Summary

Comanagement

Is Technology Making Us Lazy? New clinical technology is supposed to make our lives easier and better. But is it doing so at the risk of our clinical skills? Edited by Paul C. Ajamian, O.D.

T /.'/s month's column takes a point/counterpoint format between Dr. Ajamian and

Robert Pinkert, O.D., medical director of Barnet Dulaney Perkins Eye Center, in Phoenix.

Dr. Ajamian: Many new techno- lojîical advances are changing the way we practice. Electronic medical records are certainly on everyone's radar right now. EMR has many advantages, and we're all going to convert to them eventually. However, there could be some sig- liiHcant disadvantages, hoth short and long term. For example, when you do i\ case history with HMR, you're basically filling in the boxes or clicking the answers, rather than writing out a detailed narra- tive. This "filling in the blanks" approach could dull our ability to take and record a meaningful clini- cal history.

Dr. Pinkert: Not necessarily. Hither method—writing out the his- tory or using EMR—has the poten- tial for error, but the types of errors are different. When you're writing records, you could commit an error of omission—you forget to write something down. When you're using EMR, it prompts you to answer, so you're not likely to com- mit an error of omission. On the other hand, you may he more likely to commit an error of commis- sion—the program automatically fills in the field and you neglect to change it. Does it make you iazy? Maybe, but without question, the efficiency of EMR far outweighs the downside of potential errors.

Dr. Ajamian: Another problem with electronic medical records, in my opinion, is that they don't allow you to draw a corneal ulcer, a retinal detachment or, most impor- tantly, the optic disc. Sure, you can take a photo and do optic nerve or retinal imaging instead. But, I think there's no substitute for a careful drawing. Stereo disc photos are ideal, but how many practitioners actually do them? A detailed optic nerve head drawing is extremely useful and always will he. It's an important adjunct to a two-dimen- sional photo. Also, you apply your clinical ohservation skills as you make the drawing.

Dr. Pinkert: 1 agree that the inability to draw the optic nerve head is a potential problem with EMR. Some EMR systems do have limited ahility to draw the optic nerve head, hut it's a cumbersome process.

Dr. Ajamian: So, are we now training a generation of doctors who won't even care ahout draw- ing discs because they can just click a mouse on a cup-to-disc ratio, or take a photo with the camera? Isn't that making us lazy clinicians?

Dr. Pinkert: It very well might, because you could say, "I don't need to look at the retina. Pll just get an OCT and look at it that way." Doctors are starting to rely on the information gathered from these high-tech instruments as a substitute rather than as an adjunct for clinical data gathering.

Dr. Ajamian: I'm aware that a lot of retinal specialists, ophthal-

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\ Drawing the optic disc Is never obsolete.

mologists and optometrists say, "Yeah, there might be something wrong with the macula. Let's get an OCT." But what did we do before this technology was available? We looked, and then we looked a little harder. We're starting to rely on this technology to replace observa- tional skills, but it doesn't.

Dr. Pinkert: Right, but let's not throw out the baby with the bath- water. Yes, the potential exists for us to rely on these instruments too much and hecome lazy in our phys- ical exam. But the clinical benefits far outweigh the risks.

Dr. Ajamian: So, we agree on this point. For me, I take photos, but 1 also rely on my drawings of the disc in conjunction with the photos. I may do a CiDx, but 1 force myself to look at the nerve fiber layer while doing the fundus exam. An OCT is great for documentation and follow-up, but I still take pride in finding a preretinal membrane or cystoid macular edema using a fun- dus lens. It's not a choice of using only one or the other.

Dr. Pinkert: I totally agree. Do both, and stay vigilant. •

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