If we all expected to have life figured out at 23, then a good deal of us would be stuck with some serious life choices that we all regret. Partners that were terrible, living in the wrong city, and careers that were wrong (for some of us). Just look around your class and count the number of students who are second-career students. Not everyone decided to be an OD in high school, or even in college. Half of OD school (and life in general) is making mistakes, learning from them, and figuring things out as you go.
This piece is a bit different than my typical articles, more “Thought Catalog” style so I can pass on some of my very soon-to-be fourth year wisdom. As my title on this site would suggest, I came into OD school with a passion for pediatrics. I still have a love for children, the ocular conditions that I have learned that plague them, and the ways that we can all help kids succeed if we only got to help them sooner. Too many kids fall through the cracks of “vision screenings” passed with 20/20 VA and a simple Bruckner test at the pediatrician. Too many are incorrectly labeled as
ADHD and put on stimulant medications. This could potentially stunt their growth when they might be a +6.00 hyperope, only needing a simple Rx to read. This is part of what fueled my fire in pediatrics as a young OD-1.
Where the disconnect began to happen for me was early on in my third year. I began to take more neuro-ophthalmic based disease courses and systemic disease classes. Having my background and undergraduate degrees in Neurobiology and Human Physiology, these classes just clicked for me. I didn’t have to STRUGGLE to understand like I did with Advanced Binocular Vision and Strabismus. I don’t have to think as much about the difference between an optic neuropathy and an optic neuritis, I just get it. Meanwhile, I had to be tutored in the differences between retinal correspondence types for months. PAC1, PAC2, HAC, UHAC…it drove me insane and it killed me that what I thought I had a passion for didn’t come easy to me.
It later dawned on me that while there will always be the patient that you have to send out the door because their condition is out of your scope, many binocular vision conditions are outside of the level of ANYONE’S scope. While a strabismus surgeon can cosmetically re-align a congenital esotropia, the likelihood that it will regress over time or even flip to an EXOtropia is very high. Surgeons are often concerned with the cosmetic cure, while we as ODs are more concerned with the functional (that is, the patient’s vision). If an eye that never saw well is surgically turned, it will know something is wrong and try to correct the situation to what it thinks is the status quo. However, due to the surgery, it may flip in the opposite direction. Intense, daily VT can be used to prevent this, but even VT has variable results in some deep seated ACs. Basically, a kid went through surgery and still has a turned eye that doesn’t see well, and the parents are angry at all the doctors involved, including you.
I think that many ODs are also a little intimidated by neurology. While we are the frontrunners on anterior segment and uveitis, and retina and glaucoma sure have their appeal, nerve disorders often get referred to OMDs because we simply aren’t as comfortable with a lot of these conditions as we should be. While we take neurobiology and ocular anatomy as first years, we lose a lot of that before we get to nerve diseases. The scary part is, often the etiology of a nerve disorder or nystagmus is something more ominous like a tumor or systemic condition. It’s never something refractive. 99% of the time it’s going to need some more advanced imaging like OCT and MRI to diagnose. It will often involve a referral for a lumbar puncture or bloodwork, and usually at least a second opinion from neurology, neuro-ophthalmology, and even sometimes specialists like
rheumatology or oncology. Co-managing these difficult patients (and being the first to diagnose a potentially life threatening condition) is exhilarating and rewarding. Now it’s not to say that there won’t be times that you won’t have challenging cases in neuro. Cases have higher chances of being life threatening, and you may have to deliver life changing news. The “there’s nothing more we can do for you” talk isn’t something a lot of ODs are prepared to give, but is necessary when permanent vision loss results. When life-altering diagnoses such as choroidal melanoma are confirmed, odds for the patient aren’t great. Systemic diagnoses like MS and myasthenia gravis often present with ocular symptoms before anything else, and are often caught first by the OD.
There’s nothing wrong with knowing from childhood that you want to be a private practice, primary care OD. If you’ve grown up with a large family influence in the business, often it makes sense. But the reason that we are required to dip our toes into all the modalities of practice in classes and rotations is to expose ourselves to everything to make informed decisions for ourselves. Schools require rotations through pediatrics, contact lenses, and low vision not only to make sure that we will be able to perform these services for any kind of patient, but also to tease out anyone who may want to become a specialist in these areas. Just like some students make decisions later in life to come to optometry school, it’s perfectly okay to change your mind later in the game about the type of clinician you want to become.
