Reflection: Travis Air Force Base

Another 3 months and two rotations down! I am happy to say that I feel like I’ve gotten pretty lucky with the clinical sites I’ve had so far. Hu Hu Kam was a perfect place to find my footing and hit the ground running, and Travis AFB was a great place to continue that growth.

IMG_1469Coming to a military base, I thought I would see mostly healthy active duty people, maybe some dependents (spouses & children), but as you know if you read my first post about it, I was surprised at the variety of cases I ended up seeing. I was able to see veterans with more ocular disease, post-operative patients from the cataract and refractive surgeries performed by the in-house OMDs, and I even did some contact lens fittings through the special program for flyers & pilots. I’m very happy with the assortment of cases I encountered, and best of all I had good support and education from my staff doctors.

Tired of those Insurance and Billing Nightmares?

One thing I was aware of, both at Hu Hu Kam and Travis AFB, was the freedom you have when you’re not depending on insurance for payment. In any insurance based practice, you have to be concerned with how you will be getting paid for each part of your examination. There are LOTS of rules for what procedures they will pay for, which ones you can do at one visit and which you need to spread across different visits in order to be compensated, and it can all be a big headache. You may end up having to bring the patient back another time to finish the exam or charge them out-of-pocket for things insurance won’t pay for; and if that’s the case you have to make a quick decision about FullSizeRenderwhether the test is really worth asking a patient to pay for it, assuming they can even afford it or are willing to pay. And sometimes that’s not easy. Sometimes you want to do a test to confirm your suspicions but if it comes out negative, the patient (and you) may feel like you wasted their money on a hunch. Sometimes your hunch is right! But what if it’s not…?

At government-run institutions, they bill insurance when possible, but if insurance doesn’t cover it, the hospital foots the bill. This makes the doctors life much easier. Now it’s not a matter of “Can my patient afford this?” “What if they won’t pay for it?”; it’s a matter of “Will this help me figure out what’s going on?” “Will this help me sleep at night, knowing I did the right thing for my patient?” These are the important questions we should be asking ourselves in our decision-making, and it feels so much better not to be weighted down with thoughts of money and billing. But alas, I’m back to insurance-based practices for my last two rotations, and we must work with the system we’ve got.

Interprofessional Connections

IMG_1437Another aspect of both my sites so far has been that they were part of a larger hospital and we had access to our patient’s medical records for reference. This made treating patients easier, because many eye conditions can be related to systemic health, and patients are not always forth-coming about their medical history, especially when talking to an EYE doctor; “Why do you need to know that? That has nothing to do with my eyes…” **facepalm** followed by my standard “your eyes and body are interconnected…” speech. Note: I don’t really **facepalm** in front of patients, that would be unprofessional.

If the patient had a symptom or I saw something odd, I could just check their medications or medical history to look for something that could be causing it. Easy. Done. No need for speeches or pulling teeth for answers. It also makes you look and feel more like a health professional, because, yes, you know more than just eye stuff. I didn’t spend 4 years in OD school for nothing!

IMG_1474Two down, Two to go!

As for myself, I feel that I’ve made good progress this quarter. My decision-making is improving with each patient I see; I feel more sure of my diagnoses and treatment plans. Speed and efficiency made big improvements, especially in my last few weeks there, which of course is thrown off every time I have to adjust to a new rotation, but c’est la vie. Overall, I’d say it’s another successful learning experience under my belt and I’m ready to keep moving forward. 183 days until graduation… Plus a few hours… But who’s counting?

One Week with Ophthalmology

I haven’t written a lot this quarter, partially because it has seriously flown by, but also because it’s been fairly straight forward. I’ve been focusing on improving my speed/efficiency and I’ve been able to cut down my exam times to a reasonable length. Things have been going pretty smoothly and I’ve been happy with the progression of my skills over the last few months.

