What is an opthalmologist's take on an internist doing a funduscopic examination?

[NewYorkDoctors]

Hello.

I am a part time nephrologist / Internist who sees a large number of hypertensive and diabetic patients.
Although I do send these patients to opthalmology for a formal dilated retinal exam (which is part of the diabetes management anyway), I do have a PanOptic ophthalmoscope which I fiddle around with now and then for someone who is having uncontrolled BP for an undilated exam. It's not where near as good as those retinal photographs in the textbooks, of course. But I have gleaned some useful information in the past such as papilledema, A-V nicking, copper wiring, hard exudate etc...
I use the iphone attachment and Welch Allyn app to record and then pull stills for the record.
Personally, this has never changed my management yet... though I am still waiting for that one case of identifying malignant hypertension versus alternate etiologies of thrombotic microangiography in which the papilledema helps distinguish the etiologies... I may as well wait for Godot...

But I have heard all the arguments from all sides in the academic sphere.

Medical school educators and some old school Internists, Neurologists, and Nephrologists are state that the Internist should be able to see the fundus and glean the basic information. They all lament the "loss of the physical examination."

On the other hand, some of the same physicians express some degree of nihilism with statements such as:
- You can't see anything with a direct funduscope that is undilated anyway (counter - use the Panoptic)
- An internist without the proper medical malpractice insurance should not be dilating the eyes and triggering closed angle glaucoma (I have also heard the opthalmologist counter that if that happens, one is doing the patient a favor by identifying the issue... assuming an opthalmologist is ready and willing to come to assist and not grumble about "why'd you do that?")
- Even if you see papilledema you are already treating the hypertension based on other clinical metrics and already getting a CT head or other neuroimaging
- You need the full exam with an indirect scope or retinal photograph by the opthalmologist anyway to complete the chart and protect against a lawsuit.

What is the opthalmologist's take on this?
I would venture a guess and say "cool if you can see something but you should always refer if you are concerned."
(and then the PGY2 optho resident grumbles as he/she has to bring the luggage case to the wards)

My personal take is... it might help me convince someone in the outpatient setting to start BP meds if he/she is unconvinced by the other lab / imaging/ or clinical metrics... maybe...

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[hello lady!]

You're not hurting anyone - if you enjoy it, why not?

I'm surprised you have time to do the exam and insert the photographs into the chart, though. Do you bill for the photography?

 

[TheLesPaul]

Go for it! Just don't consult ophthalmology for inpatients unless their eye is dying.

 

[RetinaDude]

I don’t believe there’s anything wrong with you doing it but I don’t believe it’s very helpful for your hypertensive pts. I’ve been in practice for over 20 years (retina), and seeing Hypertensive related optic nerve swelling is NOT very common. And many times, when I’ve been referred a pt with “swollen optic nerves secondary to hypertension”, it’s usually not swollen or is a “pseudo-papilledema”. AV nicking and copper wire changes are very common but I find that mentioning it to pts does little to change their management. Most just say “well my BP is always good when I check it”. I then ask “how often do you check your BP?” and the common response is “when I go the the doc’s office every six months”. So, I think something even better than checking their fundus would be educating the pts to check their BP much more, and to keep a record of it for your office to know if they are truly controlled or not…..but also encourage yearly eye exams (more often if needed for significant ocular changes).

 

[Dusn]

The technology will continue to make it easier and cheaper to get a good fundus image and even photo - hopefully without needing to dilate the eye. And it has a ton of useful systemic info - it’s the most informative part of the physical exam in my biased opinion.

AI screening devices are already available to perform screening for diabetic retinopathy in primary care settings. But the AI will only detect diabetic retinopathy; it will miss a giant choroidal melanoma. I feel like some human should at least look at the picture and say that something else doesn’t look right here.

 

[PLA2]

Practice Patterns of Fundoscopic Examination for Diabetic Retinopathy Screening in Primary Care - PubMed

In this cohort study, fundoscopic examination was rarely performed and was not sensitive for detecting DR in primary care practice. Because the rate of DR screening by eye care professionals remains low, research to explore and break down barriers to the implementation of effective primary...

pubmed.ncbi.nlm.nih.gov

0% sensitivity for detecting diabetic retinopathy

 

[NewYorkDoctors]

I do not bill for this as this isn't retinal microscopy. its just using an iphone app to take a picture of the direct funduscope little narrow image to show patients. it's just brownie points for patients in that sense.

