The eye test for ophthalmic residents

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The Residents' Lounge in the Rotterdam Eye Hospital usually has a rather carefree vibe. Conversation bounces from discussions of last weekend's activities to the spectacular cases that presented the night before in the emergency room. And the conversation is always interesting. One resident recently married a Brazilian lawyer he met while in Vienna. Another resident (me) just welcomed the arrival of his first child. How's that for early-morning conversation? To be sure, the carefree vibe is punctuated by some requisite whining. After all, it's raining outside, the sun has yet to rise and the caffeine has yet to reach our blood streams, but we're generally pretty happy to be there in the morning and to get started early. A few weeks ago, we 20 residents arrived in the clinic just before 8am, as we always do. One or two arrived by train, two or three on foot and, this being Holland, the rest by bicycle. We swarmed into the Residents’ Lounge and gathered around the espresso machine. But on this particular day, the mood was different. We were all tense, agitated, excited, like greyhounds at the starting gate. There, above the espresso machine's distinctive droning hum, we looked at each other and hoped it would be relatively painless and over soon. The yearly ophthalmology exams were about to begin and the pressure was on. The exam proctor entered to tell us it was time to start. We filed out of the Residents' Lounge and into the hospital's conference room. At 8 o'clock sharp, the exams were distributed and we were off. All ophthalmology residents throughout The Netherlands take these exams simultaneously, and passing four sets of them is required before graduation. This year was my first time, and I realised that they were the first exams that I'd ever taken in which the material would be relevant for the rest of my career. Sure, information that I had studied in medical school has been secondarily useful during my ophthalmology residency. Medical retina is impossible to practise without understanding diabetes as a systemic disease. But I found myself, a year into my residency, studying the actual presentations of uveitis, the diagnostics of glaucoma and the techniques of cataract surgery, the updated versions of which I'll still be applying 30 years from now. No longer did I have the medical school feeling of, I'm going to try to learn this really well so I'll get good enough grades to be able to get into ophthalmology and actually learn what I want to learn. This was it! Learn it and remember it! Make it a part of yourself.

Learning curve

Fortunately, learning during residency is very different than it is during medical school. It's more interesting, less painful and more all-enveloping. During the week, it's a full-day experience, broken up into tolerable chunks. Half the day is spent in the clinic learning from patients, colleagues and attendings. The other half of the day is spent learning from case studies, journal articles and, via textbooks, renowned experts. Clinical experience and book learning eventually blend into a relatively seamless entity. It isn't quite effortless, but it's no longer the sort of isolated martyrdom that sometimes characterised the hours, days, weeks spent memorising pulmonary physiology and renal pathology. Nevertheless, the familiar feelings came surging forward while I was studying, wild oscillations between the excitement of learning and the dread of exams looming ahead, interspersed with totally irrational ideas (“I wish the white dot syndromes didn't exist because I don't understand them!. But this time, I was learning for my patients and myself rather than for my professors and my resume. Back in medical school, did I ever really want to know exactly what a gastric chief cell does? No, not really. Do I now want to be able to tell the difference between sterile and infectious endophthalmitis? Yes, for sure. The questions were drawn from the textbooks we were told to study, but I felt I could answer about one fifth of the questions just purely based on what I had seen in the clinic, and for another fifth, practical experience helped me eliminate at least the more incongruous answer possibilities. For the other 60 per cent, my brain was on its own and was going to have to recall what it had come across in the books. Or, more accurately, what it came across in the fields, which is where I did most of my real learning. I have developed an unusual studying method. Borne of necessity during otherwise lost hours of commuting to rotations in far-flung hospitals during medical school, I started distilling the information I needed to know into questions and answers and recording the results on a tiny digital voice recorder. I read the textbooks and then recorded the important facts, which I could listen to later. My commutes thus became intense study sessions in which the soundtrack was a stern “me†asking myself what I needed to know. Now that I'm living and working in Holland, I have no real commute, but instead endless flat terrain behind my house and bike paths connecting every point on the map. So, while my colleagues were inside sweating it out with their books, I was outside, cramming it in on my bicycle. I found I could cover the important points of a book from the AAO series in a long day in the saddle, cruising from Rotterdam to the Hague and back. Sometimes I didn't know which I was exercising more, my mind or my body. The idea was to get out of my comfort zone. I felt I could answer basic questions about glaucoma while sitting at a desk with my head in the books, but could I do the same in the middle of an iconic, wide-open Dutch field dotted with cows and windmills? Could I prove to myself that I had made this information my own? Because that's what it comes down to in the end, making the ophthalmic knowledge one's own.