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When I joined Empire Eye Physicians, it was already a fully integrated eye care practice. Prior to that, I had been in the US Navy. In that setting, ophthalmologists always worked closely with optometrists, because the latter are often the primary care providers for eye care. From early training onward, I have always been involved in the idea of integrated care. I was taught how to refract by a Navy optometrist. In fact, optometrists sometimes outranked ophthalmologists in the Navy!
Still, when I started practice in the civilian world, MD-OD integrated care was a new concept. Many optometrists saw the potential benefits for the patient, but few ophthalmologists wanted to work with them. The ophthalmologists who did share care with optometrists at that time became very busy with surgical referrals.
THAT WAS THEN
In the early days, the surgeons in our practice would pick optometrists with whom we wanted to work. We would have them come to our offices, and the ODs would do a mini cataract rotation with us, as that was the primary surgery we were collaborating on at that time. The optometrists would watch live surgery and learn how we evaluated patients preoperatively and what we watched for after surgery. Their staff got to know our staff, and we ensured clear lines of communication, which are of paramount importance. Our practice would also run organized continuing education events two or three times a year for large groups of optometrists. Education was a key component then but has become less of an issue today, because most optometry residencies provide that training.
Today, more surgeons are willing to work with optometrists, and the former see the advantages. Ophthalmologists are able to perform more surgery and less of the other things that they do not really want to do. There are some regional differences, of course, but here in the Northwest, just about every ophthalmologist who has a busy cataract practice now works with optometrists. That was absolutely not the case back in the 1990s. In fact, we were once derided by some of our local practitioners. Now, every one of those physicians practices integrated care.
THIS IS NOW
Today, surgeons often compete for optometrists’ referrals. An optometrist who has a busy practice that sees a lot of cataract patients likely has many ophthalmologists courting him or her and asking to see patients from the optometrist’s office. The tables have turned. This is one factor behind our goal to have a technology-driven practice; we want to show optometrists that we provide patients with the best possible surgical experience. For example, we perform laser cataract surgery, we use femtosecond lasers and wavefront technology for our LASIK patients. We can assure optometrists that their patients will receive state-of-the-art care.
Fundamentally, an ophthalmologist who wants to work with optometrists must value and respect the relationship that optometrists have with their patients. That relationship should be respected by the surgeon as much as his or her own bond with the patient. If not, then that ophthalmologist should probably not work with ODs. There will be problems and miscommunication, with the patient caught in the middle.
It is also important for ophthalmologists to recognize that every practice is different. Each optometrist will have a different set of expectations for the ophthalmologist in terms of the care arrangement. How much does the optometrist want to be involved in what the patient chooses to have done? Some of these eye care providers leave such choices up to the surgeon, whereas others prefer to be involved in that conversation based on their history with the patient. Ophthalmologists must respect that interaction between the patients and the optometrists and be willing to communicate clearly.
In addition, ophthalmologists must be comfortable talking to referring optometrists in a collegial manner. There will invariably be patients who ask to stay with the surgeon’s practice and not go back to the optometrist. When that happens, I tell him or her, “I think you are better served by seeing Dr. Smith, because he knows you the best, and his office has seen you. If you need glasses, you will need to go to him, because we do not make spectacles.” Of course, we always respect the wishes of the patient, but we try to maintain his or her relationship with the optometrist. These situations are much easier to handle if there is clear communication and trust with the optometrist and if the surgeon values the optometrist’s relationship with the patient.
MAKING THE RECOMMENDATION
I prefer patients to come to me already well educated by their optometrist. Of course, some are better at surgical education than others. The optometrists with whom I work closely have been in our office. They have seen me perform laser cataract surgery, for example, and they appreciate its advantages over traditional procedures. The first patient on whom I performed laser cataract surgery was an optometrist’s father. Optometrists understand the advantages of technology, and they want the best outcomes for their patients. When all parties work together, surgery goes more smoothly.
Because the optometrist is building up the surgeon to the patient, the surgeon must do the same for the optometrist. The OD has said to the patient, “You need cataract surgery, and I am going to recommend a great surgeon. His staff is great, and they offer the latest technology.” When the patient is in the surgeon’s chair, he or she should reassure the patient of the quality of the optometrist’s care. I will say, “Your surgery looks great, we are sending you back to Dr. Jones, and he is going to take good care of you. We love working with his office.” The relationship must be reciprocal.
To be successful at providing integrated care with optometry, it is important for surgeons to have optometrists on their staff. They are the people who can best coordinate and develop the relationships between specialties. At my practice, we have an optometrist whose primary role is to be a liaison and facilitate the transfer of jointly managed patients. His most important function is maintaining strong communication between our office and the practices we work with.
Integrated care with optometry once rare has become commonplace, and will continue to do so as health care evolves in the future. If done properly, it can be an efficient way to provide excellent care to our patients. n
Mark Kontos, MD
• Senior partner at Empire Eye Physicians in Spokane, Washington
• (509) 928-8040; firstname.lastname@example.org