Chairs Missing by Joe, resident at the New England College of Optometry

1Jul/13Off

The Summer of Jorge

Well, that was pretty short.  I'm back from my two week vacation and now there is officially less than a week left of my abbreviated school vacation-like summer break.  My wife and I had a great time down in the Carolinas where we visited friends for a week in Wilmington, NC, and then made the drive down to Charleston, SC, for the second week. As a cheaper alternative to Florida (or somewhere else warm), I highly recommend it. Both cities have nice beaches, interesting building architecture, and cool nature reserves to hike. On top of that, everyone down there seems a bit friendlier than people in New England. It's almost unsettling having lived in Boston for four years to have strangers say hello as you walk down the street.

More importantly, both places have a whole lot of interesting places to visit if you are the type of person that likes to do nerdy things while on vacation. While not really a relaxing vacation for us, we spent a good two weeks visiting historical sites and museums learning more about the history of places associated with plantation slavery, the Civil War and the Civil Rights movement. It was interesting to see these places through the eyes of a northerner (never having traveled much in the South), and it was also interesting to see the differing takes on the history, depending on the museum or site. The stories definitely varied based on whose ancestors were in charge of telling it. Overall, the trip rekindled an interest in history and politics that I haven't felt in very long time, which is a strange thing to get out of a vacation.

Now that we're back in Boston, I have a little bit of time to catch up on some light reading; book 4 of the Game of Thrones novels so far is better than expected. I've also been able to watch some of the backlog of movies and television I missed out on before graduation. It turns out both the newer Dark Knight movie and the new Arrested Development episodes are legitimately terrible, which is depressing. Our trip made us realize that we haven't really explored the city beyond the usual touristy stuff like the Freedom Trail or the Common. We decided that with the remaining free time left before we move out, that we are going visit some lesser known historical sites and nature areas in and around Boston.

Yesterday we visited Mt. Auburn Cemetery in Watertown, which is the oldest "cemetery" in the US (versus all previous burial sites which were called "graveyards" or something else). It is thus both a historical site and an urban nature preserve, sort of like if you mixed the Arnold Arboretum in JP with the Copp's Hill Burying Ground in the North End. If I still gave tours at the school, I would give it my highest recommendation to visitors staying the weekend. Aside from the hundreds of noteworthy people buried there and the beautiful landscaping, there is an old stone tower near the center of its hilly terrain with panoramic views of the city that are unmatched to anything else I've experienced here. Above and below are a few pictures from our visit.

As we explore Boston one last time as residents, I'm also faced with having to scramble to finish all the various things that need to be done before I start residency. I've come to realize how little time six weeks actually is, especially when there is a ton of stressful loose ends to tie up. I've made good friends with the local notary public to be sure. So far, I've had to complete training, fingerprinting and filling out forms for the VA. Also, for any potential side job down the line, I have to go about obtaining my NPI and start the process of getting a Medicare number and then after that, apply to get malpractice insurance. Above all of this is the whole process of getting licensed, which is most complicated of all.

To become licensed in Massachusetts, one must navigate a Kafkaesque maze of forms to fill out from various websites, pictures to send, and letters and transcripts to have stamped and prepared, and that's all before having to take a twenty five question law exam which covers, in part, the very process I just described. And then, after that, you need to do an extra application to be able to actually write scripts for drops. Currently I await my test date, which is this coming Wednesday, so I am studying like a law student in between writing this post. I also have to be licensed in another state, so that I can have a license that actually allows for me to prescribe oral meds and glaucoma drops at the VA.  I chose Pennsylvania. It was about twenty times easier a process, and I actually already have my license in hand.

But wait. Why would I need this extra license you ask?  Well, the VA is federal property and therefore doctors can practice to the fullest extent of their licensure level, regardless of what state it is located in. Why not orals and eye pressure-lowering glaucoma drops in Massachusetts? It's a long story, which could be its own post really. Massachusetts has not yet been able to pass a bill updating our scope of practice to that of modern levels for optometrists everywhere else in the US and even in parts of Canada (and probably Mexico, too). Thus, we are the only state in the union that cannot treat glaucoma. I guess we had to be last in something. I love being from Massachusetts, and plan to practice here my whole career, but we are not beyond improvement. Again, in a future post I might talk a bit about what tools and organizations we have as optometrists to counter forces lobbying government in opposition to our, and to our patients', interests.

That about does it for this post. Next post is in mid-July, where I will detail my opening days as a resident and maybe about moving away from Boston as well.  See you then!

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17Jun/13Off

Waiting Room

Greetings once again, noble reader. Welcome to the newer and improved version of Chairs Missing, a blog no longer about being an optometry student, but instead about the trials and tribulations of a rookie optometrist/optometry resident. To start, I shall lay some new groundwork.  The revised goals for this blog going forward are to give to the potential optometry student, as well as current students in kind, a picture of what it's like during the first year out of optometry school: the challenges, the ups, the downs, the frustrations and triumphs; the "oh yeah moments" where the training and practice click into place. Along with that, I am also going to cover what the experience of doing a residency is like: the pros, the cons, what great learning and opportunities it does or does not provide. And last, I hope to provide some insight into the choices and decisions that have to be made in this crucial first year to plan beyond residency towards one's future career, and ultimately one's life.

Now, as I wrote that last paragraph, I realized it sounded pretty self-important, or if not, maybe too broad and ambitious of a goal for a 500 word-per-post college blog.  But I figure since not only I am a doctor now but also a professional writer (of sorts), I need a stuffy sounding mission statement to keep things looking sharp.  So from here on out: Less rambling about nostalgia and feelings, less references to the difficulties I have writing this.  Less contradicting what I say in a later paragraph, more keeping on a singular message. And maybe less hidden literary illusions and obscure music references that no one gets but me.

But then again, maybe not.

Joking aside, no matter what, I hope I can come close to meeting a high standard in the coming year and get a clear point across. And hopefully I can do that without driving myself crazy with rewrites and obsessing over every last word until I miss deadlines. To this end I think I am going to keep it simpler than in the past; I plan on using a more straight forward narrative, drawing more on my day-to-day on-goings and trying to keep the posts shorter and sweeter. Well except this one. I'll take a mulligan on this one.

