The integration of efficiency concepts in our practice has beneficial implications beyond patient care. J. Fernando Arevalo, MD, FACS, is an internationally renowned retina surgeon who has incorporated the ambulatory surgery center (ASC) as part of his practice to improve his both his professional and personal worlds. In this column, he elegantly details how ASC efficiencies can be leveraged to provide better patient care, be more productive, and improve the surgeon's quality of life. To boot, when managed properly, the ASC can also be a profitable investment. It is indeed rare to find such a win-win-win endeavor.

-Pravin U. Dugel, MD

Like many retina surgeons, I maintain a hectic schedule. I made the decision many years ago that in addition to practicing retina and performing surgeries, I also wanted to devote a portion of my time to research. As many like myself can tell you, this is a daunting but not impossible task. The key components that I have found to be helpful in balancing my clinical practice with research and spending time with my family include prioritizing, working efficiently, and putting family first.

PRACTICE AND RESEARCH PROFILE
The Clínica Oftalmológica Centro Caracas contains a 250-square-meter ambulatory surgery center (ASC) facility with one OR, one pre-post surgical room, five examination suites, one laser room, and two ancillary tests rooms. The OR is equipped for general anesthesia to be performed in children or uncooperative adults. The staff is comprised of an administrator, two secretaries, three nurses, an anesthesiologist, two retina fellows, and cleaning personnel. We perform vitreoretinal surgery twice a week (Tuesdays and Thursdays), dedicating the ASC to anterior segment surgery for the remainder of the week. Every vitreoretinal surgical day we include four to five cases, for a total of eight to 10 cases per week or approximately 30 to 40 cases per month. In 1 year, we perform approximately 300 to 400 vitreoretinal procedures. This is taking into account the weeks that I am away and that I make up for these off times upon my return. When I am in town for 2 weeks in a row, everything levels up to normal.

I am also a member of the Pan-American Collaborative Retina Study Group (PACORES). PACORES is currently working on 23 different protocols, both medical retina topics including age-related macular degeneration and diabetic macular edema, and vitreoretinal surgery including the use of vital dyes in macular hole and epiretinal membrane surgery. Several of theses projects are now in the manuscript phase, and I participate in that writing committee.

I collaborate with many colleagues around the globe on different projects and am currently working on two new books—one in Spanish titled Diabetic Retinopathy, sponsored by the Pan-American Association of Ophthalmology and one in English titled Retinal and Choroidal Manifestations of Selected Systemic Diseases, which will be published by Springer.

My lecturing commitments in 2010 alone have taken me to 16 international locations in the United States, Brazil, Peru, Germany, Italy, Costa Rica, Canada, Ecuador, Japan, and Iran. It is rare that I attend a medical conference without giving at least one presentation.

PRIORITIZE YOUR RESPONSIBILITIES
Although it is difficult to prioritize at times, when a surgeon has a busy schedule, it is critical. I try to limit my travel to no more than twice a month (and when possible, once a month). When I am in Caracas, my days are filled to capacity seeing patients and fulfilling teaching and research commitments with my retina fellows. I see many patients who have few financial resources at the Arevalo-Coutinho Foundation for Research in Ophthalmology (which was founded in 2001 to honor my father, a pediatric ophthalmologist).

Monday through Thursday I begin my day at 7:30 am with fellows' reviews of retina topics and finish at 7:30 pm. Fridays are dedicated to research activities. When I am not traveling, I have my weekends free while my retina fellows are on call.

MAINTAIN AN EFFICIENT ASC
Our ASC has a special entrance for surgical patients; therefore on a surgical day everything seems calmer to them than on a usually hectic clinic day. When a patient arrives for surgery, a nurse is dedicated to ensuring a pleasant experience.

We have learned that preparing patients well in advance of surgery increases our overall efficiency. Patients, who are scheduled an hour apart throughout a surgical day, arrive 1 hour prior to the surgery time and are prepped in the pre-post surgery room. Additionally, I maintain an office at the ASC so that I can work on my research papers between cases in the event of a delay. Our administrative offices are also onsite at the ASC, so if there are issues that I must deal with there, I am able to do so in between cases.

In terms of staff efficiency, we have a well-practiced, systematic approach. A nurse guides the patient through the process and dilates the pupil. A second nurse in the OR monitors the case to estimate the time of completion of the current case. If we are close to completion, the anesthesiologist, who is always present, or the retina fellow administers a peribulbar block to the patient in the pre-post surgical room while we are still in surgery. In a smooth series of cases, I can go from one to the other with a break to talk to the family of the patient about the case and necessary follow-up. After 5 to 10 minutes of consultation, I return to the OR for the next case.

Tips regarding efficiency include the following:

• Employ sufficient staff to help the patient every step of the way.

• Have a nurse on staff who is specialized in making sure you always have easy access to the materials and resources you use—and one who can ensure that your equipment is in good condition at all times. This individual must be in constant communication with the administrative office and have the power to order supplies as needed.

• Make an effort to have your clinic, research office, and ASC under one roof so that you need not waste time traveling from one facility to the other.

DO NOT FORGET YOUR OTHER LIFE
Of course, a person's personal life is a key component for obvious reasons. Maintaining a healthy balance between professional and personal activities will also help the surgeon to perform his or her best on the job. I balance my time through organization. I work at one facility so that I do not need to travel and lose time sitting in the world-famous traffic of Caracas. In addition, working in one location allows me to easily multitask. Because of my professional organization, I still have time to enjoy my family at night, on weekends, and when we travel together. When I am home, I am always there for my family and willing to stop anything that I am doing if they need me. When I am not home, I keep always in touch and never forget that I have a wonderful and reliable family who understand that everything I do is also for them.

J. Fernando Arevalo, MD, FACS, is with the Retina and Vitreous Service, Clinica Oftalmológica Centro Caracas, Caracas, Venezuela. Dr. Arevalo is a Retina Today Editorial Board member. Dr. Arevalo may be reached at +1 58 212 576 8687; fax: +1 58 212 576 8815; or e-mail at arevalojf2020@gmail.com.

Pravin U. Dugel, MD, is Managing Partner of Retinal Consultants of Arizona and Founding Member of the Spectra Eye Institute. He is a Retina Today Editorial Board member. He can be reached via e-mail at pdugel@gmail.com.