Not long ago, Review of Optometry invited new optometrists who completed residency training to submit an essay contemplating, “What has your residency taught you?”
I had the honor of reading the submissions and the burden of selecting the best five. The essays that follow share diverse experiences, mostly about rising to challenges and personal growth. (Yet one essay describes a wasted year without lasting benefit.) Whether or not you did formal post-graduate training yourself, you’ll learn something from each of these essays.
Today there are more than 150 optometric residency programs accredited by the Accreditation Council on Optometric Education (ACOE), with more than 300 approved positions. In effect, more than 20% of new optometrists now partake in residency.
From the broad perspective, optometric residencies continue to elevate our profession in ways that can’t always be measured. On an individual level, those completing residencies usually say that they gained a more secure footing, both personally and professionally, for their road ahead.
What Hasn’t My Residency Taught Me?
Jordan Keith, O.D.
Assistant Professor of Optometry, Illinois College of Optometry
Like most students, I went into optometry to be the best possible eye doctor for my patients. However, despite excellent training at Pacific University, I found myself wondering if optometry school alone was enough to achieve that. With the overwhelming support from faculty, I applied for residencies, and I’m thankful I did. My experience impacted me deeply.
So, rather than asking “What has your residency taught you?” the more appropriate question should be, “What hasn’t my residency taught me?”
Months after graduation, I started my residency at the Kansas City VA Medical Center, directed by Tim Harkins, O.D. I’ll never forget my interview when he told me, “This is a very foolish decision financially to do a residency; you will miss out on about $60,000. My job is to give you $60,000 worth of education and make this the best decision you have ever made.”
Despite doing well in optometry school, I was nervous my clinical skills and knowledge base were not fully developed enough to be on my own—a common feeling among new graduates. Dr. Harkin quickly relieved those fears early on by telling the residents, “I’m not worried about what you know now; if you knew it all you wouldn’t be here. I care most about what you know when you leave.”
I had no idea how much I would change in just one year.
Every morning before clinic, Dr. Harkin led a discussion about ocular diseases. These discussions were engaging, insightful, relaxed, thoughtful and fun. We thoroughly investigated a topic, delving into details and nuances I didn’t even know existed. We asked questions, reviewed photos and test results, discussed strategies, and went home every day with a carefully designed question to think about. Dr. Harkin is truly a gifted teacher who teaches by asking questions.
Every day I was seeing interesting cases and making my own decisions, but I was also having meaningful conversations about them. Suddenly, confusing concepts became clear. I made mistakes, but learned how to avoid making them again. I gained the motivation to study about patients with the same urgency that I did for a final or a board exam, only now the content was entirely clinically based.
While in optometry school, evidence-based medicine was something that had intimidating statistics I didn’t understand, and I had no idea the importance it held clinically. It was hard to incorporate that level of understanding when there were many basic tasks I was still trying to master. Now it seems difficult to imagine practicing without it.
Evidence-based medicine armed me with justification for my decisions. I learned what questions I should ask myself to find the right answers, how to question what I am reading to decipher high-quality evidence from conjecture, opinion or bias, and how to apply that information properly. I became an independent, self-motivated, lifelong learner.
Before my residency, if you would have asked me what makes an excellent doctor, I probably would have cited characteristics like knowledge and experience. We all took an oath to care for our patients through compassion, caring, empathy and selflessness—but how do you study how to do this?
We had weekly readings and group discussions about the humanitarian and/or artistic aspects of doctoring. We dissected every aspect of our exam down to each word we used, thinking about how a patient might interpret it. In one of our patient education discussions, Dr. Harkin asked, “If you found a malignant melanoma in your next patient, have you thought about how you would deliver that news? What words you would use?” He emphasized not only generating a management philosophy (based on evidence, if possible) of all conditions likely to be encountered, but also practicing patient education outside of clinic so that when that time comes, important information can be delivered clearly, concisely and compassionately.
Practice patient education? Yes!
I am now much more reflective in the decisions I make, contemplating how they impact the care I give to my patients.
Everything I do as an optometrist has been influenced by my residency, from how I interact with patients to my job decision. It helped me answer Dr. Harkin’s questions, “What impact do I want to make with this chosen career? What will truly bring satisfaction day in and day out? And when I look back on my career, what do I want the people I have impacted to say about me when I retire? And when I die?”