This past week, however, was a brand new experience working in the ophthalmology department. It was interesting to see what a typical day is like for “the other type of eye doctor.” In some ways it was very similar to that of an optometrist, but there were some differences that made it a worthwhile experience.

Refractive Surgery Day

Monday was refractive surgery day (i.e. LASIK and PRK). I watched the one LASIK surgery of the day and a few PRKs. In the military, most patients get PRK (photorefractive keratectomy) to correct their vision, which differs from the typical US population where LASIK is vastly more common. This disparity is mostly because PRK was the first refractive surgery approved for use by military personnel and until the mid-2000s was the only
refractive surgery approved for flyers/pilots*.

The military has a special program that allows members to get refractive surgery done for free; which may seem like a luxury, but as the ophthalmologist (OMD) explained to me, being able to see without glasses when you are in the middle of a battle zone, sometimes with a mask or gas mask and shooting at people trying to kill you, is a far from a luxury. Fair enough, right? It’s not something civilians have to think about much, but the stresses and demands on military people are very different; seeing well every possible second can be the difference between life and death.
Not an exaggeration. Really.

*PRK and LASIK both use a laser to change the surface of the cornea to change the eye’s prescription, but differ in how the cornea above the laser-treated area is treated. In LASIK, a thin flap is cut with a blade or laser and is pulled back to expose the treatment area. In PRK, the top layer of the cornea is essentially rubbed off to expose the treatment area. Both surgeries have their pros and cons, but both provide good results with relatively low risk of significant complications. The military initially thought that cutting the flap in LASIK would impair the strength of the cornea and put the flyer at risk when subjected to high speed in the air, but studies proved this concern to be unfounded. However, since military personnel have been in the habit of choosing PRK over the last few decades, it remains the more frequently chosen surgery.

A Typical OMD Day

Tuesday/Thursday/Friday were all normal patient days. Sometimes I would just watch the OMD perform the exam or assist them; other times I would go in to see the patient first then report back to the OMD. I saw some glaucoma patients, some 1 day/1 week/1 month follow-ups for cataract and refractive surgery, and other random complaints. One of the OMDs was trained in Oculoplastics (i.e. surgery involving the eyelids and surrounding area) so I sat in on some consults for tear duct surgeries with him. This is when things were pretty much like what I would be doing in the optometry clinic, with one big difference. All of their exams were problem-focused. In optometry, we tend to do more comprehensive exams where people come in for glasses but then have some other complaints for us to look into; whereas OMDs see patients coming in for a particular problem. This is the biggest difference that I noticed between OD exams and OMD exams.

See you in the OR

Wednesday was the big day. Surgery Day. I was able to be in the operating room for two cataract extractions, an IOL exchange, and a ptosis repair (see other post for descriptions). It was pretty incredible. At the beginning, I felt sort of out of place, but by the end of the day, it was almost normal. It was interesting to see a side of eye care that ODs don’t take much part in. ODs in some states can do laser surgeries but I don’t think any state allows the more invasive ones; it’s just not what we’re trained for. I was a little afraid at first that my stomach couldn’t handle what I was about to see (I get squeamish watching Grey’s Anatomy…) but I found that seeing the surgeries in real life was actually not so bad. It was actually kind of amazing and awesome. The lid surgery was a little more intense, but the cataract surgeries were a breeze.
If you’re interested, you can watch these videos (below) to see what’s involved. If you think it’s awesome,
you might just be an eye nerd…

Cataract Surgery with Dr. Michael Richie: Surgery begins at 5:30 mark. PS: Patient is typically awake for surgery! Sometimes mild to general anesthesia is used depending on the patient.
Cataract Surgery in 6 minutes: This video seems to be sped up a bit if you don’t want to sit through the longer version above. Description is somewhat less thorough.

