Starting clinical practice is an exciting, but stressful, time in a new surgeon’s career. The operating room can be an intimidating place, particularly in a new practice or during difficult cases. Each surgical center has a different way of scheduling and preparing for cases and understanding these processes early can help communication with operating room staff. Planning to ensure that all implants, supplies, and instruments are available is critical to a successful procedure and can help with the preoperative planning process.
Key points
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Identify available implants.
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Develop your method of communication with operating room staff about implants, instruments, and graft needs.
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Develop a preoperative planning strategy.
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Determine how to best use your first assistant.
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Use the anatomy laboratory and senior partners to practice/discuss complex cases or complications.
Introduction
The transition from orthopedic sports medicine fellowship to starting practice comes with many new responsibilities and changes. Residency training focuses on guiding trainees in becoming safe and competent surgeons; however, there are many nonclinical aspects of starting practice that are rarely addressed. Performing surgeries independently without the comforting backup that exists as a trainee can be overwhelming to the new surgeon. Yardley and colleagues report an increase in feelings of burnout, depression, and anxiety during transitions in medical education. Additionally, inexperienced surgeons may lack confidence in stressful or critical decision-making situations, with fewer resources to seek support from new partners or prior mentors. This article seeks to discuss the challenges that the new surgeon face in the operating room and provide a framework for succeeding in the operating room.
Preparing for your first day
The new surgeon has successfully graduated from 5 years of residency and 1 (or more) fellowships and understands the importance of presurgical preparation. One of the most difficult things for a new surgeon is to adjust to an operating room environment that is quite different than the well-run operating rooms of established surgeons from their training. New surgeons may be starting a job at a new facility or a new practice location that does not have experience with sports medicine procedures, or even orthopedic procedures. Hospital systems or surgery centers may use different vendors, imaging equipment, operating room tables, and instruments, some of which may be new to the new surgeon. The author will detail how to best prepare for a surgery at a new facility.
Preference Cards
Each operating room has a unique way of tracking the preferences of attending surgeons and it is important to identify how your new practice collects this information. Preference cards are a common way to keep track of instruments, implants, and accessory supplies that a surgeon will use for a procedure. If you like the way a specific surgeon does a procedure during your training, making a copy of the preference card is an easy way to have a list of supplies and instruments to show your new institution. However, some surgery centers have a more global preference card that encompasses all upper extremity or lower extremity procedures, making specific details for each procedure difficult to identify by the operating room staff. In this situation, it is beneficial to create your own preference card that lists every aspect of the procedure, including positioning/table, anesthesia and/or regional block preferences, need for imaging, implants required, autograft or allograft needs, specific trays or instruments, and durable medical equipment (if provided by the vendor). This allows the new surgeon to carefully analyze each procedure and identify instruments and implants that are critical for exposure, reduction, or fixation during the procedure. Additionally, this can help you with preoperative planning of a new or complex procedure, as you carefully go through each step of the procedure. Providing the preference cards to your surgery center’s manager or clinical supervisor can ensure that the staff will receive a copy prior to your procedure. Additionally, it can be beneficial to provide a weekly update via email to your operating room staff, management, clinical team, and vendors to ensure that all parties are aware of the planned cases and required instrumentation and implants. This can also be used to highlight a unique positioning (eg, lateral arthroscopy) or a rarely used implant or graft (eg, bone dowels for 2-stage anterior cruciate ligament revision tunnel grafting).
Instruments
Surgical instruments and trays are categorized differently at each institution. When starting at a new institution, it can be difficult to determine which trays include the specific instruments or retractors that you are accustomed to using for a specific procedure. Occasionally, senior surgeons at your training institution may have specialized instruments that are only available at that institution. Trays may also be arranged with different instruments assigned to specific trays. It can be helpful to discuss instrument availability and trays with the nursing and sterilizing team to ensure that you have the correct equipment available. Additionally, you may be able to edit the contents of a tray to reduce the volume of instruments opened for a particular procedure. Each instrument has an assigned code and this can be provided to the sterile supply team to edit existing tray contents.
Communication with surgical technicians is a critical component of a smooth and efficient procedure. As a new physician, you may work with a team who has little orthopedic or arthroscopy experience, as the more senior surgeons have their established teams. There are several ways to ensure that your surgical team is aware of your instrument and tray preferences, as well as the instruments required during specific portions of the case. You can consider using a Mayo stand with commonly used instruments or laying instruments out in the order of use for a particular procedure. For a more complex surgery, some surgeons provide the surgical team with a list of surgical steps and the required instrumentation for each step. This can seem burdensome; however, as a new surgeon, visualizing each step of a procedure and the instruments you want to use can help increase your comfort level with surgeries.
Implants
Hospital systems may have vendor contracts with a variety of vendors, which may be different than the ones used during your training. The majority of sports medicine implants come from several large companies; however, the particular specifications of the available implants may vary. Additionally, the number and variety of implants located “on the shelf” versus carried in by the representative for each case is not standardized across hospital locations. It is important to discuss specific implants and implant instrumentation with the company representative before doing a case for the first time. New surgeons should be prepared to adapt their surgical plans learned during training to the available implants or vendors available. Many surgery centers do not stock multiple types of the same implant or have multiple vendors who provide the same implant.