Currently, I am working mostly in the clinic at the Illinois College of Optometry. I hope that the impact I leave on the lives of my students is even a fraction as positive as what my residency was for me. I strive to improve the quality of my patients’ lives, which I learned to be the broad answer to what a doctor’s role is. Furthermore, my residency helped me, as Dr. Harkin said, to “see life as an opportunity to improve the world around you and the people around you—wanting to make the lives of your patients, your classmates, your co-workers, and strangers better—which in turn makes your life better.”
Needless to say, I got my $60,000 worth.
‘OK’ to Change
Sarah A. Hetu-Radny, O.D.
HealthDrive, Nashua, N.H.
They say that one residency is worth five years of clinical experience. To me, that’s an understatement. Overall, my year in Tahlequah, Okla., taught me that I can be me more than I ever imagined.
My optometric confidence grew in expected ways during residency training, as I popped chalazia, presented a guest lecture to the second-year students, and clinically instructed the fourth-year students on selective laser trabeculoplasty. But there were many clinical and academic challenges for which I was not prepared; yet it was during these moments when the sweat was beading on my forehead that I experienced the greatest depth of professional growth.
Three patients in particular really through me for a loop.
One woman developed an acute angle closure attack just as I finished chipping through her thick, brown, Native American iris with a laser. I gave her the necessary topical and orals and told her husband to drive her to the hospital, where I would let them into our emergency after-hours eye clinic. As she had developed a secondary migraine, with accompanying nausea, I stopped by the ER en route and asked them for promethazine.
They handed it to me in a brown paper bag, and I jogged to the optometry clinic. When I arrived, I opened the bag to discover a tiny glass vial and an unfilled syringe. “Oh,” I thought to myself, “Where does this go?” I called the ER and the attendant told me to inject the patient’s leg; however, when I asked the patient where she had received the injection last time (she was prone to migraines with nausea), she replied, “My arm.” I decided to go with the arm.
Two hours later, her IOP had thankfully deflated from about 60mm Hg to about 25mm Hg. (Just a side note: yes, the eye really does not feel tender to palpation—it feels as hard as a rock when the IOP is 60mm Hg.)
As anxious as my closed-angle patient was, this next man was just the opposite. In the middle of the night, I was awoken by a call from the ER. A man had stuck a screwdriver into his eye. “Ow,” I thought. “I’m on my way,” I said. This was one of the calmest patients I’ve ever seen. As he explained, “Yep, I was working on my truck and the doo-hickey backfired into my eye,” I couldn’t help but marvel at his near-apathy. I figured I probably wouldn’t find more than a conjunctival abrasion. As I scanned the inside of his eyeball, I thought, “What is that piece of pink thing flapping in the anterior chamber?” Hello, uveal prolapse! I rushed him to the on-call ophthalmologist, an hour’s drive away.
Last but not least, I faced one of my biggest fears: an in-depth comanagement with a neuro-ophthalmologist. The patient who caused me to panic this time was a man with long-standing diplopia. While he had been managed successfully for nearly a decade with prisms, I could find no cause for his condition in his chart. Patiently, and step-by-step, a neuro-ophthalmologist and I worked slowly together to find the pieces of the puzzle and determine that the double vision was a result of iron deposits in a certain section of the brain.
These three patients, as well as my experience as an optometric resident in Oklahoma in general, challenged my intellect, my ability to stay calm and think during a crisis, my academic and clinical knowledge, and my gut instincts in ways that I could never have imagined. I was so surprised to find that I could rise to the occasion and be the optometric physician that I hoped existed within myself. For this, I will forever be thankful to the doctors and staff at Northeastern State University, especially my residency director, whom I hold in the highest respect.
I have applied this newfound professional confidence in so many ways during my three years post-residency. I obtained my Fellowship with the American Academy of Optometry. I began working full-time with the elderly, bringing bedside care to some very needy and sick eyeballs.
What will my future hold? I don’t think I can imagine!
A Poor Decision
Ben L. Larson, O.D.
Advanced Eye Care, Sanford, Fla.
I completed a one-year residency in a tertiary-care ocular disease and LASIK center in Orlando, Fla. I did learn a lot about treating complicated cases, but could have learned just as much working for a real paycheck at a similar facility right out of school. The meager pay didn’t even offset the accruing interest of my student loans. In hindsight, it was a poor decision economically.
It also had no impact on getting on any of the insurance panels I am currently on to be able to bill more medical visits. My wife, who is also an O.D., is on every panel I’m on and had no residency training.
On another note, the web, peer-reviewed journals and quality hands-on CE courses teach you more, they are more efficient, and cost literally thousands of dollars less!
A Year to Last
Julie D. Ngo, O.D.