Long intro aside and on to the meat of this post, as expressed in the form of a question: What is residency in optometry? Aren't MD's the only health professionals that do residency? Isn't that because only THEY need to see a large amount of cases and need intense extra training in order to specialize? The short answer is no; optometrists, as well as dentists and some other professions, have the option of continuing on to more training in a sub-specialty they find interesting. It's just that with us, it's optional. Only those who feel they want more training in a particular area do this, be it in one of several recognized sub-fields such as contact lenses, ocular disease, pediatrics and so on. Each program is run in affiliation with a school of optometry and has requirements for self-improvement beyond seeing a large volume of patients, such as doing lectures at grand rounds and initiating independent research projects.

So why would someone subject themselves to this by choice, immediately after going though the stress of four intense years of school, and for close to no money (the pay is modest at best), when the tantalizing possibility of making good money is right there for the taking? Well, it seems crazy at first and the reasons are many, but for the most part it comes down to that extra training. This extra training provided by doing a residency then leads to the opening of more doors.  It allows the resident to see cases in a sub-field to the point where they will be completely comfortable managing advanced cases on their own. It therefore allows a person to prepare to be eligible for a wider range of jobs such as in industry, in hospitals and in community health centers, jobs that they otherwise could not get. It also allows a doctor to be able to teach both as a lecturer and as a clinical preceptor, as schools usually require professors to have completed a residency.

For me, since my goal is to one day work in a hospital or community health center based setting, I sought to do an ocular disease or geriatrics residency. This will in theory allow me to learn how to diagnose and treat complex ocular disease cases, ones that are often caused by the chronic systemic illnesses that plaque our health care system, such as diabetes and high blood pressure. And long story short, my position is at an area VA hospital through NECO.

And this leads into what I am doing now, beside writing this blog. Waiting. And waiting.  The residency position doesn't start until July 1st, so I am stuck with about six weeks of time off until then.  I am pretty much officially having the last summer vacation of my life, and because I can't work yet as I am without a license to practice (the process takes months, more on this next time), this is the first summer since I was a young teen where I have seemingly boundless free time. I remember the awesomeness of summer vacation back then, where I would sleep until noon everyday, forget probably everything I learned over the last year, and stay up all night skateboarding or going to hardcore shows with friends.  No job, no bills, no one to really answer to.

Well, things done changed. In a number of ways, that's for sure. So far it's a lot less fun, with a whole lot more paperwork to fill out (license applications are a maze) and a lot more freaking out that I am making no money, all while my loans accrue interest. On the plus side, my wife and I are traveling to the Carolinas for a few weeks, and that will provide the distraction I need to stop stressing out about all this time being wasted.

Since we leave soon, I'll save the details on that for next time.  Or maybe instead for my next post: Summer School, a review of the 80's movie starring Kirstie Alley, directed by Carl Reiner. Maybe Chairs Missing could become your destination for reviews of terrible movies that I watched out of boredom on HBO during the summer of 1993. Not sure which direction I'll take yet, but either way, hopefully I drew you in such that I'll see you next time. Next time being around July 1st, which coincides with day 1 of residency.

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4Jun/13Off

It’s Been a Long, Long Time Coming

It took me a week to let things sink in before I could even attempt to write this, my way-past-deadline final post.  Last weekend, every member of NECO's Class of 2013, including myself,  marched into the Back Bay Event Center's main hall, sat and listened to the commencement speakers  (it got a little dusty during Nick, Petar and Jeff's medal ceremony), went across the stage to get their degree and hood, and then went off into the audience to embrace their families and disperse out into the real world. It was so hectic I didn't even get a chance to say goodbye or take pictures with everyone that I wanted. Everyone had a tearful last party or outing with close classmates in Boston, and now almost everyone, save for the few planning to stay in Massachusetts for the long haul, have moved away. I just said goodbye to one of my last friends to leave the city for good, and now the city feels like a ghost town. If not for the luck of having my wife and my brother here with me, it would be a pretty lonely place. So needless to say, it has been a pretty surreal couple of days. I  have only now started to process this.

But let's be honest with each other, noble blog reader. I haven't posted anything here in a few months; I am about three posts behind everyone else. It's not like things haven't been happening, both for me or at the school or even in the city itself. Every time I attempted to sit down and write, I got stuck.  There was tons to write about, and I had a quite a few great but unfinished ideas. The one about doing exams for an entire day in Spanish and Portuguese, which reminded me of my hometown and my grandparents, that was a good one.  Or the one about the tragedies on Marathon Monday in Boston -- that could have been special and emotional. Or one about observing a bunch of different surgeries with ophthalmology at my last rotation and how MDs interact with ODs -- that had so many different interesting ways it could go.  And so on.  But I just couldn't get it done.

After having time this last week to reflect, I realized that I couldn't finish what I started because each time I did, it meant revisiting my leftover fears and anxieties about the future. It also meant facing that I was one step closer to school ending and all that comes with that: friends moving away, loans coming due, and generally having to face responsibilities of the working world again.  It means leaving the relative comfort and safety of being a perpetual student both physically and in mindset.

For more years tha
075n anyone else who is my contemporary, my identity has been defined through my status as being a student; this final graduation means losing that identity in a sense. I think that sort of makes me seem like a Judd Apatow-esque manchild of sorts; a 33 year old still wanting to be this youthful student and be free from career ambition and just play video games or skateboard or something. But actually I think the real truth is that I previously found more comfort in thinking of myself as having (either imaged or real) untapped potential versus actualizing that potential and making a meaningful life with it.  In some ways, so long as you remain in the realm of  the potential and not the actual, your life maintains the illusion of being wide open.  I could fall back on my "potential" as comfort and thus the future would remain a tantalizing unknown of multiple possibilities, a place to dream about,but also a place to lay any excuses upon.  My lack of direction, my working dead end jobs, that for me meant that any failures I had were no big deal, and therefore not as scary, not as real.

