Medicine in Opthalmology

[GalenAgas]

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People say ophthalmology, as a surgical sub specialty, has the best mix of medicine and surgery (i'm excluding OBGYN; also urology and ENT are more surgical than medical).

What does this mean exactly. I have never seen an Ophthalmologist manage a patients diabetes for example. In what way does Ophtho have more medicine?

 

[RestoreSight]

People say ophthalmology, as a surgical sub specialty, has the best mix of medicine and surgery (i'm excluding OBGYN; also urology and ENT are more surgical than medical).

What does this mean exactly. I have never seen an Ophthalmologist manage a patients diabetes for example. In what way does Ophtho have more medicine?

Take any part of the eye and you will see general medicine and various subspecialties reflected. I'll use the cornea and sclera for example. Infections (HSV, adenovirus, EBV, VZV, strep pneumo, Pseudomonas, fungal), rhematology (Wegeners, polyarteritis nodosa, Shogrens, SLE, Kawasaki, Churg Straus), dystrophies (map-dot-fingerprint, Fuchs), ectasias, ocular tear disorders, acute care issues (burns, chemosis)... the list goes on and on. There is a tremendous amount of overlap between general and subspecialty medicine in ophthalmology.

You have to have an understanding of general medical care to properly treat the variety of conditions that you will see in the general eye clinic and I would argue the average comprehensive doc hour-by-hour spends much more time providing medical then surgical care.

 

[GalenAgas]

Take any part of the eye and you will see general medicine and various subspecialties reflected. I'll use the cornea and sclera for example. Infections (HSV, adenovirus, EBV, VZV, strep pneumo, Pseudomonas, fungal), rhematology (Wegeners, polyarteritis nodosa, Shogrens, SLE, Kawasaki, Churg Straus), dystrophies (map-dot-fingerprint, Fuchs), ectasias, ocular tear disorders, acute care issues (burns, chemosis)... the list goes on and on. There is a tremendous amount of overlap between general and subspecialty medicine in ophthalmology.

You have to have an understanding of general medical care to properly treat the variety of conditions that you will see in the general eye clinic and I would argue the average comprehensive doc hour-by-hour spends much more time providing medical then surgical care.

In what way beyond checking a drug interaction before you treat? Do you guys end up treating the systemic disease when it is associated with the ophthalmic manifestation?

Or are you saying that you need to know general medicine because lots of diseases (Sjogrens, Seronegative spondyloarthropathies, HIV, HTN, Wilsons, coagulation d/o's, etc) manifest in the eye so it's useful for diagnostic purposes.

I WANT Ophtho to have lots of "Medicine" in it (if you didn't guess from my last post about combined residencies). I just don't see how medicine applies beyond awareness of Ophthalmic manifestations of Systemic Diseases. I would honestly think that you guys could diagnose most things from physical exam / other test and then rationalize, "Oooohhh it's because he probably has this or that." Furthermore, I don't see Ophthalmologists managing rheumatic diseases, vasculitides, or infectious diseases like the ones you listed above beyond addressing their ophthalmic manifestations. If they don't treat the systemic disease as a whole specifically how does the medicine matter? Please give me a few more examples of specifically how you use your medicine knowledge. Perhaps what would be most useful is one specific example with one specific disease that illustrates how knowing the medicine is critical.

Just to be perfectly clear, I am not trying to belittle the field! I just don't yet know what goes on in an ophthalmologist's mind when he/she is diagnosing/treating a patient. I really want to like Ophtho since my interest in the field started in undergrad and I have already committed lots of time to research, presentation, and publications. Also, I love how you guys work miracles with cataract patients. The first cataract surgery I saw was in lady with brunescent cataracts who was essentially blind and could see light/directionality at 5 feet. Ophthalmology is one of the specialties that can perform miracles.

Thanks for your help!

 

[jsh1986]

what year are you? I think you will find the more you go through medicine, the more you will come to appreciate the broad fund of knowledge you acquire. Keep in mind that 80%-90% of EVERY field is relatively straightforward and routine. But that 20-10% is where all the difference is made. Patient's present to ophthos w visual symptoms after starting a new drug, having a recent procedure, receiving a new diagnosis. Do you understand the pathophysiology of what has just happened to them?

