Opthalmoscopy for Internists

[NewYorkDoctors]

Question for PCPs and Hospitalists here

Do you know of a general policy against Internists doing retinal exams?
I know this is hospital specific and also individual specific (depending on how comfortable one may feel about things)

Also I know the general consideration is internists dilating eyes and triggering angle closure glaucoma is a malpractice red flag.

But I have a Panoptic opthalmoscope, know what I am doing (for basic things that we learn in med school). Besides the time sink and the relative low yield for day to day issues, it could still come in handy occassionally right?

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[jdh71]

Question for PCPs and Hospitalists here

Do you know of a general policy against Internists doing retinal exams?
I know this is hospital specific and also individual specific (depending on how comfortable one may feel about things)

Also I know the general consideration is internists dilating eyes and triggering angle closure glaucoma is a malpractice red flag.

But I have a Panoptic opthalmoscope, know what I am doing (for basic things that we learn in med school). Besides the time sink and the relative low yield for day to day issues, it could still come in handy occassionally right?

Doubtful.

Anything you actually think seriously needs a look in the back of the eye will require the specialist. And they will need to do their own exam. So no need to do the dilated eye exam more than once.

This is the same phenomenon for the lady parts. I occasionally get crap from a gynecologist for not doing an exam but when I point they'll need to do one and why should the patient go through two pelvic exams, I've never had a gyn disagree with the logic.

 

[NewYorkDoctors]

Perhaps I can think of a few somewhat more common scenarios that may change management:

Hypertension to 200/100. No reported symptoms or apparent end organ damage by normal means. Creatinine might be up a bit but nothing to write home about at night. Look into the eye and see papilledema and flame hemorrhages. Might be having malignant HTN with a TMA and may need to go to ICU for a drip.... or just give oral medications and send to the general floors?

Patient walks in with an eGFR of 10. No known creatinine baseline. Volume status, acid base, electrolytes are fine. No need for HD imminently. Has a diabetic history but patient never sees opthalmologists routinely. You look inside and seen cotton wool spots, drusen, flame hemorrhages, etc.... There is probably more credence to DM nephropathy.

Patient says he can't see. You see a retinal detachment. You know the patient wasn't malingering.

Patient has candidemia. Need to rule out endolphthalmitis...


Again the Panoptic opthalmoscope does not need a dilation to get a fairly good view.


Bundled payments, full capitation coming soon. Perhaps this a way to get value added? Maybe not for the hospitalists / intensivists / ED doctors, but more for PCP?


The point is well taken about having an opthalmologist do the exam anyway for documentation and medical-legal reasons.

But if we are all now taking time to POCUS (which is great, btw), why not do a POC Retinal exam? The POCRE is not meant to replace the traditional full dilated indirect opthalmoscopy exam but to augment physical exam (or in this case do physical exam)?

Honestly it doesn't change management in most cases... but would help in a pinch.

 

[rokshana]

Perhaps I can think of a few somewhat more common scenarios that may change management:

Hypertension to 200/100. No reported symptoms or apparent end organ damage by normal means. Creatinine might be up a bit but nothing to write home about at night. Look into the eye and see papilledema and flame hemorrhages. Might be having malignant HTN with a TMA and may need to go to ICU for a drip.... or just give oral medications and send to the general floors?

Patient walks in with an eGFR of 10. No known creatinine baseline. Volume status, acid base, electrolytes are fine. No need for HD imminently. Has a diabetic history but patient never sees opthalmologists routinely. You look inside and seen cotton wool spots, drusen, flame hemorrhages, etc.... There is probably more credence to DM nephropathy.

Patient says he can't see. You see a retinal detachment. You know the patient wasn't malingering.

Patient has candidemia. Need to rule out endolphthalmitis...


Again the Panoptic opthalmoscope does not need a dilation to get a fairly good view.


Bundled payments, full capitation coming soon. Perhaps this a way to get value added? Maybe not for the hospitalists / intensivists / ED doctors, but more for PCP?


The point is well taken about having an opthalmologist do the exam anyway for documentation and medical-legal reasons.

But if we are all now taking time to POCUS (which is great, btw), why not do a POC Retinal exam? The POCRE is not meant to replace the traditional full dilated indirect opthalmoscopy exam but to augment physical exam (or in this case do physical exam)?

