Cara Cipriano MD, MSc, FAAOS | Bonnie Gregory, MD
August 10, 2022
So, you’ve finally made it: you’ve completed your residency and potentially fellowship, you’ve taken ABOS Part 1, and you’ve officially started practice. Maybe you’ve booked an elective case from clinic, or maybe it’s your first day taking call and you have an operative fracture. It’s time to do your first case as an attending – now what?
Your first case starts when you meet the patient in your clinic or ED. Although you might be eager to book your first surgery, it is important to spend ample time ensuring your indications are appropriate to proceed. This is where you lean on your training: get a good history and physical exam, review all imaging yourself (not the reports!), discuss expected surgical outcomes and details with the patient, and have a comprehensive conversation about risks, benefits, and alternatives. Make sure your notes document all the above; it’s not only important for your ABOS Part II case collection, but also for establishing good documentation habits early in practice. If possible, make the first case one that is routine; for example, a straightforward primary total joint replacement, carpal tunnel release, or ankle fracture. You will have enough to focus on navigating the new system without adding the challenge of a complex or unpredictable surgery.
Now that you’ve indicated your first case, it’s time to consider the next steps of scheduling your case and preparing the OR posting. It’s important to realize that you are no longer practicing in the system where you trained. The protocols, patterns, policies, and team that made those practices run efficiently may be different or not (yet) in place. Ideally, before leaving residency and fellowship you collected the case cards commonly used by your attendings to help you post for the appropriate trays. It can also be very helpful to take pictures of the trays and table set up of your attendings prior to leaving training; this will help your OR team prepare for your cases and help you move efficiently. However, your new hospital may not have the same instruments and trays you grew accustomed to in training, or they may go by different names. If possible, it’s a great idea to meet with the OR management and even sterile processing to see what is available before you book your first case. You may even want to open the necessary trays in advance to make sure the instruments are what you’re expecting. Lastly, schedule a light case load on your first day and allow ample time. There is no need to add stress to the day with time pressure.
In the days or weeks leading up to your first case take the time to fully prepare. Review the relevant anatomy and case notes from training; think about your table and room set-up and consider writing or drawing out all planned steps to the procedure, as well as pearls and pitfalls along the way. It’s also a great time to start thinking about your post-operative weight-bearing restrictions, pain control plan, and physical therapy protocols. Consider setting up a cadaver lab to practice in advance, particularly if the case is relatively complex or it’s been months since you’ve operated. Don’t hesitate to check in with trusted peers and mentors to run through your thought process and surgical steps. Finally, visualize or mentally rehearse the case from start to finish; this will boost your efficiency and confidence. Once you’ve prepared, try to get a good night’s rest the night before your case. At the same time, don’t stress if you have some difficulty sleeping, which can be common for your first months to years in practice.
When the day of your first surgery does arrive, try to get to the OR early, not only to introduce yourself to any operating room or perioperative staff who will be taking care of you patient, but also to confirm all the trays, equipment, and implants are ready for you. Getting there early will also allow you ample time to discuss anticipated surgical length, estimated blood loss, and any co-morbidities with your anesthesia team, as well as clarify any regional block or perioperative protocol you may be using. Additionally, being in the room early will help you set up any positioners or special table attachments you may be using, get the C-arm in the right location if using, and make sure your patient is positioned appropriately. This clearly demonstrates to your OR team that you are a team player in addition a leader. As you start your case, remember your role in setting the tone. The team will be looking to you for cues on what the culture of your OR will be, as well as what expectations you have for yourself and your team. Be respectful but clear about your requests and plans. Finally, take the scalpel and breathe – you have the skills, you know what to do. Take your time, go one step at a time, remember your training.
All of this will require much more time and effort than preparing for a comparable case in fellowship. Be patient and remind yourself that the better you can plan your initial cases upfront, the more smoothly they will go and the sooner you will build an efficient practice.
DISCLOSURES: Dr. Cipriano KCI: Paid consultant, Link Orthopaedics: Paid consultant, Musculoskeletal Tumor Society: Board or committee member Dr. Gregory This individual reported nothing to disclose
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