As you go through your training, depending on where you are, you'll see complex cases on the wards where the general medical team is often trying to put the pieces together and will ask consulting services such as Cards, ID, rheum, surgery, etc. to weigh on their opinion of a specific process going on. Even though ID/rhem/cards are all internal medicine doctors, they don't manage the issues of other specialties. The same for ophtho-- why would an ophthalmologist manage someone's systemic sarcoidosis, when there is someone better suited to that work?

Medicine has become a lot more complicated in the last 20 years with the explosion of information. Especially in major academic medical centers, leaving questions of management to specialists has become the norm, with generalists playing the role of facilitator/organizer. We are specialists of the eye, but without a fundamental knowledge of medicine, you will miss significance of relative history/findings.

Because you asked for 1 specific case:

Recent case I saw in my department: Woman with adeno pancreatic ca had an ERCP performed. 10 days later presents with painful proptosis. (In the setting of a recent procedure + pancytopenia, she had bacteremia that seeded her orbit and developed an abscess. MRI I+/I- gave suspicion to the dx, exploratory surgery confirmed.). Knowledge of gastroenterology, hematology, ID, and radiology was necessary to make this diagnosis! You will rely on your fund of knowledge to guide your clinical thinking, although you will quickly forget many of the details of management (as will virtually all specialists re knowledge outside their field...)

 

[JMK2005]

...I have never seen an Ophthalmologist manage a patients diabetes for example...

and you never will.

ophthalmologists are trained to manage eye diseases.

If you are interested in doing everything, family medicine may be better.

 

[Slide]

You need the broad fund of knowledge that comes with medicine in order to manage the wide variety of conditions that will walk in the door. You won't do medicine things like manage blood pressure or blood sugar, but why would you, as an ophthalmologist? As an ophthalmologist, you're trained to specifically treat the eye. There's no reason to do a job that another physician has spent residency training for. The aspect of medicine comes into ophthalmology in terms of taking in the systemic conditions that affect the eye.

Another medicine-ish part of ophthalmology is how to think about diseases, working them up, and understanding them. The field of medicine tends to a diverse field of knowledge along with emphasizing treatment with medicines, and understanding the full course of the disease along with pathophysiology. If you see ophthalmologists at work, you'll notice that they spent a lot of the time doing medicine-ish things, like counseling and using medical treatment.

 

[kwel]

In what way beyond checking a drug interaction before you treat? Do you guys end up treating the systemic disease when it is associated with the ophthalmic manifestation?

Or are you saying that you need to know general medicine because lots of diseases (Sjogrens, Seronegative spondyloarthropathies, HIV, HTN, Wilsons, coagulation d/o's, etc) manifest in the eye so it's useful for diagnostic purposes.

I WANT Ophtho to have lots of "Medicine" in it (if you didn't guess from my last post about combined residencies). I just don't see how medicine applies beyond awareness of Ophthalmic manifestations of Systemic Diseases. I would honestly think that you guys could diagnose most things from physical exam / other test and then rationalize, "Oooohhh it's because he probably has this or that." Furthermore, I don't see Ophthalmologists managing rheumatic diseases, vasculitides, or infectious diseases like the ones you listed above beyond addressing their ophthalmic manifestations. If they don't treat the systemic disease as a whole specifically how does the medicine matter? Please give me a few more examples of specifically how you use your medicine knowledge. Perhaps what would be most useful is one specific example with one specific disease that illustrates how knowing the medicine is critical.

Just to be perfectly clear, I am not trying to belittle the field! I just don't yet know what goes on in an ophthalmologist's mind when he/she is diagnosing/treating a patient. I really want to like Ophtho since my interest in the field started in undergrad and I have already committed lots of time to research, presentation, and publications. Also, I love how you guys work miracles with cataract patients. The first cataract surgery I saw was in lady with brunescent cataracts who was essentially blind and could see light/directionality at 5 feet. Ophthalmology is one of the specialties that can perform miracles.

Thanks for your help!

Ophthalmologists will no doubt need to understand all these diseases and be kept updated/aware of the status, severity, and management of their patients' conditions, but they will most likely NOT be the ones primarily managing these conditions. This is not unique to ophthalmology, it happens in every field. If a patient has a condition that can't be otherwise managed by their PCP it's in their best interest to be managed by a specialist in the field. To do otherwise is probably a disservice to the patient.