new m.d.
The Case of the Unusual Walk-in
Howard Amiel, M.D.

Dr. Amiel, would you be willing to see a walk-in?" the tech inquired. Fresh out of residency and without any patients of my own to speak of, most walk-ins have the distinct pleasure of seeing me, "the new guy."

I could only oblige. My schedule is still sparsely populated relative to the other docs, but having just come off of vacation, my tan is far superior. The ink on my business cards hasn't had the opportunity to dry. As a resident, we did not have the benefit of a tech to work up each patient. Seeing patients now is akin to swinging a baseball bat once you have removed the batting doughnut.

I made my way over to my designated lanes and perused the chart. The chief complaint was frightening: "Worms coming out of my eye." A rather sensational complaint I thought to myself — my confidence was tested. I thought back to my not-so-recent OKAP preparation to formulate a differential. It was a pretty short list. Well, not really a list, more like a single diagnosis.

I took a deep breath and reached for the doorknob. I walked into the room and was greeted by a well-kempt, articulate and attractive middle-aged woman. I listened attentively as she convincingly described a far more pervasive problem of a generalized infestation. I was mindful to not engage her in what I sensed were delusional convictions, but I think my empathic demeanor allowed her to describe her symptoms free from reproach and judgment. Upon returning for the dilated exam, I was greeted with slides of "organisms" she had assiduously collected over the last few harrowing months.

My exam, though, revealed nothing more than marginally dry eyes. Although verdant and unfledged, I was certain, that no ocular pathology was evident on this exam. I struggled and eventually failed in devising a way to tactfully offer her psychiatric assistance. Instead, I did my best to reassure her, walked her to check out, scheduled a follow-up and offered to see her anytime in the future. I walked away saddened by the encounter.

Indeed, I am the "new guy" with the least amount of experience. Although well trained, I recognize that I still have quite a bit to learn — not just about how to manage the 500 microns of cells that may be the source of blurry vision, but more importantly, how to best take care of my patients. I feel only slightly more comfortable handling a delusional patient than I do performing a laparoscopic cholecystectomy, and perhaps because of this, I may not have done what was best for her. In a sense, I let her down.

In retrospect, after working to gain her trust, I should have planted the seed that would better allow me to offer her what she really needed, a psychiatric evaluation. I guess I have another opportunity in the coming months. In any event, I learned a valuable lesson that day. Regardless of my enthusiasm, level of experience, or degree of training, there is always one thing I can offer my patients: compassion.

Each month, "New M.D." presents the experiences of newly minted ophthalmologists Roxanne Woel, M.D., and Howard Amiel, M.D. Through them, readers can obtain the perspective of a young physician embarking on an exciting career.