Honestly it doesn't change management in most cases... but would help in a pinch.

if it doesn't change management, then why do it?

and the case where it will change management, you will need to have optho on board (and if its an emergency, they need to see immediately and not have time wasted with an internists attempt to do a dilated eye exam....there are specialists for a reason.

 

[Crayola227]

it was something of a soapbox at my school, and something I absorbed, an emphasis on the physical exam... I, and other graduates, have been consistently praised for this elsewhere in residency, and I know many instances where it made a difference

the internists that led our department were pretty passionate about opthalmoscopic skills
we had an optional dilated eye exam skills workshop

it is a fact that there are cases where for an internist outpt or inpt, a proper eye exam can change management

maybe I'm buying too much into the romanticism of my mentor, that you can essentially read a patient's medical history off the back of their eyes... HTN, DM, atherosclerotic changes, etc

I rotated with a neuro-opthalmologist that also was of the opinion that those at primary care level, if they made the effort, could gain enough competence to safely field a number of complaints and make some referrals unnecessary

I've had a number of impassioned discussions with neurologists and opthalmologists bemoaning the lack of basic opthalmoscopic skills outside their field as well

I think we poo poo this exam because it is NOT an easy skill to master, it takes a good amount of time, practice, regularity (things that are in short supply) to even have the skills for getting a good look, and then how do you know what you're looking at? you need exposure to get a good feel for normal/abnormal, and since so many around you training you have crap skills, they often can't see what you're seeing, let alone tell you what it looks like even if they do

so no, I don't think it's pointless, I think getting good and putting it into practice is quite difficult

given the challenges, you also don't want to get all cowboy cocky about your skills and what you're seeing

if you're in a position to acquire this skill, I think that's great and should be encouraged

if you're in doubt about what you're seeing, you can of course kick it up to someone else, like an optho or whatever, but that doesn't mean that the exam you've already done is worthless (based on what consultants have told me)

the eye exam, like any exam, can change over time, and even if you're unsure, relating this to a consultant can actually be extremely useful to them

for most (not all) patients, having 2 not 1 eye exam is really NBD and really not on the level of an extra pelvic exam, and as I said, the two data points in time with the eye exam can have utility

as far as triggering acute angle closure glaucoma, my internal medicine mentor who led the workshops make a logical point I could never find fault in: if you do an indicated dilated exam, and trigger it, you will have done this patient an enormous favor, possibly even saving their vision in the long run, because the diagnosis and treatment can be initiated earlier. It is much better to trigger this in a controlled environment with a known cause than not.

obviously you need to perform and document patient counseling regarding this, and have follow up after dilating them, but usually if you're going to trigger this, it won't be long after the exam and it won't be a mystery, and it can be dealt with. It was only a matter of time for them to present anyway, IIRC

 

[NewYorkDoctors]

if it doesn't change management, then why do it?

and the case where it will change management, you will need to have optho on board (and if its an emergency, they need to see immediately and not have time wasted with an internists attempt to do a dilated eye exam....there are specialists for a reason.

This is a cynical and borderline nihilistic view on medicine.

But then again, there are some doctors I know of who do not even want to use the stethoscope anymore (and these doctors are not replacing that with lung US either)

If an expensive, potentially invasive or detrimental (radiation) treatment or diagnostic study will not change management, then it is worth re-thinking it.

But this is a free physical exam technique (the PanOptic direct opthalmoscope utilizes special optics to obtain a 25 degree field of view without any pharmacological dilation required... so risks are... photophobia in a migraine sufferer?)

This is akin to:

The patient is presenting for elevated glucose at a country fair of 130 fasting. You will do a fasting glucose check and A1c because it will change management. But you will not do a stethoscope examination because it will not change management. I can't think of any physician who won't do a basic physical examination even if the chief complaint is completely something else (of course getting the billing components documented to receive the full 9920X code is a different story...)


or maybe another example is a patient presents for CVA and no one does a complete neurological exam or attempt an NIH stroke scale... why? because neurology is coming anyway.

