Author: Melissa

I’ve given a lot of mindset tips over the last few weeks regarding approaching clinic and your optometric education. Today, let’s talk about actual exam skills.

The last few years, it’s not an uncommon occurrence when a patient or a student makes a comment regarding my BIO “dance”. I always laugh and smile and say it’s all because of my years of doing yoga. It’s really hard for me to explain it, but my BIO flow involves a combination of slow movements, scanning in combination with lens tilting, and directing patient gazes that makes it work.

And it all evolved because of a couple of things. First, I remember that as a student, I continually got myself confused when I switched eyes in between scans. For example, doing all superior gazes of both eyes first, then all horizontal views, then all inferior views. My mind just couldn’t keep track of where lesions were. So rather than try to fight that, I learned that for me, scanning one eye at a time and recording those lesions first before going to the other minimized the chance of my recording a lesion in the incorrect eye.

Second, I quickly got very tired of the inefficiency with standing up and sitting down at a stool, adjusting its height every time I needed to get a new quadrant view. So my entire “routine” now is done standing with the patient seated and the seat usually all the way to the floor rather than raised to any height at all. Sometimes that means I’m tiptoeing a bit if a patient is particularly tall, or having that patient tilt their head ever so slightly inferior so I can sweep further out. For smaller kids, sometimes that means having the child stand on the edge of the chair and sometimes it means raising the chair so I’m more comfortable doing my sweep rather than crouching down as much.

Third, when I scan, my goal is to make a continuous sweep from the edge of the posterior pole at the level of the arcades all the way out to the periphery and sweep back in. To make sure I don’t minimize the chance of missing any peripheral findings, rather than doing a straight line sweep from arcades to periphery, I’ll make more of a flower petal shape coming back, moving my head a little bit so that the return sweep is covers new retina or overlaps slightly what had already been covered.

Fourth, I keep my light beam on its medium size setting and I use a good amount of light. Don’t think you’re being nice by using a dim light setting on your patients just to make sure they’re uncomfortable. Your job is to make sure their eyes are healthy and you don’t want to miss any subtle findings. On the flip side, don’t make the light so bright that they’re noticeably trying to squeeze their lids tight every time you approach their pupils with that light. I don’t like to fiddle with the light beam settings once the BIO is on my head and over the years, I’ve just found that a lot of glare is minimized simply by using the medium sized beam. And even if I have to use a brighter light, since I’m sweeping relatively quickly for my peripheral views and not lingering in any one spot too long, most patients are able to tolerate the time spent performing BIO.

Fifth, pay attention to where your beam and the patient gaze are and try to keep this as straight a line as possible. This ensures I’m getting the exact views I want. Simple in theory, but it took awhile for that to really lock in for me. It took an attending pointing out that while I had asked a patient to look superiorly, I was off to one side of a patient so my view was not the straight superior gaze I thought I was getting.

Lastly, keep practicing and keep adjusting. I know I spent many hours in pre-clinic practicing with classmates before we were ever in clinic and I still knew I had a ways to go. Have your attendings watch your BIO flow and give you feedback too. This is NOT an easy skill to master and it took a couple years of patient care to honestly feel like I wasn’t going to miss any major findings. And if your attending does point something out to you that you missed on your exam? Do NOT take it personally. Put your BIO back on after they leave and look for what you missed. After the patient has left, figure out how you can get to that spot in your next patient and patient after that consistently. You’re calibrating your sensitivity to spotting what’s normal and abnormal as well as learning how you need to move or place your hands and light in just the right spot so everything comes together for that perfect view. And just because what I shared with you today works for me doesn’t mean it has to work for you. Play with it. Have fun while you’re practicing.

We’ll talk about troubleshooting for the not so straightforward patient another time. Happy practicing!

I still remember the first patient I saw as a student clinician. The room was crowded because besides the patient and I, there was the attending doctor and 3 other classmates. We were doing team care for this young patient in his early 30s who came in complaining about irritated eyes.

I remember being so focused on ‘my part’ of the exam, I really didn’t pay as much attention to what was going on. I listened as the patient said he had no vision concerns, all he was worried about was his itchy, irritated eyes. I watched as a classmate did refraction and someone else did anterior segment. I did posterior segment and found nothing remarkable.

And we all got together with the attending doctor who confirmed our findings and did the final consultation. He agreed that the patient did not need glasses even though we had found a small prescription. All he recommended was over the counter allergy drops for his eyes and sent him on his way. Only then did I do a double take. Why? Because we weren’t giving the patient glasses.

