I found that they would show me the picture and then just let me talk. Sometimes they would ask me questions, so I would include natural pauses during my schpiel to make it easy for them to interrupt. But a lot of the time, they would show the photo and then not say anything unless I was failing to say some important point.
I took the Osler course, they told us NOT to just prattle off a bunch of differentials and a bunch of lab findings/tests willy-nilly. I mean, always get a refraction on cataracts, always check CRx and EOMs on kids, but otherwise, it's a waste of time to say, 'I would check extraocular movements, making sure the eyes were ortho in all directions and that there was no deviation' if they give you, say, a 56-year-old on Coumadin coming in with an atraumatic subconj hemorrhage. Also, don't drag yourself down the rabbit hole of 'differential diagnosis includes epi/scleritis [for red eye].' Keep it focused, keep it efficient.
I would see a photo of, say, a pterygium and say, 'This is an external photo showing a triangular conjunctival lesion extending over the cornea. My most likely diagnosis is a pterygium; it could also be an ocular surface squamous neoplasia. I'd ask the patient if they had any complaints of decreased vision, scratchiness, or foreign body sensation. I would check the patient's refraction and BCVA, perform a complete dilated eye exam and check whether this lesion were in or close to the visual axis, and obtain topography to see whether this was inducing corneal astigmatism. I would look for flattening under the lesion and irregular astigmatism. If the patient had a lot of ocular surface complaints, if the lesion were inducing a lot of corneal astigmatism, or if the lesion was in or threatening the visual axis, then I would consider excision. If none of those were present, then this patient could be safely observed with regular followup every 6 months.'
