The lost art of medicine

By Joseph Tauber, MD

P: 816/531-910

E: jt@taubereye.com

www.taubereye.com  

Dr. Tauber is medical director of Tauber Eye Center, Kansas City, MO, where he is an anterior segment subspecialist and refractive surgeon.

I was privileged to receive my medical and ophthalmology education in excellent academic centers, from world-renowned faculty and physicians. The best among these clinician-scientists were often called dinosaurs, because “they just don’t make people like that anymore.”

We learned far more than just the science of medicine; we learned the art, the humanity, and the responsibility that comes to those who choose careers in health care. Like most physicians in training, we focused on the science, the knowledge we would need to practice, but the other aspects of these “Giants” soaked inside by osmosis.

More in this issue: What's hot in eyewear fashion right now

I could never be more than a pale shadow of these dinosaurs. However, as my hair becomes more and more gray, I find my thoughts are becoming more “old school” and I understand the wisdom of my great teachers. Part of our responsibility is to give back, to train the next generations of physicians. This notion needs to become part of the “me” generation in the digital age.

In medical school, I was taught that it is possible to make a diagnosis based on history alone, and that one could anticipate a diagnosis even before performing an examination. I was also taught that it is equally possible to make a diagnosis from a nonverbal patient, without any provided history, based on a thorough exam alone.

While both statements are true, I have had enough diagnostic “surprises” that I have learned to keep my mind open until I have collected all the observations I can. A broad knowledge base is important. The eyes only see what the brain knows.

At the same time, our brains can get in the way of our eyes. There is an old Zen saying (poorly paraphrased here) that once we label a thing, our eyes are no longer open. It is in the time before we assign a label to something that we truly are open to seeing it and understanding it.

NEXT: Old vs. New

Listening and observing are skills that make the best clinicians. This principle is one that has guided my career in medicine. Of late, this concept seems particularly relevant to the treatment of patients with ocular surface disease.

The practice of medicine in 2015 is so different from what I was taught in medical school. Whether we have advanced the level of care we provide is a matter of opinion.

Old way:

•  Look at your patient (overall body exam, habitus, emotional mood, etc.)

• Listen to your patient-take a history. Listen more than speak.

• Perform your clinical exam.

• Perform diagnostic tests as needed to narrow differential diagnosis. Does each test ordered help choose between treatment options? What will you do differently if the test is positive versus negative?

• Prescribe and explain treatment, schedule follow-up.

In case you missed it: Navigating patient perception

New way:

• Log into EMR.

• Check if pre-testing technician performed tear osmolarity, MMP-9, Adeno-Plus, LipiView interferometry, corneal topography, wavefront analysis, endothelial count.

• Verify that appropriate diagnoses (and modifiers) were coded to ensure proper reimbursement for those tests that are covered and do not require ABN waiver.

• Turn to do slit lamp exam. Tell scribe what to record.

• Tell scribe what “patient education” to provide and record in EMR to satisfy Meaningful Use 2 criteria. Exit the room.

• Check time to be sure you remain on schedule.

NEXT: Implications

I like to think I am skilled in the evaluation and management of both common and complex ocular surface conditions, and I regularly lecture on this topic at local and national venues, including the annual meeting of the American Academy of Ophthalmology.

I am an active clinical researcher. I strive to stay current on the latest diagnostic tools available, which have rapidly multiplied over the past decade. Beyond our ability to measure tear production, osmolarity, MMP-9, IgE and lactoferrin levels, we can measure lipid layer thickness, visualize meibomian glands and even dynamically assess tear film stability and induced corneal aberrations.

Soon, we will be measuring tear film cytokines and other aspects of the all-important tear film. But, are we any better at helping our patients with complaints of ocular surface-related discomfort (a term I favor over “dry eye” or “tear film dysfunction”) than we were 30 years ago?

I have heard it said that the instruments we mainly rely on for ocular diagnosis have remained unchanged for at least 30 years (i.e., slit lamps, tonometers, direct and indirect ophthalmoscopes). I believe that the best diagnostic tool clinicians possess is even older, and is also the handiest-the one we have between our ears.

Despite all the forces encouraging us to use the latest tests and instruments for dry eye, I find my clinical judgment remains my most useful tool.

Ocular surface disease (OSD) is a phrase that encompasses allergic conditions, lid margin diseases, and tear deficiency/dysfunction conditions. Likely, dysfunctional blinking, neurotrophic neuropathic pain and hormonal conditions are involved in the same symptom complex as the more widely recognized diseases, too.

For me, much of medicine is pattern recognition, and a well-taken history rather easily separates allergic and lid margin diseases from the overall group of OSD. Most of the available testing available-and I own most of them-can confirm or quantitate one aspect (e.g., low lipid thickness or abnormal osmolarity), but do not differentiate the subgroups and do not help me choose an effective treatment plan.

NEXT: Advice from a dinosaur

I institute a stepladder plan for lid margin disease when I see it at the slit lamp, escalating from lid hygiene to oral anti-inflammatory/oil-liquefactive medications to mechanical means (probing or LipiFlow, according to duct patency). I institute a stepladder plan for insufficient tear production when history informs me that particular environments or tasks generate irritative symptoms.

To quote something I read from Dr. Darrell White: “You can’t make an asymptomatic patient feel better.”

Treating data and not patient complaints will not help achieve satisfied patients.

Clinicians should practice the art of medicine, which seems harder in these times of declining reimbursements and the proliferation of new shiny toys we can use, and charge for, to measure aspects of the tear film. If that sounds like advice from a dinosaur, I’m proud of it.