Photo courtesy of Kevin Caldwell Photography.
“See one. Do one. Teach one.” This time-honored formula is the key to learning any new medical procedure. Each of these stages on the pathway to proficiency poses different challenges and opportunities.
“Seeing one” brings everything from fascination to revulsion and demands our attention and self-control. “Doing one” recalls the moment when guiding hands were released from our bicycle and we were set free to ride on our own for the first time; a crash was certainly possible, but frantic pedaling brought exhilaration more often than injury. “Teaching one” marks the first steps on the path to mastery. One learns to see not only the procedure as it unfolds in the student’s hands, but many possible outcomes and complications at formerly unappreciated branchpoints.
Have another look at the 1902 photo on the cover of this issue of the Journal of VitreoRetinal Diseases, featuring William W. Keen, MD, of Jefferson Medical College in Philadelphia—credited as the first brain surgeon in the United States. Dr Keen, a preeminent and innovative surgeon, would be consulted in 1921 by Franklin D. Roosevelt to determine whether the future president’s sudden paralysis could be improved.
As was typical for the times, many students in the steeply raked surgical amphitheater in 1902 lacked didactic medical education or even a college degree. They paid hefty fees for the opportunity to crane their necks and get a glimpse of the surgical genius before them. Indeed, our parents—and certainly our grandparents—had surgical procedures by those who were “trained’ in this way.
Eight years after that cover photo, Abraham Flexner would have some strong words to say about the sorry state of medical education in America. His influential “Flexner Report” would close many ineffectual medical schools and energize the transformation to rigor and standardization in medical education.
Nevertheless, as Yogi Berra said, “You can observe a lot just by watching.” A pinnacle achievement resulting from observational learning occurred in December 1942. As the sole medical officer on board the submarine USS Seadragon, Pharmacist’s Mate First Class Wheeler B. Lipes confronted a seaman with acute abdominal pain. Despite recommendations to temporize, he correctly concluded that the patient had acute appendicitis and further delay might well prove fatal.
Given that they were in enemy waters and no other options were available, Lipes secured the permission of his captain—and of course, the terrified patient—to perform an emergency appendectomy. Although he had assisted at appendectomies during his medical officer training, he had no experience as a primary surgeon. Adding to his difficulties was the lack of laboratory diagnostics and surgical instruments; worse, his training had taught him that appendectomy surgery was not always straightforward and could easily prove fatal in highly experienced hands.
Fashioning retractors out of bent spoons, and with shipmates administering ether drip anesthesia with a tea strainer, Lipes successfully removed a gangrenous appendix—the first ever performed on board a submarine—and saved the seaman’s life.
The astonishment we feel as surgeons for this extraordinary achievement is, sadly, in sharp contrast to what occurred when news of the event bubbled to the surface along with the sub. In what must be a leading contender for entry number 1 in the “No Good Deed Goes Unpunished” file, Lipes was strongly considered for court martial for acting outside his professional credentials, but this punishment was fortunately dropped. Lipes was finally recognized for his exceptional innovation and bravery with a Navy Commendation Medal a mere 63 years (!) after his lifesaving operation.
The present issue includes an article by Drs Talia N. Shoshany, Joshua S. Agranat, Grayson Armstrong, and John B. Miller in which the engagement and educational experience with a 3-dimensional (3D) heads-up visual imaging system was compared to conventional microscopic viewing by medical students, residents, fellows, attendings, anesthesiologists, and operating room (OR) staff. (Full disclosure: D.J.D. is a consultant to Alcon Laboratories, Inc, which markets the technology evaluated in the article.)
This 3D technology is novel, but certainly not essential for performing excellent vitreoretinal surgery, and this is an area of active study and technological evolution. The advantages of 3D heads-up viewing are many: better depth of field for macular maneuvers, better video recording, better availability as a platform for telemedicine, etc—but there are also disadvantages such as diplopia in the far periphery, instrument cost, and ergonomic changes to the OR.
While many of these attributes are open for debate, the study found that engagement and surgical teaching were improved using large-screen stereoscopic viewing in the OR. (Anesthesiologists were the exception; they felt barricaded by the device and saw only the screen back. A satellite screen would almost certainly have improved the experience for these valued and essential OR companions.)
The photo in this editorial demonstrates the sense of engagement in the 3D heads-up microsurgical experience by all members of the OR team (Figure 1). In stark contrast to the surgical amphitheater of the last century, it is itself but a step to a future OR as unimaginable as it will be powerful.
Figure 1.
The author and surgical colleagues beginning combined vitrectomy with implantation of a Dohlman permanent keratoprosthesis. Photo courtesy of Donald J. D’Amico, MD.
This issue also includes in-depth reporting on the complex issues encountered in surgery for advanced Coats disease and spherophakia, a comparison of costs and benefits of examination-directed antivascular endothelial growth factor treatment for wet age-related macular degeneration, a compendium of posterior segment findings in patients sustained by extracorporeal membrane oxygenation, a careful and alarming look at the largely untreated psychological burdens faced by patients with diabetic retinopathy, results of a duel between posterior retinotomy and perfluorocarbon liquid use for drainage of subretinal fluid during retinal detachment surgery, 2 articles describing new manifestations by the shapeshifter of ocular syphilis, and many more articles for your education and enjoyment.
“See one. Do one. Teach one.” “Seeing one” has always been the most difficult element to acquire in learning any surgical procedure, and especially so for ophthalmic surgeons, given the tiny size of the eye—no bigger than a quarter when you spin it. Let us celebrate—and critically evaluate—every innovation that offers a chance to sharpen our focus and include much more, and many more, in our view.
Donald J. D’Amico, MD
Editor-in-Chief
Journal of VitreoRetinal Diseases