Looking Back

Overall, I really enjoyed my week with ophthalmology. It was like a mini vacation (did I mention OMDs like to start late and end the day early…? Score!) where I got to learn about a whole new side to eye care. I got to ask all my questions and get some insight into how OMDs decision making may or may not differ from that of ODs and learned some new things along the way. I am very grateful that the doctors and staff were so welcoming and willing to teach throughout my time with them. Here’s to interprofessional relations and the fact that I do not have to perform any of those surgeries that I observed. Still glad to be a future OD.  🙂

 

**All experiences/insights described here are based on the OMDs and practices observed. Other practices/hospitals/OMDs may be very different than those described above**

Instagram: Surgery Day

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Working with ophthalmology this week: #SurgeryDay ? Watched 2 cataract extractions, an IOL exchange, and a ptosis surgery! Super awesome day!#gotmynameontheboard

*An IOL exchange is when you have already done a cataract extraction (removed patient’s lens and replaced it with a plastic lens, aka Intraocular Lens or IOL) and the IOL needs to be replaced for some reason. Its not a very common surgery, so I was really excited to see it!

**A ptosis (pronounced TOE-sis) is when the eyelid droops a little more than it should, sometimes obstructing the patient’s vision. It can be just one or both eyes. This surgery removed a small part of the eyelid to make the lid height of each of the patient’s eyes more equal.

Today was pretty awesome… Look out for a summary of my week with ophthalmology this weekend!

Getting on Base… Travis Air Force Base

It’s been a while since my last post and so much has happened! I began my 2nd rotation at Travis Air Force Base in Fairfield, CA. It’s certainly different
here, but I’m really enjoying it. Since the hospital serves mostly active duty military and their family members, the majority of my patients are healthy young to middle-aged people, which has helped me with my efficiency and problem solving, especially for the typical complaints that I expect to see on a daily basis in private practice—glasses prescriptions, contact lenses, dry eye, eye allergies, etc. However, we also see a lot of “retirees” and their family members as well.

Note: One thing I noticed about the military is that just because someone is “retired,” it doesn’t mean they don’t work anymore. From what I’ve seen most people retire from the military relatively young, usually by age 55, but sometimes as young as 40! This means that they often start a sort of second career upon “retirement.” Some Air Force pilots become airline pilots, lawyers and doctors find another practice to work in—I even met a man who was a mechanic for the Air Force for 20 some-odd years, then retired only to work at a car wash for another 20! Now he’s fully-retired and doesn’t have anything to do but relax and spoil his grandkids. That’s the life… and he earned it!

Though most people are relatively healthy, I’ve seen some pretty cool things too. I’ve seen some cases of glaucoma, diabetes, red eyes, and other randomIMG_1111 things. The hospital has a popular refractive surgery program (LASIK/PRK) so I get to refer people on a regular basis and do post-op exams. A few weeks ago, my staff doctor and I referred a woman, Mrs. G, to neurology after spotting swollen optic nerves at the back of both eyes. The most common cause of this is called Idiopathic Intracranial Hypertension (IIH, formerly Pseudotumor Cerebri), which is just a fancy term for high pressure in the skull from an unknown cause that pushes on parts of the brain including the back of the eyes. Though our patient was a textbook-case for IIH, it is standard procedure to order stat neuroimaging to rule out a tumor or bleed in the brain. The scans came out clean and other tests will be done to rule out any other cause. Treatment for IIH is simple; losing weight (as little as a 5% reduction) and avoiding hormone supplements (i.e. birth control) and a few others, so I’m sure Mrs. G will be just fine in no time. Just last week, I was calling for my 10 year old patient in the waiting room; when I looked up, I realized the child’s mother was Mrs. G, herself! She remembered me, thanked me, and told her son I was a “nice lady” so he’d better be good. He was.

I’ve found my first 6 weeks at Travis very productive and fulfilling. I’m happy when my patients leave happy, and I feel like I’m really getting the hang of this whole doctoring thing. Just 8 more months and counting!

