Efficiency is an art, a skill, and can truly be achieved when you have an understanding of your patient’s purpose of visit. While patients appreciate the comprehensive nature of our exams, they also appreciate execution in a timely fashion. As a beginning clinician, it may seem daunting to keep a balance of both, so here are a few tips to make your exam smoother and more efficient.
Standing Case History: Establish a dynamic flow to your exam from the get-go. The idea behind standing is that you are engaging the patient in conversation, building rapport, and simultaneously cleaning all the equipment. This saves you transitional time from one skill to the next because your equipment is set for use. As you are cleaning, get to know your patient’s lifestyle and how they use their eyes. Ask problem-focused questions so that you know how to direct the exam and address the chief complaint. Case history starts from the moment the patient walks into the exam room. Save any small talk or trivial chitchat for retinoscopy!
Pinhole Visual Acuity: Assess the entering visual acuity with an occluder that can be converted into a pinhole. This way if your patient cannot read the 20/20 line, you can determine if this a refractive error or pathological issue using the pinhole. If vision through the pinhole shows no improvement, you know that you don’t need to spend 30 minutes refracting because the problem is likely due to an ocular media or retinal abnormality. If you suspect dry eye or abnormal tear film as the cause of reduced vision because the patient’s response is fluctuating, administer a drop of artificial tears and re-measure visual acuity. It is important to establish an accurate baseline before beginning refraction.
Cornea, Angles, Tonometry: Increase your slit lamp sequence efficiency by covering the basics and getting the dilation drops in by 20 minutes into the exam. If there are no ocular surface complaints, you can administer Fluress before getting behind the slit lamp. Then, check the angles and cornea under white light, utilize the cobalt filter, and perform tonometry. If it is safe to dilate the patient, administer the dilating drops and then proceed to check the anterior segment comprehensively. This will save you time otherwise spent waiting for your patient to dilate. (This is only if you do not need to request permission from your attending to dilate!)
Dilate & Chart: During dilation time, you should be finishing most of the chart through anterior segment and printing out any necessary prescriptions. It is perfectly okay to ask patients to hang out in the waiting room so you can complete required paper work. This is especially true if your patient is a “Chatty Kathy” and will distract you from accurate charting.
BIO Before 90: Starting with BIO allows you to take a look at the big picture first – the retina. It allows you to observe the clarity of the view into the eye and predict the clarity of the patient’s view out of the eye. It may also help you to pick up on the subtleties of vitreal abnormalities and retinal findings. You will then have direction when you move to the slit lamp to swiftly observe the lens, vitreous, and retina.
Patient Education: Take charge of educating the patient yourself. This will promote your own learning because patients will ask you questions that force you to think about their treatment plans. It will also make you more aware about your understanding of diagnoses. When you educate the patient yourself, it establishes trust and confidence in your abilities as a clinician. Any questions that you or the patient have about the plan of action can then be directed to the attending doctor while checking in! It may even be of value to do the consultation in the presence of your preceptor so you can fine-tune your dialogue. A great way to direct your patient education is to start with the good news first. For example, if the patient has signs of diabetic retinopathy but their glasses prescription is the same, start with telling them that there is no change in their prescription. Your education should cover prescriptions, binocular vision status, and ocular health so that your patients can understand the comprehensive nature of their exam. If everything is unremarkable, it can be as simple as, “Your glasses prescription is stable. Your eyes work well together as a team, and your eyes are healthy both inside and out.”
Efficiency will improve as your time in clinic increases and you refine your skills. Don’t forget to make your exam a dynamic process and have some fun!
The two graduating fourth years and co-authors of this article have some parting words of advice for all clinicians:
Sloan Rajadhyksha (Berkeley 2017): Clinic will undoubtedly have a steep learning curve for even the most astute clinician. My biggest advice is to allow yourself to become a sponge and soak up as much knowledge and clinical pearls to increase your efficiency. As a student, now is the time to make mistakes – you will learn the most from them. Be open to critique, make it your goal to identify the gaps in your knowledge, and most importantly treat every patient as an individual who is more than just a pair of eyes!
Nicholas Green (Ohio State 2017): Always remember that your ability to give an efficient eye exam should never cause the quality of the exam to suffer. It is always preferable to perform tests and get the correct diagnosis than to speed through an exam and miss something important. As you become more experienced, your clinical reasoning skills will be refined and coupled with these tips, you will decrease your chair time per patient and increase patient satisfaction.