How to Be Successful When on Call

I was on call over Christmas here in Spokane, and it was fairly busy. Not as busy as it would be for some other specialties, but still busy. For 96 straight hours, I was the ophthalmologist covering all consults for three hospitals in the city, and I was also on call for the patients in our call group, which consists of about 25 ophthalmologists. 

For the past eight years, I've had the opportunity to be on call hundreds of times. It's not my favorite part of my job -- and I'm not sure it is for anyone! -- but I've found a few tips that have helped me be successful on call:

1. Manage your expectations. If you assume you won't be busy, at best you will be satisfied, and more than likely you will be disappointed. By contrast, if you prepare for nonstop action, you will be pleasantly surprised and grateful if you get some sleep or time to sit down.

2. Be efficient. Focus on the "W-I-N" strategy: what's important now? What do you need to do to save this person's life/limb/vision until the morning? Don't get bogged down.

3. Most importantly: Remember, you signed up for this. Your patient did not. He or she is seeing you at one of the most vulnerable times in their life. They need your help.

When I posted this on my Facebook page, Dr. Tom Oetting, a great mentor and friend, had the following to say:

People are scared and often just need reassurance. Took me a long time (and having kids) to figure out just how anxious we as parents can get. . . Even though some of the things we see on call seem trivial to us they can really jazz up a family unit! So we shouldn't be surprised or resentful if some of our on call activity seems trivial.

Another friend, the retina surgeon Dr. Jayanth Sridhar, whose new podcast can be heard here, recommend the following:

Keep snacks in your bag. Something quick may end up being longer than you think. Always carry a phone charger.

What do you think? What tips for success on call have you found? Have you had any experience with on-call physicians that were particularly memorable? Comment below!

Being Fast

It was a hot, sunny summer afternoon, and we were all excited for high school graduation the next day. As was our habit, after school got out, my friends and I went over to a neighbor's house to play basketball on their beautiful outdoor full court, complete with painted lines and breakaway rims, just like the pros used. I grabbed a rebound, dribbled the length of the court, and went up for a dunk. I vividly recall being in midair, the defender underneath/in front of me, and realizing my body was now parallel to the ground and bad things were about to happen. I landed awkwardly on my arm, figured it was broken, and went to the emergency room with my mother.

Dr. Swensen, recipient of the Utah State Orthopaedic Society's  2013 Sherman S. Coleman Humanitarian Award .

Dr. Swensen, recipient of the Utah State Orthopaedic Society's 2013 Sherman S. Coleman Humanitarian Award.

Mom asked for Dr. Laird Swensen, a hand surgeon who had taken care of my family in the past. Dr. Swensen, a tall, kind, soft-spoken 50-something-year-old, graciously rearranged his schedule to come see me. My wrist was indeed broken, and Dr. Swensen set the fracture and put on a cast. A few weeks later, when X-rays revealed the fracture wasn't healing perfectly, Dr. Swensen recommended surgery. Nervous that I would never be able to play basketball again (18-year-olds have a different version of what's important), I called him the night before surgery. He reassured me. The surgery went great, and my wrist has been as good as new ever since. Dr. Swensen became a hero of mine.

A few years later, I had the opportunity to work as an orderly in the operating rooms where Dr. Swensen and other orthopedists operated. I took patients to and from surgery and helped prepare and clean the operating rooms. Early on, while chatting with one of the surgical technicians, I mentioned how highly I thought of Dr. Swensen. My coworker shrugged and said, "He's so slow."

This comment caught me completely off guard. Slow? What does that mean? Who cares if he's slow? Why is that even a thing? Isn't the only thing that matters whether he's "good" or not? Perhaps my colleague was just accustomed to other orthopedic surgeries, which are often much quicker, and not to hand/wrist surgery, which, due to the intricate anatomy, is meticulous and often drawn-out. But I was still miffed that the first adjective used to describe this excellent surgeon was the word "slow."

Since that time, I have on occasion noticed that a slow surgeon can be an annoyance to others that work in an operating room -- including nurses, technicians, anesthesiologists, etc. -- because of how long their cases take. Also, from a patient safety standpoint, all other things being equal, the less time spent under anesthesia, the better, and from a business standpoint, the quicker a procedure is, the more time available for other patients and procedures. And slow doesn't automatically equate with good. I understand all of that. Maybe I was naive, but I just never imagined that a physician's speed would have any bearing on what colleagues thought of him or her.