For a long time I was in that mindset;  I can't really say why or when it started, but it was certainly something that started in high school, where despite being smart enough, I blew off classes and assignments to hang out with friends and came dangerously close to not finishing.  It took years of community college and working on my own to afford state school to turn it around. Since then, there have been ups and downs (my lowest point may have been my failed attempt at moving to New York and going to grad school), but luckily I was able to discover optometry. I re-examined what I wanted out of life and with the help of my wife, I started down this path that I have just now finished.  I also have come to realize that seeking a grand career to give ultimate purpose is a false dilemma; you are not solely defined by your job, your life has meaning only so far as what you perceive it to be. It really took crossing the stage on commencement day to finally bring this into clearest focus and realize how far I've come. I couldn't be more happy with the decision we made together to come here. And I finally feel like I have lived up to my potential at long last.

So although it's still strange and sad to think that my time here is over, these last four whirlwind years were a blast, and reflecting on it helps to move past and look beyond. What strikes me the most is that I find myself not thinking so much about what I did, or what I accomplished, but rather what everyone else around me did to help me. I feel that no one really achieves anything in life by themselves, no matter what sort of delusional Ayn Randian fantasy one might believe. On a basic level, we all stand on the backs of those to come before us, who built our society and institutions, and the collective people who complied knowledge or blazed the paths that we use everyday without thinking about it. But we also stand on the class and position in life we were born into, on our families, and how well (or not well) they were able to take care of us. And last of all, we stand on top of those we choose to associate with willingly, our friends and significant others.

This is evident in my life through the support I relied on from my wife as she herself toiled and struggled in a job she did not like for four years to put a roof over our heads. She should have been able to hood me and get one for herself. It also is evident in the amazing friends that I was able to cobble together and rely upon for study help and to hang out and blow off steam with.  And of course very evident that we had great support from folks at NECO itself, both the faculty and the staff equally. You cannot overrate the job they did teaching us and keeping things running; yes there were minor complaints along the way, about trivial this or thats that cropped over the four years: "oh the library should be open until this time", "oh this class didn't need to repeat this material" and so on. But that was in the fog of war, so to speak.  Now that it's over, having witnessed the amount it took to put it all together from orientation day to commencement day, it really is quite amazing. So to get to the final point at long last: to all these people above, thank you!  I could not have done it with you, especially my wife, but especially everyone else. I will never be able to fully express what it has meant to me,  I'll never be able to pay back the great debt I owe you, and most of all I will never ever forget your kindness.

....

Postscript:

So now whats next? Well it turns out that this is not my final post. My plans going forward: I will be spending the next year working as a resident optometrist at a veterans hospital in the greater Boston area. We will be moving to a suburb outside of Boston in search of cheap rent and bigger space. I will also be back at NECO as an occasional resident lab monitor, clinical tutor AND I will be staying on as a resident blogger, so to speak. There should be a lot to talk about as I provide insight into my first year navigating the world as an OD and as I attempt to become licensed, complete the residency program and establish my future mode of practice for years to come. It promises to be at minimum a continued long winded and grammatically challenged year for this blog. Please join me!

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12Feb/13Off

A Blizzard of Options

So remember my last post when I said that winter was already on its way out? Well turns out that estimation was just slightly off. Boston just got hammered by about 2 feet and some change worth of snow, and nearby coastal towns saw catastrophic flooding. Many people have lost power. The Greater Boston area in general has come to a standstill on this weekend as the subway system shut down and there was a government mandated driving ban. My street is presently no longer a two way road and may not be for another few days.  My buddy spent about 6 hours digging out his car after it was buried by a plow, and then another plow almost completely re-buried it later that day. Other friends were either coming from taking or going to take Part 3 in NC and got stuck out there or had their flights from Boston cancelled; really makes me glad I chose to take it so early. In light of the last two winters being so unseasonably mild, I had forgotten what a joy real East Coast winter is like in the city.  Thus I spent the weekend mostly barricaded indoors writing this post and watching the John Adams HBO mini-series with my wife, baking cookies and playing squash with my brother and some friends (my gym is right next door and apparently never closes no matter what).

But life it seems will be quick to continue on. While NECO closed Friday through Sunday for the storm and clinic was cancelled Friday afternoon for many 4th year students in the local area, things are back on as regularly scheduled for Monday. And for myself I have one day to prepare for several residency interviews, all scheduled in one day.  So this begs the question for the potential optometry student, what are residencies in optometry? Are they necessary? While there are many websites out there that answer these questions much better and in more detail than I can (and can be found by Googling the accreditation organization for optometric residencies: the ACOE), I will give my two cents.  Unlike in medicine where they are an essential and obligate part of specialty training and board certification for the MD (and last several years), residencies are optional for the OD.  There are about 10 or so programs supervised by each of the optometry schools. They provide one additional year of training, usually in one of the 11 or so recognized sub-specialties of optometry such as vision therapy, low vision or pediatrics.  The pay is low, much lower than what you could get to start at most private practices. But the tradeoff is three-fold. One is that you get the chance to extend your learning another year and have the chance to manage much more complex or specialty cases, with attending doctors that have years of insight and knowledge to share. By doing a residency, you also are expanding the type of job you can get afterward; most medically based practices, community health centers and Veteran's Hospitals require a residency to be hired. And finally it is all but necessary to do a residency if you want to teach unless you already have another higher degree like a PhD or Masters.  Pretty much if you want to become a leader within the profession, a residency is non-optional.

So with those things in mind, I decided to apply, mainly to VA residencies because ultimately I see myself working at a VA or community health center somewhere down the road and because maybe I will even try to teach one day. Many folks in my class seem to think the same way; it seems a good chunk of my class is also applying to programs all across the country. But it's not for everyone; just as many people can't wait to jump start their careers and to be on their own and start practicing independently, working without a "net" so to speak.  Certainly all of us will be ready to see primary care patients when we graduate. But for me, to keep my options as wide as possible, I feel a VA residency provides the best training in the types of challenging cases I find interesting: complex ocular disease and neuro-ophthalmic disorders. And who knows, the direction optometry is going may one day lead to a residency becoming a more important (and necessary) part of our training. I'd like to try to stay ahead of the curve.

