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Complement your clinical skills by incorporating new technology
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For those of you who do not know me, I am a pretty fundamental clinician. I have always aspired to the teachings of Sir William Osler – a commitment to keeping the patient front and center. I believe by asking patients the right questions and affording them the courtesy of describing exactly what is going on you pretty much have the diagnosis before commencing an actual examination. In short, I have always felt one need nothing more than a good history, eye chart, ophthalmoscope, retinoscope, slit lamp, tonometer, perimeter and phoropter.
However, given today’s complex health care environment, is this still true? Let’s look at three patients of mine, and I will let you be the judge.
Grace is an active, youthful 72 years old with the primary diagnosis of cataract. She has done her research and would like to proceed with a presbyopic IOL in both eyes. However, her left eye visual acuity loss is somewhat disproportionate for the degree of cataract despite her 90-D ophthalmoscopy looking amazingly normal. Should we dare proceed with a presbyopic IOL without first obtaining an ocular coherence tomography image?
Robert is a 57-year-old Caucasian whose father and sister have chronic open angle glaucoma. His cup-to-disc ratio is approximately 0.6 with fairly symmetrical, healthy neuroretinal rims in both eyes. His pachymetry is about 550 µm and threshold visual fields reveal no defect. However, his IOPs, which historically track in the upper teens, are now 24 mm Hg OU. He prefers observation over treatment, but wants to “do the right thing.” Would you offer him your opinion without first obtaining a nerve fiber layer analysis?
Todd is 38 years old and interested in laser vision correction. While he is modestly myopic (approximately 4 D), he has 2 D of astigmatism in the right eye and is spherical in the left. He corrects to 20/20 in each eye, but reports a fair amount of “ghosting” around lights, especially when driving at night. Would you recommend LASIK surgery without first obtaining pachymetry, topography and wavefront analysis?
I think we would all agree that each of these patients provides a pretty compelling argument for embracing new technology. I think we would also agree that emerging technologies create certain challenges for clinicians.
We encounter challenges as new technologies require us to expand our skill set, execute an implementation strategy and do so in a cost effective fashion. Fortunately, these goals can be met by following a few basic steps.
While it is not imperative that we have every conceivable instrument in our respective offices, it is essential we have access to each, which can be accomplished by working with colleagues or referral centers. Additionally, it is equally important that we understand for whom and when a particular technology is indicated. Employing a new instrument indiscriminately and without justification results in additional cost (to an already burdened system), insurer scrutiny and – ultimately – reduced reimbursement. Fortunately, embracing our “older” skill set, which includes listening well and practicing fundamental optometry, provides us with the clarity we need to select additional tests.
It should come as no surprise that integration of a newer technology is really all about complementing – and not replacing – our time honored clinical skills.