This is a practical thing to do... but it also admits defeat and admittance that one has forgotten a basic principle and tenet of Internal Medicine

(This post is not a personal attack on you. Rather a commentary of the entire population)

 

[NewYorkDoctors]

i
I rotated with a neuro-opthalmologist that also was of the opinion that those at primary care level, if they made the effort, could gain enough competence to safely field a number of complaints and make some referrals unnecessary

I've had a number of impassioned discussions with neurologists and opthalmologists bemoaning the lack of basic opthalmoscopic skills outside their field as well

In private practice and even a busy hospitalist service, the mentality is either or both of:

1) I have to keep the assembly line moving. Check the list and refer and move on.
This is, after all, how the private practice revenue is generated.

2) I am here to check in and check out. I cannot waste time with this time sink.


Again I am a practicing Internist (not a resident) and am occasionally guilty of this mentality, but more often than not I do what I do by the book.
How do I do this? Typing accurately at 180WPM or higher is a start...


Again, this is not an aggressive post. Just a commentary (and a lament)


Lost in all of this is that in a busy hospital, it is neither practical nor prudent to be doing routine internist opthalmoscopy examinations as that time spent is time NOT spent with another patient who needs your expertise and time.


However, my posts are more probably pointed at PCPs (which I practice partially as one right now). If a patient is diabetic, CMS mandates they have their annual eye examinations documented. Saves money long term. But in the short term, the patient may or may not feel compelled to an opthalmologist and pay the specialist $40 copay. I will not be supplanting the opthalmologist, but by using my handy PanOptic, I can at least get some basic optic disc images and some of the retina and then share with my patient and better explain the need to go to an opthalmologist. "DM is the #1 reason of blindness so you better go" can only take you so far...

It seems many PMDs nowadays just take the path of least resistance... to the patient's inconvenience (at best) and detriment (at worst).

 

[jdh71]

it was something of a soapbox at my school, and something I absorbed, an emphasis on the physical exam... I, and other graduates, have been consistently praised for this elsewhere in residency, and I know many instances where it made a difference

the internists that led our department were pretty passionate about opthalmoscopic skills
we had an optional dilated eye exam skills workshop

it is a fact that there are cases where for an internist outpt or inpt, a proper eye exam can change management

maybe I'm buying too much into the romanticism of my mentor, that you can essentially read a patient's medical history off the back of their eyes... HTN, DM, atherosclerotic changes, etc

I rotated with a neuro-opthalmologist that also was of the opinion that those at primary care level, if they made the effort, could gain enough competence to safely field a number of complaints and make some referrals unnecessary

I've had a number of impassioned discussions with neurologists and opthalmologists bemoaning the lack of basic opthalmoscopic skills outside their field as well

I think we poo poo this exam because it is NOT an easy skill to master, it takes a good amount of time, practice, regularity (things that are in short supply) to even have the skills for getting a good look, and then how do you know what you're looking at? you need exposure to get a good feel for normal/abnormal, and since so many around you training you have crap skills, they often can't see what you're seeing, let alone tell you what it looks like even if they do

so no, I don't think it's pointless, I think getting good and putting it into practice is quite difficult

given the challenges, you also don't want to get all cowboy cocky about your skills and what you're seeing

if you're in a position to acquire this skill, I think that's great and should be encouraged

if you're in doubt about what you're seeing, you can of course kick it up to someone else, like an optho or whatever, but that doesn't mean that the exam you've already done is worthless (based on what consultants have told me)

the eye exam, like any exam, can change over time, and even if you're unsure, relating this to a consultant can actually be extremely useful to them

for most (not all) patients, having 2 not 1 eye exam is really NBD and really not on the level of an extra pelvic exam, and as I said, the two data points in time with the eye exam can have utility

as far as triggering acute angle closure glaucoma, my internal medicine mentor who led the workshops make a logical point I could never find fault in: if you do an indicated dilated exam, and trigger it, you will have done this patient an enormous favor, possibly even saving their vision in the long run, because the diagnosis and treatment can be initiated earlier. It is much better to trigger this in a controlled environment with a known cause than not.

obviously you need to perform and document patient counseling regarding this, and have follow up after dilating them, but usually if you're going to trigger this, it won't be long after the exam and it won't be a mystery, and it can be dealt with. It was only a matter of time for them to present anyway, IIRC

If individual body part exams were lab tests you'd never order it because they lacks sensitivity and specificity.

Might as well order an ACE and LDH on every case and pat yourself on the back every time you meet your confirmation bias.