And so that's that from my perspective.  I'll keep you posted on what ends up happening. Hopefully I'll do well enough in my interviews to snag a position and maybe I'll be a blogger as a resident at NECO for another year. Up next, all about my third rotation: clinic in a Boston based community health center.

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24Jan/13Off

Winter Is Coming… Winter Is Here…. Winter Is Gone?

It's been awhile since my last post.  When I started writing this, it was mid-November and I had just finished reading the first book of the Game of Thrones series, so I figured the title of this post was fitting.  But then writer's block set in, rotations changed over, Boards Part 2 struck and finally, winter came (figuratively and literally).  In a blink, it's mid-January and it's almost like time is accelerating even faster.  Many things are different and changing.  The end of school is in sight; we are well beyond the halfway point of fourth year, which is pretty crazy. And it seems like winter can't decide whether it's staying or leaving; we've had all of an inch of snow in Boston so far, and since December, we've had alternately a day of twenty degree weather followed by three or four days of mid-fifties each week.  How anyone can deny the existence of global warming is beyond me.  But I digress.

It’s been so long in fact that I took Boards Part 2 and already found out that I passed. Not much to say about the exam itself except that it was straightforward and I found that I studied just the right amount, which incidentally was way less than for Part 1.  Much of the credit needs to go to Dr. Sleight, who teaches the third year Advanced Ocular Disease class.  His class, with its detailed notes on treatment and management, online learning modules with color slides, and its tough but fair exams really prepped us for the material that Part 2 covers.  I am quite grateful.

Thus I have officially passed all three parts with scores that qualify me to practice in any US state. The feeling of relief is fantastic; my era of studying non-stop toward some future huge exam is officially over. (Well, unless of course the whole ABO Board Certification exam thingy catches on nationwide:  a topic for a future post).  My free time can now be used for whatever time wasting activity I feel like, guilt free.  I can go to the gym and run a few extra miles without worry.  I can read fiction for pleasure without the creeping sensation that time should be better spent.  I can watch like 7 classic Simpsons episodes back to back without the fear of falling behind in class work and like this will somehow lead to my flunking out of the program. Basically my anxiety and neurosis is gone and I can have an adult life again!  Awesome!

That, of course, doesn't mean that I don't study.  In fact, I still pick up the books pretty much daily to look up diseases or treatments for things that I see in clinic.  As a fourth year student, you are still expected to think on your feet and do research about things you encounter through the day, whether it's in a journal or textbook.  Your preceptors still hold you responsible for learning; passing fourth year rotations is not a passive process where you can just float through and hope to pass.  But knowing that there is nothing lurking out there in the darkness clears my mind and I feel like I am able to better remember the things I read.  Though health care professionals must truly be perpetual students in a sense and keep up with continuing education and all the latest advances in their field, the "student" life dials down.  I am finally able to see what it will be like to be done as a student and practice in the real world, and that reality is only 4 months away and counting.  Unless of course I chose a different path post-graduation: applying for a position in an optometry residency program....

So I leave on a cliff hanger:  what is residency in optometry?  Is it mandatory or necessary?  If not, is it worth it?  In my next post, I will tackle that question and discuss what I think my choice will be.  Beyond that, in the post after that, I have to talk about my third rotation: clinic in a Boston community health center where exams in English are third in frequency to exams in Spanish and Portuguese.  Spoiler alert:  I love it, and I feel like it’s another thing I could choose to do for the rest of my career.  See you then.

...

As a postscript, I wanted to mention my friend.  I mentioned previously that her son had been fighting an optic glioma. Sadly, he passed in late November.  I can't really put into words how it makes me feel other than to say it sucks and it's terrible.  Many members of the NECO community got to meet him and know his story, and he touched many other lives.  His mom is hanging on and is actually starting her own non-profit to go with her already well trafficked blog.  To those interested in learning more about the blog and non-profit, please email me for details:  socialmedia@neco.edu. Thanks.

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1Nov/12Off

Frankenpost Part 2: Eye of the Storm

Part 2 of this double post: blogging during the super hurricane of 2012; or what I did to waste my day off while everyone had to deal with more serious things.

During 4th year rotations, rare is it that you ever get a day off; pretty much a natural disaster would have to occur in order to get a non-federal holiday off (and in some clinics you don't even get those off).  Unfortunately, that's what happened today; Sandy has made landfall.  I woke up to find out clinic is cancelled.  Boston seems to be just outside the area of major damage, but just enough wind and rain to knock out power intermittently and cause local pockets of flooded roads.  I lost power intermittently throughout the day, but it's back on for now.  Many friends at rotations south of here in NYC, DC, Philly and New Jersey are facing a fierce storm with likely many days without power, damaged homes or worse.  Hopefully it all shakes out to be good.  As for us here in Boston, cancelled clinic and classes, the subway closing for a day, and cheesy blog puns seem like nothing in comparison.

With my day off, I had planned to get a ton of stuff done. Highest priority: start really studying for Part 2, which is rapidly approaching in less than 6 weeks.  I was also going to do laundry, work out, do a quick grocery run, learn to play the harpsichord and finish writing this post.  I only got about two of those things started today.  It’s been a very distracting day, with a lot of being glued to weather updates and reading random stuff on the internets.  The NBA season is so close I can taste it and I feel like a kid the day before Christmas waiting for the presents under the tree (incidentally, the Celtics are going to be really good, even dark horse contenders this year, you heard it here first).  So while I didn't really touch Part 2 material at all, I did get the chance to reflect on my second rotation, as it is quickly coming to a close; T-minus 3 weeks until we switch again.

This rotation has been challenging and a learning experience in ways unexpected.  In many ways, it's a clinic experience unlike anything I've ever had, and probably unlike anything I ever will be do in my career.  As I've mentioned, I'm in Special Populations.  Instead of being at just one clinical site, I’m at three different ones, each with its own type of specialization.  On Mondays, it's pediatric ophthalmology.  On Thursday and Fridays, it's specialty contact lenses.

