Thinking one step ahead

October 1, 2006

Use the time in residency to think one step ahead. 'If I were the attending, what would I do?'

While the perks of such a position are not to be discounted (we have worked a long, long time to get there), I suspect a stark reality will also quickly set in. Several young attendings have described this epiphany as an "oh sh*t" moment-it hits them that all that autonomy and status suddenly comes with the tremendous responsibility that goes with being the attending.

On some subconscious level, we all know this is true, but it is dramatically illustrated during a complex clinical decision or a complicated surgical case. As the attending, your name goes on the dotted line-there is no one else around to provide cover. This uncertain moment can be temporarily paralyzing, yet liberating at the same time (given that you made the right decision, or the patient had a good outcome).

There is an additional step we can take: we should use our time in residency to think one step ahead. "If I were the attending, what would I do? How would I approach this patient? What would I tell the patient and family about that complication?"

Easy to forget

In attending clinic, a resident can easily fall into "observation" mode, even though ophthalmology is fundamentally an "action" field. Even if the resident takes the history, performs the exam, and offers an assessment and plan, there is still the safety net that the attending provides. It is the attending's patient, and he/she is there to correct anything that we, the resident, did wrong. When these clinics get too busy, there is pressure to "keep things moving"-and the resident often never finds out if the attending had a completely different assessment, or amended our plan.

In the surgical setting, similar pitfalls exist. The resident relies on the attending to "turn over" parts of cases, and rarely performs the preoperative clinical examination-a key component of surgical training (Can this patient tolerate topical anesthesia? Will I need iris hooks? Trypan blue? Should I even operate on this monocular patient?). Depending on scheduling issues, the resident may not have the chance to follow the patients through their postoperative recovery. Thus, even though the resident performs specific actions related to the surgery, we often miss out on all the analysis and thinking that are behind the scenes. Our attendings are so good that they make that thought process look easy.

You can imagine the anxiety experienced by a young attending that is suddenly faced with making quick decisions on these issues that he/she never dealt with as a resident. There are obvious steps residents can take to avoid this, such as reviewing the charts the night before surgery, and thinking through the approach to surgery for that patient. In the OR between cases, we should ask the attending why he/she did a given step, or why not do it another way. In clinic, we can make it a point to tell the attendings that we would like to go with them into the exam room to see how they handle a given clinical situation, and perhaps discuss the management plan on the especially interesting cases at the end of the day.

Resident clinic