Neuro exam notwithstanding

 

[Crayola227]

I don't mean to suggest that eye exams should just be done routinely, just that I don't think it's a tool in the internist's toolkit to be blithely tossed aside, which I fear that it is

beyond just being a shame to me -

usually there's an opthalmoscope somewhere on the floor, not in each room like in clinic, but often you can't find it and if you do it isn't charged
that said, they're there because I stand by the fact you need it sometimes

In any case, as a med student and as a resident I carried my own personal one with me, and the only limit on its usefulness was in its operator

As the poster above said, the only limit on doing the exam and getting good at it, is time. I made a point of owning an opthalmoscope and finding time to use it fairly regularly to have the tool in my toolkit. But I am a wonk that way. I also believe in the white coat and being called Doctor Last Name, and referring to patients by theirs. Call me old school wonk.

 

[Crayola227]

If individual body part exams were lab tests you'd never order it because they lacks sensitivity and specificity.

Might as well order an ACE and LDH on every case and pat yourself on the back every time you meet your confirmation bias.

Neuro exam notwithstanding

It's been argued the eye exam is one of the most important parts of the neuro exam

like the neuro exam, no exam of a body part should be taken in isolation, it all must be considered in the whole picture, for the reasons you said

 

[jdh71]

It's been argued the eye exam is one of the most important parts of the neuro exam

like the neuro exam, no exam of a body part should be taken in isolation, it all must be considered in the whole picture, for the reasons you said

Agreed a dilated eye exam can tell you alot about *the eye*. You can do as many of them as like. It is my opinion it a huge waste of time. Your mileage may very.

 

[NewYorkDoctors]

Agreed a dilated eye exam can tell you alot about *the eye*. You can do as many of them as like. It is my opinion it a huge waste of time. Your mileage may very.

I agree with your point that in a busy hospital on a medicine service or with moribund ICU patients, to have an internist without the proper tools to struggle to do an eye exam is a waste of time. Especially when that wasted time you can do more for your other sick patients.

And you still have not addressed my point on the NON dilated panoptic opthalmoscope that has a camera that can get clear retinal images without too much hassle other than patient cooperation.

But would you concede the point that outpatient internists who readily dismiss this skill are merely trying to ramp up their revenue (private practice mill, see as many as fast as possible and defer and refer) or want to check in and check out and put personal lifestyle issues over the art of their craft?

(again... this post is not a personal attack on you... but strawman debates are not very useful for public discourse... this last line may be an attack on your post... but not you as a person or doctor...)

 

[jdh71]

I agree with your point that in a busy hospital on a medicine service or with moribund ICU patients, to have an internist without the proper tools to struggle to do an eye exam is a waste of time. Especially when that wasted time you can do more for your other sick patients.

And you still have not addressed my point on the NON dilated panoptic opthalmoscope that has a camera that can get clear retinal images without too much hassle other than patient cooperation.

But would you concede the point that outpatient internists who readily dismiss this skill are merely trying to ramp up their revenue (private practice mill, see as many as fast as possible and defer and refer) or want to check in and check out and put personal lifestyle issues over the art of their craft?

(again... this post is not a personal attack on you... but strawman debates are not very useful for public discourse... this last line may be an attack on your post... but not you as a person or doctor...)

I don't concede that point because I think it's horse****.

You want to do eye exams? Knock yourself out. You aren't a hero. And the docs who don't waste their time time aren't money grubbers or lazy.

 

[NewYorkDoctors]

I don't concede that point because I think it's horse****.

You want to do eye exams? Knock yourself out. You aren't a hero. And the docs who don't waste their time time aren't money grubbers or lazy.

Lol stay mad bro. Don't know why you took this so personally all of a sudden.

If there were a CPT code for doing basic internist level fundoscopy, more people would do it. Would you concede this point?

Since you took things so personally, let me ask you:

Would you honestly do POCUS or any ICU procedure or any bronchoscopy *routinely* if there were no CPT billing codes for it? Be honest.

 

[rokshana]

Lol stay mad bro. Don't know why you took this so personally all of a sudden.

If there were a CPT code for doing basic internist level fundoscopy, more people would do it. Would you concede this point?

Since you took things so personally, let me ask you:

Would you honestly do POCUS or any ICU procedure or any bronchoscopy *routinely* if there were no CPT billing codes for it? Be honest.

dude, you are picking the wrong person to try to convince to concede a point...(though i tend it agree with him).

 

[jdh71]

Lol stay mad bro. Don't know why you took this so personally all of a sudden.

