It was another morning at the Bronx City Hospital, and Ms. D’s chart was at the top of my bin. Tuesdays were glaucoma days. Most patients presented with already severe optic nerve damage, or their disease could not be controlled on the maximum number of medications prescribed in our general clinic.

I began seeing Ms. D during my first July rotation as a resident. She presented with an IOP of 26 mm Hg and moderate optic disc changes. As a brand-new ophthalmologist, I proudly started her on the first of many glaucoma drops. She diligently completed visual field testing and had nonspecific changes with routinely high error rates. Each subsequent resident started Ms. D on one eye drop after another; she saw a different person at each visit by virtue of the clinic schedule. She never missed an appointment.

When I saw Ms. D again the following year, she was on maximum therapy, yet her IOP had remained 26 mm Hg at each exam. She had brought her drops to every visit, recited her medication schedule, and correctly identified each bottle. We were discussing laser trabeculoplasty as the next step in her treatment. While I was filling out the extensive booking paperwork of the public hospital system, Ms. D stated that it was time to re-apply her drops. I applauded her effort and offered her the sink to wash her hands.

Ms. D then retrieved all of the colorful bottles from her bag and reached for a tissue. I looked up from the papers on my desk and watched as Ms. D walked up to the mirror, opened one of the bottles, and carefully swept the tip from one corner of her lower eyelid to the other. She smoothed the upright bottle on her eyelids like lipstick.

I could not believe my eyes. Nor could I help but wonder if Ms. D’s course of treatment over the preceding 2 years would have been different if she had been seen by the same physician at every visit, someone who might have detected this problem sooner. Her IOP would have decreased, and she probably would have been spared a few appointments. Perhaps she would not have required multiple drops.

At that moment, I realized the importance of continuity clinics in training. Perhaps the easiest thing to do in medicine is to offer a patient with a chronic condition a novel treatment that has the potential to help him or her. It is a very different experience to see that patient return as one therapy after another fails and to seek to understand what went wrong.

Glaucoma patients need continuity of care from a physician who knows their definition of adherence and their tolerance of medications, procedures, and testing. They need a doctor who knows them well enough to identify the most appropriate treatment plan for their abilities and lifestyle. That is the kind of relationship that I want to have with my patients after the haphazard rotations of residency training. n

Section Editor Albert S. Khouri, MD
•associate professor and program director of the ophthalmology
residency as well as director of the Glaucoma Division at Rutgers
New Jersey Medical School in Newark, New Jersey
•(973) 972-2045; albert.khouri@rutgers.edu

Felina Z. Kremer, MD
•glaucoma fellow, Icahn School of Medicine, Mount Sinai Medical
Center, New York
•(212) 241-8979; albert.khouri@rutgers.edu