January 9, 2016 | POSTED BY | Articles, Clinical Optometry, Clinical Pearls
Tags: ,

One of the things I hear most often now in my fourth-year rotations is “How can I make my exams faster?” Although patients are usually aware of the extended exam process and time in academic and university settings, you should have an exam flow down by fourth year and shouldn’t be taking over an hour with your patient before getting dilating drops in (most of the time). Here are a few things that I’ve found that speed me up as well as tips I’ve heard from other students, residents, and attendings along the way.

1. Combine tests when possible.

When learning how to perform tests in lab and practicals, we are taught to explain to the preceptor in excruciating detail how the test works and why it’s being performed. This is not practical in real exams for several reasons:

  • The patient isn’t listening when you tell them details of every test because they either don’t understand or don’t care.
  • Simplification is better–tell people what you need them to do, not why. If they ask why, then explain in Layman’s terms.
  • It’s absolutely slowing you down.

I was taught to do EOM testing by having the patient follow my finger, lit up by a transilluminator. In reality, that’s not necessary and the patient just needs some type of target to follow. I use a military-grade LED penlight to do my pupil testing because it’s smaller and brighter than my transilluminator and I never have to worry about the charge. At the end of the “double H” pattern, I have them follow it in toward their nose for a gross estimate of NPC. I don’t whip a ruler out of my pocket unless it’s extremely receded. This is 3/5 of my preliminary testing taken care of in 90 seconds with one instrument.

For tests that use a cover paddle, I often hold it over my patient’s eye for them. I find a lot of my patients tend to peek or hold it incorrectly, and if I hold it for them, I find they answer much more quickly. I do DVA OD/OS/OU and then the cover paddle is in my hand for cover test. I do distance and near, and then I switch immediately to my penlight for the above mentioned sequence. Quick and dirty.

2. Keep (irrelevant) chit chat with the patient to a minimum. 

I’m in a clinic where there is a large Spanish speaking population, and I speak little to no Spanish. I had a few friends in my class who are native speakers sit me down and give me a few rudimentary lessons on “medical Spanish” so I can conduct my exam with as little of a headache as possible. Usually I have to grab a fluent speaker at the beginning of the exam to get the history and at the end for the treatment plan. But during the exam, the patient can’t talk my ear off, and we can only focus on what we need to: the exam.

This is the philosophy by which I conduct all my patient exams now. For the “talkers” who derail exams by blabbering on about irrelevant topics forever, you need to cut them off and redirect their attention to what you’re doing. It’s not rude–it’s efficient. If they want to talk, they can do so when it’s appropriate, such as during BIO when their mouth can move. Also, try to direct conversation to relevant topics, like their complaint or history rather than the weather or their church choir. There is a delicate balance between creating a rapport with a patient and letting them throw your entire schedule off.

3. Give the patient fewer choices.

VAs: This is when you have to assess the type of responder your patient will be. If you have a picky type who you know will be 20/20+ and still cranky, it may help to show them full lines. However, I typically start by isolating 3 letters in descending sizes (i.e. 20/100 to 20/60) until I see them start to struggle, then I open up the line above where they struggled. This can decrease the time it takes on VA for the people that will read every letter from 20/50 all the way down to 20/20 at glacial speed.

Refraction: The same applies for refraction–show one or two letters rather than a whole row to avoid this: “which is clearer? 1 or 2?” “FZBD….” To make the refraction simpler for those who respond this way or for difficult patients, rephrase by asking“Does this lens make it clearer or blurrier?”

Retinoscopy: Many offices rely on previous Rx and autorefraction as the starting point for subjective. In our third year clinic, we were required to perform retinoscopy on all patients. Although we now have the option to use the autorefractor, I still prefer ret. I find that patients still find a way to accommodate in the autorefractor, and my eye is more accurate. It can be useful even if you’re using autorefraction results as a starting point and getting nowhere on refraction to swipe a few times and see what’s up. Don’t lose touch with the skill because you’ll still need it, such as for patients with irregular corneas.

