An ongoing dialogue on HIV/AIDS, infectious diseases,
August 30th, 2015
(Not) Doing the Retinal Exam, and the Importance of Acknowledging Limitations
This past week, the New England Journal of Medicine released one of its excellent instructional videos, detailing how to do direct ophthalmoscopy to examine the retina.
That’s the use of one of those hand-held gizmos — an ophthalmoscope, see picture on the right — to look at the back of the eye.
As usual, the video was clear, succinct and professionally done. A great resource for clinicians, young and old.
But here’s a confession — the video could be a nominee for this year’s Oscar for Best Picture, it wouldn’t help me a bit. Because I’m absolutely horrible at this procedure, always have been.
I’m as likely to see something important in someone’s eyes using an ophthalmoscope as I am using a shoe, an avocado, or a tennis racket (to choose three random things that happen to be in the room right now as I write this).
The inability to do a particular part of the physical examination creates some uncomfortable moments, in particular during medical school when learning the skill. Asked to acknowledge that yes, we do in fact see/hear/feel what we’re being taught to see/hear/feel, medical students face a dilemma when failing to do so. In essence, there are three options:
- Tell the truth: “I can’t see the venous pulsations” — and ask the instructor for more guidance right there on the spot.
- Lie: “Oh yeah, the optic disc margin is sharp” — this gives the teacher a sense that you’ve mastered the technique, but it’s basically cheating and a very bad idea in clinical medicine, for innumerable obvious reasons.
- Silence: Be quiet on the matter, blending into the background and allowing the class to move on — and remain hopeful that you’ll pick up the skill later with more practice.
I wish I could say I had the maturity to go with #1, but in fact #3 was the route I chose.
Even if I had chosen #1, however, I’m not sure it would have made much of a difference. The reason I can’t do this procedure is because my own eyes are so bad — which, for a variety of reasons having to do with the optics of it, make direct ophthalmoscopy virtually impossible.
Trust me on this one — it’s not just an excuse. (Of course it is.) The right eye is particularly useless, which means I’d have to use my left eye to look into a patient’s right eye. If you imagine doing this, it sets up a very uncomfortable nose-to-nose encounter with your patient — highly unhygienic and socially weird, a reason right there not even to try it.
In the face of limitations we have as doctors, we invariably come up with rationalizations to make ourselves feel better. And here are mine about this particular deficit:
- Visual complaints are serious business — wouldn’t this deserve a referral to a real pro, an ophthalmologist? You can be sure that in the CMV retinitis days, my threshold for referral was very very low.
- Similarly, let’s say I found something incidentally on ophthalmoscopy — certainly this would warrant having an ophthalmologist see the patient to confirm, right? What non-eye doctor would be 100% sure saying that what they visualized with their crude scope is benign?
- Direct ophthalmoscopy isn’t even the best technique to look at the retina — the indirect method is far superior, preferred by all retina specialists.
- There are many other things in medicine I can’t do (replace heart valves, biopsy colons, do immunohistochemical stains, interpret EEGs, remove thyroid tumors) — this is just one more.
- I may not be able to see someone’s retina (especially their right retina, see above), but I’m pretty good at listening to heart murmurs, if I do say so myself. Hey, I once noticed that a patient with endocarditis developed aortic insufficiency before the cardiologist did. Granted, she hadn’t seen him that day yet, but still …
In all seriousness, the real reason for this confession is that I’m pretty sure we all have limitations. Why else would the orthopedists consult us ID doctors for essentially every infectious complication on their patients, no matter how simple? After all, before their residency, these pre-orthopods were some of the smartest medical students — did they suddenly lose their brains when they began doing knee replacements?
Not a chance. It’s simply that at some point, it makes much more sense to acknowledge these limitations — and move on — than to pretend they don’t exist, or even worse, to fake it.