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The crowd is gathering at the watering hole in the Serengeti that is Friday teaching at the Major Teaching Hospital. Would there be enough different species of consultant present or would there be insufficient numbers?

If a critical mass of consultants was not reached we almost certainly would not be treated to the full flamboyant display of some of the rarer species, although a large crowd would run the risk of causing some that might otherwise speak and impart actual knowledge to remain silent.

But today we are in luck. Word has spread that the Allergan rep has sponsored tea and the crowd is larger than usual. The added prospect of biscuits seems to have had an additive effect and the ST1 first on to speak is looking decidedly nervous as he approaches the podium, eyeing the crowd in a desperate attempt to predict whether he will survive or be badly mauled.

He unfortunately triggers the volatile crowd into a full on attack by referring to a right colour fundus photograph as a left eye. The person second on to speak is visibly taken aback by the reaction only three slides into his colleague’s presentation. “Tell me then,” a consultant from near the very front asks icily, “if that is the right eye then what does it show?” The picture obviously shows diabetic retinopathy but that answer is obviously not what is required. As the bumbling ST1 tries valiantly to answer the increasingly difficult questioning, a second consultant pipes up that the optical coherence tomography (OCT) scan shown on the previous slide was actually not a straightforward cystoid macular oedema. Would it be possible to go back and check again?

Almost collectively the trainee body in the audience groans silently and attempts to avoid eye contact with anyone. One or two of the more confident ones begin talking loudly to nobody in particular about various trials in an attempt to gain some form of acceptance by the consultants. “Look at me,” they say. “I know stuff too.” The majority though are cursing the fact that the audience has caused the presentation to go into reverse so soon into the afternoon.

“Kindly point out which layer is the outer plexiform layer?” the first contributor says, looking around for approval. The ST1 obviously has no clue and begins to open and close their mouth rhythmically. The consultant smiles and asks about other various layers and once it is established that nothing is known about anything he sits back delightedly but offers no instruction as to what any of the answers are. Dejected, the presenter moves on once again to the colour photograph and a female consultant at the back asks whether he knows which eye it is this time. Some people laugh but sensing some injustice an affable peacock of a surgeon cracks a joke about not knowing himself what any of the layers are (though he obviously does as he then throws in an anecdote about the inner nuclear layer) and the tension eases.

A fluorescein angiogram is next to come up. What phase is it? What are the times? These are not known as no note was made of their importance by the presenter so he makes the fateful error of making up a number that seems plausible rather than admit he doesn’t know. The icy consultant jumps at the chance for further humiliation and while a further jolly anecdote about an indocyanine green (ICG) angiography run helps things along, the ‘things were so much hugely better in my day’ consultant wanders in having arrived late from an outlying hospital. Without knowing anything about the case he laughs ironically and announces that as juniors no longer have to do any of the runs and take the pictures and escort the patients out or drive them home like they did in the old days how could it possibly be expected that they’d know even the most basic fact about any investigation whatsoever anyway? So it was not the fault of the presenter but of society and the modern world.

A well respected and very intelligent consultant then patiently explains to the juniors about the various phases of an angiogram whist those yearning to further demonstrate their prowess and general greatness are impatiently chomping at the bit throughout.

One of the registrars then performs one of the greatest betrayals possible by asking a question intended to prove their own worth. “What are the ranibizumab guidelines here?” it sounded like but “I can be a consultant too” was what the other trainees heard. The visibly perplexed presenter was devoured whole by everybody throwing college guidelines and National Institute for Health & Care Excellence (NICE) guidelines all over the place. The affable consultant then made a joke about avastin that helped calm things and after a brief one-upmanship between some consultants of quoting increasingly unheard of and irrelevant papers, the presentation was allowed to continue.

As the last slide, thanking the audience for their attention, comes up a consultant who had been silently scowling throughout refuses to clap along with the others. The first part of the ritual was almost done. Two of the kindly consultants get up and compliment the ST1 on his presentation as the next person up fumbles with the USB stick in the departmental laptop and realises with horror that their presentation is incompatible with the software and so tea is called early while they attempt to sort out the problem.

So, as everyone helps themselves to tea, coffee and the Allergan biscuits while a desperate registrar tries to convert his presentation to a Windows 97 format we must ask ourselves about the nature of teaching ophthalmology in the 21st century. Should it remain devout to its trial by humiliation roots or should it evolve? Can it evolve without losing something vital about what it means to be a consultant and exposing future consultants to unexpected weaknesses from other sources? Weaknesses that might lead to extinction? Or is it just an antiquated means of a bullying opportunity and ego boost with no real benefit whatsoever?

But there we must leave it for now. For the display will continue for the remainder of the afternoon and be repeated the next week and the week after; unless it is August. And as the sun sets behind the eye clinic it cannot be denied that this is truly one of the most awe inspiring sights in the natural world, for whilst the consultants have faced the trials of life and triumphed, for the little ST1 those trials are only just beginning.


The views expressed are those of the author and do not represent those of the editorial team or the publisher.



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Gwyn Samuel Williams

Singleton Hospital, Swansea, UK.

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