What it is like to be a surgeon in one of the most difficult surgical specialties?

Dr. Buchbinder and Dr. Khelemsky both authored the Le Fort I Osteotomy and Orbital Floor Reconstruction simulations and more recently visited the Touch Surgery Lab. We are very happy to have hosted these two exceptional guests at our lab in London where they shared with us the challenges of being a Maxillofacial surgeon and what it is like to be a resident in one of the most demanding surgical specialties…

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Dr. Buchbinder: “Renata and I felt it was very important to come and meet everybody here at the Lab, we started this journey quite some time ago.

This all started about a year and a half ago, we were looking at vetting and doing due diligence to find high-value digital platforms to teach surgeons. We felt it was very important for us to find another way to train the surgeons of the future. Nowadays, the number of residents’ duty hours have shrunk tremendously, also concerns about patient safety are increasing and patients are increasingly demanding to be operated by the consultant or professor.

From a training perspective, if you are in a hospital for less time, then you are going to see a lot less surgery and, therefore, be less experienced when you are done with your training. We knew that something had to be done about that. Surgical simulators have been around for a long time, just think every time you go to the anatomy lab and you dissect a cadaver you are essentially practicing a surgical approach and simulating a surgical procedure. We are very grateful for the people that donate their body to science but it is really an impractical way of doing things. The cadavers may not be in ideal condition or you may not be the first one practicing this approach limiting its teaching value.

The idea of moving to digital surgical simulation to start teaching trainees is really important. Everybody is interested in the million dollar platform with high fidelity physics, but it is quite hard to implement and distribute that tool to the masses. We did a lot of research and were very fortunate to come across your project. We really did look high and low to partner with people we thought were cutting edge and doing really great stuff, so we started working with Touch Surgery a year ago and hopefully we will be producing more modules, and in time would like to invite other colleagues from different specialties to join us on this very special journey. I think this is important not only for the work we do but also for the patients we care for.

Nowadays we start to realize the importance of cognitive learning. Pilots never take off without a checklist and surgeons should do the same before going to the OR. I think that going through that checklist in the cognitive learning portion of the surgical procedure is probably just as important as the psychomotor skills that the surgeons should have. Because if you don’t know what you are doing even though you have the best of hands, you can be very dangerous…”

Le Fort I Osteotomy

We then asked Dr.Buchbinder -“what pushed you to become a surgeon?”

He joked: “Because I was an awful artist..”

Then answered: “I was kind of genetically engineered to go into medicine, which is fortunate. I am a third generation physician in my family. I fought it very hard, and I though that it’s not because my grandfather, my father were physicians that I had to become a physician myself.

-‘I am going to be smarter than everybody’ I said to myself.

-’I am going into dentistry’ … and that genius idea lasted 2 weeks!

That’s when I realized what I wanted to do. I went back to medical school, I guess that if you have a passion and suppress it, it will resurface at some point. I have been in academic medicine my entire professional career. The fact is that I really enjoy training young surgeons. I like being constantly challenged by young trainees, it keeps me on my toes.

I am also thankful for the opportunity to work with young people and be able to mold the next generation of surgeons. One day I hope that my legacy to the profession will be the introduction of a blended simulation curriculum that will help train surgeons in the future and improve patient safety and outcomes.

Maxillofacial surgery requires a certain amount of expertise both in Medicine and Dentistry.

The training is 11 years long and that is if you decide not to do a postgraduate fellowship. The training is is even longer than neurosurgery if you can believe it but it is also a very interesting field. My personal area of interest is reconstructive surgery. We take care of patients with gunshot wounds to the face or treat cancer that has completely disfigured them. The idea of getting their face back together as best as possible and giving them their quality of life has been so rewarding for me. Unlike with reconstructive surgery to another part of the body where it is possible to hide under your clothes, you cannot hide your face. For our patients, their face is the mirror of their soul and it is quite important at the end of the day to satisfy them.

When asked, “What is the worst case you’ve had?”

Dr. Buchbinder replied:

-“The worst cases are when I have pediatric patients with horrible malignancies, it is quite frustrating taking care of this patient population. You want to do your best for every patient but it’s quite a tough decision to make as surgery is not always the best option. It is so difficult because, at the end of the day, it is about the patient’s quality of life. Technically you can remove the tumor but if it comes back 3–4 months later and you mutilated the patient in the meantime, you have done the best for the patient. The more difficult thing is to know when to say no and to know your limitations as a surgeon. Sometimes there is nothing we can do. It is heartbreaking.

