by Dr. Harvey A. Fishman, MD PhD
The most frequent question that EyeCare doctors, both ophthalmologists and optometrists, have about telemedicine is, “what conditions be accurately diagnosed and treated in a remote exam using a mobile device or a webcam?” The telemedicine platform often intimidates MDs and ODs alike by the lack of a slit lamp or an indirect. By its very nature, the eye exam often immediately reveals the diagnosis. As a result, in clinical practice, EyeCare doctors often abbreviate the history and jump straight into the exam. It is far more efficient just to get the answer by looking than by asking.
However, it is well known that a meticulous history taking is central in the clinical decision process. The Nobel Peace Prize laureate, Bernard Lown, in his book, “The Lost Art of Healing,” quotes a paper that the correct diagnosis can be made solely from the information in a detailed history 75% of the time, and that the physical examination only an additional 10% of the information towards a correct diagnosis. The importance of the history in making a correct diagnosis prior to examining the patient have been well known by seasoned clinicians and confirmed in numerous additional studies. As Dr. Lown said, “I am convinced that listening beyond the chief complaint is the most effective, quickest, and least costly way to get to the bottom of most medical problems.”
So, to answer the above question of “what ocular conditions can be diagnosed and treated using a mobile phone or webcam,” the answer is that with a good history and some assistance using a mobile phone or webcam, all ocular problems can be managed at some level. This is not to say that the final diagnosis can be made, but, as in all of medicine, a detailed history afforded by the telemedicine platform can be used to diagnose and treat a large number of conditions and at the very least, can be crucial in triaging the patient in a timely and appropriate manner. While clinicians have become increasingly dependent on testing, the very nature of how we deliver care is changing rapidly and the inherent limitations of the physical exam in a telemedicine platform requires us to shift back to the basics of clinical medicine: a meticulous history.