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Residents & Fellows Corner | Jul/Aug '14

The First Year

I remember my first day of residency. I was entering a new hospital with seven co-residents, all of whom were new to me. Even though I had spent several rotations in medical school studying ophthalmology, both in a research and clinical setting, I still felt unprepared. Very little time is dedicated to studying ophthalmology in medical school, and most exposure in the clinical setting is optional. Because ophthalmology is extremely subspecialized and most of the ophthalmic equipment is difficult to use and master, most medical school rotations are essentially observorships. Medical students rarely see patients independently and often only examine the eye through a side-viewing scope.

Every year, I think about this transition from medical school to the first year of ophthalmology residency, most likely because each year I am directly affected. I have each first-year resident in our program rotate with me during the cornea block of his or her first year. The first couple of months are difficult, and the learning curve is very steep. I always try to put myself in their shoes. How did I learn how to use the slit lamp, the indirect ophthalmoscope, or the Goldmann tonometer? How did I learn how to see patients in an efficient but thorough way? What helped me the most? How did I become a competent resident?

My first rotation as a first-year ophthalmology resident was the night float block. We had a dedicated emergency room solely for ophthalmology and ENT (ear, nose, and throat). I was responsible for all of the walk-in patients who came in each night as well as consults from the main hospital. I had no idea there could be that many eye emergencies in a single night shift! Diagnoses ran the gamut from simple (corneal abrasions, conjunctivitis) to complicated (retinal detachment, corneal ulcers). At the beginning of the year when I did my rotation, a senior resident would take buddy call and stay in house with the first-year resident.

I had a love-hate relationship with the emergency room. There was such a wealth of pathology that came through the emergency room, and I had to learn quickly. It was very challenging and rewarding and, at times, a bit scary. Did I make the right diagnosis? Did I miss anything? In a given night, I could be taking care of an open globe, a chemical burn, a retinal detachment, and an eyelid laceration—all within the span of a few hours. It took me awhile before I felt comfortable with my clinical skills and even longer before I felt confident with my assessments and plans.

For me, having a senior resident with me during that 6-week rotation was invaluable. We would discuss each patient, form a differential, and devise an assessment and plan. I would supplement my rotation with excerpts from the Basic and Clinical Science Course (BCSC) texts. In addition, we had a daily lecture series dedicated to first-year residents with lectures that were at my level. I think the combination of lectures, independent study, and mentorship made my transition easier.

I surveyed my first-year residents to get their thoughts. Below are the answers I received.

What was the hardest thing about starting first year?

“The hardest part about starting first year, besides the normal scenery change and getting accustomed to a new environment, would be the learning curve and minimal ophthalmology teaching/exposure you have as a medical student.”

“Starting everything over again was the hardest part for me. It was difficult to transition from medicine to something totally new.”

“Moving to a new location was the hardest thing for me.”

What was expected/unexpected?

I expected the learning curve to be steep and to have difficulties performing the slit-lamp and indirect exam. I expected call to be tough from speaking to previous residents; however, I was surprised to see how often we get consulted.”

“I expected to be humbled, and it’s been happening every day!”

“I expected not to spend much time in the operating room. I knew that learning clinical ophthalmology was the priority in the beginning and that surgical exposure would come later in residency. For me, the unexpected was the difficulty of call on certain days. Having come from a surgical internship, I was quite used to busy call days and nights. I was, however, surprised at how crazy call can get in ophthalmology when streams of consults get called in at the same time.”

What prepared you the most for residency (rotations, reading material, etc.)?

“I think doing as many clinical rotations as I could as a medical student helped me feel more comfortable with my clinical exam. Practical ophthalmology, the American Academy of Ophthalmology’s Basic Ophthalmology book, and online resources like OphthoBook were also extremely useful.”

“ Talking to current residents prepared me the most. “

“Previous exposure to ophthalmology through clinical rotations, research, and lectures prepared me the most. “

In your first month of training, how have your skills/knowledge changed, and what has helped you the most?

“My skills and knowledge have definitely improved, and I am starting to feel more confident about my examination. I think just seeing patients and practicing, as well as reading for our weekly quizzes, have helped the most.”

“I am slowly getting better at developing my clinical skills, and I am slowly accumulating knowledge. Working directly with faculty members and senior residents has helped the most.”

“The practical skills I’ve picked up have helped the most. Practical skills would be the one area that is hardest to develop prior to residency, as it comes from routinely examining patients from start to end. Knowing what ‘normal’ looks like has also helped, as there have been several times where I have noted something abnormal, wasn’t sure what it was, but was able to communicate to more senior ophthalmologists by describing what I saw.”

Jessica Ciralsky, MD

Jessica Ciralsky, MD, is an Assistant Professor of Ophthalmology at Weill Cornell Medical College in New York, specializing in cornea/cataract/external disease. Dr. Ciralsky may be reached at (646) 962-2020;jbc9004@med.cornell.edu.

Jul/Aug '14