Coming from someone who’s needed glasses since I was 6 years old, I obviously did not understand the concept that not everyone who went to the eye doctor would get glasses. Obviously, I knew that some people came in for other eye problems, but this was the first time it really hit me that even though this patient had a minor amount of refractive error, it wasn’t something to prescribe because he wouldn’t benefit from using it for his daily needs. I had to speak to the attending doctor about it afterwards and he was said that in his mind, why would he ask someone to pay good money for something they wouldn’t use? Yes, there were other kinds of doctors who would probably do the opposite and push and strongly recommend their patients to always obtain glasses to give themselves the best vision possible or latest fashion trend, regardless of actual need.

My attending that day, in a way, asked me what kind of doctor I desired to be. At that moment, I realized I had come into the profession with a preconceived idea of what an optometrist does. See a patient and give a prescription and maybe address some dry eyes. It was suddenly hitting me that there was more to my profession than just repeating a formula. What I was truly being asked was if I could provide personalized care to each and everyone of my patients. Sometimes, that would mean giving glasses. Sometimes that would not. Sometimes that would mean not seeing someone and referring them straight out to get other needs taken care of more urgently – it’s happened a few times already where a patient’s blood pressure is checked early in the exam and found to be emergency room level high and we stop an exam to get the person the more pressing care they need.

This exam showed me that some expectations should be let go. Rather than coming into a patient encounter expecting one thing, what is more beneficial is to be curious about what can come out of asking more questions, anticipating your findings, cross-checking to see if your guess matches results and determining why – why is the patient here, why are their eyes working and functioning and behaving the way they do, and why are they here in your chair at this moment?

When you let go of expectations and stay curious, you switch from technician mode who does everything according to a checklist to a patient advocate who partners with their patients in their overall care.

Outside the exam room and school setting, it wouldn’t be a bad idea to let go of expectations in other areas too. Can you identify where such thoughts are causing more stress than worth? Time to let it go… *cue Disney music here*

One of the simplest things I did as a student clinician was keep a patient log. Starting with the first patient I saw on my own, I kept track of certain facts about each patient – refractive error, best visual acuity, final prescription, ocular health findings, and – most importantly – any interesting pearls to take away from each patient.

Every patient, especially in the beginning of your clinical career, should have at least one thing you haven’t encountered before or have something that you didn’t understand. Those first few months, there should be a lot of “firsts”.

My first patient ever was a middle aged woman who needed to update her multi-focals. My attending and I spoke about the first instinct of just increasing an add to address her near blur as opposed to going over multi-focal designs, work environment and lighting and lifestyle needs to make sure her glasses were appropriately made. I have since had to adjust prescriptions for dental hygienists with decreased working distances, violin players who perform in in symphonies and need to see both the conductor in the distance and their sheet music up close, office workers who are on the computer long hours out of the day using multiple screens, and elderly patients who still sew and knit by hand.

I remember a male in his 40s, refracting one eye to an easy 20/20 but not the other eye. I did retinoscopy and refraction 3 times trying to get him to see better before moving on. After dilation, my attending took one look and ended up taking pictures – it turned out to be my first time seeing central serous retinopathy in person, explaining why this patient could not be refracted better than 20/60 in that other eye.

I remember a patient who had a moderately high myopic prescription who came in complaining that her vision was blurry with her new glasses. After checking their vision and refraction again, I found no change to the prescription. It wasn’t until another attending asked how the glasses were sitting on her face and demonstrated how adjusting the vertex distance that I realized how much of an impact that small detail could make because she was suddenly able to see much better and things seemed less distorted around her.

I wrote notes on how different doctors came up with a final prescription if an incoming visual acuity did not match refraction results. I wrote notes on how different doctors treated and managed their glaucoma patients. There were notes on how different types of urgent care patients were managed.

All of that went into a small notebook that I continued to add to until graduation, and then I hung onto it for a few more years afterwards even as a new doctor. It was always interesting to see what pearls I could take away.

Keeping a log is extra work, I know, but the ability to look back and see what you did for one patient can truly help you develop an understanding of how you can manage something similar when you see it again later. As an attending myself, I know I have spoken to more than one student about the benefits I got from it. One of them took it a step further and kept his log on google drive and then shared access with his attendings so we could give added input too for his patients. I thought this was brilliant – even if we couldn’t always go in depth about every single patient encounter, there were at least takeaway points from both his side and the doctors’ side for the student to review afterward.

Keep a log. In the end, it will also be a written testament of how much your clinical thinking has developed and how you’ve grown as a clinician in just two years.