Allograft is a unique implant and each surgery center will have a different way of ordering and storing allograft. To save on cost and prevent waste, most operating rooms order the specific requested allograft and do not have backup grafts in cold storage. There are several allograft vendors and your new institution may use a different allograft supplier than in training. It is important to note specifics of allografts during training to streamline your ordering process as a new surgeon. These principles can be applied to allograft tendons, allograft bone dowels, and allograft bone for cartilage restoration or bony augmentation procedures. The availability of other biologic cartilage restoration implants is very variable between centers and varies based on cost and storage of the graft/implant. It is important to confirm which cartilage restoration techniques or procedures that require allograft are feasible prior to booking a procedure.
Backup Implants
Particular focus should be given to any backup implants that may be needed, as some operating rooms may only carry 1 size or type of implant. For example, for a rotator cuff repair, you should confirm that your first choice implant is available, but also backup anchors of a larger size or of a different material should also be confirmed to account for anchor breakage or poor purchase in bone. Determining which implants are available in case a different fixation type, anchor size, or suture type is required can be done by talking to the administrative staff in charge of ordering implants or the implant representative.
Company Representatives
Representatives from implant or instrument companies can provide a wealth of information regarding available implants at your surgery center or operating room, as well as provide you with insight into which implants are commonly used. It is important to meet with the representative in your region prior to starting your first job. If you are unsure who the representative is, your local representative from training can provide you contact information or assist with introductions at a course or meeting.
Implant representatives can also be very helpful in instructing new or inexperienced operating room staff about trays or instruments that are needed for a procedure. Additionally, a knowledgeable representative can assist an inexperience scrub technician during a procedure to ensure the correct instruments are available during implant placement.
Operating room staff
Operating room staff are a critical component of the operating room team. Staffing generally consists of a scrub technician, circulating nurse, first assistant, and the anesthesia team. Operating rooms may have dedicated orthopedic staff or may have employees who rotate between services. It is important to be prepared to work with staff who may not have experience with sports medicine procedures or arthroscopy. The new surgeon can do several things to prepare for a procedure with less-experienced staff. First, ensuring that the operating room management and implant representatives are aware of required instruments and implants prior to the surgical date is critical to start a procedure smoothly. Next, the new surgeon should plan to arrive to the operating room early to be available for questions regarding implants, trays, fluoroscopy, and additional supplies for the procedure and/or postoperative durable medical equipment. Preoperative briefings have been shown to improve efficiency, decrease flow disruptions, decrease procedural knowledge disruptions, and decrease miscommunication during a procedure. There are several strategies to communicate with the scrub technician regarding the surgical steps and instruments required and you will naturally develop a method of communication with your staff. The most important part is to ensure that there is open and clear communication between you and the operating room staff. At the end of each case, the team can meet to discuss ways to improve efficiency with regard to supplies, intraoperative steps, and so forth.
New surgeons are generally used to working with large operating room teams during training. Most new surgeons will start with a small team, usually consisting of a circulating nurse, a scrub technician, and a first assistant. The first assistant can vary from a trained surgical assistant to a physician assistant employed by the hospital or surgery center. Most first assistants have general knowledge of retracting or how to assist with a procedure; however, some may be new to orthopedics or arthroscopy. It can be beneficial to meet with your first assistant prior to a procedure to understand their level of skill with regard to orthopedic procedures and which aspects of the procedure they feel comfortable assisting with. The new surgeon should critically analyze each procedure and determine which portions can be performed without assistance, the portions that require assistance, and which aspects of the procedure will be performed by the first assistant. For example, during an anterior cruciate ligament reconstruction, there are many parts of the procedure that require an assistant. The new surgeon should decide if he or she will be the one to hold the femoral guide and the camera versus the one to place the guide pin and reamer. Similarly, will you hold the camera and guide the graft into the tunnel or be the one actively pulling the graft into the tunnel and confirming that the button has flipped? The same decisions can be applied to other procedures: Who will apply valgus during a medial meniscus procedure? Who will hold the drill guide and perform the drilling during a labral repair? Will you hold the camera, guide, and/or awl during anchor placement for a rotator cuff repair? It can be difficult to explain how to hold the arthroscopic camera or use a reamer during a stressful portion of a procedure and you should be prepared to explain in a simple, step-by-step fashion how to assist during your procedure.
Surgery
Preoperative Planning
Preoperative planning is a critical component to a successful surgical procedure. Planning strategies have evolved as new technologies arise and surgeons have a variety of computer-based planning software that can be applied to many surgical procedures. Traditional surgical planning involves writing down each step of a procedure with contingency plans and backup plans if certain difficulties arise during the procedure. Using this method during the first years in practice can help the new surgeon understand and refine the surgical plan with each case. The surgical plan can be updated for the next case with notes about improving retractor placement, complications encountered and how the surgical plan changed, and general notes on surgical efficiency. In addition to writing surgical steps, studies have shown promise for the use of cognitive training and mental rehearsal. Anderson and colleagues published a meta-analysis evaluating the use of cognitive training in orthopedic surgery and noted improved surgical performance and knowledge. Mental rehearsal can help the new surgeon visualize each step in the procedure and can be an important adjunct to preoperative planning. Studies have shown that use of mental rehearsal shows improved performance in virtual surgery and can decrease subjective stress while increasing self-confidence. ,
Another strategy for preoperative planning is to practice a procedure in the anatomy laboratory. Most academic institutions have an anatomy laboratory for medical students and resident teaching and is generally available for staff use as well. If you work in the community setting, implant representatives can help set up a laboratory as well. The anatomy laboratory can be used to practice a new procedure or a complex procedure that you may not be as comfortable with. Additionally, new implants or instruments can be used in the practice setting to learn the intricacies of a new arthroplasty system or novel implant. Box 1 lists helpful tips for preoperative planning.
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