I set up my chronic hypertensives with remote BP monitoring. Basically patients get a machine that measures their BP remotely and sends in the values to a portal via a 4G connection. I know all their BP trends and then I make adjustments on meds or lifestyle that way. This is something I bill for.

I do other Internal Medicine type of things to follow their blood pressure like point of care ultrasound (of their organs and volume status), labwork, and physical as well.
The eye exam has never been the convincing

But the sheer number of old farts in residency and fellowship kept on harping about "the lost art of physical exam" when I doubt they themselves know how to even do direct funduscopy anymore.

I have seen those machines that do retinal photography that can upload to an ophthalmology tele-service. I can imaging how this might be useful for an internist in a remote area. However, it is not something that I would require in NYC as there are many available ophthalmologists and even optometrists who can do the diabetic eye exam.


I do see how its futile for an internist to use inpatient.
I mean there are a few Internal Medicine cases in which funduscopy changes management. The most common one is probably to rule out candidal endopthalmitis in an immunosuppressd neutropenic patient with candidemia. Even if I could pretend to know what I am seeing, we need the opthalmologist's expert report from the indirect funduscopy ... for the lawyers...

 

[TheLesPaul]

Funny you should mention candida as the AAO actually recommends not screening for this with fungemia in the absence of symptoms:

Academy guidelines for Candida-related endophthalmitis screening now available

The American Academy of Ophthalmology has published its recommendations against routine screening of patients for endophthalmitis caused by Candida septicemia.

www.aao.org

 

[VA Hopeful Dr]

The technology will continue to make it easier and cheaper to get a good fundus image and even photo - hopefully without needing to dilate the eye. And it has a ton of useful systemic info - it’s the most informative part of the physical exam in my biased opinion.

AI screening devices are already available to perform screening for diabetic retinopathy in primary care settings. But the AI will only detect diabetic retinopathy; it will miss a giant choroidal melanoma. I feel like some human should at least look at the picture and say that something else doesn’t look right here.

FP here, my hospital is piloting such a program now. We'll use the iphone set up described above but the pictures get sent to a tele-ophthalmologist for interpretation.

We have plenty of ophthalmologists and optometrists, but none of them are good about sending a note about the results of the diabetic eye exam (though admittedly the MDs are better than the ODs about this by a decent bit). Since proving patients are getting their diabetic eye exams is a big Medicare quality measure these days, this was our work around since the other option is calling a patients eye doctor every time we notice they are due for an exam and the patient tells us they already had it done recently.

 

[NewYorkDoctors]

FP here, my hospital is piloting such a program now. We'll use the iphone set up described above but the pictures get sent to a tele-ophthalmologist for interpretation.

We have plenty of ophthalmologists and optometrists, but none of them are good about sending a note about the results of the diabetic eye exam (though admittedly the MDs are better than the ODs about this by a decent bit). Since proving patients are getting their diabetic eye exams is a big Medicare quality measure these days, this was our work around since the other option is calling a patients eye doctor every time we notice they are due for an exam and the patient tells us they already had it done recently.

i have noticed the same thing regarding not always receiving the optho notes from other private practice groups.

however, the insurance companies are kind enough to send me a record of ICD10 and CPT codes that the ophthalmologist used from the billing reports that proves the patient had an exam... and the patient tells me that injections were not required so.... i can feel good enough that the DM is probably harming the eyes in that case... that's good enough for the quality metrics around my neck of the woods.


I checked out one of those tele-ophtho services.. the cost seems a bit prohibitive for most primary care practices. I suppose it would generate enough revenue to break even in a remote setting in which there is no easy access to an ophthalmologist.