In addition, to that Dr. Khelemsky was asked about her experience as a resident and working with Dr. Buchbinder:

“As a resident, every year is different. I am currently in my fifth year out of 6 total years of training in Oral & Maxillofacial Surgery. Essentially there are 4 years of surgical education as the first two years are medical school combined with medical clerkships. Prior to these 6 years, you must also complete 4 years of dental school, which is a very hands-on experience. Hence, the need to pay attention to details happens early on. Personally, I hate to go to the operating room without having done a certain amount of pre-operative planning. Textbooks, when you are post-call and tired, don’t cut it when you’re looking for high yield information. You can spend hours scanning for the right approach or anatomical rendering before you find what’s helpful in that moment. I became quite frustrated and that initiated my motivation to start working with Touch Surgery. I have spent hundreds of dollars on medical books but I doubt that I have even opened half of these.

When I was rotating on General Surgery for a year, I watched various videos because I just couldn’t get my mind around the 3-dimensional “soup” of tissues, as I was mostly used to bony surfaces and hard tissue landmarks. I wish I had Touch Surgery to help me better understand the body’s various components and tissue layers as you encounter them in surgery.

When I was on Breast and Plastic Surgery rotation, I was assigned to assist on a DIEP flap just a few hours before the surgery. To prepare, I knew I would need to spend all night reading about this highly technical procedure. While protracted hours are a part of any residency training, the goal here is to retain what you read, and apply what you retain. Unfortunately, there is little you could do to improve these unforeseen circumstances. I wished I had something high yield, visual and accurate, that I could rely on. This was especially true when learning is a priority, regardless of time.

But the main reason I like Touch Surgery is because it showcases a lot of anatomy in a condensed space. Being able to zoom in on a portion of the eye, for example, knowing that there are several difficult tendons attached there, is truly great. There are many inaccurate sketches in textbooks and other medical resources that caused great frustration for me.

Additionally, the first time in the operating room for a resident is not unlike the first time for a training pilot in an airplane — it is extremely stressful because time is moving fast and you cannot call a pause. With Dr. Buchbinder assisting me, I am not ashamed to say ‘I don’t know or I need help’. Sometimes, having a sense of what’s coming up next in the surgery helps you be even more proactive, knowing your questions and doubts come from your own personal learning curve, rather than poor preparation. When an expert is watching you, it’s important not to let this go to waste.

Dr. Buchbinder added: “One of the things that I always tell my residents is that they need to show me that they know the steps of the operation. I have had residents with exceptional hands, but they expect me to tell them every step of the procedure. To me this is inadmissible and I kick them out of the OR no matter who they are. If somebody comes in and knows the various steps but just doesn’t know how to perform the operation, I am more than happy to help and teach them the ways of the procedure.

If you are a good surgeon, you need to have a plan B for everything, even a plan C and D. There is no time to start thinking once you are in the OR, it is very much like flying an airplane, you need to go through the checklist. I always make sure all the instruments I need are there because, under extreme situations, you cannot lose time looking for your instruments. It is essential to walk in the OR prepared for any situation.

It is an awful feeling to be holding pressure to control the bleeding while the nurse is running around to get the instrument you need. We always try not do any harm to the patients and we owe it to them to be prepared for any situation. Knowing what you need to do is really essential.

Finally, we asked both doctors: “In 10 years time, what do you think the operating room is going to be like?”

Dr.Khelemsky, said: “I think I see Surgery in a more continuous and accessible context, something that will lessen how fragmented today’s surgical training experience is. The recent advent of technology has already brought the ability to accurately record and share the OR experience with trainees. Sharing capabilities will evolve enabling surgeons from all around the world to discuss complicated cases openly. Alongside this, I foresee surgical simulation as a compulsory step in every resident’s training. Ideally, the patient will no longer be a part of their early learning curve. This will make novice residents feel more confident performing surgery since they have already rehearsed the cognitive components, which I argue are essential for meaningful learning using your hands and instruments. I hope that people will be able to easily rehearse difficult surgeries such as those with difficult anatomy before the actual procedure to minimize the chance of complications. That’s the future!

Dr.Buchbinder commented: “The way I see it, I think that technology is here to stay and it will play an even more important role even in the OR of the future. VR will be there and we will have so much more information available to us. The surgeons of the future will be making decisions based on previous cases. I really see a huge growth for technology in medicine and I think that in the same way Touch Surgery does, we will do a better job treating the patients thanks to the easy of access to multiple scenarios databases.”

Dr.Buchbinder is the Chief, Division of Oral and Maxillofacial Surgery and Professor of Oral, Maxillofacial Surgery and Otolaryngology at the Mount Sinai School of Medicine. He is also the Director of the residency training program in Oral, Maxillofacial Surgery at the Mount Sinai School of Medicine.

Renata Khelemsky, MD, DDS is a resident in the Oral & Maxillofacial Surgery training program of Mount Sinai Beth Israel


Originally published at www.touchsurgery.com on March 24, 2016.