Melissa Valdellon

Receiving criticism

It’s that time of year when we transition from summer sessions to fall. That also means it’s quite possibly time for evaluations.

First off, let me remind you that as part of your education, you are obligated to receive feedback on what is going well with your exams and your performance, and sometimes more importantly, what areas require improvement.

I cannot stress enough how important it is to not take this feedback personally! Having been on both the receiving and giving end, it is never a pleasant experience when one has to discuss less than stellar skills.

I’ll give a personal example – when I was a fourth year student, in my last rotation before graduation, I ended up working with an attending who left me feeling stupid each day I worked with him. I felt like he was pushing me harder and treating me differently than my peers, who were getting along with him just fine. He had critiques for every part of my exam, from refraction, to slit lamp, to BIO. I felt terrible.

At the same time, one of my other attendings at the same time happened to be a preceptor of mine during my summer of third year clinic. One day working together close to graduation, he made a comment to me that hit hard – he had seen me in third year, confident, engaged, happy to be in clinic and learning. Now this close to graduation, I seemed the exact opposite – the confidence was gone, I seemed to be questioning everything… “What happened?”

It wasn’t until years later when I was watching this video of a professor giving his last lecture that I understood the feedback wasn’t about me. The lecture has since served as a source of inspiration for me, and despite his having since died of pancreatic cancer, many of his tips still resonate with me. The one relevant here goes like this:

“When you’re screwing up and nobody says anything to you anymore, that means they’ve given up on you. You may not want to hear it but your critics are often the ones telling you they still love you and care about you and want to make you better.”

This is a classic way of how you get to decide how to look at the feedback you receive. Do you take it to heart and let it eat you up because you have failed, or do you take it as an opportunity to grow? Because your instructors are giving you feedback, they have noticed your effort and want to contribute to your growth. For those instructors who don’t offer any solid feedback and let you go on silently, well then, I might be more worried because that is a sign that they didn’t get to know you well enough to monitor your progression.

So take the feedback as what it is – a gauge on how you are doing as a student and clinician and how you can improve from there.

And if you have free time, I highly recommend watching Randy Pausch’s The Last Lecture or reading his book of the same name. I found both fun and easy to watch and read.

The really pediatric exam

So let’s talk about those kids who are in that 3-5 year old range, where letters and numbers aren’t quite necessarily solid, left and right directions can be confused, and attention span is very, very limited.

What do you do?

I know back when I was an intern and doctor, the first thing I was told to do and followed ever since was take off my white coat before entering the room with them. For a lot of kids, a doctor’s office is really scary – who likes being poked, prodded, getting shots, and all that? It’s unpleasant enough for me now as an adult and to see it from a child’s eyes, well it can be pretty traumatizing too. So if there’s one less thing distinguishing me as a scary authority, then I’ll happily forego the white coat for these exams.

Next, I try to break the ice to see how open the kid is. That usually means asking if they have two eyes and their eyes are in their head. If I can get at least a smile, I know we’re going to be ok.

Depending on the child, I might have them sit in a parent’s lap or sit in a chair on their own – it might not necessarily be the exam chair at first! I want to get them comfortable and that has sometimes meant I bring out the color vision and stereo testing to do first wherever they are, just so they get comfortable. Then I have a handheld lea symbol guide and ask them to name each shape first when it’s super big so we all know what shapes they can grossly see under binocular conditions. Based off of those responses, then I can attempt a near VA with them either pointing to the guide or naming what they see so the child has options.

The patient’s confidence level can make or break this part of testing. I really try not to push an initial VA too hard because I know I still have other testing I need to do. I have them focus for a near cover test and some accommodation/convergence testing, and only after all that do I attempt a distance visual acuity, based off the child’s responses so far.

At this point, I have a couple options, I prefer free space retinoscopy with ret racks over autorefractor, although I will try to get both if I can, especially if I am concerned about any amount of cyl.

Biggest thing here is this though: do not spend more than 5 minutes total on refraction. The younger the child, the shorter refraction testing should be. Unless they are a very good, patient kid, they will lose interest and your results and their responses are just going to get worse and worse. Better to just get a rough idea and then move on to dilation.