 

[NewYorkDoctors]

Funny you should mention candida as the AAO actually recommends not screening for this with fungemia in the absence of symptoms:

Academy guidelines for Candida-related endophthalmitis screening now available

The American Academy of Ophthalmology has published its recommendations against routine screening of patients for endophthalmitis caused by Candida septicemia.

www.aao.org

Meh. I have no stake in this argument as I do not routinely take care of Candidemia patients anymore as I am not doing routine ICU work anymore...

but the IDSA does continue to recommend routine dilated examination in all patients with fungemia (with a delay of a few weeks for acutely neutropenic patients due to lower sensitivity during the neutropenic period). they cite how the ophtho recommendations were based on systematic reviews of varying quality, etc... technical research paper factors, and how there is greater use of echinocandins (caspofungin, micafungin, etc...) which does not have good intraocular penetration.

from the Internal Medicine / ID side of things, if a caspofungin is being considered, then identification of intraocular involvement would necessitate upgrading to amphotericin (a big change in systemic toxicity profile). If it's someone's vision on the line, then even an asymptomatic case ( < 1%) may be considered too much at stake... (for the lawyers anyway).

at the end of the day, IM tries not to call ophtho for inpatient stuff

 

[TheLesPaul]

i am not a retina person but the IDSA guidelines were updated in 2016 from what I understand, and the AAO guidelines are new as of 2022 to address specifically those concerns

 

[Slide]

Meh. I have no stake in this argument as I do not routinely take care of Candidemia patients anymore as I am not doing routine ICU work anymore...

but the IDSA does continue to recommend routine dilated examination in all patients with fungemia (with a delay of a few weeks for acutely neutropenic patients due to lower sensitivity during the neutropenic period). they cite how the ophtho recommendations were based on systematic reviews of varying quality, etc... technical research paper factors, and how there is greater use of echinocandins (caspofungin, micafungin, etc...) which does not have good intraocular penetration.

from the Internal Medicine / ID side of things, if a caspofungin is being considered, then identification of intraocular involvement would necessitate upgrading to amphotericin (a big change in systemic toxicity profile). If it's someone's vision on the line, then even an asymptomatic case ( < 1%) may be considered too much at stake... (for the lawyers anyway).

at the end of the day, IM tries not to call ophtho for inpatient stuff

Not to derail the original discussion but I had to set the ID department straight about the IDSA guidelines at my academic center, and this was my take. The IDSA guidelines, despite from 2016, are very archaic and cite literature from 20-30 years ago. If you look closely at the guidelines and references, the guidelines are almost all "expert consensus with low evidence", meaning that the recommendations have been ID dogma passed down generations. The references supporting their claims would not pass academic peer review these days, especially if an ophthalmologist were involved in reviewing the manuscripts. In fact, one of the references they cite most recently states that routine consultation is not recommended (oops). The newer evidence published has shown the NNT for a consultation in an asymptomatic, alert patient that leads to treatment is really, really low, and even then, with newer agents like voriconzaole, the treatment may not even change anyway other than injecting intravitreal ampho B - if it's possible/if the patient will even let you.

I know most attendings like you try not to get us involved as much as possible (and we greatly appreciate it)...however unfortunately your ID colleagues are much more trigger happy about this and don't understand that how wasteful this is - which is ironic how ID tends to be very evidence focused about their treatments yet are happy to look the other way on this one. Having an average of 10 consults a week for ocular fungemia ruleouts - staffed by an attending- may not sound like a lot but it adds up to waste in the medical system. Great if I were an inpatient ophthalmologist because it's a low thought RVU process, but it's not great for the healthcare system as a whole (more unnecessary medical care which CMS obviously will keep tabs on). From a malpractice standpoint, I think all the recent evidence as well as the increasing clarion calls from subspecialty groups showing how unnecessary this is would protect everyone involved. Also, the reality is if there is really bad ocular fungemia and sedated/intubated, the patient may not be around long enough for the eyes to matter.

 

[NewYorkDoctors]

Good take. This is what my ophtho friend tells me as well.

The big "boogeyperson" is probably the term "standard of care" if a case went to a lawsuit. perhaps hold off on the optho inpatient referral if asymptomatic and have patient follow up outpatient?

If the patient remains inpatient for a while, what would the threshold for referral be? In other words, what would be considered "symptomatic" for those kind of patients? Visual symptoms such as floaters, auras, visual field loss, color vision issues etc...? or eye pain? probably not just "dry eyes."

Maybe have the IM people do some panoptics... we know the ID won't be doing that. Though that would ultimately lead to more "i dont know what im seeing but i think it could be bad" type of consults... so maybe not. Although in a more collegial environment, perhaps the ID or IM person would share the panoptic stills with the opthal as a curbside before deciding on the need for a formal consult.

