Moment of Trust

There comes a time when a senior ophthalmologist decides to place his or her trust in a resident’s judgment and skills even without a formal teaching moment, without an official evaluation. There is a transfer of trust: “I think you can do this on your own, even though you’ve never done it.” There is an acknowledgement of maturation and of the inevitability of competence: “Within a year or two, your legal status as a certified ophthalmologist will equal mine, so let’s get on with it.” And there comes a time when it simply becomes more practical to allow a resident to do it him- or herself. By 'it' I mean small surgical procedures that senior ophthalmologists do regularly, but what we residents have to earn the right to do outside the traditional training plan.

As residents, our surgical training occurs within a highly structured framework. The interventional learning process starts off slowly, step-by-step. We’re taught how to laser the retina to treat tears, laser the posterior capsule to eliminate opacities and laser the iris to relieve acute angle closure. We remove sutures from corneal transplants, excochleate chalazia and epilate distichiatic cilia. We perform strabismus surgery, suture scleral buckles and extract cataracts. We revitalise upper eyelids, tighten lower eyelids and eviscerate or enucleate all that which cannot be saved.

But there are surgical interventions that are excluded from the official training modules because of their infrequent and unpredictable presentation. Their need usually arises unexpectedly, often as a complication of a prior surgical procedure. Yet once the decision has been made to perform the intervention, the question arises: who will do it?

I had one of these moments recently. I presented a case to a senior glaucoma specialist, Dr de Waard, during his clinic: “Mrs Suykerbuyk has been vomiting since she returned to the inpatient ward after her glaucoma drain operation this morning. Her IOP is 66. I don’t think topical treatment will help much here. What would you like to do?” “Drain it,” he replied. “Ok, I’ll get her prepared and I’ll call you when she’s ready,” I said. “No, I mean you drain it,” he countered. “Pardon?” “Drain the anterior chamber. The temporal paracentesis incision is fresh and will open easily. Indent the posterior lip of the incision and the pressure will be relieved.” I hadn’t expected him to request such an invasive manoeuvre, and my surprise was probably obvious. “You’ve done intraocular surgery before, haven’t you?” he prodded.

Yes, of course, I thought. In fact, Dr de Waard had been the first staff ophthalmologist to allow me to perform an intraocular manoeuvre when he let me insert an IOL at the end of a standard cataract operation. This he had surely forgotten long ago. “Yes,” I answered, with more confidence. I had since successfully completed my surgical cataract rotation. He said: “Well, get it done. It’ll be fine,” and he turned to examine his next patient. “Let me know how it goes.”

So I returned to Mrs Suykerbuyk to explain the plan. “The specialist recommended we release the pressure,” I said, while contemplating all the possible complications of such a manoeuvre. “Sure,” she said, without requesting further details.

A patient with extremely high IOP will agree to nearly anything to be relieved of the discomfort. I performed the paracentesis, the IOP dropped and the patient felt better soon thereafter. Dr de Waard was happy to hear that it went well. And he was pleased to have been able to continue with his clinic essentially undisturbed. The moment that trust is transferred to a resident occurs with each resident and each staff ophthalmologist at specific and unpredictable moments. An important factor seems to be the senior doctor’s confidence in his or her own skills. Dr de Waard is not lacking in confidence. He seems quite assured that if we were to mess something up, he could probably fix it.

Another factor is confidence in the residents themselves. Dr van Meurs, a senior retinal surgeon and director of residency training, has this to an unprecedented degree, despite his profound, near-philosophical deliberations about nearly every case. “Dr van Meurs, I have a pseudophakic patient with gas in his anterior chamber a few days after vitrectomy. The pressure is in the 50s and he’s quite uncomfortable.” “Hmm… that gas isn’t too useful there. No sense in keeping gas in the anterior chamber. Use a 30-gauge needle,” he replied, as he continued with his retinal laser clinic.

Off I went. An anterior chamber gas paracentesis makes a distinctive “pppfffttt” sound, and it’s surprisingly effective. I called Dr van Meurs to tell him that it went well. “Goed. Goed gedaan.” Well done. I had thus performed two anterior chamber paracenteses and felt like a pro. This was fortunate, because a few days later, during the Avastin clinic, a patient experienced amaurosis after an intravitreal injection.

“Did the lights go out? I can’t see anything at all,” he said. “Not your hand, not the lights, nothing.” In this situation, there’s no time to consult with a senior doctor. I turned to the nurse, requested new sterile gloves, a fine needle, extra anesthetic drops and antisepsis. “I’m going to release some pressure from your eye, sir.” I flattened the patient’s chair to horizontal, stabilised my hands on his face and penetrated the temporal cornea with the needle. One drop of aqueous oozed out of the end of the needle. Done. “Yes, it’s coming back! I can see the light again!” I could see the light as well. New skill: paracentesis. New feeling: confidence.  

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