Binocular balance: First of all, don’t bother balancing absolute presbyopes because they don’t have a stimulus to accommodation to balance! This knowledge alone will save you time if you’re doing this procedure. Prism balance is annoying to many patients because not only do they hate being diplopic, they hate being blurry. They often will not understand that this is not their final Rx. I use red-green duochrome much more often since the patient is binocular and their acuity is clear. I have had far more success this way and explaining and performing the procedure takes less time.

4. Drop and examine at an appropriate time.

One reason we spend forever refracting is to get patients to 20/20. But not everyone can be corrected to 20/20, and there are hundreds of reasons why. Especially if the patient is new and you can’t reference that BCVA is 20/70 OU, you need to figure out a reason. Often we don’t figure the reason out until we pull out the slit lamp. This was a recent recommendation I’ve been trying out and I’ve been loving it so far. After my preliminary testing, I sometimes pull out the slit lamp BEFORE my phoropter. To those of you dropping your jaws in disbelief, I did at first too.

After preliminary testing, grab the slit lamp and do an anterior segment assessment (without any drops). This will let you quickly determine if there are any dense cataracts, severe dry eye, corneal deposits, etc. Many reasons for decreased VA are in the retina and that will have to wait until dilation to assess later. Don’t spend so long that you bleach the patient and it ends up being counterproductive, but you can get most of your anterior segment done.

After a 2-3 minute assessment max, move the lamp, refract, put in your fluorescein, take IOP, and instill DFE drops–then on to the next patient for now. Rinse and repeat.

5. Chart faster.

EMR is “the way of the future.” However, unless you have a scribe in your room, it’s hard to not keep your back to your patient while on a computer. I chart as little in front of my patient as possible to keep both people engaged. When they come in and give me a chief complaint, I’ll put in the required info so it will let me go onto the next screen, then go back and clean it up later. I can remember “broken glasses,” but if it sounds like a retinal detachment to me, I’ll take more time in the room and ask all the pertinent negative questions, etc.

I write down long lists of medications, pertinent medical history, ocular history, and old glasses Rx on paper and enter this information later since some modules in our EMR are slow. I use the back of the intake form and scribble all over it. Also, I don’t enter preliminary testing until later if all is normal. After entering VA, nothing gets entered until I enter the slit lamp template. My retinoscopy, refraction, and preliminaries all get entered simultaneously.

Similarly, in our EMR template “WNL” populates a certain lists of norms for the exam template which can be helpful in most exams. However, in the clinic I’m currently at, I find myself typing “abnormal” findings so often that I don’t click “WNL” anymore because I end up deleting and retyping. Knowing your software and patient population is key.

6. Use your technicians.

At my current clinic, we don’t have the help of techs for every comprehensive exam, only ancillary testing. Your situation may vary, but almost all practices that aren’t 100% university based will have some sort of technician available for testing to help speed exams up. Typically instructors make students do all the work themselves as a means of teaching in the beginning, then allow preliminary testing to be delegated to technicians once the student has progressed. If you have techs to run your OCT, take your fields, etc., use them! While your techs are performing preliminary testing, you can see another patient or finish charting in the meantime. If you have techs working with you on every patient, often they will take entering VA, assess color vision and stereo, read old glasses, and run an AR/K. This can save you a lot of time in the exam room knowing all this information.

Assuming all staff has been trained in the same way that you have to perform the same procedures to ensure validity of testing, this can really help expedite the exam so use it to your advantage. If something doesn’t seem to make sense, repeat it yourself! It will never hurt to “measure twice, cut once.”

Exam flow is something that many practitioners say is a learned art that comes with practice. Just like building a rapport with your patients, it takes time to build these skills and they aren’t learned from books. However, when we aren’t checking in with instructors and there isn’t somebody double checking your work, things tend to speed up. Just be sure that once you’re on your own and running at the speed of light that you’re not missing things when you’re signing your own name to charts!

Check out other tips on how you can speed up your exam. What are some tips that help you speed up your exam? Share in a comment below!