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Online Exclusive | Mar/Apr '22

Three (and a Half) Steps to Expanding Your Armamentarium

Getting from an N of 1 to confidence.

Think back to your first cataract surgery and how you felt. If you are like most, I bet you felt a combination of excitement, nervousness, and optimism as you embarked on this rite of passage in ophthalmology. Recently, the same constellation of feelings hit me while I was sitting in a surgical training session in preparation for an emerging retinal device and served as a reminder that we will all continue to encounter situational firsts far beyond residency. 


Before we talk about how to optimize your performance and confidence when facing an unfamiliar clinical or surgical scenario, we should first address the “why.” One of my wise mentors used to say, “If you’re still doing things the way I taught you 10 years later, then I’ve failed you as a teacher and you’ve failed me as a student.” Reasons why it is critical to continue expanding your armamentarium over your entire career include: (1) techniques, instruments, and standards of care evolve, 2) a versatile skillset can be a practice and reputation builder, (3) continual learning keeps your career stimulating, and (4) one size does not fit all in patient care. To the latter point, the best surgical technique for a large chronic macular hole may not be the best one to use for a smaller acute one. Being able to tailor your approach optimizes patient outcomes.


Whether it’s a new technique, approach, imaging modality, drug, or device, you cannot utilize it without knowing about it first. Once you have developed awareness, critically evaluate any associated data while keeping in mind that new does not always mean better. Read the literature; peer-reviewed journals are obvious sources, but I find non–peer-reviewed publications to be extremely valuable, as they are often the first to discuss upcoming technologies. Utilizing online resources, attending meetings, joining forums, and interacting with mentors and friends will also help you stay at the forefront of our field.


Everyone has an N of 1 at some point, so if you use inexperience as an excuse for not trying something new, you will never try anything new. At the same time, do right for your patients by being the most prepared you can possibly be. Read everything you can find on the topic. Watch surgical videos. Talk to colleagues who are experienced with the product or technique so that you can glean pearls and learn from their past fumbles. Practice if feasible: Model eyes, wet labs, and simulation machines are fantastic if you have access. Regardless of whether you get hands-on practice beforehand, performing mental surgery is a must. Many people think through the steps assuming a straightforward surgery, but take that one step further and consider all the what ifs. Finally, check in advance that all the instruments and supplies you need in the OR are ready to go.  


The final step is to get a good night’s rest and execute! I advise not straying from your usual routines.  For me, that means waking up at my regular time, not working out my upper body the day before, avoiding caffeine the morning of, and operating out of my normal OR room. While operating, I silence my phone and minimize any other potential distractions. Record all your surgeries if possible. If anything unexpected occurs intraoperatively, stay calm and take a moment to pause and figure out next steps. Take notes immediately afterward about what went well and what did not. Compare these notes with the postoperative follow-up so that you can connect your actions with their consequences. Review your videos critically, preferably with others. Don’t hide your struggles; share them and solicit advice from others. Lastly, teach others how to do it better—write an article, publish a video, or deliver a podium talk—and I promise that this will also enhance your own learning. 


Remember that, of all the skills you have, none is more valuable in your career than the desire for perpetual self-improvement. Continually expanding your armamentarium is an important part of this growth, and the same principle extends beyond the clinic and OR to other facets of your career, such as leadership and research. By following these steps (Figure 1)—Know, Prepare, Do (Refine)—your ever-expanding armamentarium will fuel a rewarding career of lifelong learning. Enjoy the ride. 

Figure. Three steps to expanding your armamentarium.

Christina Y. Weng, MD, MBA
  • Associate Professor of Ophthalmology and Fellowship Program Director, Vitreoretinal Diseases & Surgery, Baylor College of Medicine, Houston
  • Director, Medical Student Clinical Elective-Ben Taub General Hospital, Houston
  • weng@bcm.edu
  • Financial disclosure: Consultant (Alcon, Alimera Sciences, Allergan/AbbVie, DORC, Genentech, Novartis, Regeneron, Regenxbio)
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