On Tuesdays and Wednesdays, I am at Perkins School for the Blind, made famous by the story of Helen Keller over a century ago.  Here we do low vision and functional vision exams on patients with impaired vision, blindness, deaf-blindness, rare congenital diseases and developmental or cognitive impairment.  We work to meet our patients' visual needs rather than focus on discovering disease or correcting them to perfect "20/20" vision.  The doctors provide education, feedback and future referrals to the patients and their caregivers.  It is a team based exam with myself helping the attending doctor, the (fabulous) Dr. Kran, along with a resident doctor, and another 4th year intern. We also get to observe Dr. Mayer who works next door, doing amazing work with visual field testing, helping to monitor brain tumor growth in children, sometimes before even an MRI can pick it up. The clinic coordinator, Darick, is both a clinical orientation and mobility specialist and low vision therapist and helps direct the patients toward goals in these areas.  This includes a wide range of things, whether its figuring out how to teach them to navigate in unfamiliar environments (such as learning to use a white cane) or obtaining and using magnifying devices (such as to read small print in a book).

At Perkins, some of the most difficult parts of the exam are figuring out what exactly I need to do to engage the patients in order to take vision and basic entrance tests.  We need to use toys, colored lights, cartoons, or music in order to reach them.  We are on the floor playing with toys while at the same time trying to sneak a peek at whether their eyes are crossing.  Sometimes sign language is needed, other times matching of basic symbols is the best we can use.  When we are able to make what might seem like a small inroad into completing an exam where others cannot, even just proving that the patient is using some part of their vision and nothing else, it is a feeling of accomplishment that has been unmatched in any other clinic experience thus far.

For some of the patients, we are able to achieve results in glasses correction where other providers simply did not have the luxury of time to help the patient provide this data.  Other patients get much needed referential to O&M services or other educational services, such as a teacher for the visual impaired.  Other times the patient is visually impaired to the point where there is little to do other than provide education on their condition.  In fact, the thing I've learned the most is the importance of communicating with patients and caregivers.  Often times the thing that is needed the most is being able to just sit for an hour and talk to an expert about what exactly their condition is and what it will mean going forward in their lives.  And so that is what I will take away from this the most; while I may not be able to fully examine such patients totally on my own, I know more fully the value of taking the proper time to talk to patients and caregivers, as both a means to put them on the road to find the services they need, and as well as an end in and of itself.

And with that, I take my leave.  The storm is beginning to let up here in Boston and hopefully everyone makes it out in one piece.  While the storm is over, the last surge to finish boards is on the horizon.  Next time: Boards Part 2 and reflections on the (hopefully) last high stakes multiple choice exam in my life, ever.

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1Nov/12Off

Frakenpost Part 1: The Magic Number

Well, you’re in luck, a double post!  Thanks to a generous deadline extension (on account of my being away on a business trip), here are two posts on two totally different subjects.  Up first: taking boards out of sequence.

Some background first.  Last year represented a bold step forward for board certification in optometry.  There was a change in the way Parts 2 and 3 of Boards are administered.  Part 2 is switching from paper based to computer based exams, which makes it somewhat similar to taking the OAT.  Really not a huge change, it just makes it a little more convenient for us.  It allows the examiners to show higher quality photos for diagnosis of ocular diseases and I imagine the new format will also help the turnaround time on scoring.  Additionally, we can take it at any location of a national chain of testing centers throughout the US, which may reduce travel time to a testing site.  Part 3 on the other hand received the greatest change in terms of how students have to plan, study and budget for that exam.

Part 3 traditionally has tested students’ clinical skills on real patients, in real time.  That component hasn’t changed at all.  What has changed is the when and the where.  Previously, the exam was held twice a year at each of the 20-something schools’ clinical sites, with patients and examiners plucked from the local community.  But now, in order to standardize the process and make us more similar to other health professions (or so they say, I’m actually not sure what other types of health schools do for boards), the NBEO opened a centralized testing center in Charlotte, NC, and requires all students to make the trip out there to take the exam.  This might seem a bit unfair.  After all, the added expense of flying and having to get a hotel room easily adds at least an extra $500 to the cost of becoming an optometrist.  But as the NBEO correctly points out, the cost of registration to take the exam has actually remained flat over the last 10 years or so, thus adjusted for inflation, we actually pay about $175 less than folks in 2001 paid to take the exam locally.  Not an obvious consolation right now in 2012, but true nonetheless.

In losing the ability to take it locally, we gain the ability to take the exam at practically any time throughout our fourth year, 5 days a week, 50ish weeks a year.  You can even, as I have chosen to do, take it out of sequence prior to taking part 2.  Therefore it is possible now to finish all three parts of boards just as the third rotation starts. That, in my mind, is fantastic.  The convenience of being able to take it whenever I want, and repeat it if something went wrong, as many times as needed, is more than worth what really is only a minor gripe over money.  An extra $500 is a small price to pay to advance the profession into the 21st century.

Travelogue

So now that I’m all done, I can report that the whole of my experience could not have been any more positive or gone more smoothly.  I spent the month in the lead up to my exam date, a weekday morning in mid-October, practicing in a room that NECO built to match the layout and equipment of the exam room in Charlotte.  There are four “stations” on the exam, each broken into skills for a total of 20 skills total.  The first station is case history and basic entrance exams, measuring glasses power and so forth, another is the dilated health part of the exam, another contact lenses and refraction for glasses prescription and so forth.  I found that I really didn’t have to practice as much as I anticipated; in reality, every day of my rotations this far was like practicing for Part 3 little by little.  Additionally, NECO’s lab proficiencies over the last 3 years (where we are tested in real time on clinic techniques in lab) helped more than I realized in setting up the mindset for this sort of test.

As far as the traveling part, flying from Boston to Charlotte was simple and stress free.  We are allowed 3 days off from clinic, a travel day there, the test day and a travel day back.  Luckily for students currently in the Boston area, Logan is a great airport to fly out of.  You can get to it quickly from almost anywhere in the city for the cost of a 2 dollar subway ride.  There are tons of cheap carriers with direct flights from Boston to Charlotte; mine was about 79 bucks each way.  Other than waking up at 4:30 in the morning to catch the flight, it was a breeze; the air time was about an hour and a half.  Once on the ground, you can opt to take a cheap shuttle that brings you directly from the airport to the center of downtown, which is exactly where the testing center and the major hotels are located.  And the ride is only about 10 or 15 minutes, too.