However, most general IM physicians tend to be risk averse and probably would not do that.

 

[Slide]

Good take. This is what my ophtho friend tells me as well.

The big "boogeyperson" is probably the term "standard of care" if a case went to a lawsuit. perhaps hold off on the optho inpatient referral if asymptomatic and have patient follow up outpatient?

If the patient remains inpatient for a while, what would the threshold for referral be? In other words, what would be considered "symptomatic" for those kind of patients? Visual symptoms such as floaters, auras, visual field loss, color vision issues etc...? or eye pain? probably not just "dry eyes."

Maybe have the IM people do some panoptics... we know the ID won't be doing that. Though that would ultimately lead to more "i dont know what im seeing but i think it could be bad" type of consults... so maybe not. Although in a more collegial environment, perhaps the ID or IM person would share the panoptic stills with the opthal as a curbside before deciding on the need for a formal consult.

However, most general IM physicians tend to be risk averse and probably would not do that.

You’re spot on - usually it can be seen outpatient or if they’re in the hospital for a long time, nonurgently before discharge - our hospital requires consults to be seen within 24 hours but it often more becomes the consulting attending wants the exam stat rather than giving some heads up. The main symptoms typically we worry about are vision loss, new floaters, or cloudy vision. If the eye is visually red/angry that would require a consult regardless.

 

[NewYorkDoctors]

I used to carry around the PanOptic (and an otoscope for that matter) in my bag in residency many years ago. I would walk around taking a look. One time a patient was dilated by ophtho already (HIV patient looking for retinis I suppose) and so I told the patient BRB ONE MOMENT and i saw a glorious view... of nothing in particular.

The only issue is even if motivated trainees in IM want to do these old school techniques, they lack the attending mentorship to get the proper education and reinforcement.

Therefore, I find the whole IM side of the argument of "woe is me. lost art of physical exam. milennials and Gen Z do not know how to do physical exam. wah wah wah " to fall on deaf ears when these same attendings are not actually performing and teaching these techniques.

 

[Dusn]

I used to carry around the PanOptic (and an otoscope for that matter) in my bag in residency many years ago. I would walk around taking a look. One time a patient was dilated by ophtho already (HIV patient looking for retinis I suppose) and so I told the patient BRB ONE MOMENT and i saw a glorious view... of nothing in particular.

The only issue is even if motivated trainees in IM want to do these old school techniques, they lack the attending mentorship to get the proper education and reinforcement.

Therefore, I find the whole IM side of the argument of "woe is me. lost art of physical exam. milennials and Gen Z do not know how to do physical exam. wah wah wah " to fall on deaf ears when these same attendings are not actually performing and teaching these techniques.

One of the areas where I think some screening from primary care would be helpful is in headache patients. Some overweight patients might have pseudotumor cerebri but the overwhelming majority wont and will have sleep apnea or some other cause for headaches. On the other hand if you miss a patient with pseudotumor they can lose significant vision or go blind. Missing other intracranial causes of elevated ICP are even worse.

Sending every headache patient to Ophtho to rule out papilledema seems like complete overkill. But I have no idea how else you can be sure you won’t miss anyone.

 

[NewYorkDoctors]

whats the ophtho take on IM using tropicamide or whatever to dilate eyes?
is that something that's spelled out in your ophtho malpractice insurance? do you get consent? etc...

 

[Doc320]

What's an ophthalmologist's take on doing a rectal exam before cataract surgery? In medical school during the general surgery clerkship, it was a major omission if you skipped the rectal exam for any patient going into surgery, any surgery.

Should an ophthalmologist do any pre-op workup besides the eyes? I'd say "yes", even if the patient is seeing their internist for a full pre-op workup. Sure, it may be a cursory exam, looking for lower extremity edema, listening to the heart and lungs, etc. but it is more than some ophthalmologists who do no pre-op physical exam other than the eyes. Our office has one exam room table, which is unusual for an ophthalmology office.

Right after residency, I continued to do rectals but stopped doing them because patients might find it odd or even lose confidence in their ophthalmologist. I found one patient that had a prostate mass leading me to recommend workup for that first. He did, found he had metastatic prostate cancer, delayed cataract surgery, and eventually died within a year or so. His cataract was not so mature that he would have benefitted from better vision for a year.

