Junior residents can appropriately triage patients with symptoms of a posterior vitreous detachment (PVD), retinal tear, or retinal detachment, according to investigators. A team of researchers affiliated with the University of Michigan evaluated the residents’ performance and found that, with proper oversight, physicians at this stage of their career are capable of diagnosing these urgent and sometimes complex complaints.
Acute onset of flashes or floaters are among the most common complaints in ophthalmology clinics. Usually, this is merely a sign of PVD. However, 14% to 22% of patients with symptomatic PVD experience retinal tears or detachment. To reduce the chances of retinal detachment, a careful exam is critical.
“The backbone of the clinical exam for retinal tears, scleral depression, is perhaps one of the most difficult physical exam skills to master, and most research on detecting retinal tears has involved exams by post-residency ophthalmologists,” the researchers said.
The report questioned if on-call junior residents are capable of providing the level of care needed for these difficult, yet critical exams. Investigators followed patients seen by on-call first-year or early second-year residents for a full calendar year ( January 2017 to December 2017). They found that the system does provide safe triage “at the expense of modestly high resource utilization” in the form of confirmatory exams by senior residents or fellows.
All patients in the study (228 total) presented with flashes, floaters, curtain, or blurred vision (or a combination) across the entire visual field without an anterior segment, lens, and focal retinal or neuro-ophthalmic cause. Because 14 patients presented more than once, the study evaluated a total of 246 unique screenings.
Of the 246 screenings, 83 (33.7%) had a perceived retinal tear or detachment. Of those, 10 (4.1%) were false positive tears/detachments, with the presence of intraretinal heme predicting a false positive exam (adjusted odds ratio, 3.86; 95% CI, 1.1-13.5). False negative tear diagnoses were made in 13 (5.3%) cases but no false negative detachments were diagnosed. A false negative was defined as a tear identified on follow-up exam that was not established on-call.
Approximately 25% of patients with flashes, floaters, curtains or blurred vision (or a combination) did require a senior resident or fellow to confirm the junior resident’s findings. The researchers note that 30.5% of the senior resident confirmations were mandatory, per the rules of the residency program—all findings during the first 4 months of residency must be confirmed.
The investigators point out that one data point is of critical concern; 5.3% of false negative tears, or the rate of tears not seen during the on-call encounter, but detected on follow-up. No tears progressed to detachment by the time of follow-up. The researchers say the study demonstrates “that junior residents were able to appropriately adjust the interval for follow-up based on high-risk exam characteristics.”
Jarocki A, Durrani A, Zhou Y Miller J. On-call exams for acute onset of flashes, floaters, or curtain by junior ophthalmology residents: outcomes, safety, and resource utilization Ophthalmol Retina. Published online August 11, 2020. doi: 10.1016/j.oret.2020.07.030.