A Country Doctor Writes:

My new glasses were years overdue. The eye doctor understood perfectly my request that the focal point and pupillary distance for my iPad reading glasses had to match my habitual reading style – right under my nose. The result couldn’t be more pleasing.

The other day my wife squinted over her iPad and said “I don’t know if I’m getting a cataract or if I just need new glasses. My right eye is blurry”.

“Why don’t you just make a pinhole and find out?” I asked.

She made a fist and peered between her tightly curled fingers.

“Oh, yes, it’s just my glasses!” she exclaimed with relief.

Both of us medical providers, and both of us lifelong photographers and former dark room enthusiasts, we started talking about everyday optics. We speculated whether younger primary care clinicians still use pinholes to distinguish between eye diseases and simple refractory errors, for example when doing a quick vision check on a patient with eye pain who left their glasses at home.

The pinhole test is one of those examples of low tech, bedside – or, rather, exam room – assessments, that have been around for generations. So much of medicine today is complicated and dependent on technology. And there is more and more being written about point-of-care testing with smartphones and miniaturized gadgetry that people might be forgetting some of the basics that almost don’t require any equipment at all.

The other day I saw a patient with tension headaches. I had him look at a poster across the exam room through my ophthalmoscope. Switching between the neutral and the plus one diopter built-in lens, he could read with both through his left eye, but only with the neutral lens on the right, suggesting he may be a little farsighted in his left eye. I referred him for a formal refraction.

Maybe it’s the Boy Scout in me that finds it interesting to still use my earliest medical school lessons, my common sense and everyday tools to evaluate patients.

For example, I still use my tuning fork a lot. I love explaining the Webber and Rinne tests for conductive hearing loss to my patients.

I use my regular blood pressure cuff to record a palpatory blood pressure at the ankle for a quick ABI, or Ankle Brachial Index, in patients at risk for peripheral vascular disease.

One of my pet peeves is using the peak flow meter when evaluating asthmatics. Every hospital emergency room I have seen checks oxygen saturation as a routine vital sign. But a low oxygen saturation is a very late warning sign in asthma – almost immediately before needing intubation. A peak flow meter is a much simpler tool than an oximeter. In fact, all the guidelines I have seen recommend using peak flow meters at home, so why not at the doctor’s?

And, of course, that universal symbol of the medical profession, the stethoscope is more than an identification symbol:

I regularly listen for bruits over the carotid arteries and have found a few critical stenosis cases. I also listen for the kidney arteries and sometimes the femoral arteries in the groin.

There is a growing movement among medical educators to bring bedside clinical exam skills back into focus, instead of just being part of the introductory courses, somewhere between the history of medicine and applied Mendelian genetics. Abraham Verghese and others, as recently as a few weeks ago in The Journal of the American Medical Association, emphasized the importance of mastering both clinical exam skills and the use of technology.

It was here in North America that Osler revolutionized medical education by bringing it from the lecture halls to the hospital wards. But today’s medical students and residents spend only a small fraction of their workday in the presence of their patients. It is my hope that that will change, and that medicine will strike a healthier balance between hands-on bedside assessment and hands-off high tech testing.

I enjoy new technology, but direct observation by a skillful physician isn’t necessarily inferior to the latest gadgetry. My iPhone can tell me what the weather is where I live, but if I get soaked when I step outside in the morning, I won’t need to check the weather app to verify my observation.