BACK TO PAGE ONE

Residency is like a roller-coaster ride, with intense highs and dramatic lows. There are the short-term fluctuations, measured in moments: making a correct diagnosis of a rare entity is fantastic; completing a successful operation makes you feel like you’re on the top of the world; a surgical complication makes you wonder what you’re doing there with a scalpel in your hand; and answer incorrectly to a supervisor’s question and you feel like you don’t belong. All of these things can happen within one day.

And then there are the long-term variations that are built into the rotations from one sub-specialty to the next. As each four-month rotation comes to a close, I have the feeling that I know what I am doing. I'm able to see patients without making people wait for an hour in the waiting room. The advice I seek from my supervisors becomes less frequent, and my questions sound more knowledgeable. When assisting in the operating room, I feel like an asset, rather than a burden. During Grand Rounds, I take the time to research and present an interesting case or two and hopefully initiate a discussion on a tricky topic. I generally have the feeling that I have a certain understanding of the topic and overall, I'm feeling pretty good about my knowledge, my abilities and myself.

And when the rotation ends, this feeling of competence seems to spill over into the next rotation. Although I am aware of my limited knowledge of this new sub-specialty, I seem to view my expertise through a rosy mist of self-assurance generated during the previous rotation. Glaucoma: Sure, no problem. What’s the IOP? Too high? Prescribe a drop and see the patient in three months. Surgical retina: Simple! If the retina is detached, operate; if not, do nothing. Medical retina: Is there bleeding? Oedema? Occlusion? Start up the laser and fire away, and if that does not work, inject anti-VEGF. Cataract? That sounds too easy to discuss.

The right questions

And then I step into the role of sub-specialist and realise that I know very little, at least in terms of practical, executive knowledge. I am back to page one. Sure, I have read the literature and I know what the pathology should look like. But successfully playing the role of subspecialist is more than just knowing what is in the books. It involves asking the right questions, noticing subtle abnormalities and recognising variants of the norm. After the first half-day clinic, my confidence has been severely, and justifiably, diminished; any previously developed feelings of aptitude and even usefulness have totally disappeared.

And yet, in the clinic, residents are often the first doctors the patient sees. Their trusted general ophthalmologist, often a doctor who they have known for many years, or even decades, has referred them. Those eye docs, some of whom started practising before I was even born, have in these cases decided that, with this particular patient, they have reached the limit of their own sub-specialty knowledge and need to entrust their patient to the care of a tertiary referral centre. And there I am, on the first week of my rotation, still trying to figure out what I need to know to come to some sort of an intelligent conclusion.

This feeling was particularly acute at the start of my glaucoma rotation. The glaucoma specialists each have about 25 years of experience. The fellows had been seeing exclusively glaucoma patients for the past 12 months. And then there was me. I had read a book or two on glaucoma, treated a few cases of angle closure in the emergency room and referred many a patient with excavated optic discs to the glaucoma clinic. Needless to say, I felt under-qualified.

So, on my first day, with my first patient, I started out simply, with a family history. The patient had been referred to the glaucoma clinic, but he evidently had not been told too many details: I asked him, “Does anyone in your family have glaucoma?” “Pardon?” Keep it simple, I thought. “Do any of your relatives have eye disease?” “Yes, almost all of them.” OK, I though to myself, now we’re getting somewhere. “Really?” I answer, “Which disease? What kind of problems do they have?” “We all wear glasses. We’re practically blind without them.”

Oh no, I thought, back to square one. I had started a whole line of conversation that was clearly going nowhere. Time to backtrack. “Did they have to use eye drops?” “No, not that I know of.” I moved on. I asked about his personal history, according to what I had heard the glaucoma specialists ask patients, like whether they scuba-dive, play horn instruments, or regularly stand on their heads while practising yoga. That line of questioning, I later realised, makes patients wonder whether you’re serious or joking.

I moved on to more familiar territory: refraction, visual acuity, cornea, anterior chamber, iris, gonioscopy, lens and optic nerve. Other than a glaucomatous optic nerve, I found no abnormalities. Primary open-angle glaucoma, I wrote. Great, a first diagnosis!

I walked to the supervisor and presented my first case with confidence. At the end of my case presentation, he looked at me, expecting more. “That’s it,” I said. “But what’s the IOP?” he asked.

I practically disintegrated from embarrassment. Just a week earlier I had been doing multiple solo strabismus operations per day. Now I had examined my first glaucoma patient and forgotten to measure the intraocular pressure. The roller-coaster never stops.