residents overwhelmed and flustered is not good for anyone. If residents do not know what to do, they must stop. This does not mean they can't start again, but continuing with no clear-cut plan and being flustered is a bad habit. I want residents to pause and define the problem, propose the solution, and regain focus before proceeding with the surgery. Sometimes the residents do not have the skills to do this, and it is an opportunity to model this behavior and demonstrate the specific technique to correct the problem.

Taking over the surgery should not be seen as a punitive action or one that is to humiliate or embarrass the resident. It should be done for the best interest of the patient and to prevent a complication that the resident is incapable of preventing or managing. It is an excellent opportunity for teaching. It is also a style of teaching to demonstrate and fine tune surgical techniques.

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