THE capsulotomy step of modern cataract surgery is fundamentally finicky, the kind of step beginner surgeons find difficult, and if done incorrectly may result in imperfect vision of the kind that makes the patient’s head swim with nausea and the surgeon’s head swim with trying to deal with complaints – a double threat.
During the capsulotomy, I manoeuvre a slim pair of fine-toothed forceps to create a perfectly circular hole in the fine membrane of the eye’s lens, through which the yellowish, cataractous lens material is gently broken up and suctioned. An artificial lens is then inserted through the hole and stabilised within the membrane.
The ideal hole is 5 to 5.5mm in diameter – too small, and there is a danger of tearing the membrane during surgery; too large, and poor overlap by the membrane of the artificial lens may occur, resulting in what we call secondary cataract, which will require an additional laser procedure.
I’ve learnt, through the years as an ophthalmic surgeon, that the capsulotomy step becomes second nature after roughly 500 cataract surgeries. In the early days of operating, the increased speed with which you attempt a capsulotomy often results in a kidney-shaped hole. After 500 or so cases, I learnt to slow down, refine my movements, and the roundness of my capsulotomies improved.
Repetition, as they say, “opens doors”, to quote Tim Lucas from The Book of Renfield. I realised over time that only when capsulotomies are done again and again and again will they become better sized, better centred and result in better outcomes.
With cataract surgery, you often cannot pick and choose. Despite the universality of symptoms of poor vision, cataracts come in all types of density and stages of difficulty. You reach a point where you ask: “Am I good enough?”
It is at this point where your mettle is tested – and known – in whether you can confidently handle even the most harrowing cataracts and in how you manage complications. Your mettle is tested when you are the first person junior colleagues turn to in hazardous cases, and when the steadiness of your hands could be the difference between blindness and light.
So is mettle thus tested across all medical disciplines.
Medicine, in all its glory and travails, is messy – much like life. We are unable to pick and choose what we want to happen and package them in eight-hour packs to fulfil your monthly quota of assisted appendectomies. Patients will get ill, sometimes catastrophically, and not tell you. You will not plan on having a return to surgery until you notice that post surgery, Mrs Y’s abdominal aortic repair has started bleeding. You will not expect to be kept back until the child you’ve been fighting to keep alive through the night Blue Codes at the end of your shift.
Opportunities to comfort and to improve will come at all times of the day, sometimes in the dead of night when you can hardly move your feet due to tiredness.
Houseman tagging has long been the introductory course to housemanship in Malaysia. It draws parallels with various military and paramilitary hell weeks which are touted by none other than the US Navy SEALs to test “physical endurance, mental toughness, pain and cold tolerance, teamwork, attitude, and your ability to perform work under high physical and mental stress, and sleep deprivation. Above all, it tests determination and desire.”
Are we so different from soldiers after all? Are the requirements for a neurosurgeon to focus and operate on a 2mm square surface area of brain stem matter continuously for 18 hours any less rigorous or demanding than the mental focus a Navy SEAL requires?
A good houseman is not built through carefully arranged six-hour sleep times interspersed with eight-hour shifts of medicine, as if you could pick and choose which trauma cases or complications you would see in each shift. No, a good houseman and, by extension, a good doctor is built by pure repetition and the amount of time spent seeing and treating patients, as they are impossibly non-textbook. Clinical acumen is built by wealth of experience in managing non-classic cases, where you have nothing to fall back on but your experience. And this is precisely where tagging will give you the opportunity to understand the sacrifices medicine requires of you.
Tagging has its share of problems that we, especially senior clinicians, need to take responsibility for.
We have often been patronising and merciless. We need to realise that the aim of housemen tagging as an essential tool to bring new doctors up to bare functionality can only be achieved when we recognise the difficulties and apprehension that our junior colleagues have, when we strive our best to ensure that honest mistakes are not unfairly penalised and when we take the time to remember that we were once housemen as well.
As we welcome you to our fraternity, we hope you will keep an open mind throughout your housemanship and its tagging.
DR JULIAN TAGAL
Sarawak General Hospital