Reflection: Leaving Hu Hu Kam

Sad news everyone… Wednesday was my last day at Hu Hu Kam… I know, it went by so fast! I can’t believe how quickly the summer flew by, but now I am sitting here, back in California waiting to begin my next rotation tomorrow morning (more on that later).

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Michelle, Me, and Clarissa on one of the last days in clinic. Now, we are each off to SoCal, NorCal, and Texas!

As I reflect on my time at HHK, I feel lucky to have had such an experience. I saw some crazy things that I will probably never see again and I grew so much as a clinician. I truly feel better prepared to see anything that may come my way; if I don’t know what to do, I won’t panic or feel lost and I’ll figure it out. I also made some good friends that I’ll never forget and miss terribly!

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“Family Photo” of the summer interns we gave to the staff docs. PS: We did not plan our outfits on this day… it just happened.

Over the past 3 months, I grew a great compassion for the people in the Indian community that I served. As I said in another post, their genetics predisposed them to diabetes, high blood pressure, and low tension glaucoma; all sight-threatening conditions that can be somewhat difficult to manage. Making lifestyle changes is one of the hardest things to do, be it diet and exercise or taking multiple eye drops each day. They know what they should be doing and they are doing their best, but it’s not as easy as it sounds. All you can do is make sure they understand what’s happening to their bodies and their eyes and what they can do about it. The rest is up to them. And it’s not that they don’t care about their health or are lazy, it’s just darn hard! For some tough patients, you feel sort of helpless, and it’s difficult thing to accept at first and I’m not sure I’m fully there yet, but I know you just have to do your best to make sure they are informed and take the best care of them that you are able. You can’t fix everyone, but you should never stop trying.

IMG_0779I also found, as my confidence grew, my patients’ confidence in me grew as well. One day I was discussing cataracts with a patient and letting him know about the surgical options; his cataracts were small and only slightly affecting his vision, but he had asked about it so I began to go into details. I told him about the surgery, but said that if they weren’t too bothersome, I thought he could hold off on the surgery for at least another year. But in the end, I said, it was up to him. He then said, “well you’re the doctor, so I’ll do whatever you recommend.” I was kind of stunned for a second. First, he mistook me for the doctor, which gave me a little confidence boost. But also, he trusted me and my expertise so much that he was ready to base his decision on my opinion alone! I suppose this is the norm for doctors, but I guess I hadn’t realized I had so much influence. I really felt like a doctor in that moment.

I’m not sure what these next few rotations have in store for me, but I can only hope to get as much from them as I have from HHK. Great staff doctors, lots of interesting cases, and good people; staff, docs, interns and patients alike. HHK set the bar high and I can’t wait to see what else is to come!

Residents in Action

As a fourth year intern, our main focus is to soak up as much knowledge as we possibly can from our rotations so that we can be more prepared when we leave school. One of the many benefits that Hu Hu Kam provides (along with many other rotation sites) is the optometry residents on staff. These doctors are usually freshly graduated ODs who are continuing their education for an additional  year to learn more in depth or gain more experience with a particular topic within optometry—specialty contact lenses, pediatrics, vision therapy, low vision, etc. At Hu Hu Kam, they specialize in ocular disease.

Residents have to demonstrate certain skills before they leave… That means you get to do scleral depression on the staff docs!

Residencies are optional for optometrists but to me the experience seems so valuable. It allows you to practice in an environment where you see more complex cases with a team of doctors at your disposal who will give you advice or guidence when you’re not sure where to turn. Many doctors I’ve talked to who have done residencies feel it gave them a larger knowledge-base to take with them into practice, as well as more confidence in their ability to treat anything that may come their way.

As an intern, I have really enjoyed having the residents around. They give us tips and hold occasional journal clubs to teach us about different topics. We get to observe their Grand Rounds with the retina and glaucoma specialists; they present cases to the ophthalmologists and ask their opinion on what they they the course of action should be and why.

The residents planned one last prank for one of the staff docs before they graduated... It was awesome.