When is a cycloplegic dilation warranted over just using normal tropicamide and phenyl? That will certainly depend on all the data that has come up so far, especially if this is the patient’s first eye exam ever – referral, chief complaint, visual acuity, retinoscopy, and refraction results. Generally, if there is some amount of plus, astigmatism, or eso tendencies, I will use cyclo for that first exam.

What if the kid has been great but then the idea of eyedrops freaks them out and they start screaming or crying before you can get near to them again? Well, there’s a few things. I can step outside and give the kid a moment to decompress and see if the parent can talk them into it after a bit (unlikely, but possible). I can try to force the kid to just take the drops and have the parent restrain their kid enough so that they hopefully don’t hit or kick you (also not ideal).

Personally, I’d rather build trust with the kid and try to not make the experience overly traumatic if possible. My goal is to make sure their eyes are healthy and they see well. If I can’t do everything at this first visit, then there will be a second visit to finish everything off. But I send the parent home with homework. I tell them to get a bottle of artificial tears and practice putting in an eyedrop in each eye every single day until they come back for their follow up. Hopefully, that few weeks’ worth of eyedrops is enough to desensitize them so that by the time they’re back, they’re okay with getting eyedrops in office and then I can perform the ocular health portion of the exam (I tell them I’m going to try to look inside their eyes so I can try to peek into their brains) and get more objective results for any needed glasses.

And that’s it. That’s my approach to a basic pediatric eye exam. I try to keep other questions light so they stay engaged – what grade they’re in, what’s their favorite subject, what’s their favorite food – and not as hyper focused on all the testing going on. And of course, giving them an end of exam sticker or two is always nice.

I hope you find this useful. Do you have any extra tips on how you deal with your peds exams?

The complete case history

When a patient comes in for their comprehensive eye exam, we have a few things we need to address. We need to assess visual status of each eye, binocularity and visual function, and ocular health. How does that translate to in my case history?

I have mentioned before that I have kind of developed a bit of a speech for the beginning part of my exam that helps me hit all the necessary points for a comprehensive eye exam. And if the patient brings up other topics, I re-direct them here and there to make sure we get my main questions asked, which are:

  1. Do you have problems with your vision in the distance or up close?
  2. Do you use glasses for distance or up close?
  3. How old are the glasses you are using?
  4. When was the last time you had your eyes examined?
  5. Do you have any headaches or eyestrain in general?
  6. In general, how do your eyes feel? Do they feel dry, itch, or burn?
  7. What eyedrops do you use?
  8. And how about your general health – do you have diabetes, HTN, or other systemic conditions?
  9. What medicines do you take?
  10. Do you have any allergies to any medications?
  11. Do you have any history of surgeries or injuries to the eyes?
  12. And in the family, does anyone have any eye problems or conditions and how are those conditions being managed?

Of course, depending on the patient’s response, I would go into more or less detail on some of these points. Obviously, I wouldn’t ask about glasses if I actually know this is a child’s first eye exam after failing a vision screening. I would ask a diabetic patient what year they were first diagnosed, what’s the highest and lowest blood sugar reading they’ve had over the past month, their latest HbA1c if they know it, and how closely they’re being monitored by their PCP or endocrinologist. And if it were a patient I have been monitoring for an ocular condition, like glaucoma or macular degeneration, I would follow up about their compliance with eyedrops or supplements and Amsler testing if needed.

And as a reminder, I spread out my questions to the appropriate part of the exam so it doesn’t feel like an interview right at the beginning of the exam. In the example questions above, you can see I have them grouped into vision and visual function questions for the first part of the exam and health questions for the second half.

Over the course of my practice, I have found these pointed questions to be more helpful in getting the best information out of my patients than asking open-ended questions. But what about you? Are there any you would add or subtract? I’d love to know.

The art of pre-charting

I can laugh now, looking at the days when I would show up to early and pre-chart for every patient that was on my schedule for the day. Yes, it gave me an idea of what kind of day to expect, if there were any challenging patients to look forward to or if I was going to be able to catch up with some of my favorite patients. I inwardly chuckle now when I see my students doing the same thing.

When I was working on the Navajo reservation, however, I quickly came to realize that my schedule always changed. Forces outside my control would mean patients would miss their appointments and follow ups. Sometimes, that would be because of lack of transportation. Other times, there would be work they could not get time off for. It did not matter of the weather was rainy or snowy or sunny – the show rate varied all the time. And then we would get a lot of walk in patients who were okay waiting to be seen if no one showed up or urgent care patients needing a red eye treated.

