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The numbers game


Optimal performance has a limited window.

“Life is a game. He who dies with the most toys wins.” – unattributed proverb ridiculing people who compulsively pursue accumulation of material possessions.

When I was a young corneal surgeon recently out of fellowship, my belief was that the best way to put my training to use was to perform as many surgeries as possible on as many people as possible, allowing them to see better and live better lives. Sort of like the quote above, but with corneal transplants and cataract extractions instead of sports cars and yachts.

From time to time when we would decide to schedule surgery, a patient would ask me how many of these surgeries I had done already, or they would encourage me to be sure and get a good night’s sleep the night before. But one day a patient who had been referred to me for a corneal transplant asked me something I had never been asked before. “How many of these surgeries do you perform in a typical day?” he inquired. I think my answer was “about 8.” He responded: “Then, please make mine your third operation.”

I was intrigued. This person was a very intelligent and successful entrepreneur but had no medical background. “I am happy to put you third on the schedule. But please tell me why you want that,” I said.

He explained. “When you first start operating that day, I figure you will be warming up, because you haven’t operated for a couple of days. By the time you finish operating on eye No. 2, I figure you will really be in the swing of things. But by the time you get to eyes 7 and 8, I think it is only natural that you might start getting a bit tired. So I think being third or fourth in the sequence would be optimal.”

“That’s a very interesting analysis,” I said, smiling. 

Everything went well with this gentleman’s operation, and I have never heard of anyone doing a study to see if the order of surgical procedures is an important variable contributing to surgical outcomes. I do know some surgeons who place patients at the end of the day who they think might be at higher risk for complications (due to something like pseudoexfoliation syndrome or a bad outcome in the fellow eye).

I thought of this patient recently when recently I heard an interview with Nobel Laureate Eugene F. Fama.

According to Fama, a professor of economics at Tthe University of Chicago Booth School of Business, one can only optimally perform work that requires careful thought for four hours per day. After that, he thinks, quality suffers. Is that right? If so, what does that portend for patients who are being operated upon towards the end of an 8- hour day in the operating room? 

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Doctor Esen Akpeck from the Wilmer Eye Institute, Johns Hopkins University School of Medicine.
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