 

[Slide]

I used to carry around the PanOptic (and an otoscope for that matter) in my bag in residency many years ago. I would walk around taking a look. One time a patient was dilated by ophtho already (HIV patient looking for retinis I suppose) and so I told the patient BRB ONE MOMENT and i saw a glorious view... of nothing in particular.

The only issue is even if motivated trainees in IM want to do these old school techniques, they lack the attending mentorship to get the proper education and reinforcement.

Therefore, I find the whole IM side of the argument of "woe is me. lost art of physical exam. milennials and Gen Z do not know how to do physical exam. wah wah wah " to fall on deaf ears when these same attendings are not actually performing and teaching these techniques.

The flip side of all of this, from what my friends in other fields tell me, is that the knowledge base is ever expanding compared to even 10-15 years ago. 40-50 years ago, you had maybe no more than 30-40 medications, of that maybe half you’d use, and there was much less to do. My classmate’s dad was an oncologist, and he told me that when he started, if someone had cancer that wasn’t amenable to resection or the early generation alkylating agents, your job was to call the flower shop for condolences and be a glorified therapist. Nowadays, modern medicine gives us so many options and choices thankfully, but that it means you have to learn even more in the same amount of time. That’s not even factoring in the paperwork/scut work.

Long winded way of me saying, while annoying at times, I don’t mind if other fields consult us for the proper reasons and don’t do more than a cursory eye exam. It takes some of our younger residents 3-6 months to feel comfortable doing a good exam, I can’t imagine someone in another field practice the eye exam enough to know what they’re looking at. There’s just too much crap to do in our respective fields these days. The only exceptions I have to this are neuro and EM due to the nature of their fields in relation to ours.

 

[eyeeye_captain]

What's an ophthalmologist's take on doing a rectal exam before cataract surgery? In medical school during the general surgery clerkship, it was a major omission if you skipped the rectal exam for any patient going into surgery, any surgery.

Should an ophthalmologist do any pre-op workup besides the eyes? I'd say "yes", even if the patient is seeing their internist for a full pre-op workup. Sure, it may be a cursory exam, looking for lower extremity edema, listening to the heart and lungs, etc. but it is more than some ophthalmologists who do no pre-op physical exam other than the eyes. Our office has one exam room table, which is unusual for an ophthalmology office.

Right after residency, I continued to do rectals but stopped doing them because patients might find it odd or even lose confidence in their ophthalmologist. I found one patient that had a prostate mass leading me to recommend workup for that first. He did, found he had metastatic prostate cancer, delayed cataract surgery, and eventually died within a year or so. His cataract was not so mature that he would have benefitted from better vision for a year.

Please tell me this is the premise for the next Dr. Glaucomflecken video. I recently got a hearty chuckle from a local ophthalmologist wearing a stethoscope in their headshot.

 

[hello lady!]

I used to carry around the PanOptic (and an otoscope for that matter) in my bag in residency many years ago. I would walk around taking a look. One time a patient was dilated by ophtho already (HIV patient looking for retinis I suppose) and so I told the patient BRB ONE MOMENT and i saw a glorious view... of nothing in particular.

The only issue is even if motivated trainees in IM want to do these old school techniques, they lack the attending mentorship to get the proper education and reinforcement.

Therefore, I find the whole IM side of the argument of "woe is me. lost art of physical exam. milennials and Gen Z do not know how to do physical exam. wah wah wah " to fall on deaf ears when these same attendings are not actually performing and teaching these techniques.

I think a big part of this is declining reimbursements with increasing administrative burden. Who has time to do these nuanced exams anymore?

 

[NewYorkDoctors]

I think a big part of this is declining reimbursements with increasing administrative burden. Who has time to do these nuanced exams anymore?

true statement.
i think this is what is lost on the old timers (who probably don't even know how to use an EMR)

nevertheless, I still like to dabble with these things now and then.

on a side note, what is the ophthalmologist's take on using ultrasound to detect optic nerve sheath diameter?

The critical care literature has some stuff on this .

