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Mention collaborative or cooperative care to many physicians and you are likely to find yourself on the receiving end of some concerned expressions, even some criticism. In an increasingly complex medical environment, the once-commonplace arrangements between optometrists and ophthalmologists have become a topic of concern in some circles as a result of misinformation and some misguided practices.
When managed appropriately, cooperative management of LASIK, refractive, and refractive cataract surgery patients is not only ethical, but it can benefit the optometrist, the surgeon, and the patient. In my large and growing surgical practice in upstate New York, we have established a protocol that allows us to practice collaborative care consistently, ethically, and effectively. This article describes the key elements of this protocol that has helped us to establish close partnerships with referring optometrists and allow smooth and efficient collaborative care for all surgical patients.
FOUNDATION OF EDUCATION
Many surgeons choose to lean heavily on the referring doctor for patient education, both pre- and postoperatively. I advise optometrists to look for every opportunity to educate themselves on the entire refractive surgery process. This would include education on femtosecond laser and premium IOL options and an understanding of the differences between near, intermediate, and distance vision. The costs, benefits, and risks of each surgical procedure must be understood as well.
Once it has been confirmed that a patient is a candidate for particular surgery and the patient has elected to proceed, the referring doctor should educate the patient on appropriate expectations for outcomes, normal postoperative symptoms and side effects, and the risks for potential complications. Patients will also benefit from an overview of the procedure, and they must be given detailed information regarding postoperative care.
Optometrists interested in enhancing their expertise might consider reaching out to an area surgeon to inquire about following a patient through the pre- and postoperative process. Our surgery center has established a program in which we invite area optometrists to follow a patient through LASIK, including attending the actual procedure and observing pre- and postoperative appointments. Our program, for which doctors can earn continuing education credit, allows optometrists to gain a deeper understanding of the variety of refractive surgical options available to patients and how we evaluate candidates for each of these options.
For example, our practice was one of the first in the country to acquire the Victus femtosecond laser (Bausch + Lomb), which can be used in LASIK flap creation and in laser cataract surgery. Although most patients can benefit from laser cataract surgery, those with minimal degrees of astigmatism or a desire to keep their spectacles after the procedure may do wonderfully with traditional cataract surgery. When optometrists are familiar with the different technologies and how we identify appropriate candidates for each, they can clearly communicate this information to patients who are interested in refractive surgery or laser cataract surgery. Understanding the potential complications also better prepares them to follow patients postoperatively.
DEFINE YOUR ROLE
It is important for the optometrist to determine what level of care he or she is interested in performing and to discuss this with the surgeon to ensure all parties are aligned to a plan. The level of involvement that surgeons and optometrists maintain can vary greatly based on personal preferences. Some surgeons see patients for a preoperative evaluation, the procedure, and a 1-day postoperative appointment, and then they expect the referring doctor to handle the 1-week and 1-month postoperative visits. Others see the patient only on the day of surgery.
In addition to considering one’s own preferences and those of your surgeon, the optometrist must be sure to consider his or her patients as well. Many patients appreciate having a familiar face with them throughout the surgical process. In these cases, the optometrist may consider attending the surgery.
A good surgeon will respect the referring optometrist’s preferences and his or her practice and will make every effort to send the patient back at the point when the optometrist prefers.
Payment structure is a critical discussion, particularly because, in most cases, refractive surgery is elective. Once the optometrist and ophthalmologist have aligned their roles in elective patient care, they can establish a payment structure based on their respective levels of involvement. This should be done in a written transfer agreement. For example, if the surgeon charges $2,000 for a particular surgery but the optometrist agrees to manage most of the postoperative care, the ophthalmologist might charge only $1,500, and the optometrist would bill $500 to cover the cost of those visits. Be sure the fee structure is within the guidelines of applicable state and/or federal laws.
As with so many things in medicine, successful cooperative management of refractive surgery is both an art and a science. It requires good communication, a willingness to collaborate and be flexible, and, most important, a commitment to doing whatever it takes to provide the best possible patient care. These qualities, along with the strategies outlined above, have contributed significantly to the thriving partnerships we enjoy with many area optometrists, and thus to the growth and success of our practice and theirs as well. n
Michael J. Endl, MD
• Fichte Endl & Elmer EyeCare, Buffalo, New York
• (716) 564-2020; email@example.com
• Financial disclosure: consultant to Allergan, Bausch + Lomb, Ocular Therapeutix, and Refocus