Stephen Lash Eye Surgery

Improving Surgical Skills and Outcomes: A Multi-Perspective Approach

Due for publication July 2024

I am pleased to announce the publication of my Book in July 2024. This section will have updates from time to time and some links/ previews and thought provoking comments that will make more sense when the book is published.

It all started over a surgical debrief with two fellows over coffee. Following our usual interaction they said "You should write a book about this!" So, with a slow start, I did. Here are their reviews of the book.

"What started as a suggestion by Mohamed and I while sipping on decaffeinated coffee (trust me, Steve does not need any caffeine!) during our casual reflection meeting at the end of another hectic surgical morning, came to light as an outstanding book which is crucial to everyone who is involved in training or learning a new skill, especially if this skill involves dealing with the human life!Steve, with years of experience under his belt in training eye surgeons from different parts of the world, has elegantly put together his doctrine of doing so ( and I reassure you he is very good at it ). The way he illustrates, compares and reflects on the training process sheds light on new areas which few writers did before him. As his ex-fellow, I can‘t recommend this book enough to everyone considering training in surgery, in training or training others, this book is an eye opening message to them all.

As the Latin proverb once stated "by teaching, we learn” this summarises what this book is all about."

Mr Haytham Rezq, MSc, ICO, FRCS

Consultant Ophthalmic Surgeon and Vitreo-Retinal Specialist

In the realm of surgical excellence, where skill meets artistry, and precision intertwines with practice, we often find ourselves navigating the vast landscape of medical literature in search of guidance. Yet, there exists a distinct void, a gap in understanding that transcends the boundaries of technical prowess and scientific rigor. "Improving Surgical Skills and Outcomes: A Multi-Perspective Approach" is a profound exploration of this elusive realm, authored by one of my distinguished mentors, a virtuoso of ophthalmic vitreoretinal surgery, excellent teacher and a team leader armed with an MBA degree. In an era where specialization reigns, this book takes a unique path, focusing not on the minutiae of subspecialties but on the holistic journey towards becoming a better surgeon. It dares to venture into the softer, more contemplative dimensions of surgery. It is not a manual for surgical manoeuvres but a profound discussion on the intricate thought processes that underpin those manoeuvres. The author introduces surgery as an art that must be honed within the theater of our minds and the operating theater itself. The book is written in dialogue style fostering critical and original thinking. While the book primarily targets ophthalmologists, its wisdom extends its reach to all surgeons. It sheds light on the often unnoticed challenges that we face in the operating room, guiding surgeons toward enhanced performance and efficiency. I find this book an invitation to explore the nuances, the mysteries, and the subtleties that elevatea good surgeon to a great one. It is a testament to the collaborative spirit of medicine and management, embodying the shared wisdom of a seasoned surgeon with extensive management experience and I acknowledge his generosity in sharing his expertise within these pages.

Mohamed Elnaggar, MD, FRCS

Vitreoretinal and Ophthalmic Surgeon

London 2023

Having qualified in medicine in 1982, and spent the last 38 years of my working life in a variety of surgical specialties, I have witnessed the somewhat haphazard way we are taught (or more frequently not taught) the myriad of skills required to work safely and effectively as a surgeon. There are endless books about surgical technique, but a woeful lack of information on how to be a surgeon.

In his book, Steve covers a variety of apparently disparate topics, which come together to help surgeons learn, operate safely, practice efficiently and teach. I am aware of no other publication, journal or professional course which covers this range in such depth. Once aware, I believe surgical trainers and educationalists will come to view these topics as core knowledge. 

I believe this is an important and much-needed step forward in surgery, and I highly recommend it.