Eye Center of Texas, Houston
When my friends heard I was planning to do a yearlong residency after optometry school, they were all baffled. “Don’t you want to make some real money?” they asked. Or, “You don’t need a residency to learn or see more. You’ll eventually see it all once you’re in practice.” My favorite was, “Isn’t a residency for people who don’t want the responsibility of being the doctor so they are just prolonging school?” (By the way, this is the exact reason no residency director wants a graduate who’s unsure of why they are applying for a residency. A residency program does not want to be someone’s Plan B.) I have never regretted my decision and I feel truly blessed to have had such an opportunity.
In all aspects, my year as an ocular disease resident was well spent and set me on my present course. I hold fast to the belief you never stop learning, especially after that diploma is handed to you. Once my residency started, I quickly realized I knew very little when it came to ocular disease. This is not to say that school didn’t prepare me, but 90% of the pathology I learned in school were things I had never seen or experienced clinically. A great mentor once said, “Uncommon things often present like a textbook, but common things often have various presentations clinically.” Thus, the year of intense exposure to various components of even the most common types of ocular disease made me very comfortable in managing them when others would shy away.
I have had the fortunate opportunity to work under some great mentors, both optometrists and ophthalmologists, working together side by side. The dynamic relationship between both realms has been an eye-opening experience and given me the opportunity and freedom to do more than I could on my own. I never think twice when ordering MRIs, sedimentation rates, CRP, fluorescein angiograms, removing foreign bodies or sutures, handling acute angle closures, or deciding whether a retinal detachment is an urgency or emergency at 7p.m. on a Saturday night—all of which I experienced in the first month of residency.
I loved the challenge that a private practice residency offered because the complex cases were referral based. Other optometrists have now entrusted their patients to me and it was my responsibility to make sure their patients were taken care of and that the referring doctor is kept up to date on their progress.
The greatest compliment I could ever have is when a fellow colleague calls me for a second opinion or a consult on one of their patients. Now I’m someone else’s mentor, and I often encourage my students to seriously invest in one more year of their life into a great residency program to give themselves an edge in their profession.
A Priceless Opportunity to Improve My Skills
Jeff Cohen, O.D.
Fort Lauderdale, Fla.
After graduating from Nova Southeastern University College of Optometry in May 2009, I began a residency in primary care at the Veteran’s Affairs clinic in Gainesville, Fla. I am a veteran myself, having served a combined eight years in the United States Air Force and the Florida Air National Guard, so I knew that being a resident at the VA would be a great match for me.
My clinical experience was extremely diverse, and included rotations such as primary care optometry, performing basic low vision exams, working in retina clinic, assisting cornea specialists, and providing specialty contact lens fittings for medically necessary cases. In addition, I attended lectures and presented my most interesting cases at several educational gatherings. I learned a great deal of information by not only creating case presentations, but also by discussing the cases with other clinicians.
The patients at the VA were more challenging than I had expected. Some patients were very healthy and presented without any systemic or ocular conditions, while others had numerous medical and ocular diseases. I often examined veterans with longstanding corneal injuries, diplopia, cranial nerve palsies, and retinal pathology that they had incurred during or after their military service. Every now and then I examined a monocular patient that had one eye exenterated for traumatic gunshot blasts or shrapnel injuries.
I often woke up wondering what kind of pathology I would encounter that day. Would it be a patient with a retinal detachment, or a patient with a recent-onset parietal lobe stroke? I can say with 100% confidence that completing a residency has increased my awareness for detecting and treating ocular and systemic disease.
During residency, I also learned one of the most important responsibilities: time management. As clinicians, we know that working on additional assignments can be a daunting task. During residency, I definitely learned how to efficiently maximize my time in order to complete the required case presentations, poster assignments and research paper on time.
Another important quality I learned during residency is the ability to practice independently. My supervisors empowered me to think and act on my own, but they were always close by whenever I needed clinical or academic guidance. After the first few months, I was able to treat and manage patients without help, and it felt wonderful! On multiple occasions, I supervised fourth-year optometry students and helped them treat and manage ocular conditions. This reminded me that as a student I sometimes felt unsure about certain cases, but after completing residency, I’m more confident and competent than I imagined.
Besides the superior clinical experience I obtained during residency, I learned about professionalism from some of the best optometrists and ophthalmologists. Even during some of the most hectic days with demanding patients, my attending doctors taught me to remain cool, calm and collected. Their professional manner enabled us to act intelligently and swiftly while providing the best patient care possible.