The residents planned one last prank for one of the staff docs before they graduated… It was awesome.

Another benefit of my specific rotation is that the residencies end in June, so we got to work with both the graduating residents and the new incoming residents. Its interesting to see the new residents who have just graduated from OD school a month ago and have the confidence and expertise that I hope to have a year from now; and the graduating residents, just 1 year out of school but so knowledgeable they seem to know almost as much as any of the other doctors here.

I am interested in pursuing a residency after graduation, so it has been a great experience to see one in action. Each residency is different, but one thing that seems universal is that, as a resident, you are a doctor and are treated as such. The wall of student and teacher is broken down even further and the level of respect that I’ve seen seems to be a type of learning environment that I would thrive in.

Instagram: Eye Nerd Alert

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Congratulations! It’s an Adenovirus! #AdenoPlus #positive #rps#viralconjunctivitis #notpregnant

AdenoPlus is a in-office test used to determine if a red eye is caused by an adenovirus. Most offices don’t have them because they’re somewhat expensive and it really just confirms your diagnosis and doesn’t change your treatment plan too much. BUT its a really cool eye toy for us eye nerds that we learned about in school, so I was excited to get to use it in real life!! 🙂

Holy, Weather!

The other day we left for work just like any other day… Sun in the sky a few scattered clouds… then on the way home, BOOM! Rainstorm. And not just any rainstorm; it was windy, with big fat drops hitting the car. The wind made the rain come down in sheets so it felt like someone was throwing individual buckets of water from the sky onto our car. And just when we thought it was as crazy as it could get… it started hailing.

When we got to our carport, we stayed in the car until it calmed down long enough to run inside. This summer Arizona weather is something else. We’re definitely NOT in California anymore…

Charlotte 7-18-15 136

 

 

Meanwhile, on the other side of the car… there was sunshine and a rainbow. Arizona is so confused…

Learning to Think

I’ve only been here for a few weeks now, but I can already tell you: Hu Hu Kam is a fantastic place to learn. Really. The staff doctors are kind and helpful and make it easy to ask questions. They give constructive feedback and don’t make you feel terrible when you do something wrong (I still feel terrible on my own, but at least they don’t try to rub it in). It is a respectful environment and you can tell that they really care about our education. Everything they do is meant to help us grow and provide the best care possible for their patients.

Bonus: HHK has the same slit lamp as the one used for National Boards Part III! Ill have plenty of practice under my belt by the time I leave here.

Bonus: HHK has the same slit lamp as the one used for National Boards Part III! I’ll have plenty of practice under my belt by the time I leave here.

The thing about HHK that was scary at first, but now its what I love the most, is how much they trust us and push us to start thinking like a doctor. This is something every preceptor should be doing by now, but I like how the doctors here go about it; they’re encouraging, not intimidating. Throughout 3rd year, I relied a lot on the staff doctors advice and guidance . I began to make some decisions on my own, but because the staff doctors knew SO much more than I did, it felt safer to defer most decisions to them. I would present my data, maybe make a suggestion, but the staff doctor made most of the decisions. I would go to them to confirm any special procedures I should do during the exam, because I didn’t want to do the wrong thing or miss something important.

At HHK, I started out this way, but a few weeks in, the doctors started encouraging us to make most decisions on our own. To look at the patient’s case and decide what needs to be done. To use our data to come up with a diagnosis and plan and to educate the patient accordingly. If you think a patient needs a special test, don’t ask for permission, go do the test! (within reason of course) Sure, you might make a few more mistakes or come up with a wrong answer, but that’s how you learn!

After a discussion about this with one of the doctors and trying it for a week or two, I had this realization—I actually know what I’m doing (the majority of the time) and I’ve learned enough to start making decisions for myself and for my patients—I started to feel completely different about my work. I feel more confident during exams, I analyze the data as I go, come up with a plan, and discuss it with the patient. I actually find that, by not second guessing myself and relying on someone else’s advice, I’m better than ever before. Of course, the final decision is always with the staff doctor and I don’t always know the right answers, but more often than not, I do and the doctors trust me and my plan. I learned that I need to sure of myself.

