Melissa Valdellon

Keep a patient log

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.

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