Now that I am working in community clinics, it’s still the same. My patients still have to deal with transportation issues, time off from work, family obligations, and more. I’ve learned to not let that get to me. If I have a light day, great. If I have a busy day, great. The no show rate is highly variable. But what I do know is that when the patients do show up, they are serious about getting their eyes checked out and I am here to (hopefully) help them.

So what do I do when a patient actually shows up, especially if they are a return patient? I generally only look at 6 few things:

  1. When was their last visit with us
  2. What was their best corrected vision at the last visit (and put their last prescription in to the phoropter if applicable)
  3. If their vision was not correctable to 20/20, why
  4. Quick review of last chief complaint
  5. Quick review of last plan
  6. Quick review of any prescription eyedrops or medications

Any other details and specifics, I can look at again later when I’ve greeted the patient and after I have already started the testing.

This review should only take a minute or so, depending on the patient complexity. You don’t have to spend five or ten minutes going into all the details because things may have changed since the last visit and you need to prioritize the reason for today’s visit anyway, which may or may not match the last exam’s plan.

So in brief, I would suggest keeping the majority of your pre-charting to an efficient minimum so you can maximize your time with the patient in your chair.

What do you add or subtract from your pre-charting to help with your efficiency?

The malingering patient

So I was speaking to my students recently about how a lot of the kids we see at this clinic are amblyopic and that they don’t see a lot of normal kids. I agreed, saying we are a referral center for the kids who have failed their vision screening either at school or with their pediatrician.

Somehow after that though, we got onto the topic of the malingering patient and how they had not come across one so far. I told them the stories of two of my patients who I remember to this day because of their stories..

My first patient was a 6 year old black male that I was seeing as a fourth year student at Bascom Palmer Eye Institute. The kid seemed like he was in good spirits and was enthusiastic to participate, but had come in because he had failed a vision screening. Throughout my testing, I had no idea what was going on for the first couple minutes because none of the letters he said for his vision check in the distance or near matched anything on the charts I had. When I did retinoscopy, I found a tiny amount of hyperopia, but nothing that matched his really reduced visual acuity. He did well on his color vision though, stereo was great, there was no strabismus on cover test, and his ocular health was completely normal.

I checked his VAs again after I dilated and confirmed that on a wet retinoscopy there was no sudden change in his prescription. I finally figured it out – every letter he saw on the chart, he added one more letter to it. For example, an A became a B. The O became a P.

It hit me that I had a brilliant kid in front of me who was so happy to have this attention on him – but I was the only one paying attention. His mom was in the room fussing with a newborn sibling and his father was in and out of the room on his phone the entire time.

I told the attending doctor that the child was fine but there was some social stuff going on that probably needed to be addressed. He comes in and tells the parents that the child is normal and doesn’t need glasses and sends them on their way.

My other story is about a girl, I think she was 8 or 9 years old, who came in and was literally bouncing off the walls the entire time she was here. She could barely stay focused to do VAs, asked about every little test, every little bit of equipment, wanted to touch everything – you know this patient, right?

She’s in the exam with her grandmother and from what testing I could do, this girl had maybe a +0.75 or +1.00 prescription. The grandmother had come in because she wanted to make sure the patient didn’t need a glasses prescription but that she had no other concerns.

After confirming that the prescription also did not change after dilation and her eyes were healthy, I spoke with the grandmother in the waiting room and let her know my findings. I also asked if the granddaughter had always been like this personality-wise, jut to see if they needed to be connected with other resources for behavioral issues.

The grandmother confided that the child’s mother had been murdered just a month or two prior and everything had been stressful what with court stuff and all. She was grateful I could confirm that nothing was wrong with the child and we agreed that it wouldn’t hurt to give her a mild prescription to see if it would help her focus with her homework at least and just see how things go.

My heart broke with each of these patients who were obviously going through huge family changes and were reacting the only way they knew how. That being said, I knew I had a job to do, to make sure these kids’ eyes were healthy and to make sure they had the right prescription if needed. Outside of that, it was my place to be a listening and open ear to a grandmother worried about her granddaughter and a nice doctor who could spend some quality time with a child and pay attention to them when no one else could.

