Dr. Mamalis has spent more than 40 years as an ophthalmologist, intraocular lens researcher, and medical educator. We asked Dr. Mamalis, who recently retired from surgery, to share perspectives from 38 years of teaching residents in the operating room.
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Be the voice of calm.
It's important to remember that residents, especially newer residents just learning, are very nervous. And when they’re nervous, it’s really important for attendings to do whatever they can to calm them down. One of the things I found helpful is modulating your voice inflections and tones. I tried to speak in a very even, monotone way, what is described as my “HAL” voice, referring to the HAL 9000 computer in the movie “2001: A Space Odyssey.” If a resident was getting too deep in the eye or too shallow, you couldn’t say, “OH, don’t go so deep!!!” Then they got even more nervous. Instead, you would talk calmly and say, “OK, we’re not going to go quite so deep, and we’re going to go a little more superficial.”
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Teach ‘inside-out’ cataract surgery.
It's in our nature as ophthalmologists to like to teach cataract surgery from Step A to Step Z, but that’s not the way it works. Sometimes, if Step A is done improperly, it throws everything else off. I used the method of what we call “Inside Out Cataract Surgery.” Residents started with the parts they could do most easily that wouldn’t affect the other parts of the surgery. For example, in a cataract surgery, I would make the incision, and I would make the capsulotomy (capsulorhexis). Then, I would have the residents start the procedure where they remove the hard part of the cataract, and the softer parts, and put in the lens implant. We started from the inside first and added more pieces to the surgery as they became more confident.
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Customize your approach to each learner.
Not all residents are alike, and some residents are naturally gifted. Their hands are steady, and they are very precise with what they do. We could accelerate their training and help them go through the steps more quickly. With others, we had to work more slowly through the steps, ensuring their hands and feet were properly positioned. The nice thing about the Moran Eye Center is that the residents do a very large number of cataract surgeries. No matter how gifted they are, by the end of their residency, they are all good surgeons because they’ve done enough cataract surgeries.
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Understand when to take over versus when to guide them through.
A lot of these decisions depend on the level of training of the residents. I used to work a lot with second-year surgical residents, so I tended to jump in sooner when they started to get into trouble. But when I worked with more senior residents who had a lot of cases under their belt, when they started getting into trouble, I thought it was important to let them work their way through the problem. I talked to them a lot and told them, “OK, you need to do this technique, or that technique,” and worked with them to rescue what was happening. There were times when they got into trouble and they weren’t going to get out, so in that case, you would have to trade places with them.
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Speed is not efficiency.
As a medical student at the University of Utah, I found that I learned best when the attending who was trying to teach me was very patient and calm. You can’t push the pace on residents beyond where they want to go. If you try to get them to go faster and faster and faster, there will come a time when they’ll make a mistake. Speed doesn’t come from going fast, speed comes from efficiency. As you get more efficient at doing the steps of the procedure, you get faster. We have to take as much time as it takes for the resident to learn and to do the technique without creating problems.
Dr. Mamalis directs Moran’s Ophthalmic Pathology Laboratory and is co-director of the Intermountain Ocular Research Center. He holds the Calvin S. and JeNeal N. Hatch Presidential Endowed Chair. His awards include the 2020 Distinguished Alumni Award from the University of Utah School of Medicine Alumni Association, the 2015 Life Achievement Honor Award from the American Academy of Ophthalmology, and the 2013 Binkhorst Medal from the American Society of Cataract and Refractive Surgery.