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Moment of Trust


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.

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Colin Kerr
Executive Editor,
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