Be patient with these individuals. They may be some of the most frustrating exams ever, but there is a reason for their ‘acting up’. It’s our job to find out why and see how we can support them.

What’s your story with malingering patients? Care to share here?

How to manage a difficult refraction

One of my students recently brought up a good case of discussion. She was working with a 65 year old Asian female who came in for her annual exam reporting that her vision was not as clear anymore.

She had last come into our clinic in 2021 and due to cataracts, was best correctable with the following:

OD -3.00 -0.50 x 060  20/40
OS -1.25 -0.75 x 120  20/50

This is in comparison to refraction results from 2019:

OD -4.00 DS               20/40
OS -0.75 -1.75 x 120  20/40-2

Both times, she’s been noted to have moderate mixed cataracts in both eyes but she wasn’t ready to pursue cataract surgery.

When she came in for this year’s exam, however, she was wearing something completely different:

OD plano -2.00 x 090  20/200
OS plano -2.00 x 093  20/50

The student also did auto-refraction before bringing starting her refraction and got this:

OD -5.00 DS
OS -3.00 DS

Afterwards, the student let me know that with all the different data, she didn’t know where to start her refraction so she had started with a random one and tried to work with them all to see if she could get anything better.

Her final refraction ended up being:

OD -5.00 -1.00 x 120  20/40–
OS -3.50 -2.50 x 156  20/40–

The patient was told about her cataracts again and she was now ready to pursue surgery since we mentioned that we’d have to change her prescription a lot for minimal gain in clarity.

After the patient left, the student and I discussed how she could have had a smoother refraction, and it relates to simply asking a couple extra questions:

The patient had mentioned her vision was more blurry. Where were things clearest? With the pair of glasses she brought in today, with an older pair she got from us previously, or without glasses at all?

The student recognized how getting this extra info could have directed her to a better starting point for refraction. She already knew that the patient’s cataracts were affecting the best visual acuity for a number of years now and that refraction was unlikely to yield anything better, but it would have saved her time knowing which direction to start from.

I hope this helps drive the point of asking more detailed questions when the data doesn’t make sense. It doesn’t hurt to clarify things in a way to help you understand the patient’s point of view or expectations, and it makes them feel like you’re invested in working with them to find the best solution for their needs. Win-win for all.

Directing Your Patients

Your time is valuable. Your time with each patient is valuable. You need to be able to connect with your patients and guide them along the exam as efficiently as possible.

So for me, that means I generally ask more pointed questions rather than leaving things too open ended and broad. Even as I sit patients in their exam chair, one of my first questions is “how is your vision doing in the distance and up close?” If they start going into how their eyes are feeling or anything else, I acknowledge their points but redirect them, informing them that there are two parts to the exam, the vision part and the health part, and that I want to check the vision part first.

Most patients respond favorably to that and voila, you’re back in control of an exam that could have led you down a strange rabbit hole. At this point, I’ll ask my vision related questions and do my initial confrontation testing. Here, I have found that holding the cover paddle myself means I make sure the patient’s eye is appropriately occluded and they can’t push the paddle up against their own eye. It gives them less change to fumble too. Typically, I only let a patient handle equipment during pinhole testing.

Next, I repeat that the next part of the exam is where we’ll be evaluating the patients’ vision status and needs. During refraction, I really try to keep in mind that patients’ incoming visual acuity and anticipating how much change is required to get them to see their best – if any changes are needed at all. I also keep in mind that a patient can only tolerate maybe 0.75 to 1.00 diopters or 20 degrees of change in any direction at any time from their starting point for my final refraction. With that in mind, I don’t typically keep a patient ‘accepting’ a certain direction if they keep saying it’s better after 3 or 4 options, as I know that’s usually going beyond what I’d be changing the prescription by anyway (unless it makes sense with their incoming visual acuity!).

Once refraction is complete and I have demoed their new prescription, I tell the patient that we’re switching gears and going into the ocular health portion of the exam next. This is where I’ll usually ask about how their eyes feel in general as well as their systemic health, medications, and allergies. Then I tell them I’m going to use eyedrops to check their eye pressure. When I explain that the eyedrops are necessary to help with evaluating their eye health, most patients are willing to comply. I do the same when I later go to dilate their eyes, explaining that it’s the best way for me to make sure their eyes are healthy and free of diseases like diabetes and glaucoma. For me, I have found that by explaining what I’m doing rather than making the ask if I can use eyedrops first, I find that more patients are willing to be dilated for their ocular health check. Too often, I have heard my interns ask first and their patients declining more as a result even after explaining the reasons why dilation is important.

