Module 5: Guidelines for Observing and Assisting Doctors

In The Operating Room

At this, the start of your surgical internship, it is well that you be told how to behave in an operating room. You cannot observe decorum unless you first know what decorum is. Say that you have already changed into a scrub suit, donned cap, mask and shoe covers. You have scrubbed your hands and been helped into your gown and gloves. Now stand out of the way. Eventually, your presence will be noticed by the surgeon, who will motion you to take up a position at the table. Surgery is not one of the polite arts... The first rule of conversation in the operating room is silence.”(1)

It is important to be respectful, professional, and quiet at all times when observing surgery. Even if you have previously been granted permission, you must ask the operating surgeon if you may enter the operating room.  The medical staff or the supervising doctor will show you how to dress if special attire is required (e.g. scrubs, sterile gowns, gloves, masks, head or shoe covers.) Be sure not to wear excessive jewelry, make-up, or perfume, and be careful not to touch anything in the operating room.

While watching an operation, you will likely have questions about what you are seeing. Remember that for you, “the first rule of conversation in the operating room is silence.” This rule holds even if the surgeon is speaking to you about what he is doing. Although in the past you have likely been encouraged to actively ask questions of your teachers, in this case you must reserve your questions until the operation is complete so as not to disturb the surgeon or the patient.

Eye surgeries are typically performed while the patient is awake, so patients will be able to observe you in the operating room. When surgical patients hear people talking around them, they may assume the conversation is about them, especially if they cannot understand English. It is thus especially important not to laugh, smile, chat, banter, or joke with others in the operating room. This behavior is disrupting to the patient and can damage patient-doctor trust. Surgery, no matter how minor, is risky, and the patient needs to be confident that the entire medical team is focused, serious and careful.

There are various accounts from the international medical community of surgical patients being talked about or ridiculed during their operations, particularly when they are thought to be unconscious.(2),(3) It should go without saying that such disrespectful behavior is never appropriate.

There are many things the surgeon may tell you to do while in the operating room. You must obey all of his or her requests, particularly if you are asked to leave. If you are asked to leave, do not be insulted; there could be concerns over sterility, too many people in the room, or the patient could simply have indicated discomfort with your presence. If you find yourself feeling queasy or uncomfortable, you should simply leave the room discreetly so as not to disturb the medical team. Once you leave the operating room, you may not reenter until you are told to do so.

Finally, Unite For Sight’s accounting protocol requires that both the operating surgeon and an observing Unite For Sight volunteer sign their name to confirm each surgery sponsored by Unite For Sight. While observing surgeries, you will be asked by the surgeon to sign your name to the list of patients. Be sure to sign your name after each surgery is completed, and be mindful of accurate accounting.

In The Clinic(4),(5),(6)

The protocol for observing a doctor examination is very similar to the protocol for observing surgeries, although the dress code may be different. When working in an overseas clinic, you are required to maintain professional appearance comparable to how you would appear while working at a hospital or doctor’s office in your home country. This means clothing should be clean, unwrinkled, conservative, and free of fraying or holes. Shoes should be close-toed. Personal grooming is also important; men should shave or properly groom their beards, women should wear minimal makeup, and both men and women must maintain proper hygiene.

When you are observing a doctor’s examination, as when you observe surgeries, you must remain silent. Be sensitive to patients’ privacy and comfort; avoid touching patients, and do not stare at “interesting” medical cases. Follow any directions given by the doctor without asking questions. If you are asked to leave, do so. Any questions you have about why you were asked to leave, as well as questions about the diagnosis or exam procedure, can wait until after the examination is complete. When you leave the exam room, a quiet speaking voice is essential to maintain patient confidentiality.

Just as you should be serious in the operating room, it is unprofessional to laugh, smile, or chat in the clinic. Refrain from holding personal conversations in front of patients, as this is unprofessional and may be misinterpreted. Gossiping about patients and/or their conditions is never appropriate, whether within earshot of patients or in private. Patient-doctor trust is of the utmost importance, and patients need to know you take their health concerns seriously.

With the Surgeon

The surgeries that you observe may be different than those you may have seen in your home country.  For example, cataract surgeons provide Phacoemulsification in the United States, whereas as a different procedure known as SICS (Small Incision Cataract Surgery) is performed in many quality clinics in developing countries.  SICS in particular is notable for its time- and cost-efficiency, making it an excellent option for cataract surgeries in developing countries.(7)(8) In contrast, Phacoemulsification machines are very expensive to purchase and to maintain, break easily and require maintenance that is often not an option in developing countries, and can result in more complications for the advanced, mature cataracts typical of patients in the developing world.(9)

It is important that those who are not surgeons do not criticize or negatively comment on the surgical facilities or practices in comparison to your home country. Dr. Aron Rose, Associate Clinical Professor of Ophthalmology at the Yale University School of Medicine, recounts:

"It was terrific to work with my Ghanaian counterparts.  I worked with two doctors...and I found both of them to be extraordinarily talented, extraordinary humanitarians, with boundless energy.  These are doctors who work enormous numbers of hours under difficult conditions, seeing an extraordinary array of pathology and a huge number of patients per day, their energy is tireless, their idealism is inspiring.  I was really quite amazed how their level of energy to carry out this level of work on a regular basis.  In addition, they had a wonderful sense of humor, and they were light with patients.  It is not easy being a doctor around very sick patients.  Patients look to you for a tremendous amount of support, and you alone realize what some of the risks are taking care of that patient, and they maintain an ability to do terrific level work at the same time as be a resource for strength among their patients, and I think that is an incredible combination. I was very, very impressed."(10)

Footnotes

(1) Selzer, R. “Letter to a Young Surgeon II.” In Selzer, R. Letters to a Young Doctor. New York: Simon and Schuster, 1982.

(2) Ziel, S.E. “Spectators in the OR – discussion of operating room nursing law.” 1997. AORN Journal. Accessed on 2 December 2008.

(3) “Two doctors, nurse, suspended over ‘YouTube rectum surgery scandal’ in Philippines.” 15 May 2008. www.fridae.com. Accessed on 2 December 2008.

(4) “Guidelines for Professionalism in the Clinical Setting.” University of Illinois at Chicago College of Medicine. Accessed on 2 December 2008.

(5) “Guidelines for Volunteers.” McLean Hospital. Accessed on 2 December 2008.

(6) “The Volunteer Handbook: Code of Conduct for Customer Service.” The University Hospital, UMDNJ. Accessed on 2 December 2008.

(7)Ruit, S., Tabin, G., Chang, D., Bajracharya, L., Kline, D.C., Richheimer, W., Shrestha, M., and Paudyal, G. “A Prospective Randomized Clinical Trial of Phacoemulsification vs. Manual Sutureless Small-Incision Extracapsular Cataract Surgery in Nepal.” American Journal of Ophthalmology. 143.1 (2007): 32-38. Accessed on 13 January 2009.

(8)Foster, A., Gilbert, C., and Johnson, G. “Changing patterns in global blindness: 1988-2008.” Community Eye Health. 21.67 (2008): 37-39. Accessed on 13 January 2009.

(9)Chang D.  "Tackling the greatest challenge in cataract surgery."  British Journal of Ophthalmology.  89.9.(2005): 1073-1074.  Accessed on 13 January 2009.

(10)"Dr. Aron Rose: Volunteering Abroad." Uniteforsight.org.