PulmCrit: Algorithm for diagnosing ICP elevation with ocular sonography

Introduction with a clinical question A young woman is transferred to the ICU from an outside hospital due to severely depressed mental status, thought

emcrit.org

I know optho uses B mode ultrasound for eyes in their office all the time for retinal stuff or something

can this actually be a suitable replacement (or not) for funduscopy for papilledema for an IM/CCM/EM provider?

 

[NITRAS]

Do you guys actually look at other doctors’ exams? I mean I look at Eye doctor’s eye exam, ortho‘s joint exam. Maybe the occasionally nephrologist volume exam. But I look at GI’s scope, a cardiologist’s echo, and for most surgeons, I look at the CT report.

 

[Dusn]

true statement.
i think this is what is lost on the old timers (who probably don't even know how to use an EMR)

nevertheless, I still like to dabble with these things now and then.

on a side note, what is the ophthalmologist's take on using ultrasound to detect optic nerve sheath diameter?

The critical care literature has some stuff on this .

PulmCrit: Algorithm for diagnosing ICP elevation with ocular sonography

Introduction with a clinical question A young woman is transferred to the ICU from an outside hospital due to severely depressed mental status, thought

emcrit.org

I know optho uses B mode ultrasound for eyes in their office all the time for retinal stuff or something

can this actually be a suitable replacement (or not) for funduscopy for papilledema for an IM/CCM/EM provider?

I suspect that you trying to see papilledema with a panoptic would be more sensitive and specific than using an ultrasound.

The technology for getting beautiful wide field fundus photos without dilation is available. It’s just too expensive for it to be worth it outside of an eye clinic. Hopefully in the future it’ll become much cheaper.

 

[NewYorkDoctors]

I suspect that you trying to see papilledema with a panoptic would be more sensitive and specific than using an ultrasound.

The technology for getting beautiful wide field fundus photos without dilation is available. It’s just too expensive for it to be worth it outside of an eye clinic. Hopefully in the future it’ll become much cheaper.

can you link some products? i like to learn about this tech even if I cant splurge on it.

 

[Dusn]

can you link some products? i like to learn about this tech even if I cant splurge on it.

The Optos is the one most retina specialists use.

Optos Ultra-widefield (UWF™) Retinal Imaging Devices for Eyecare - Production

Optos products give the most complete view of the retina and help with early detection of systemic and ocular disease. Learn about our products here.

www.optos.com

There are smaller and cheaper options that would be more relevant to non-ophthalmologists but I'm not as familiar with them.

 

[Splenda88]

Good take. This is what my ophtho friend tells me as well.

The big "boogeyperson" is probably the term "standard of care" if a case went to a lawsuit. perhaps hold off on the optho inpatient referral if asymptomatic and have patient follow up outpatient?

If the patient remains inpatient for a while, what would the threshold for referral be? In other words, what would be considered "symptomatic" for those kind of patients? Visual symptoms such as floaters, auras, visual field loss, color vision issues etc...? or eye pain? probably not just "dry eyes."

Maybe have the IM people do some panoptics... we know the ID won't be doing that. Though that would ultimately lead to more "i dont know what im seeing but i think it could be bad" type of consults... so maybe not. Although in a more collegial environment, perhaps the ID or IM person would share the panoptic stills with the opthal as a curbside before deciding on the need for a formal consult.

However, most general IM physicians tend to be risk averse and probably would not do that.

IM here.

Until the IDSA guidelines clearly say no ophtho consult unless there are worrying symptoms that you mention above, it is an automatic ophtho consult from ALL my hospitalist colleagues. One bad miss can follow you for the rest of your career.

Most physicians are risk averse, not ONLY general IM.

 

[TheLesPaul]

IM here.

Until the IDSA guidelines clearly say no ophtho consult unless there are worrying symptoms that you mention above, it is an automatic ophtho consult from ALL my hospitalist colleagues. One bad miss can follow you for the rest of your career.

Most physicians are risk averse, not ONLY general IM.

You are welcome to follow your guidelines and we can follow ours. I think I would trust the society to whom the organ belongs. Outside academic centers where there is resident coverage, it is a useless consult in the asymptomatic patient...

