Retina Fellowship Pearls: Keeping a Surgical Log
Da Vinci' kept detailed notes of his ideas, experiments, and inventions.
Whether you are an athlete, a businessman, or a surgeon, it is important to track your prior efforts in order to improve and progress. As a retina fellow, keeping an accurate log has multiple benefits:
1) Requirement: All AUPO programs (and many non-AUPO programs) will require submission of a log upon completion of fellowship to earn graduation certification. In addition, the American Society of Retinal Specialists (ASRS) has partnered with several programs to standardize a more detailed logging of surgical cases. Fellows who complete the ASRS blog can become fellow members, bypassing normal application process to gaining full membership.
2) Privileges: As a newly minted retina attending, you will need a surgical log of some sort to provide most hospitals or surgery centers before obtaining surgical privileges at that site.
3) Self-Improvement: Your memory will play tricks on you. On a micro level, unless you record a log you will forget individual cases that may have taught a great deal. On a macro level, examining all of your surgeries will help give an honest general sense of how your results are with different surgical techniques.
4) Research: Often reviewing one’s log will lead to innovative and interesting research ideas and data that may contribute to the field.
5) Habits: Talk to any of the best-known retinal surgeons and they dutifully track their results over time by logging surgeries. Building good habits early in your career will serve you for a lifetime.
Before moving forward please note that it is critical to make logs HIPAA-compliant, whether by de-identifying patient data completely or storing a log in a secure, HIPAA-compliant encrypted server or computer.
Logs also lend themselves to controversy. Applicants often ask the question: how many primary surgeries do fellows graduate with from each program? How many assists? The answers you will receive as an applicant are variable and that can make it extremely difficult to compare different programs. Fellows and programs are not intentionally trying to make things confusing. In contrast, the major issue is the lack of standardization individual to individual about what constitutes a primary surgery.
The AUPO log, similar to ACGME log systems for general surgery or neurosurgery, simply uses a binary system. Each trainee surgery is classified as 1 or 2, 1 indicating either a primary role as the surgeon (or a teaching role) and 2 indicating role as assistant. Retinal surgery is often not so easily defined, however. If as a fellow you complete the vitrectomy and fluid-air exchange but not the laser or closure is that primary or assist? If you place a scleral buckle but the attending does the external drainage is that 1 or 2? Ask different individual physicians, both out in practice and in fellowship, and you will get many different answers.
Simply put, perhaps the most important factor is to be internally consistent with yourself. As long as your log is internally consistent, and we understand implicitly that we cannot compare one fellow’s log to another, then the log still serves all five of the purposes listed above.
To help track your progress, it may be useful to further subdivide cases in a 1-5 numerical score. As fellows we utilized this scale, and while it still leads to individual decision making on what score to assign a case, it helps better define for yourself how you are improving over time:
1: primary or teaching surgeon
2: assist with more than core vitrectomy, including membrane peeling
3: assist with core vitrectomy
4: assist with entry/closure
5: primary assist
The hardest differentiation will be of course between grades 2 and 3 and 3 and 4. That’s where each of the fellows in our program differed in interpretation. All systems will have flaws, and I encourage you to develop your own methodology and share it. But, as long you are logging faithfully, honestly, safely, and consistently (and you review your log regularly!), you will provide better and better care for patients over time.
Jay Sridhar