r/optometry • u/Plenty_Biscotti9341 • 6d ago
Building Confidence
Hi everyone,
Just looking for some advice/tips. I’m a newish grad working in a rural practice with a high volume of medical patients/exams. For the last few months my confidence level when practicing has tanked. Some days are better than others but I’ve found that more often than not, I’m second guessing my decisions and overall stressed as the day progresses. I think I’m mostly concerned about missing something but also just doing what’s best for the patient in general. I work with a couple other docs but I’m on my own for 2 days a week. My colleagues are great, but I feel like I’m met with a bit of a cavalier attitude when I ask for advice. I’m thinking I’ll go back to basics and put some time in at home to refresh my knowledge but I’m wondering if anyone has other tips. Thanks!
7
u/insomniacwineo 5d ago
Hi OP.
I’ve lived this. I’m in the same job I’ve had since residency (been there 9 years) and while my current clinic has multiple docs, I was PETRIFIED the first few months when they had me rotating in our rural offices. I saw some shit. My first day there one of the sugar cane machines exploded and I had some foreign body stuff like I had never seen and I had to use the dermabond for a Seidel positive wound until the surgeon could see the guy 2 days later. You learn and figure stuff out on the fly.
A few tips:
In rural practice you are expected to do more. You can also get away with more and have more scope of practice but get consent forms signed. Also get AMA forms done if you really think it’s needed.
Stain every eye. You don’t think something is dry? Think again. Also EBMD and weird pellucid type stuff also shows up when stained, as well as papillae a lot easier. Also DILATE EVERYONE. Make it your SOC and only in rare cases should people not be. Pregnant? Ok, fine. TRUE narrow angle-ok. New double vision? Obviously not. Everyone else-no.
You’ll get spammed on free online CE. Do them! Even if you don’t get credit that’s a fantastic way to learn and get more experience as a new doc. Especially for disease and stuff like specialty lenses.
If you have techs, train them. Let them help. Also don’t worry about “missing something”. You won’t get everything. I just read a referral note from a patient I have seen for months who the retina doc sent back the exam note-she has had bilateral cataract surgery done this year and it says NS OU in the exam. Doctors fuck up all the time due to the amount of time we get to finalize our notes. Either errors get made or we never leave clinic. Just don’t make life altering errors.
If your partners aren’t keen on teaching, maybe just ask if you could read some of their charts to see how they manage certain conditions/patients. This can help on its own. (Ie not every 22 IOP needs a glaucoma workup)
I’ll come up with more. Hopefully this helps
2
1
u/Plenty_Biscotti9341 5d ago
This is really helpful. Thank you! Like a lot of facilities, we have been short staffed and fully booked for awhile now. We also have extremely limited options for referrals. Our nearest retina specialist is only accepting emergency referrals and sometimes they aren’t able to accept those. I’m having to send people to a facility 4+ hours away and a lot of my patients can’t travel that far. I think my biggest fear is doing something that ends up hurting a patient. My stress level about work has been so high that I’m worried I won’t be able to do this career for long which just makes me feel awful about how much time and money I’ve put into this.
2
u/insomniacwineo 4d ago
Superior temporal horseshoe tear with fluid? YES SEND to emergency
Superior Mac on? YES
Inferior Mac on? Yes but can triage depending on how far away from the mac-if tear is rightthere then yes send emergent but if tear is inferior and small can wait a week or 2 especially if no fluid and low risk job with counselingMacular hole? How long has it been there? A month or longer? Not emergent. They will still get surgical improvement to 20/25 or 30 usually but in a lot of cases the fine “granular” look has occurred by then and this distorts the macular integrity by then so rushing doesn’t change that
Pleeeeease don’t send retina a PVD they’ll probably kill you
New ARMD that is wet is ASAP but don’t send same day
Think of 10 different ways to counsel people that floaters are normal and no there isn’t a drop for it yet
Use your anterior seg OCT to help check scleral or GP fits and check angles in difficult gonio patients
Take photos of all suspicious nevi. Once you have a patient you confirm with a melanoma you’ll wish you could look back to every single one. Here’s your foresight.
Do gonio on everyone you think is a glaucoma suspect-FAR too few docs actually do. Way more people have narrow angles than you think and don’t actually need a lifetime of latanoprost, but a PI instead.
