In the fictitious advice column below, program director Evan L. “Jake” Waxman, MD, PhD, aka “Dr. Jake,” imagines a few sticky situations that residents new and old will all be familiar with. Read on as he combines a bit of wit and humor to tackle some of residency’s toughest conundrums and steer a few trainees to safe shores.
Dear Dr. Jake:
I’m a first-year resident on overnight call. I’m writing to you from the emergency department at 2 a.m. There’s a patient who’s come in for a subconjunctival hemorrhage. She has no pain or change in vision and said she noticed it two days ago. She came to the ED because it hadn’t gone away yet. I’m thinking unkind thoughts. Is this allowed? Love your column.
—Hoping to Avoid Hatred
Dear Hoping to Avoid Hatred:
I apologize for not getting back to you more quickly. I’ll assume that this problem has been resolved and that you are still in the residency program.
Learning to deal with patients similar to the one you describe is a rite of passage on the road to becoming a practicing physician. Those of us who aren’t saints can find ourselves irritated and even angry at patients who “waste our time,” “don’t do what we tell them to” and “don’t take care of themselves.” It’s especially easy to feel this way when we’re experiencing physical (lack of sleep) or mental (the OKAP is coming!) stress.
Mindfulness is a frequently used word these days. IMO it’s meant for these situations. Be mindful of how you feel. Separate that from what you need to do. Remember that the patient is truly concerned and that big red blotch on her eye really does look scary. Remember that this situation cannot upset you. Only your reaction to the situation can upset you. You get to choose. Remember also that you’ll get back to the call room and back to sleep more quickly if you complete your exam. Don’t forget to dilate though! :)
Dear Dr. Jake:
I’m a first-year resident. I frequently get to scrub in on cases, but all I ever get to do is watch. I don’t understand how I’m ever going to learn to do surgery if I’m never allowed to operate. Should I switch programs? Awaiting your reply.
—Cornea Waterboy
Dear Cornea Waterboy:
What an excellent question! Don’t switch programs yet. Just about every new resident can’t wait to operate. It’s important to remember though that while your education is a high priority, our most important obligation is to our patients.
Surgery in the OR is for keeps, and your attending can’t always undo something you might not do right. There’s an ethical tension in learning surgery. Every cataract surgeon must do their first cataract surgery. Very few people would want their mom to be someone’s first case though. We address this ethical tension by learning outside the operating room. You need to read and watch videos to understand the science of surgery.
You need to use your opportunities as a “waterboy” to observe and learn from what you see. (Another opportunity to be mindful.) You need to practice in the surgical training lab. Prepare in advance and you’ll be ready and on good moral footing when you’re eventually handed the instruments.
Dear Dr. Jake:
I’m a third-year resident and an avid reader of your column. The coordinator in my program is so unfair! She is always on me about finishing online modules, filling out faculty evaluations and completing my duty hours. I’m busy learning ophthalmology. Why do I have to do all this paperwork?
—Fed Up
Dear Fed Up:
Thanks for following the column. As I write this reply, having completed my charts, filled out my evaluations of residents and medical students, reviewed resident duty hours, completed my online modules on HIPAA training and coding requirements, renewed my license and DEA paperwork, completed my yearly conflict of interest paperwork, attested to my fitness for duty on recredentialing paperwork and paid the American Board of Ophthalmology to keep track of my continuing medical education hours, I have to say I agree with you. Your coordinator is unfair. Life sometimes is.
For better or worse though, administrative responsibilities are vital to the practice of medicine. They are critical to patient care and to the maintenance of the residency program (and later to maintenance of certification!). Failure to complete these violates the essence of professionalism, one of the six core competencies.
Fortunately, as soon as you’ve graduated from residency, you’ll never have to do any of these ever again.
Dear Dr. Jake:
I’m a first-year resident and first-time writer to your column. I just had my semiannual review with my program director. She said that something called the CCC met and determined that I need to read more. I read all the time though. What’s a CCC? How can I read more than I’m already reading?
—BCSC-Related Exposure Keratopathy Victim
Dear BCSC-Related Exposure Keratopathy Victim:
Thanks for writing in. Let’s get some basics out of the way. The Clinical Competency Committee (CCC) represents the faculty in your program who are charged with monitoring and recording your progress on the milestones.
Per the Accreditation Council for Graduate Medical Education (ACGME), the milestones are “learning trajectories highlighting significant points in resident development to assess learner competency in six key areas of medical education.” In other words, they are a list of things you’re supposed to make progress on during residency annotated with descriptions of what progress looks like.
Your program director and your CCC are, of course, right. You need to read more. We all do. Sometimes this is what we routinely tell residents to do when they’re doing well, and we can’t come up with any action plan for you.
They’re also a little bit wrong though. Most of us were never taught best strategies for learning, and many of us equate studying with reading and rereading the material we’re supposed to master. It turns out that’s not the best strategy. It gives us a false sense of what we know and it’s not time efficient. Reading should be followed by immediate reflection and self-assessment.
Journaling, flash cards and practice questions are great ways to self-assess. It’s important to follow with delayed assessment down the road. Save the rereading for material you get wrong. The Academy’s Basic and Clinical Science Course (BCSC) Self-Assessment Program is designed to help with this. Every question is linked to an excerpt of the BCSC.
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About the author: Evan L. “Jake” Waxman, MD, PhD, is chair of the Association of University Professors of Ophthalmology’s Program Directors Council and program director at the University of Pittsburgh School of Medicine.