If there were a CPT code for doing basic internist level fundoscopy, more people would do it. Would you concede this point?

Since you took things so personally, let me ask you:

Would you honestly do POCUS or any ICU procedure or any bronchoscopy *routinely* if there were no CPT billing codes for it? Be honest.

I took nothing personal. Why would I? Why would *I* be mad you want to do eye exams?Knock yourself out. I merely think your eye exam thing is stupid. That is all. Don't start threads if you only want hear things you want to hear. That would be my advice.

 

[gutonc]

If there were a CPT code for doing basic internist level fundoscopy, more people would do it. Would you concede this point?

No. There's a crapton of stuff I could do in the office, with CPT codes to go with them. But I ain't got time for that s***. And in this particular case, I'm not going to make any treatment decisions based on that exam anyway. So why bother?

 

[jdh71]

No. There's a crapton of stuff I could do in the office, with CPT codes to go with them. But I ain't got time for that s***. And in this particular case, I'm not going to make any treatment decisions based on that exam anyway. So why bother?

I don't have a bass boat but if I did, bronchs wouldn't be paying for it. I only bronch patients who need a bronch for diagnosis or less likely for therapeutic aspirations. I don't bronch to bill because that is wrong and unethical and illegal.

 

[VA Hopeful Dr]

PCPs should not be doing dilated eye exams. Full stop.

In terms of the panoptic, it's fine for papilledema for most of us and maybe RDs or hemorrhages if you know what you're doing but very few PCPs do. It's a malpractice landmine because if you think you can spot a retinal detachment and miss one you're now on the hook for a blind patient.

It's easier for us and almost always better for patients if you have a major eye concern to send to someone with an indirect and a slit lamp.

 

[Siggy]

Lol stay mad bro. Don't know why you took this so personally all of a sudden.

If there were a CPT code for doing basic internist level fundoscopy, more people would do it. Would you concede this point?

Since you took things so personally, let me ask you:

Would you honestly do POCUS or any ICU procedure or any bronchoscopy *routinely* if there were no CPT billing codes for it? Be honest.

Counterpoint:
Basic bedside procedures like paracentesis, thoracentesis, and lumbar punctures that are well within the scope of an internest are often shopped out to IR because they don't generate enough RVUs to make them worth wild over seeing another patient.

Also, using that argument, an intensivist really should farm out vent management to pulmonology because you can't bill for the vent management CPT in addition to an E/M code (inpatient/critical care CPT).

Having a CPT code alone is not simply enough.

 

[IM2GI]

No. There's a crapton of stuff I could do in the office, with CPT codes to go with them. But I ain't got time for that s***. And in this particular case, I'm not going to make any treatment decisions based on that exam anyway. So why bother?

This.

Stay in your lane. Waste of time, and way too sketchy legally if you miss something.

 

[gutonc]

This.

Stay in your lane. Waste of time, and way too sketchy legally if when you miss something.

Fixed that for you.

 

[PlutoBoy]

I will not be supplanting the opthalmologist, but by using my handy PanOptic, I can at least get some basic optic disc images and some of the retina and then share with my patient and better explain the need to go to an opthalmologist. "DM is the #1 reason of blindness so you better go" can only take you so far...

So you do plan to send them to the ophthalmologist anyway...

Honestly, it is a skill I'd like to have but simply put we don't do enough of them to reassure anyone. In primary care, there's more value in doing I&Ds, nail avulsions, and paps than using a handy panoptic.

 

[PlutoBoy]

Lol stay mad bro. Don't know why you took this so personally all of a sudden.

If there were a CPT code for doing basic internist level fundoscopy, more people would do it. Would you concede this point?

Since you took things so personally, let me ask you:

Would you honestly do POCUS or any ICU procedure or any bronchoscopy *routinely* if there were no CPT billing codes for it? Be honest.

What the hell, man? Of course we would do it.
We are doctors. We are here to diagnose and treat. A routine eye exam is not in the same category as an ultrasound to diagnose ascites or pleural effusion to do a paracentesis/thoracentesis.

If a patient shows up to my clinic saying that all of a sudden he can't see out of one eye I'm sending him to ophthalmology STAT anyway. There are few eye emergencies. Those need an ophthalmologist. The other non emergent stuff can wait... so I'll get them to the ophthalmologist.