The oldest resident in an eye hospital

[caption id="attachment_8559" align="alignnone" width="750"] Illustration: Eoin Coveney[/caption] Just about halfway through our residency it happens, abruptly, unexpectedly. On a given morning, sometime during the third year of training, our schedule indicates that we are the chief resident in the Emergency Room of the Rotterdam Eye Hospital. In our hospital, the chief resident in the ER is referred to as, The Oudste,  which in English is The Oldest. This is a relative term, since we are only older than the other residents working in the ER that morning, but it sounds good. When we make the sudden transition from junior resident to Oudste, our tasks multiply. Although patient care remains our most important job, we are also there to assist the four junior residents, manage patient flow and serve as a gateway for tertiary referrals. The Dutch are highly organised, efficient workers who hate chaos, so The Oldest is also expected to manage and motivate the whole ER team. Having internalised this mentality, I remind myself: "It is not a circus; it is an ER. Make sure it stays that way." That is easier said than done. The four other residents can come to ask for advice regarding any patient they see. Nurses from the inpatient ward wait outside our exam room door, requesting clarification of patient care instructions prescribed by other doctors. Nurses from the patient phone hotline drop by for prescription refills for patients who have run out of eye drops. General practitioners call to discuss patients who are sitting before them in their examination room. General ophthalmologists call to ask whether they can refer their patients immediately, which of course they can. Subspecialists in our own hospital refer patients who need to be fast-tracked to the inpatient ward or to the operating room. And all the while, there is a medical student sitting next to us on a little stool, trying to find a manageable way to both learn as much as possible and stay out of the way. While I am examining a retinal detachment, Itsje, a junior resident, walks into my exam room. "My patient's IOP won't decrease. I've already administered all the standard meds. What next?" she asks, looking at me as though I've been an ophthalmologist for 25 years. I try to play the part. "What's the etiology? Uveitis? Steroid response? Posner- Schlossman? Closed angle? Neovascularisation?" I ask. "I'm not sure,"she responds. "I'll take another look." "Okay, report back to me when you have some more information." Assisting the juniors is my favorite aspect of being The Oudste. "It's a study of contrasts: at every moment, I am lifted by the realisation that I have learned so much during the past 2 and a half years while being confronted by the fact that we all have so much to learn before we graduate. As a first- and second-year resident, I always found it fantastic to be able to discuss a patient with The Oldest. They seemed to know so much, to have an answer for every question, a solution for nearly every problem. But not for everything. What I now realise is that a great deal of what I am unsure about cannot be found in the literature. Instead, we have to rely on judgment and feeling that can only come with experience. So, I don't hesitate to refer junior residents and their patients to the senior subspecialists, with instructions to tell me what the answer was. Antje, a nurse from the inpatient ward, is waiting to ask me something. "Do you think Dr Bootsma really meant hourly eye drops, day and night?" She shows me the patient's record. The instructions seem clear to me. "Yes, acanthamoeba is nasty and painful and terrible. Hourly drops." A general practitioner calls regarding a patient sitting before him. "She has a red, painful left eye. No contact lenses. Unknown herpes simplex status. No history of uveitis. No trauma. Possible visual loss." There's only one appropriate response in this case. |"Okay, well, send her in. We'll be here all day>" Meanwhile, my patient with the retinal detachment is waiting. While I'm completing the documentation for surgery, one of our secretaries interrupts. "A general ophthalmologist called regarding a wheelchair-bound patient who was referred from the nursing home with a huge corneal ulcer in her best eye. Are we willing to assume responsibility for her care?" Another phone call, this time from a senior subspecialist. "Hi, this is Dr van Dijk from glaucoma. My patient has a superior retinal detachment in his best eye. Can you make sure he makes it to the operating room, today?" Oh yes, and there are also about 80 ER patients who would like to be seen before the nightfall. Ideally, each patient should be treated before the end of normal clinic hours, so that the other 20 residents in the hospital don't need to come assist after having finished their own specialist clinics or surgical cases. The other residents call before they come to the ER. "Do you need any help" they ask, hoping that the answer will be, "Nope, we've got it all under control here!" But it takes a while before a new ER Oudste can say that with reliability. The first few times that anyone is the Oudste, the waiting room is still overflowing at the end of clinic hours. The patients get restless, the secretaries become unhappy and the younger residents get stressed out. Time-management, multi-tasking, and delegating responsibility become the keys to success, and it takes quite a while to learn it all. After all, we're all just young docs with book smarts, a few years out of medical school and still new to many of the realities of busy practical work.

Tags: training