It is easy now to see why the NBEO chose Charlotte; it’s a great little city.  Its downtown is smaller than Boston’s, and it’s on a grid so it’s easy to navigate.  It’s a very clean and safe area, and there are tons of shops and eateries within a block to make it as easy as possible to arrive and get comfortable in order to focus solely on the impending task at hand.  And we get a super cheap corporate rate on most of the downtown hotels.  For a moderately fancy hotel room that I split with my buddy Petar (who was taking it at the same time), I ended up paying about 90 bucks for two nights.

The night before the exam, we spent most of the time going over the elements of each of the stations on the exam; making sure to get down the exact order of when to do what and what to say when. Then, we did some mock run-throughs on IV injections using rubber bands, socks and pens (tourniquets, fake “arm” and needle respectively).  Oh, did I mention we also have to pass an IV injection test as part of the whole exam?  Well, there’s that too, and it was really the only part I felt shaky about prior; we don’t exactly do this on a regular basis on patients in clinic.  It turned out to be just fine for me on the actual exam, but it was stressful in the lead up.  On the exam, it’s on a fake arm and while we got a chance to try it in lab third year, it wasn’t something we do repeatedly like using a slit lamp every single day in clinic.  So then this begs the question:  why it’s on the exam at all?  Well, it’s all for the potential future direction of optometry.  The future, Conan?  That’s right, optometry student, the future!  (And the present, it turns out.  Little by little, states in the south are expanding the scope of optometry to allow IV and even lasers!)

After some frustration watching the presidential debates, we went to bed.  In the morning after some quick eats, we made the five minute walk over to the exam center.  Now I can’t really talk at all about the exam and how it proceeded, short of reiterating what’s already open knowledge to the public through the NBEO website anyway.  All I will say is that everyone working at the exam center itself there was very nice, and the time there was well managed and organized.  You even get almost an hour to play around with sample equipment such as the fake injections arm and so forth.  Needless to say, save for a few minor flubs, I feel it went well.

As we were sitting in the Charlotte airport, our flight slightly delayed, myself and Pete agreed it couldn’t have gone any better.  We were relaxed and considerably less stressed than when we emerged from the testing center post-Part 1.  Maybe it was because we were well prepared, but I think that’s only part of it.  A little touch of southern hospitality and the convenience of Charlotte as a destination made all the difference, almost like we were on vacation.  Hopefully someday I will come back, not on business, but to explore the city more properly.

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17Sep/12Off

Writing Myself into a Corner

I originally wrote this post about my friend Keri’s son, who has an inoperable brain tumor, which started as an optic glioma; I was in fact down to the proofreading phase. Keri had given the okay, and indeed she herself has kept a very well written blog about her experiences.  She even came in for our Pediatrics class and allowed students to examine him, and I wrote a term paper about his condition.  However, in the recent weeks, his condition has greatly worsened. I get to visit with him on a nearly weekly basis, and the changes have been disheartening.  His doctors have discontinued all chemotherapy treatment, and have turned to palliative and hospice-like care in the hope of at least relieving some pain. It is feared that even in the best case scenario, he may not have more than a few months left.  It is a very tragic situation, one that I do not wish to exploit for the purposes of this blog. Therefore I am unable to say anything further, other than to ask that whatever beliefs you may have, religious or non-religious, that you keep people such as him with inoperable brain tumors in your thoughts. Beyond that, if it’s possible for you to do more, please volunteer or donate to reputable pediatric cancer organizations such as the Jimmy Fund or the Pediatric Brain Tumor Foundation.  A sad way to start a blog post, but I needed to mention this nonetheless.

New rotations, new rules

Life seems to keep speeding forward, no matter what else is going on around me.  My current rotation, second out of four, is called Special Populations. Instead of being at just one clinical site, I’m at three different ones, each with its own type of specialization.  In a way, it’s almost like being a third year student again, in that I am a transient again.  Not being at any one place for more than two days in a row means I had to dig out my equipment bag and lug all my gear from site to site each week.  I have yet to master any one site’s paperwork system. And I have to drive to three different locations with three different wake up times. But the tradeoff is more than worth it, as I have been able to see a much wider variety of patients and exam types than I ever would at any one place. It’s been almost the exact opposite of the VA.

On Mondays and Wednesdays, I see kids with a pediatric ophthalmologist. I have already helped manage the treatment of about 30 plus kids with amblyopia (aka a lazy eye).  On Thursday and Fridays, I am in specialty contact lenses, where I see patients with irregular shaped corneas, for whom glasses don't allow them to see as well as they will with a special hard lens. On Tuesdays, I am at Perkins School for the Blind, which is an entirely different animal, so much so that I want to save much of what I have to say for its own post.  Needless to say, the type of exam there is much different as we work as team to provide a functional assessment of the patients' visual needs rather than focus on discovering whatever illness they may have.  "We" being myself, my attending doctor, the resident doctor, and another 4th year intern, along with an orientation therapist and occasionally a third year student. We all work together at the same time, all in the room together.  It’s been quite eye opening and humbling, and I’m only 3 weeks in.

So much more to talk about, so much that next post, I’m not really sure what to pick from. Beside the stuff I mentioned above, there are many exciting events set to happen around the school in the next weeks, such as the NECOlympics.  Or the fact that I get to vicariously re-live life as a First Year; turns out my brother has moved to Boston and begun at NECO as a member of the newest class, the class of 2016.  On top of all this, I am on the verge of experiencing the Return of the Boards, parts 3 and 2! In three weeks, I’ll be flying to Charlotte to take Part 3, before I take Part 2. Should be interesting to say the least, so stay tuned!

 

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15Aug/12Off

Intermission/Transition

The meds robot malfunctioned and got stuck in the elevator today. You could hear its error messages in the hall for a half hour, telling people to stay clear until help came.  Pretty quickly the repairmen were able to get into the elevator shaft and fix the problem.  Within an hour, the robot was back to making its rounds, as if nothing happened.  I’ve seen the future, and apparently it does work, albeit with a few kinks to workout.