Remember, I’m trying to get the patient to work with me. Most of your patients will want to cooperate if it’s in their best interest. They just want to be informed.

Overall, directing how your patients answer your questions can help streamline your exam. For example, when asking about headaches, rather than asking them to describe their symptoms off the top of their head, I go into specifics using questions like – Is it sharp, stinging, boring? Show me on your head where the pain is. Does this happen every day or few days? Does this happen when you’re doing something like reading or watching TV or when you’re walking around?

Of course, you want your conversations to still be in the flow and natural, and I don’t suggest that every patient response should be some kind of forced response. Incorporating more directed questions and limited patient options during key parts of the exam though can help you keep your exam moving in the direction you need it to go and uncover information that is important to your management and treatment plan.

Happy testing!

Play a guessing game

My attending doctor the summer of my third year asked us to guess our patients’ glasses prescriptions each time we walked them back to our room. There were no prizes or incentives for us to guess ‘right’, but what inadvertently happened was that started a path of guessing every part of the exam moving forward.

Sure, it’s one thing to peek at a person’s glasses when you first introduce yourself – obviously myopic lenses will look different from hyperopic lenses. And based on the patient’s age, I could guess if a patient was wearing progressives or not before I neutralized their prescription. I would guess the patient’s add if they were in a multi-focal design.

Taking that guessing game into the rest of the exam though, that was where the fun started and I believe that’s what helped me grow as a clinician. I was always anticipating what the next result would be and that kept me curious. Depending on the answers I got, that helped refine which way an exam would go.

Let’s say a middle-aged patient came in and off the bat says they can’t see well out of one eye. Immediately, I’ve broken things down categorically – can this be a refractive issue, a binocular vision issue, or related to some kind of ocular pathology? What question or set of questions can I ask to help me focus on a likely differential within the first few minutes of the exam?

Let’s say you go through your confrontation testing and the right eye is light perception and the left eye is a soft 20/20- without correction. EOMs are full but you notice a mild RAPD in the right eye. Also, when you’re doing pupil testing, you notice something white where the lens should be – the other eye seems clear. Confrontation fields are full for the left eye but he is unable to distinguish anything besides light in the right eye.

At this point, you probably have ruled out refractive error and binocular vision as a top differential to this patient’s poor vision. With that in mind, you should know anticipate that refraction really shouldn’t take you very long – big steps are likely not going to help the right eye and you should already guess that the left eye will have a very minimal prescription at all. Recommending an age appropriate add is likely okay here but your goal here was to get to dilation as quickly as possible to fully assess the patient’s ocular health.

As you’re dilating the patient, what can you anticipate about this patient’s ocular health? Does a white cataract account for light perception vision? What could have contributed to this patient’s cataract development in the right eye? Would you anticipate any lenticular changes in the left eye? What are some causes of asymmetric lens changes, especially if the patient (including this one) strongly denies any history of ocular trauma?

Take a different patient now who was last seen two years ago, was correctable to 20/20- in both eyes but already showed evidence of moderate nonproliferative diabetic retinopathy OU. If this patient came in and saw you today saying his vision in the right eye has been bad for the last year, what would you expect? There could be a refractive shift, sure, but less likely if it was only monocular. If I told you he came in needing extra help with walking because he had his left foot amputated from diabetic complications in the last couple months, what would you expect to see in terms of this patient’s ocular health?

Predicting what you’re going to find can help you decide if you need to spend time doing a thorough, careful refraction or performing different binocular vision tests or going straight to ocular health. You can also anticipate your patients’ concerns – is their vision going to get better, are they going to need a referral for surgery or other specialty care, are there any supplements or exercises that you’d recommend for their condition, etc.

Approaching exams this way has kept a lot of exams from feeling too ‘routine’, especially if I can force myself to give at least two two three differentials for whatever it is I’m finding. Besides, who can resist having fun in the exam room even if it’s a game you’re playing by yourself and no one else has to know?

Happy guessing!

BIO tips for the straightforward patient

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!

Letting go of expectations

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*

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