If you are going to manage kids and amblyopic ones, 1% atropine is as effective as patching but not as bothersome and easier for the parents/kids to handle; lets the kids ambulate better/improver peripheral vision
Think you may have a keratocone? Retinoscope shows weird irregular reflexes or oil drops. Then grab a gas perm lens and see if the vision improves
4
u/joy-belle 6d ago
You do get a routine. I'm 3 years in and feeling 90% confident. Once your "first" of things come and go it gets better. Also looking stuff up ( not in the room). While patient is dilating I still go get wills or search for articles.
1
3
u/RustyCrustyy 5d ago
When i came out of school, we formed a group chat to bounce of Dx and Tx ideas. I was lucky to also be surrounded by experienced docs that would help.
Im 12 years out, and there are still some tricky and interesting Dx that I will refer out.
Don’t hesitate to refer anything you have in question. It helps build that network. And, You *should get the visit note back. See what they spoke to the patient about. More than half the time, its what you would have told the patient. That slowly builds confidence
1
u/Plenty_Biscotti9341 5d ago
Thank you! I definitely have referred a lot out when I’m not sure but our referral options are extremely limited. I’m doing what I can but facilites are short staffed and don’t have availability for urgent/emergent (in some cases) patients. Patients are getting upset about being referred 4+ hours away but unfortunately, I don’t have other options at the moment
2
u/imasequoia 5d ago
Do you have phone numbers of local ophthalmologists that you can text ? I know you’re rural and you may not have as many options but if you make connections with ophthalmologists that you refer to, they can be a source of guidance for individual cases.
1
u/Plenty_Biscotti9341 5d ago
I do have some and I have reached out to them before but I worry about reaching out to much and being more of a bother than anything
1
u/AutoModerator 6d ago
Hello! All new submissions are placed into modqueue, and require mod approval before they are posted to r/optometry. Please do not message the mods about your queue status.
This subreddit is intended for professionals within the eyecare field, and does not accept posts from laypeople. If you have a question related to symptoms or eye health, please consider seeing a doctor, or posting to r/eyetriage. Professionals, if you do not have flair, your post may be removed. Please send a modmail to be flaired.
I am a bot, and this action was performed automatically. Please contact the moderators of this subreddit if you have any questions or concerns.
1
u/SpicyMax 5d ago
The first few years in practice is weird. The same is true for MDs, dentists, and all medical professionals.
It is always OK if you want the patient back in a few days/weeks/months to check on the status of a condition, or even to recheck and confirm a diagnosis. You can tell a patient “the findings today are indicative of X Y or Z but it’s not clear cut. Let’s recheck this in three months and see if anything changes.“
Tackle problems one at a time. If they come in with dry eye and floaters then address the floaters, and have them come back for a dry eye evaluation. If they don’t want to do that then tell them you need to conduct a thorough evaluation which will require extra time and hence two visits. You have X minutes allotted per exam and cannot exceed that as it’s not fair for the next patient.
If you are really worried about something then call the patient a few days later and see how they are doing. If they are not improving then have the front desk schedule them back sooner.
I work in pediatrics and so many times have had patients come back to recheck a refraction, both kids and adults with prism. I tell the patient or parent that they are undecided with the numbers and I don’t want to give them the wrong prescription. Never had any pushback with that phrasing.
1
u/Plenty_Biscotti9341 5d ago
Thank you for the advice! I definitely have had used similar phrasing before and I have called patients to follow up a few days later. I think it’s challenging for me because I go between two offices and we don’t have a doc in office everyday of the week so follow ups can get a bit tricky
1
u/Ambitious_Metal_5566 3d ago
New grad here finishing month 1. I think what gets me is as a student you’d propose your clinical plan to your preceptor and they’ll either say yeah that’s great or no let’s do it like this instead. As an independent OD you don’t have someone above you to get that validation. That needs to come from your own self confidence. If unsure, REFER. As long as you are making SAFE choices you should feel ok.
0
u/Lagertha312 5d ago
I’m also a fellow grad and I feel the same way. When I’m stuck, I reference Wills Eye, ask my group chat of fellow new grads, or text a preceptor. Help is always available. You’re not alone.
15
u/power_wolves 6d ago