Since it is my last week at the VA, I figured I’d delay the final part of my cancer series to briefly say goodbye and reflect on my time at the VA.   Overall, it’s been both a surprising and positive experience, and it’s gone by so fast.  As I’ve mentioned in past posts, the VA today is not the VA of 30 years ago.  They are well staffed, and both patients and worker alike are happy to be here and always willing to help.  I’ve really loved all the people I’ve met and worked with, and I’m really going to miss it.

I also need to mention how much I’ve learned.  My preceptors, all three of them, are great people who were fun to work with.  They were fair and willing to go the extra mile to make sure I understood any hard concept or difficult to perform technique.  In three months (with their help), I was able to see over 300 patients, and I’m finally beginning to feel like I could do this whole optometrist thing on my own.  But really that was pretty much expected.  The most surprising part was in actuality the technology, including but not limited to robots!

The modernization of the VA means that they have had technology at the same time or sooner than most private practices.  For example, the VA had electronic medical records for at least 10 years before anywhere else had it.  This means that medical records are integrated and we have all of the patients past problems, blood work and so forth right at our finger tips.  Need to know if a diabetic patient has recently had an exam, or what their blood sugar numbers were? No problem, just click a tab.  And if we needed to run scans of the back of the eye, we have brand new imaging devices and visual field machines, newer even than ones we ran in labs at NECO.

The meds robots, though not really related to what we do in the eye clinic, are most amazing of all.  They are like little R2D2 style robots that self-navigate and go from floor to floor to drop off medication to various nurses stations.  They use robot arms to pick up and drop off, and they usually seamlessly get on and off elevators.  It’s been really interesting to see how the patients respond to seeing the robots run the halls.  Many guys give the little R2 a friendly pat on the back as its goes by, which usually triggers the warning signal to go off, telling them not to touch the robot.  It’s pretty funny!  Frankly, robot delivery “people” is about the last thing I expected to see here.  Soon the pharmacy will get automated robots to actually fill the bottles.  Who knows how many more things robots will be used for in the day to hospital operations of 20 years in the future?

And so I leave the VA a little bit wistful; I don’t want to go.  It’s weird to think of some other student moving around all the things in my room and seeing patients in my place.  But with that thought, I have a good sense of how I may want to shape my career.  A VA residency might just be in my near future, or at least an application into one.  In a future post, maybe I’ll talk about that.

My next rotation is special populations, where I’ll be seeing kids and patients with special needs.  I’m pretty excited.  My next post will be as promised, about my friend’s child with cancer and I’ll tie that into a talk about my new assignments and kids with blindness.

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7Aug/12Off

Part 2: Cancer for Cure

I’m more than two thirds of the way done with my rotation here at the VA.  I’ve been very happy with the experience, especially with the patients, who are some of the nicest, and frankly, most patient population of people I’ve worked with.  It’s also made me feel unusually wistful as well.  Much of this is because at our particular VA, there are several large “wards” which serve as nursing home-style, end of life hospice for vets who are dying of various illnesses.  As a result I’ve examined quite a few a patients who live here and have late stage or terminal cancer.

As cancer can metastasize from practically any tissue to invade the eyes and the brain (and by extension, affect control over eye moments, pupil reaction, and so forth), each patient requires a very thorough exam.  Beyond this, the patients need glasses in order to make life more enjoyable for however long they may have left, whether it’s months or years.  One patient told me his oncologist had gone from telling him he had only a few months to possibly a year or more.  He seemed uncertain if this was good or bad.

Unexpectedly, a large part of seeing these patients is simply taking the time to talk to them and giving them a chance to let someone listen to their stories.  They seem to appreciate having a new person to interact with, even if just for an hour.  Some have had relatives visiting and can accompany them to appointments, but many don’t.  The unfortunate truth is that for many, they simply don’t have any family members left; their wives, brothers, sons, daughters may all have passed on before them.  Others have living relatives, but they live far away and can no longer take care of them, for whatever reasons.  Some are okay with life in the wards, but other admit openly to being lonely and are scared to live out their remaining days in an unfamiliar place.

Every time I see a patient with terminal cancer, I wonder about what it’s like for them and what the story is for their families, how it’s changed all of their lives.  It makes me quite sad, especially those who have had trouble adjusting to the diagnosis or the place itself.  I can only somewhat relate.  You see eleven years ago, my cousin, Jason, fought his own battle with cancer.  So for every hospice patient that comes in, I am reminded of him.

Rags

When I was really young, I felt like a middle child, despite being the oldest, thanks in part to the relative chaos of my home life.  Back then, I always wished I had a wiser, protective older brother.  Luckily, Jason was able to fill some of that role from time to time.  Jason was in most ways everything that I was not.  A year older than me, he was tall and athletic, and self-assured. He loved basketball, and pretty much played all the time at the court just across the street from his house.  He had a thick skin, too; he never really knew his dad and was raised by a single mother during a time where this was uncommon out in the ‘burbs.  Out of necessity, he developed a razor wit and was pretty much the funniest guy I knew; he had a joke for any situation and never took things very seriously.  And on top of that, he was cool and had style; he had even heard of this music called “rap” way before anyone else I knew.

Jason’s mom worked several jobs and so he would have to stay over at my great aunt’s house almost every day after school so his mom could go to work.  My grandparents’ house was right next door and I, too, was often dumped off there after school and on weekends.  Hanging out with Jason in those formative elementary school years changed my life.  From him, I learned to be more confident and to stand up for myself.  He got me into basketball and music.  Basically, I bit his style and personality in every way possible, right down to his sense of humor.  I don’t know if he ever realized the influence.

As years passed and we went into high school, we hung out less frequently.  But Jason was always there if I need help or advice, looking over me if I got into trouble.  If I strayed too far into doing something really stupid, he would let me know.  And when my dad left home, he was there to talk about it, having grown up without a dad.  It helped a lot.

The Hard Part

Sometime around the summer of 2000, Jason began to get mysteriously clumsy.  He lost his coordination slowly; first he would inexplicably fumble and drop things.   Eventually he began to just trip over his own feet walking around.  Things like this went on for a while, but nobody thought much of it.  During this time, Jason and I drifted further apart.  I was doing the college thing, but we still saw each other from time to time at rare family functions and the occasional game of basketball.  One of the last times I played with him, I noticed he was a little clumsy handling the ball.  “Yo man, you’ve been slacking, you’re rusty!”

