Comparisons between elite surgeons and elite athletes have been made before. In both professions, a combination of physical talent, knowledge, intuition, grace under pressure, practice and preparation, and pursuit of mastery are common elements. Professional athletes optimize every modifiable factor they can in their sport, and this includes their choice of equipment and uniform. Advances in tennis rackets, golf clubs, swimsuits, and even running shoes have all positively affected the newest generation of athletes.
So what about anterior segment surgeons? When it comes to our OR attire, is there anything we can optimize to improve our performance? We don’t have too many choices. We wear a head covering (and, yes, there is a heated ongoing battle between bouffant caps and surgical caps, which prompted a recent study), mask, gloves, scrubs, and footwear. The first four items are usually chosen by the hospital or surgery center—but with our feet, we have options. We can express our individuality and perhaps even enhance our performance.
Athletes certainly choose their shoes based on comfort and function, but they also factor in fashion and individuality. The same holds true for surgeons. High-volume cataract surgeons are constantly on the move from OR suite to OR suite, to preop holding area, and to postop recovery. Our shoes, as part of our attire, must be comfortable yet portray professionalism. Most importantly, we must have function and protection from the OR environment. Finally, as premium refractive surgeons, with a focus on the patient experience, looking the part is also important.
I polled about 50 leading anterior segment surgeons (CEDARS/ASPENS members) about what they wear on their feet during phaco surgery. Of the 41 who responded, 68% of surgeons prefer to work the pedals in their socks, and 22%, with OR-specific shoes. The few exceptions preferred disposable shoe covers over their socks or foot covers over their street shoes (Figure 1).
We cataract surgeons must utilize two foot pedals simultaneously. The microscope pedal (Figure 2A) can have 10 different foot-controlled push buttons and rocker switches plus a joystick. The phaco foot pedal can be depressed through three different modes, kicked to the side, or yawed and allows for four or more programmable side push buttons (Figure 2B).
Feeling the foot pedal is of utmost importance to surgical success. A surgeon’s foot proprioception of the different buttons and controls must be optimized, as does the ability to seamlessly toggle through and operate them by feel.
Sock-wearing surgeons argue that nothing permits as good a sense of the pedals as their socked foot. Shoe-wearing surgeons counter that they like the protection of shoes.
In my survey, most sock-operating surgeons wear clog type footwear in between cases, citing the good support, ease of slipping on and off, and good traction on wet OR floors. Some of the surgeons listed Crocs brand as their favorite; a few voted for Dansko, Merrill, Ugg, and Native. Alice Epitropoulos, MD, prefers Danskos, as she says, “They have good arch support and are very breathable, so you can take off your shoes without clearing out the entire surgical floor.”
Of the sock-wearing surgeons, most wore regular socks, but some opted for water socks, padded socks, or shoe covers over their socks. In the name of fashion, Mitchell Jackson, MD, prefers socks “with a theme that matches my surgical cap, ie, Cubs, Blackhawks, or superhero-themed, such as the Dark Knight.” He is known as DJMJ for a reason and has his brand to promote.
In the shoe-wearing camp, Audrey Talley Rostov, MD, prefers ballet slippers (Figure 3). “They are thin enough to provide tactile sensation but prevent your feet from getting wet and from stepping on sharp objects,” she wrote. Kathryn Hatch, MD, who prefers thin-soled minimalist shoes, explained her vote: “I don’t take my shoes off to drive; why should I in the OR?” Cathleen McCabe, MD, prefers her Vibram five-finger shoes, as they “give the feel and control of a sock without the need to be removed each case” (Figure 4).
I’ve been on both sides of the issue. As a resident and for my early years as an attending, I always slipped off my clogs once seated in the OR and operated the foot pedals in my socks. The traditional sneakers I had tried didn’t allow me to feel or operate the controls well enough. However, a few incidents made me look for an alternative. There were the rare cases where a suture needle flew off the field and had to be searched for on the floor. Also, the occasional fluid spill from a loosely connected I/A or phaco probe could make the floor and pedals wet.
Meanwhile, in the running world, a barefoot versus sneaker debate ensued after the 2010 publication of Born to Run, a book about a barefoot tribe that ran long distances without ill effect. This prompted Vibram and other footwear companies to release and promote minimalist running shoes, which purportedly maintained the benefits of barefoot running with the added protection and comfort of sneakers.
I tried on a variety of minimalist sneakers and settled on the New Balance Minimus (Figure 5). This shoe, like many others of its type, has characteristics that make it quite favorable to the cataract surgeon: a very thin protective sole, a minimal heel-to-toe drop, and flexibility allowing the shoe to fold from heel to toe. Most importantly, this minimalist sneaker allows for proprioception of the pedals, is comfortable, keeps my socks dry, and I’m told they look good. I keep both a yellow and a red OR-only pair at different surgery centers, and patients frequently comment on them ... um, mostly positively.