This pressure, to be not only excellent but also efficient, is something that every surgeon and every physician faces. Clearly, the ideal is that care is both excellent and efficient, 100% of the time. That's what's best for patients. In most cases, it's possible. But sometimes things aren't straightforward; surprises happen in the operating room or in the clinic, and when that happens, it's crucial that speed take a back seat to quality. I believe it's important to strive for perfection, not just "good enough."

My favorite anecdote regarding this issue comes from a surgeon I know who, during a meeting with his boss, was made aware that he took longer to do a given type of surgery than his colleagues did. The surgeon -- accurately, by the way -- replied, "Yeah. But mine work." That surgeon understood that while time is of the essence in the operating room for many reasons, the most critical aspect of the case is that it's done well, not that it's done quickly.

Every time I enter the operating room, I think about that surgeon, and about Dr. Swensen. I am so fortunate to have trained at the University of Iowa and to work at the Spokane Eye Clinic with colleagues that share this same approach.

What do you think? Have you faced pressure to be both good and fast in your career? How have you handled that? Comments welcome!

Isn't strabismus just a cosmetic problem?

Strabismus is more than just an aesthetic issue, as it can interfere with visual development in childhood.

Strabismus is more than just an aesthetic issue, as it can interfere with visual development in childhood.

This is a common question. The short answer is "No!" Want the the longer answer? Here are five reasons why:

  1. Strabismus, or eye misalignment, in children can cause amblyopia, or poor visual development, in the eye that isn't straight. This can be so severe as to cause permanent, severe vision loss. Fortunately, if detected, it can be treated effectively and reversed.
  2. Strabismus in children can prevent the natural development of something called "binocular fusion," a process in which the eyes learn to work together, so to speak. In the first year or two of life, the neural connections between the eyes and the brain are rapidly developing, and the brain learns to put the images produced by both eyes -- images which are similar, but not identical -- into one single image. This process allows us to develop depth perception. Strabismus very commonly inhibits this.
  3. Strabismus in adults typically causes diplopia, or double vision. It's easy to understand why: if the eyes are looking in different directions, they will produce different images, which the adult brain will see as double images. Want to know what that's like? Cross your eyes and walk around for a few minutes. It's decidedly unpleasant!
  4. Strabismus surgery, because it is not cosmetic, is covered by medical insurance.
  5. Strabismus in our society is unfairly associated with things like reduced intelligence and diminished potential for success in the workplace. Below is a review of the scientific literature on the negative societal implications of strabismus:
  • A 2001 study published in the Journal of the American Association for Pediatric Ophthalmology and strabismus allowed children to play with "normal" dolls and dolls that had been made to have strabismus. They were questioned after 10 minutes of play. Grade-school children were 73 times more likely to express a negative bias toward the dolls with strabismus. PubMed link
  • A 2003 study published in Acta Ophthalmologica Scandinavica showed photographs of the same children with and without strabismus to 30 elementary school teachers. Kids with strabismus were considered by teachers to be more unhealthy, less hard-working, and less happy. They were also felt to be less likely to be accepted by their peers and more likely to have difficulty learning. PubMed link
  • A 2000 study published in Ophthalmology showed photos of the same job applicants, both with and without strabismus, to potential employers. Women with strabismus were less likely to be considered for the job compared to women without strabismus. Strangely, this unfair bias was not seen toward men with strabismus. PubMed link
  • A 2008 study published in the British Journal of Ophthalmology interviewed 40 dating service agents, and 92.5% of them felt that a client having strabismus would make it more difficult to find a partner. Among facial disfigurements, only very prominent acne or a missing tooth had a greater negative impact. PubMed link
  • A 1993 study published in the Archives of Ophthalmology interviewed 43 teens and adults that had strabismus in childhood which was not corrected. Over 1/3 of them reported that their friendships had been moderately to severely affected, particularly friendships with the opposite sex. 84% reported that their strabismus interfered with school, work, and/or sports. Sadly, 50% said they had experienced ridicule or abuse because of their eye misalignment. The majority said it had a negative impact on their self image, and 1/3 made some attempt to hide their strabismus, with their hair, head position, or sunglasses. PubMed link

In sum, strabismus is much more than just a cosmetic problem. It has a significant impact on people's vision and quality of life. And it can be fixed! Helping patients fix their strabismus is one of the most gratifying parts of my job.

What do you think? Have you had strabismus and realized it's much more than a cosmetic issue? Have you treated patients who had been told previously that this was the case?

Special thanks to Dr. Scott Larson, MD, for compiling these scientific papers. Dr. Larson, a mentor and friend, is a pediatric ophthalmologist at the University of Iowa. His excellent website can be found here.