“I know!  I gotta play more, but it’s hard when you’ve got bills to pay,” he said.  This was one of the last times I saw Jason while he was healthy.

A few months passed and one day I got a call from my grandmother.  “Jason had a fall at work yesterday; he had to go to the doctor.”  She didn’t seem too concerned, so I thought nothing of it.

“That sucks, hope he’s okay,” I said.  More weeks passed.

“Jason’s been feeling lousy again.  His mom said he still feels weak and has been missing work.”

“He probably just got mono… when I got it, it knocked me out for a long time too.”

Weeks later at her house:  “Jason is in the hospital you know.  He can’t really move much on one side anymore.  I don’t understand why. They’re saying it’s some kind of brain cancer, I wrote it down…”  She pulled out a scrap of paper usually reserved for writing down the lottery numbers. The words were like gibberish to me at the time, like it was written in Polish.  “Tumor of the brain stem?... Well, you should go visit him; he could be there a while.”  I felt my heart sink.

“Sure thing, I will.”  As I left the house and got in my car, a wave of fear rushed over me.  To myself I thought, “I can’t go.  I’m too afraid.  I just can’t face it.”  I waited weeks to even think about it at all.

Eventually my friend, Ed, also a mutual friend of Jason, confronted me and talked me into facing my fear of seeing him so sick.  Jason had been transferred from the ICU to a rehabilitation floor.  As we drove over to the rehab center, I remember thinking to myself, “That must be a good sign, he’s rehabbing.”  I didn’t realize this place also served as hospice.

We got to the room and Jason’s mom was reading a book near the doorway.  She had never left the hospital this whole time, going back to months prior when he was first diagnosed.  She looked really tired.  “Hi Joey, how’s your grandmother?   Dana just left, you just missed him.”  Dana was Jason’s best friend and was probably there every day, too.  I felt a terrible sense of embarrassment.  They must all hate and resent me for not visiting.  I looked down at her and said, “I’m sorry.  I should have been here more.  I am a total coward.”  She looked up and smiled.

“That doesn’t matter.  All Jason cares about is seeing you.  Go in.  He’s waiting.”

We walked into the room and there was Jason, lying in the bed.  He looked frail and skinny.  He had an IV and tubes every which way and his hair was shaved short with bandages barely concealing surgical wounds.  His nurse was there, tending to something near the bed.  She smiled at me and asked, “Oh haven’t seen you before. Who are you?  Relative or friend?”

“I’m his cousin, Joe. This is our friend, Ed.”

“Nice to meet you.”  She whispered into Jason’s ear, “You have visitors.”  She turned to us, saying, “You have to get close, he can’t see or hear very well unless you go in.  I’ll leave you guys.”  On the way out she laughed, “He’s so funny, you know. All the nurses here want to go on a date with him.”

At his bedside, he grabbed my hand instantly, with a grip that was surprisingly strong.  “Hey Jason.  It’s Joe and Ed.”  He struggled to move his head up to look at us and his whole body tremored as he did.  As we made eye contact, his eyes looked crossed and twitched as they moved.

With a half-smile, the other side of his face paralyzed, he said, “Of course I know it’s you.  How are you?”  He spoke slowly and with a gravelly voice, but I could understand.  Time seemed to stand still in that moment.  I can’t remember exactly what I said next or what we talked about, but we stayed there for hours, talking about random things.

The nurse came back in and said it was time to go.  As I got up, I felt frozen to the spot.  After a few seconds, Jason moved slowly over again and looked at me.  In a hoarse voice, he said, “I love you, Joey.”  We had never said those words to each other.

“I love you, too, man.”  He grabbed my hand tightly again and then released.  Ed and I walked stone faced out of the room, said goodbye to Jason’s mom, and walked down the hall.  Ed was probably one of the toughest guys I have ever known; once he even pierced his own nasal septum with a nail.  But that day, as we got into the elevator, we both looked at each other and began to cry uncontrollably.

The Long Way Back

Jason held on for many more weeks, but his symptoms got much worse. He stopped breathing on his own and lost the ability to communicate all together.  I went back to see him with my grandparents and he was pretty much unresponsive.  Later that year, in late June, I was on a road trip, helping a friend move to the West Coast.  We were stopped over in Salt Lake City for the night and I called home to check in.  My then girlfriend (now wife) broke the terrible news that Jason had died earlier that day.  I took an early flight home.  At his funeral, I felt like I was out of my body, like I was watching someone else’s life on a TV.  It seemed like the whole high school class was there and there were lines out the door.  They buried him with a basketball under his arm.  That image is still burned into my memory.

Eleven years ago, I had absolutely no understanding of cancer or the brain.  What happened to Jason was scary and, in my mind, inexplicable. I avoided science and math in high school and I had no inclination towards pursuing a career in a health profession.  Now, years later, through my time at optometry school (and a biology degree before that), I have a completely different perspective and a fuller understanding of how cancer affects the brain.  I never would have predicted this is where I would end up.  Although optometrists do not manage the treatment of a brain tumor, they can serve to help initially diagnose its presence and are also involved in the long-term monitoring of progression via assessment of visual fields and the retina.  Perhaps most importantly of all, optometrists can help in the management of day-to-day activities through low vision aids and rehabilitation and also provide understanding and empathy.  I feel fortunate that one day I will be able to, in some small way, help those affected by all of this.

As the days wind down at the VA, I wonder more about the details of how Jason’s healthcare providers handled his case, from diagnosis to treatment.  But I’m not much closer to understanding fully what sort of toll it took on Jason and his mom and his close friends, or any of the patients I’ve seen for that matter.  In time maybe, maybe not.  But so it goes.

On and On

And that’s that.  In my final blog of the summer, I’ll close my three part post by talking about children with disabilities, Perkins School for the Blind, and about a friend with a child who has an inoperable optic glioma.  Should be a good one.  I’ll see you then.

 

 

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