 

[NewYorkDoctors]

from a hospitalist perspective ; they will never see the hospital patient outside so they have no control over whether this patient sees an ophthalmologist outpatient . Hence that Potential lawsuit dangles over everything

I mean in a perfect world Perhaps the patient in question gets an ophtho outpatient apppintment set up - but patients gonna patient at the end of the day

 

[eyeeye_captain]

What do you do if you have a fungemic patient in a hospital without ophthalmology coverage (probably the majority of hospitals in the country)? Are these patients getting transferred for screening exams? If not, then an exam is not the standard of care and likely isn’t necessary, especially when our guidelines say it isn’t. If yes, then while I completely respect the want and need to CYA - that’s some serious medical systems waste.

TBF, I’ve had 2 hospitals I didn’t even work at call to try to get me into their ICU stat for this.

 

[TheLesPaul]

from a hospitalist perspective ; they will never see the hospital patient outside so they have no control over whether this patient sees an ophthalmologist outpatient . Hence that Potential lawsuit dangles over everything

I mean in a perfect world Perhaps the patient in question gets an ophtho outpatient apppintment set up - but patients gonna patient at the end of the day

Does lack of planning on the patient's part constitute an emergency? They have a colon and they are over 50 -- do you get them scoped as an inpatient also? What if they have dental caries? Those are pretty bad. I've seen patients die from cellulitis adjacent to periodontal disease.

Point being -- outpatient issues do not become inpatient issues just because the hospitalist's world revolves around the hospital.

 

[Slide]

I’m just curious as a general question: what really happens in the real (private world) for these consults? Most private guys in my area can’t tell me the last time they were in the ICU or hospital to see a patient for fungemia or dilated eye exam. Transferring a patient to a level of higher care for a dilated eye exam also seems like a waste of resources.

 

[Slide]

IM here.

Until the IDSA guidelines clearly say no ophtho consult unless there are worrying symptoms that you mention above, it is an automatic ophtho consult from ALL my hospitalist colleagues. One bad miss can follow you for the rest of your career.

Most physicians are risk averse, not ONLY general IM.

When thinking about it, in the court of law, I doubt something like this would really result in a lawsuit, much less a victory for the plaintiff. If following the rule of limiting consults to symptomatic or nonverbal/non communicative patients, the risk of a miss is super low, and the risk of this causing actual issues is much less. You also have to weigh the risks of injections/surgery in a patient who is asymptomatic and may improve on systemic therapy alone.

I can’t see any expert witness in ophthalmology testify against the defendants in this situation. Also, a good expert witness would eviscerate the IDSA guidelines to the point of the prosecutor trying to quickly reach a deal to avoid embarrassment.

 

[NewYorkDoctors]

W was

Does lack of planning on the patient's part constitute an emergency? They have a colon and they are over 50 -- do you get them scoped as an inpatient also? What if they have dental caries? Those are pretty bad. I've seen patients die from cellulitis adjacent to periodontal disease.

Point being -- outpatient issues do not become inpatient issues just because the hospitalist's world revolves around the hospital.

i hear you.

this is why hospitalist signing out to PMD is crucial. now even if the hospitalist had time to call the PMD, the PMD may not have time to pick up the phone call.

maybe the ophtho departments can get those retinavue machines for inpatient use. train the medicine department on its use and set up a tele-ophtho service...

Welch Allyn RetinaVue 700 Imager

The Welch Allyn RetinaVue 700 Imager and other medical equipment and supplies are available at JakenMedical.com.

jakenmedical.com

but easier said than done I understand

 

[TheLesPaul]

W was

i hear you.

this is why hospitalist signing out to PMD is crucial. now even if the hospitalist had time to call the PMD, the PMD may not have time to pick up the phone call.

maybe the ophtho departments can get those retinavue machines for inpatient use. train the medicine department on its use and set up a tele-ophtho service...

Welch Allyn RetinaVue 700 Imager

The Welch Allyn RetinaVue 700 Imager and other medical equipment and supplies are available at JakenMedical.com.

jakenmedical.com

but easier said than done I understand

To this end, I try to make myself very accessible, and if the inpatient team calls me and needs someone seen urgently, we will make it happen ASAP. And if the patient has financial difficulty, we don't charge them, that is part of the deal of taking care of your community.

 

[NewYorkDoctors]

any input from ophtho regarding this welch allyn retinavue?

although I am in NYC and there are opthalmologists and optometrists a plenty, there are just a subset of patients who just can't be bothered or cannot easily make another visit to the eye doctor for their diabetic screening.