In summary, completing a residency was an experience I will never forget. I learned how to manage numerous patients, further educate myself on past and current treatments in optometry, conduct independently as a clinician, and how to be a skilled professional. I commend all the attending doctors who take the time and effort to teach residents to become not only better clinicians, but with the overall guidance they provide.
For those of you who have also completed a residency, I hope you gained lessons similar to those that I’ve learned. For current students or recent graduates thinking about pursuing a residency position, I strongly encourage you to do so. It will change your life!
Failures and Successes
Carolanne Roach, O.D.
Brain & Eye Connection Vision Clinic, Oklahoma City, Okla.
Are we defined by our successes or by our failures? One might argue that successes reveal one’s abilities and good qualities, thereby, illustrating that person as a whole. Others might defend the proposition that failures unveil a person’s true identity by showcasing the flaws under the intricate facades we hide behind.
I want to take a stance somewhere along the lines of being defined by the experience we gain from failures and the confidence we can achieve through successes. For me, this is what a residency has helped shape in my life and career.
The fear of failure can paralyze a person into never taking a risk. I suffer from this fear as I am sure many other soon-to-be-optometrists do. Add to that my desire to pursue a highly intricate and complex specialty in optometry: vision therapy. Despite my excellent education in optometry, no student can learn all the nuances of vision therapy nor gain the experience necessary to feel confident in taking it to a private practice; I know I could not.
To remedy this, I chose to enter a residency program. I thought about applying to a program for months; but the deadlines crept up, and I missed my opportunity—or so I thought. Come mid-March, while I was completing my final clinical externship at a veterans hospital, my supervisor and the other optometrist on staff walked into my exam room together. My initial thought was, “Uh oh! What did I do wrong?”
Seeing the horror written all over my face, they quickly reassured me that they had come by to inform me about an available position at Northeastern State University Oklahoma College of Optometry as a family practice resident.
Although I don’t recommend waiting so long to apply, I was happy to be accepted into the program later that spring.
So began my journey as a resident. The first several months I nervously presented my cases to the staff doctors. Would they find my decisions correct? Did I diagnose properly? On more than one occasion I left with my head hanging low, for I had inadequately taken care of a patient.
I remember one instance in particular; I was working with a student on a really young baby. The mother had a history of congenital cataracts and wanted reassurance that her baby would not suffer severe visual problems, if not caught early. So, after the student came out to discuss the possibility of dilating the patient, I hesitated. I was unsure about dilating such a young child. I examined the infant’s ocular media through undilated pupils and could not see any sign of inequality of the reflexes. Therefore, I figured the baby was healthy and sent her along.
Shortly after, the staff doctor came by and asked about the case the student and I had just seen. I relayed the information and was told to promptly recall the patient in order to dilate her eyes, as this would indeed not cause harm to the baby. The student caught the patient before she left the building, and we dilated her eyes. Drawing from my limited experience, I had made the false assumption that because the reflexes were equal in an undilated pupil, they would be free of media opacities.
Fortunately for my patient, the dilated exam proved to show that no congenital cataracts existed, and she had a good bill of health after all. And though my pride was significantly wounded, I learned a valuable lesson that day—one I will use to serve my future patients well.
Just as failures can teach us, if we are willing to grow from the experiences, successes can earn us confidence and encourage us to strive to learn and improve patient care.
For me, this success manifested itself in a case of a little girl for whom I provided vision therapy from the beginning until near the end of my residency. This little girl came in with complaints of headaches, occasional double vision and an alternating esotropia. I was not the first to see her, and I had never provided therapy to a patient with esotropia, so I was a bit nervous to work with her during my first few months. Thankfully, my residency director, the head of the vision therapy department, and my staff doctor for this case were not only the same man, but he had been the doctor in charge of her case from the beginning.
Dr. Wesley J. DeRosier spent hours after clinic almost every week for the first several months helping me assess and manage her treatment. Through his help in detailing the finer points of vision therapy and his encouragement to think on my own, despite my reserve, she graduated from vision therapy 10 months later a functionally different girl. To see her esotropic visual symptoms resolved as well as a positive shift in her behavior and demeanor gave me the determined motivation to continue with my career of optometry in vision therapy.
Now, as I strike out on my own in the private sector, I look back on my residency days as an essential stepping-stone to my future professional development. I hope to always learn from any failures and at the same time find satisfaction and encouragement with every success.
Dr. Chou is an industry consultant and private practitioner in San Diego. He did his postgraduate training in refractive surgery management at Jules Stein Eye Institute. As an optometry student in 1998, he won Review of Optometry’s Student Case Report Challenge.