Expectations In The Clinic

As the resident, you are our designee and extension in clinic.  The patient population on the VR service is unique with known or suspected vision threatening disease.  They will interact with you first and your doctoring skills (clinical exam, professionalism, compassion) will be called upon to put them at ease. As the resident, your goals should be the detailed evaluation and treatment planning of the new patients you see and the interval assessment of the return patients.  Please let us know if there are any particular exam skills, management, or testing interpretations that you would like additional training or assistance so that I we provide supplemental reading or skills training.

We would like this not to be a perfunctory experience—instead we rely on you as a vital member of the Service and expect you to take ownership of your patients and their conditions. Reading is required and is not optional on your patients’ conditions and should reflect in your clinic notes, letters, and in our discussions.

For new patients, we expect you to take the initiative regarding the patients care and think critically about the case. We expect you to perform a detailed hx (HPI, PMHx, Social hx, Surgical hx, meds, allergies, complete ROS), PE, have an assessment and plan (it doesn’t have to be correct), and communicate with the referring doctor (when appropriate) with a letter and/or by phone. Retinal drawings should be performed on most new patients (unless there is no retinal pathology) and on returns with retinal pathology. Our goal is to not only treat our patients but also educate (in a respectful way) the referring physicians and the patients who seek our opinions.

One unique aspect of our clinic is the role of ancillary testing including imaging, ultrasonography, and some systemic testing.  We will work together on making you an ultrasound and imaging expert, but you should attempt ultrasounds on all patients who require this test. Testing interpretations should be noted in the progress note.

We expect the resident to participate in clinic based office procedure such as lasers and intravitreal injections. Sometimes, there are special requests or circumstances that require the attending or the fellow to personally perform these procedures. Please do not hesitate to notify us if you are uncomfortable or need additional training performing these tasks. As the attending will be coming in to see the patient after the resident, the resident should refrain from delivering any major diagnosis as this may create unnecessary patient distress, especially if the attending does not agree with the residents' diagnosis/treatment plan.

Some key points in your evaluations are detailed below

• Think of any patient in a systematic pattern focusing on detailed history (with new patients think about being able to fit their presentation into the framework of at least 3 of these elements:  location, quality, severity, duration, timing, context, modifying factors, and signs/symptoms). 
• Retinal drawings with labels (in epic) should be performed for all new patients with retinal disease. Examples include PDR, RD, choroidal tumor, and others.

Think critically and systemically about patients and have that thinking reflected in your assessment section of the note.  In the grunt of the clinic, please do not hesitate to discuss a patient or a workup with us.  Above all, my hope and goal is for you to become better physicians and gain mastery, if not comfort, in assessing these challenging patients.

Examples of Diagnostic Testing Interpretation:

Optical Coherence Tomography Imaging

Right eye - normal foveal contour, diffuse thinning with some central sparing, with loss of outer retinal layers and some central preservation. no subretinal or intraretinal fluid. cpRNFL 91, no sig thinning

Left eye - normal foveal contour, diffuse thinning with some central sparing, with loss of outer retinal layers and some central preservation. no subretinal or intraretinal fluid. cpRNFL 97, no sig thinning

Nonspecific macular outer retinal loss in both eyes. No significant cpRNFL thinning OU

Color Fundus photography

Right eye-the optic disc is without significant pallor, subtle pigmentary changes at the peripapillary region

Left eye- the optic disc is without significant pallor, subtle pigmentary changes at the peripapillary region and temp macular region

Autofluorescence fundus photography

Right eye-stippled hypo-autofluorescence pattern in the peripapillary region with extension along the inferotemporal arcade and to a lesser extent in the inferior perifoveal region and temporal macular region.

Left eye- stippled hypo-autofluorescence pattern in the peripapillary region with extension along the inferotemporal arcade and temporal macula, and to a lesser extent in the inferior perifoveal region

Fluorescein angiography

Right eye-there is a stippled hyperfluorescence around the optic disc and in the macula most notably in the inferior and temporal macular regions which likely represent staining. There no definite leakage, there is no disc leakage.

Left eye- there is a normal arteriovenous transit time of the left eye. Early hyperfluorescence in the temporal macular region likely a transmission defect and corresponding to the RPE atrophic changes on clinical examination. There is no leakage at the disc or elsewhere. Notable is a stippled hyperfluorescence at the peripapillary region and macular region most notably inferior and temporal macula.

Color coding for retinal drawings:

In The Operating Room

While we don't expect all residents to be able to perform retinal surgery upon completion of the program, we do expect residents to serve as surgical assistants in a variety of surgical procedures, including vitrectomies, scleral buckles, membrane peels, and depending on our level of training, we would like you to perform specific aspects of select cases. The resident is expected to understand the indications for retinal surgery, and demonstrate a level of knowledge of how and why each of these procedures are done as well as basic post­operative management. They should be familiar with the potential complications for each type of surgery. For first year residents, you will perform many aspects of the external components of the case such as port placement and scleral buckling preparation as well as assist with the internal aspects of the case (scleral depression, movement of the noncontact system, etc.). Your role is very important. For more senior residents, you will perform both the external and some internal aspects of the cases.

In addition, third year residents are expected to

• take primary responsibility for the preoperative evaluation and postoperative care of operative patients
• assist in the supervision of junior residents
• when necessary, provide direction to medical students, junior residents and staff to assist with efficient patient flow