Mr Andrew Luff MA, MBBS, FRCS, FRCOphth

Consultant Vitreoretinal surgeon


Improving Surgical Skills and Outcomes: A Multi-Perspective Approach


Since my earliest memories of surgery, I have found myself asking this question, what makes a good surgeon? It has fascinated me mostly because I always wanted to be a good surgeon and it occurred to me that I might be more likely to become one if I had some idea of what one was in the first place! If we can discover what makes a good surgeon then this opens up the possibilities of trying to become a great surgeon, or at least to get better. The quip most commonly heard is that “They have good hands”. This does not really do the question justice and certainly leaves little scope for improvement beyond nail care and regular moisturiser.
This book represents thoughts formed over my 25 years as an eye surgeon, reflecting on my own practice and, in teaching others, reflecting on others. It is also heavily influenced and perhaps unlocked by my MBA which enabled me to become more comfortable intellectually walking on sand rather than concrete. I have limited the perspectives to ‘three boxes’ but there will be others. You can view the boxes as frames to look through or boundaries to think within but each one sits within and is influenced by the others. It’s hard to think outside all the boxes!
Picture a surgeon in theatre sitting at the table surrounded by staff and stuff, lights and laminar flow. Box 1 is what is experienced in the surgical field in the moment of surgery, it is about dealing with stress and performing at the highest level, it is ‘How’ we do surgery. I will look at Sports Psychology and Elite Athletes and apply the techniques to surgery. I will look at airline pilots and explore simulators and assess their utility in our quest to become good surgeons and finally look at musicians and virtuosos and ask the question ‘are we aiming high enough as surgeons?’ Are there virtuosos in surgery or just primma donnas?
Box 2 sits around the surgeon’s head and is the organisation and planning of surgery, it’s the ‘What’ we do of surgery.  I will explore Toyota car manufacturing and apply ‘Lean’ processes to surgery. Can we eliminate muda and pursue Kaizen? I also explore why we might not embrace ‘Lean’ looking at locus of control and exploring failure through the ages. Why is failure so hard and yet so useful and why is this the worst time in history to fail?
Box 3 is the theatre the surgeon is sitting in and the air they breathe. This is the least conscious of the three boxes and asks the ‘Why’ of surgery. It is the influence of decision making, heuristics and finally personality. It is perhaps the most powerful in terms of influence on the practice of surgery and yet the least seen, like the tiny rudder on a huge ship sitting beneath the surface.
My hope is that in exploring surgery in these three boxes anyone involved in surgery, from Podiatry and Dentistry on the high street to Neurosurgery and ophthalmology in specialist units, might benefit. I hope to stimulate ideas and thoughts and potential directions of travel that would lead the surgeon ever upward towards better surgery. It may also appeal to anyone interested in this particular breed of human willing to cut another in the pursuit of wholeness. 
Stephen Lash

In 'Box 1" I look at what happens in the surgical field and draw on Sports Psychology and elite athletes. I then move on to simulators and airline pilots and finally musicians and the concept of virtuosity and ask the question- are we aiming high enough as surgeons? I discuss the role of surgical simulators as a tool for practice but find significant limitations. As part of wrting this chapter I decided to pick up the guitar again after 35 years and try to learn something new and complex and found this this guitar solo by Nuno Bettencourt of 'Extreme'. The process of learning something new was fascinating and I have applied various elements to the practice of surgery. It took several weeks and was painfully slow! I just wish we could all 'practice' surgery like we cana musical instrument!

Below I will release some of the questions I attempt to answer in the book.

BOX 1- Questions

Can you 'borrow confidence' from your consultant? 

How does that affect your surgery?

What does the Catastrophe model indicate? 

What interventions does the model suggest? 

How might imagery improve your surgery? 

How can you introduce goal setting theory into your surgery and what benfits might it deliver? 

BOX 2- Questions 

Is this the worst time in history to fail? 

Is the culture within medicine an obstacle to embracing failure as opposed to the culture in the airline industry?

Are you treating the patient or yourself in order to avoid failure?

BOX 3- Questions

Is there a surgical personality? There is! Do you have it? Does this matter?

How does the availability heuristic interfere with your surgery?

What do Speed Cubers have in common with experienced surgeons?