Julie, the pre-op nurse called me to the OR. “You've got to talk to her.”

I audibly sighed, thinking about the op notes, discharge orders, patient instructions, and consents I already needed to take care of. “Couldn't it wait for Dr. A? I am just the resident, you know…”

Julie shook her head. “We've got to get things moving. There are 10 more phacos (cataract surgeries) scheduled for this afternoon, and we're already running behind. It doesn't help that I've spent the last 20 minutes trying to convince her.”

“Convince her to do what?” I wondered aloud as I was logging into Epic.

“She's scheduled to have phaco on the right eye today and the left eye next week. But, she wants the left eye done today and the right eye next week.”

I sighed again. “Why?”

“No reason. I've spent the last 30 minutes trying to explain to her how big of a headache it is to change eyes. She just won't listen.”

Ah yes, the paperwork. As a resident, I was well acquainted with paperwork.

Over the past few months there had indeed been a proliferation of paperwork regarding which eye would have surgery. As with all paperwork and records, this was designed with good intent—to prevent wrong eye surgery. The surgical eye was recorded on 3 separate paper forms, 3 additional sites in Epic, written on the board in the OR, and 2 more places in the OR master schedule. All of these had to match up to ensure that there was no mistake. Changing them would require approval of the charge nurse, operating room coordinator, anesthesia, and the attending. Then the forms would have to be changed. And Epic. And the board. And the OR schedule. It would be my job to get the approval, and then Julie and I would each have to make some of the changes in the records. And all of this would take time.

Julie, ever efficient, said, “Well, I'm going to be working with my patient in bed 4. She is in bed 2.”

I scrolled through the record in Epic, searching for a reason that surgery had to be for the right eye today. I found none. We typically do cataract surgery for each eye about 1 week apart. Most surgeons do the worse eye first, but it really doesn't matter. I made my way to bed 2.

“Good morning Mrs. H.” As I smiled I felt like a used car salesman.

“It's got to be the left eye today,” she replied without hesitation.

“I was looking at your record. Dr. A noted that we would do the right eye first, and I think we should stick with that plan.”

“Well, when I was in clinic, I wanted the right eye first. But, I've been thinking and thinking about it, and now I want the left eye first.”

I sighed, a bit too loud. “Why?”

“Well, I think that I like to see at distance with my left eye better than my right eye. I'd rather be using my left eye for that week.”

That doesn't make sense. At all. Fortunately I didn't say that aloud.

“Well, Mrs. H,” I replied, still with my forced grin, “It doesn't really matter which eye we do first, because either eye will work well for distance. I really think that we should stick with the plan you made with Dr. A and do the right eye first.”

“Look, I want my left eye done today. And I want to talk to Dr. A about this if you won't change it.”

“He's still at lunch,” I appealed.

“Then go find him,” she said.

I walked out of the pre-op area. It felt like she was purposefully making my already difficult day more difficult. I looked up to see Dr. A walking down the hall. He was stooped, slightly kyphotic from many years of looking through an operating microscope, though his bright smile did not look tired.

“Hey, Brian, ready for some more surgery?” he greeted me enthusiastically. I have never met someone who loves cataract surgery so much.

“Well, Mrs. H is next on the schedule…”

“She's tough, huh?” he interrupted, reading my facial cues.

“Yeah. She's scheduled for right eye this week and left next week. But now, for no reason at all, she wants to switch.”

“Okay,” he replied. No hesitation.

“But!” I blurted in surprise. My first thought was the extra paperwork. Her request didn't make sense. In my mind, the only effect of switching eyes was to make my day more difficult.

He nodded knowingly, “It's okay, I know it's extra paperwork. And that makes it a lot harder to switch. I'm sorry. But, it's her eye. She's nervous. I'll talk to her about it.”

I went to do the paperwork. It took a few minutes, not nearly as long as I had predicted. I talked to Julie about switching. She was a little frustrated but smiled and said okay. We went on with the day, slightly behind schedule.

As I went home that night, the simple point Dr. A made stayed in my head. “It's her eye. She's nervous.” She wasn't just trying to ruin my day. Viewing the situation through my paperwork-centered perspective had kept me from seeing what was actually happening. Of course, she was trying to cope with her anxiety. After all, the surgery was for her.

A year later, I walked into the OR, an hour early. As a new attending, I still felt like it was important for me to be early. As I walked in, the pre-op nurse walked up.

“You've got to go talk to your patient in bed 7. He's scheduled for the left eye today and the right next week, but he wants us to do the right today. I've been trying to talk him out of it.”

“It's okay,” I reassured her. This time, I didn't hesitate. “I'll start the paperwork now. It's his eye; he makes the decisions.”