I realize that I can trust myself—my knowledge, my skills. I’m starting to feel more like a doctor; slowly, day-by-day building my knowledge-base and confidence. Its a completely different feeling that I’m not quite sure I’m explaining properly. I just know that at this rate with continued hard work and confidence, by the time next May rolls around, I’ll definitely be ready to do this on my own.

First Installment: Life as a Fourth Year

Let me introduce myself…

My name is Maggie Francisco and I’m a fourth year (wow, it feels weird to say that…) at SCCO at MBKU. I’m originally from the San Francisco Bay Area and went to the University of the Pacific in Stockton, CA for undergrad. I have wanted to be an optometrist since I was 15 years old and haven’t stopped moving since! I’m a huge eye-nerd and I get really excited about the weirdest things—crazy eye injuries, retinal detachments, macular holes, finding cranial nerve/muscle palsies—but then again, I think just about all of my classmates will tell you the same thing.

Optometry school has been one of the toughest, yet most rewarding times in my life. School is hard and that will always be the case, but now that I’ve been out of classes and seeing patients all day-every day, I find everything sort of coming together. I see something new and I flashback to that time I was sitting in class looking at a powerpoint of this very thing and all the little facts I learned about it! Its a bit like when you learned about dinosaurs as a kid and then you finally got to see a real T-rex skeleton for the first time. It gives you new perspective on everything you thought you knew. And you never forget it.

SCCO's Summer Interns at HHK

SCCO’s Summer Interns at HHK

I’ve had a lot of these moments in my first month at Hu Hu Kam Memorial Hospital (HHK) in Sacaton, AZ. The hospital is on an indian reservation and is part of the Indian Health Services program set up by the US government. Though any member of a Native American tribe can get medical care at an indian health clinic, we primarily serve the Gila River Indian Community (pronounced HEE-la). The Gila River Indian Community has one of the highest rates of diabetes in the world, as well as a lot of high blood pressure, normal-tension glaucoma, and many other health issues related to diabetes and obesity. This population is VERY different from the one at SCCO, which is mostly healthy middle to upper-middle class who have regular access to healthcare. That’s not to say that we don’t see cool things at SCCO, because I’ve seen plenty, but here it seems every patient has something “unusual” going on—diabetic retinopathy, uveitis, retinal detachment, eye injury, conjunctivitis—the list goes on!

Over the next year, I’ll be writing about my experiences as a fourth year intern. I’m excited to share them with you because I think I have really great variety in the clinical sites that I’ve chosen. I’ll be at Hu Hu Kam through mid-August, then I’m off to…

  • Travis Airforce Base, Fairfield, CA (Fall: August-November)
  • SCCO University Eye Center, Fullerton, CA (Winter: November-February)
  • Hellerstein & Brenner Vision Center, P.C., Denver, CO (Spring: March-May)

Each site will provide me with the key experiences that will guide me and shape me into the doctor I will become, just over 10 months from now. I hope you’ll enjoy this adventure as much as I will!

What’s a hobby?…

Between school and work the past few summers, classes and clinic each week during the last year of school; it’s been a really long time since I had a decent amount of free time. I forgot what I even like to do… But now I remember; television shows and food.

yum, cupcakes...
Me & my roommate, Michelle, trying not to eat all the cupcakes by ourselves…

I’ve found that most of my free time the past month has been consumed by catching up on all the shows I’ve missed and spending time in the kitchen whipping up another new creation.

Its nice to feel like a real person again and actually have hobbies. The only problem with having baking as your hobby is that… someone has to eat all your goodies and it can’t just be you! I hope the staff and interns at Hu Hu Kam are ready for a treat-filled rotation!