Reflecting on my initial days post-qualification, I recall the blend of excitement and trepidation that filled my first solo clinic. The absence of a supervising safety net meant that every decision hinged on my judgement.
As someone who previously hesitated over decisions, the responsibility felt immense. I was plagued by the fear of overlooking crucial details or being caught off-guard by an assessor lurking in the shadows. However, a decade into my practice, I can affirm that no assessor has sprung from hiding to challenge my choices, nor have any optometrists or ophthalmologists that I have examined (there have been a fair few) have pointed out any issues with my method of practice.
My journey has equipped me with the skills to navigate the myriad of atypical situations that a standard clinic day presents. This article aims to impart the wisdom I’ve accrued, the kind I yearned for at the start of my career.
The Myth of a Routine Eye Examination
If there’s one piece of advice I could travel back in time to give myself, it would be this: expect the unexpected. Most consultations will present a primary concern—whether it’s altered vision, eye discomfort, or headaches—necessitating a more thorough approach than a routine examination, which most patients will be booked in for. Sure, some will come in for a test in response to a recall, but, from experience, 90% will have additional needs that will require you to investigate further.
Some deviations from the norm are straightforward (such as investigating a decompensating phoria), while others (such as patients with a shopping list of symptoms, unexpected dilations for symptoms of flashing lights and floaters or comprehensive glaucoma testing to ascertain if a referral is necessary) can disrupt a busy schedule.
Avoid setting your heart on a predictable day; it’s a surefire way to dampen your spirits. Be adaptable to face whatever scenario sits in your chair.
Beyond the Textbook
I admit, I was one of the few who relished OSCEs, primarily because the clinical presentations mirrored our textbook teachings, demanding minimal adaptation. The answers to the case in front of you were exactly as you would find in classic presentations, meaning that you would excel if you knew your stuff and had revised appropriately. After all, the College of Optometrists aren’t there to try and make you fail – they just want to make sure you are competent to become qualified to perform optometry on the public.
In contrast, real-world scenarios are seldom textbook-perfect and often call for deeper analysis. A patient may exhibit symptoms indicative of one condition while the signs suggest another, with some reading between the lines needed.
I recall, during my pre-registration placement at Bristol Eye Hospital, observing a patient with concerns that he’d hit his eye with a garden trowel and could still see bits of soil from the trowel floating about in his tear film. He had no pain and his anterior eye was quiet. At this stage of my pre-registration period, I had cottoned on to the idea that the trauma of the trowel hitting his eye had caused a retinal detachment and he was seeing floaters, not soil, in his eye. It was this reading between the lines that enabled the right tests and right treatment to be conducted – but this could have been easily dismissed if not investigated thoroughly!
Additionally, it is important to remember, the absence of symptoms doesn’t rule out conditions like retinal tears or macular degeneration. It’s crucial to perform all the relevant tests to rule out issues before coming to a diagnosis or management plan, as just relying on textbook presentations may cause you to miss something important.
Interpreting Patient Narratives
Here’s a potentially contentious assertion: take patient narratives with a care as opposed to gospel truth. Memories can falter, exaggerations can skew, and misinformation can mislead. Whilst you should always take patient concerns seriously and respect them entirely, sometimes what is said by them may be incorrect, irrational or impossible – so do not
I’ve encountered patients who’ve forgotten previous tests or recounted improbable surgical experiences. Some have said “I’ve never had this test before”, where on the record card you can see that you saw them last time and performed the same test they claim that they have never had done. Others have denied ever visiting a hospital eye unit or having surgery, despite having intraocular lenses. I even had someone tell me they had their eye taken out, polished and put back in – as we know, it isn’t possible to do that, but it was a patient’s reality. Listen, take note and perhaps steer the patient towards the correct explanation as to what happened, but never mock or make the patient feel stupid.
Such tales aren’t confined to the exam room; dispensing opticians and optical assistants also have their share of improbable anecdotes. With experience, you’ll refine your ability to discern fact from fiction, all while maintaining a respectful demeanor. Often, confusion or misinformation underlies these accounts. It can be all to easy to think “That other optometrist/practice isn’t doing their job properly” based on what a patient is saying, but err on the side of caution from what they tell you as you are only receiving half the story!
I’ll add a caveat though; do not simply dismiss patient symptoms or concerns. Whilst there is often a straightforward cause, a case of someone malingering or something that is beyond current medical practice to put right, your role is not to judge but to investigate their concerns and make an assessment accordingly. Your handling of the patient’s appointment can make a big impact on their lives and often improve it, even if it isn’t possible by just prescribing a new pair of glasses. Go that extra mile and it’ll boost your reputation as a healthcare professional that truly cares.
Expect the Unexpected
In line with the unpredictable nature of our work, readiness for any scenario is key. You might encounter contact lens wearers that turn up for a contact lens assessment without their lenses or have a recheck in that haven’t brought in the glasses they are having issues with. Be prepared for the unforeseen, from severely damaged glasses to significant eye disease. Flexibility is your ally; having contingency plans, like adjusting appointment sequences or rescheduling, can save the day.
This really highlights a topic I always have pushed – you need to work as a team. Having a great team dynamic will help when things go askew and they will be a real asset should a clinic run late or you need someone to hold your place in the line when calling eye casualty.
You Don’t Have to do Every Test on Everybody
This is one that I did have some knowledge of to begin with, but it is still an area where I see many students and pre-registration optometrists fail to take on board. There are many times where doing every test in your routine will lead you astray, waste your time and potentially make you look incompetent in front of your patient or assessors.
There are some tests that you have to do by law and some that may be contractual as part of the eye examination you are providing, but there are many tests that can be done but are not necessarily needed. I’ve seen students perform binocular assessment techniques on monocular patients or try to assess amplitude of accommodation on patients with intraocular lenses. You will know the likely outcome of these tests prior to doing them and as such should extrapolate that into not needing to perform them as they will give you no extra knowledge.
Take the time as a student optometrist to really understand what tests need doing and on which patients, as well as the reasons behind performing the tests. Connecting the dots will become much easier if you do what is necessary as opposed to creating noise to distract you away from the problem at hand.
These are just a few insights that I wish were imparted to me as I embarked on my optometry journey. Do you have any pearls of wisdom to add? Feel encouraged to share them in the comments below! Enjoy these posts? Please consider subscribing or Buying Me a Coffee – all support benefits the ongoing work on The Eye Care Advocate.
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