 

[NewYorkDoctors]

anyway just to provide an update, I have the hillrom retinavue set up in my office now for the diabetic and hypertensive checks. for my purposes I think it works great. i mean I have had a very poor conversion rate for patients going for their diabetic eye checks. the patients tell me its because "the ophthalmologist keeps asking them to get their cataracts done."

anyway great device for Internists!

Since I prescribe a fair amount of ethambutol (I treat TB and NTM quite a bit) and manage patients on hydroxychloroquine quite often, I find this to be a good tool.

Also now I can never call ophtho for a fungemia patient ever again! lol

 

[hello lady!]

anyway just to provide an update, I have the hillrom retinavue set up in my office now for the diabetic and hypertensive checks. for my purposes I think it works great. i mean I have had a very poor conversion rate for patients going for their diabetic eye checks. the patients tell me its because "the ophthalmologist keeps asking them to get their cataracts done."

anyway great device for Internists!

Since I prescribe a fair amount of ethambutol (I treat TB and NTM quite a bit) and manage patients on hydroxychloroquine quite often, I find this to be a good tool.

Also now I can never call ophtho for a fungemia patient ever again! lol

Pretty neat, though be careful. If you're monitoring and detect changes from Plaquenil toxicity on this thing you may want to call your malpractice carrier first instead of ophtho.

 

[NewYorkDoctors]

Pretty neat, though be careful. If you're monitoring and detect changes from Plaquenil toxicity on this thing you may want to call your malpractice carrier first instead of ophtho.

Right good advice .

You would not believe how many patients I see who decline everything I offer despite counseling and explaining because they find seeing another doctor to be a “waste of time .” I’ll probably tecommend ophthalmology first . But if they decline and I document then Ill offer this and state it’s not as good but hey better than nothing. I mean it is better than documenting the patient refused then the patient crying later when they get retinal problems

 

[TheLesPaul]

I'm not retina, but aren't early Plaquenil changes not seen on fundus, you need VF and OCT AF to diagnose? so you might be operating under a false sense of security -- which is actually worse than nothing?

 

[LightBox]

I'm not retina, but aren't early Plaquenil changes not seen on fundus, you need VF and OCT AF to diagnose? so you might be operating under a false sense of security -- which is actually worse than nothing?

Fundus photos are not standard of care. By the time you see maculopathy on a fundus exam, it is too late. You don't know what you don't know.

 

[dantt]

Right good advice .

You would not believe how many patients I see who decline everything I offer despite counseling and explaining because they find seeing another doctor to be a “waste of time .” I’ll probably tecommend ophthalmology first . But if they decline and I document then Ill offer this and state it’s not as good but hey better than nothing. I mean it is better than documenting the patient refused then the patient crying later when they get retinal problems

Most rheumatologists I know decline to prescribe plaquenil if patients decline to get their eyes checked.

 

[Slide]

Right good advice .

You would not believe how many patients I see who decline everything I offer despite counseling and explaining because they find seeing another doctor to be a “waste of time .” I’ll probably tecommend ophthalmology first . But if they decline and I document then Ill offer this and state it’s not as good but hey better than nothing. I mean it is better than documenting the patient refused then the patient crying later when they get retinal problems

Check with your insurance carrier to see if there are any issues with it. I know OMIC (ophthalmology malpractice carrier) makes a big stink about plaquenil toxicity being a surprisingly litigious topic. I do sincerely appreciate that you’re doing the best you can for your patients, it’s becoming harder to find that aspect these days.

 

[dantt]

Check with your insurance carrier to see if there are any issues with it. I know OMIC (ophthalmology malpractice carrier) makes a big stink about plaquenil toxicity being a surprisingly litigious topic. I do sincerely appreciate that you’re doing the best you can for your patients, it’s becoming harder to find that aspect these days.

A big stink based on prior claims experience.

 

[NewYorkDoctors]

anyway good advice everyone thanks. i WONT bother with the plaquenil patients then at all.

back to the original point of this thread, I showed those "old school internists who lamented loss of physical exam" and their takes were one of the following

1) wow cool . that's nice. wish we had this in our day
2) how much does it cost? too much! just refer to ophtho!
3) in my day, we just squinted with the direct ophthalmoscope and we never complained!


pretty much what i expected