If a surgeon operates enough times, complications will be encountered—it is unavoidable. That is not to say that care should not always be taken to avoid them, but rather sometimes circumstances are out of our control. Other times, a surgical mishap leaves the patient with an obvious complication such as facial nerve injury or vertigo due to a lateral canal fistula. In those cases, it is most important to recognize the problem intraoperatively and treat it at that time rather than later. If the facial nerve is injured during surgery, specific treatment should take place at that time. If the labyrinth is inadvertently entered, repair is necessary at that time. Once the complication occurs and is treated, the surgeon must explain the condition to the patient and the family. That discussion can be as difficult as any conversation in medicine. The surgeon must present the facts without assigning blame, which can be delicate as well as challenging. The best way to present the case is to be straightforward and discuss what is current and relevant, not to circumvent the situation or try to deflect responsibility. On the other hand, it is paramount not to apologize or admit to a surgical error. Situations arise that happen in an instant, and before you know it the damage is done. Surgeons are not perfect technicians. If a surgeon experiences repeated complications, then an assessment of some kind must be done to ensure patient safety. Ideally, the surgeon will realize that limitations in practice are not a sign of ineptitude, but instead are an honest appraisal of personal strengths and weaknesses. If a surgeon refuses to evaluate results, lawsuits or complaints may render the final answer on what a surgeon does or does not do.

With experience, most surgeons identify what operative procedures make sense in their practices.

For some, chronic ear disease becomes their forte. Others may become proficient in otosclerosis surgery. Some may find that skull base surgery and treating complicated tumors of the temporal bone is their calling. With neurotology fellowships now 2 years in length and often oriented toward steering fellows into academic careers, opportunities exist and will continue to be available for otolaryngologists to develop strong otologic private practices. In fact, otolaryngologists will necessarily perform many of the otologic cases in the future. Thus, it is important to identify surgical strengths and incorporate them into your practice. In large groups, neurotologists may be hired. There may be situations where one or two of the associates have an interest in otology and eventually become otologists for the group by default.

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