Yesterday morning I had my Stage 2 assessment. Now, it’s been a bit of a nightmare week for me, Tuesday and Wednesday were just one problem after another.  We had a lot of emergencies and I tested three challenging children in a row on Wednesday (after that, I needed a lie down).  Needless to say, I didn’t have time to get all my Stage 2 cards ready during my working day so I stayed late to make sure that I was happy with every card that I presented.  I got home after midnight that night and then I spent most of Thursday (my day off) procrastinating before finally sitting down to study in the early evening.  By 9pm, I was panicking slightly.

During this blog, I’m going to talk about the Stage 2 assessment in detail but also about my preparations for it.  I think the key to a good visit is being confident with your choice of patient episodes.  Of course, in an ideal world, we would have several cards that fulfill a competency.  For some of them (i.e. children with BV anomalies, at risk of BV anomalies, cyclos), I had a multitude to choose from but I had only one low vision patient dispensed with a magnifier (and that wasn’t a perfect record by any stretch of the imagination).

On Wednesday night, I sat down with the list of competencies and made sure that every single card:

1) Had been signed by the px or had verbal consent marked on it

2) Actually demonstrated the competency in question

3) Was complete in other ways

4) Had a coherent “story”

The fourth one is something I feel makes you seem really confident and competent.  When I present a card to my assessor, I will give them a short summary of the patient’s presenting issue, what I did during the test and what the management was.  I also include any follow up.

For example, for my px with diabetic retinopathy, I presented a px I have talked about on this blog.  I said, “This is X, she was diagnosed with type 1 diabetes when she was 13, she’s now 36.  In her twenties she had poor diabetic control and two years ago, developed proliferative diabetic retinopathy and had a CRVO in her right eye.  She is 6/60 in her right eye, 6/4.5 in the left. She was attending HES every three months but missed an appointment so didn’t go back.” I then showed my assessor the fundus photo of the right eye then the left. “I showed X the photo of her right eye, explained that, after two years, this is the best her vision is going to get in that eye so it’s vital we keep her left eye healthy.  I gave her the phone number for the HES she had been attending and instructed her to phone and ask for an appointment.  If they did not offer one then I said I would re-refer her.  Since then she has been seen at HES and they are monitoring her every three months.”

My assessor then asked me to identify features of retinopathy on X’s fundus photo (which was good, since I know that photo by heart).

So, this is what took me so long on Wednesday night: reading through all of my cards and remembering the patients and their stories.  I also found some letters from HES that had been filed without me seeing them.  A note about one patient’s cataract surgery (successful), a note from an orthoptist agreeing with my Rx and recommendations, a note informing me that a patient who had a splinter haemorrhage at their disc was seen but no haemorrhage was found (not surprising since it was 4 months later).

For every competence, I had the facts at the top of my mind, ready to present as I handed over the card.  This gave me some confidence.

Anyway, I should really start at the beginning.  I got into work early on Friday but, unfortunately, so did my assessor.  He arrived at 9.15am instead of 10.15, which, I don’t mind admitting, really flustered me.  He apologized and went for a coffee for half an hour.  I needed this time to get my room set up and destress.

When my assessor returned, my first patient showed up (also a little early) so we got started just before 10am.  My assessor had never worked with my patient before so he spent the first 15 mins checking the patient, while I photocopied the patient record list and stood outside eating Smints by the handful.

The presbyopic eye test went well.  I was worried about ret (I tend to do this: instead of generalised worrying, I tend to focus on one thing and this time, it was ret).  When I tested vision with my post-ret Rx, my patient was 6/6 R&L (internal sigh of relief).  In the end, I was +0.25 out in one eye but I got the cyls and cyl axes bang on for both.  My assessor said he was impressed with my timing, which was good since this had been my downfall in the mock Stage 2 assessment I sat last month.

Then there was a 15 minute break.  When I came out the room, everyone rushed over to ask how I was getting on.

The next part was a contact lens fit and aftercare.  The patient was a rather shy girl in her twenties who wanted daily lenses.  I did the pre-fitting measurements (HVID, palpebral aperture and then pupil size).  I had found a Burton lamp in a cupboard a few months ago so I whipped it out to measure max pupil size (feeling smug at having a Burton lamp).  I plugged it in, switched it on and… nothing.  Oops, really should’ve checked that.

My assessor then asked about max pupil size and when we really needed it.

Anyway, so my patient had a small palpebral aperture and tight lids.  I thought about all the dailies we keep in practice (1-day Moist, Trueye, Focus, Focus Aquacomfort Plus, Clariti) and decided on the one with the smallest TD (Focus).  I told the assessor that I was going to fit a Focus Daily because it was a 13.8mm lens and the patient had a small palpebral aperture.  He seemed quite happy with my choice and the lens was a nice fit.

The aftercare was the same patient (pretending to be a different patient) but the other eye.  She was wearing some cheap, horrible hydrogel 16 hours a day and occasionally slept in them.  It was a little tight and didn’t wet very well.  She actually washed her hands before removing her lens! I was overjoyed.  Anyway, I checked for oedema and neovasc using white light (no swelling but a little neovasc inferiorly).  She was twitch blinking and very rarely closed her eyes fully.  This left a lovely line of punctate staining across her cornea.  Her eyes showed signs of dryness (LIPCOF and staining) but she had a FTBUT of over 10s.  My advice was basically a refit with a daily SiHy lens as the hydrogels she was wearing were unsuitable for 16 hours wear (and a definite “no-no” for sleeping in!).

Anyway, I got through the contact lens part in about 20 mins, the patient left and I took another couple of minutes to finish writing my management and advice down and double check everything on the record card.

Another 15 minute break (this time I tried to bribe my assessor with a nice cup of coffee but instead, he asked for water).

Then we got onto the patient episodes.  The fourteen cards that he chose were all patients with interesting stories.  He showed me a couple of field plots, asking me to describe them then give my thoughts on what was causing the defect.  They were pretty straight forward.

For one of the BV competencies, he gave me a case scenario and I replied that I would refer to an orthoptist so he changed a couple of details and asked if I would still refer.  Now, on paper, you could manage the second patient in practice but I said that I don’t think we have the best equipment in store when it comes to testing children’s vision.  At this point, I turned on the chart and showed him our picture chart – dog duck fish flower.  I explained, “We only have dog duck fish flower and some children don’t recognise the shapes (especially the flower), some kids realise it’s the same four over and over, the chart only goes to 6/9 and, finally, I’m not convinced about the Snellen acuities that are marked on them in comparison to letters.” He seemed quite happy with my answer.

Anyway, it was a really long morning and I was exhausted by the time my assessor left.  I had a half hour break (ate my lunch and drank a lot of caffeine) and then I had a full clinic for the rest of the day.  When I finished work at 9pm yesterday, I was ready to just climb into bed.  Luckily I have today off to recover.

Oh, I probably should tell you the happy ending: I got an e-mail from the College at around 5pm yesterday telling me that I had passed Stage 2 and asking me to apply for the OSCEs.  Can’t believe I forgot that part!