A Progression of Clinical Thinking, Part 1

Midterms begin tomorrow, already, and it seems impossible that we could be halfway done with the semester. I’ve been able to fall into a routine at clinic, concentrating on trying to improve my speed and to ask my preceptors as many questions as I can while I’m at this location. I’m seeing a lot more glaucoma patients than I have at previous sites, and am taking that opportunity to integrate knowledge from my glaucoma elective course and gain more insight into different strategies of patient management. Last year as a second year, I was almost always partnered with a third year student in clinic who helped me improve my exam flow and understand what questions to ask. This year I’m able to play the opposite role in working with second year students as a third year myself, which helps me to analyze what I do in clinic more fully and to question and challenge myself. Working with another student enables us both to learn, because it provokes us to discuss patients aloud and compare what the second years are learning in their classroom-heavy year to what I’m learning in my more clinic-heavy one. It has also provoked me to think about my clinical education not as something tangible that is spontaneously realized one day with a definitively perfect eye exam, but as a progression of thought that evolves as we question ourselves, our patients, our techniques, and our preceptors. It is shaped both by our successes and mistakes, by the days we learn by identifying an unusual ocular finding correctly and by the days that we are baffled by what we are seeing. It makes me think of my first clinical experiences, performing vision screenings on children as a first year student.

Your first time, you will be so nervous that you completely forget how to take visual acuity. There will be a calm eight-year-old staring at you expectantly, assuming that because of your blazer and nice shoes that you are a doctor, an adult, or at least someone who knows what she’s doing, and you will think to yourself, wait, what do I do first? Which eye should I tell him to cover? Can he tell that I’m nervous? Is he laughing at me? You will suddenly realize that you don’t have the visual acuity cards memorized and desperately attempt to strike a balance between watching the child’s eyes and checking to make sure he is reading the letters correctly. You try to be fast, panicked by the lines of children waiting to have their eyes screened, and you stop your preceptors and ask them to check your work, holding your breath to see if you are correct that this child is hyperopic, or has normal vision, or an eye turn.

Or you will be kneeling in front of a four-year-old who is much too busy and excited to pay attention to you as you gesture wildly across the room saying, look over there! Look at the wall! Look at that poster! What color is the poster? Look out the window! as you frantically try to test their pupils in the milliseconds they are not changing their mind and looking instead at you, at your light, or at the stereo glasses you shouldn’t have left within grabbing distance. You will call your preceptor over with a combination of anxiety and excitement the first time you see movement on cover test in a child, be surprised the first time a child tells you earnestly that he’s sure he needs glasses because they look so cool yet has perfect vision, and get increasingly inventive at coming up with new methods for getting children to stop looking at you while you’re doing retinoscopy. You learn how to reassure, how to encourage, and how to sympathize with the tiny patient in front of you.