Formalized Training in Integrated Care

All fourth year students at the Rosenberg School of Optometry have a mandatory rotation in a busy ophthalmic refractive surgery center.

By Gregory D. Parkhurst, MD, and Kyle A. Sandberg, OD

Collaboration between ophthalmologists and optometrists in the care of patients is becoming increasingly normalized. Many eye care clinics now employ professionals from each discipline, and even those clinics that are exclusively ophthalmology are likely to see patients referred from optometrists practicing in the community.

According to data compiled by the American Optometric Association, optometrists perform over 88 million of the 104 million refractive eye examinations each year, thus accounting for 85% of all comprehensive eye examinations.1 While a great number of those patients will stay within the primary eye care setting, it is also likely that the care of many of those patients will intersect with other disciplines, including formal comanagement of refractive surgery, interoffice integrated services, referrals to other specialists, and beyond.

On top of this, the aging Baby Boomer generation is likely to bring even more patients into the eye care setting in the near future for surgical treatment of cataracts, glaucoma, macular degeneration, and other age-related eye conditions. There are also several other factors—excitement over new refractive surgical procedures, safe and effective surgical solutions for treating presbyopia, increased habitual use of digital devices that may set the stage for dry eye, growing appreciation of the implications of dry eye on quality of life, etc.—that could drive exponential growth in the need for eye care services. The bottom line is that, as our patient rosters swell, a more efficient model of care must emerge to ensure that high-quality care can be consistently delivered to patients along the continuum of eye care.

What these factors ultimately lead us to conclude is that most, if not all, subspecialty-trained ophthalmologists will, during the course of their career, encounter situations where the care of a patient in some way involves the work of an optometrist, even tangentially. Given this reality, we believe it is time for a more formalized approach to training with respect to the principles and practices of integrated care to prepare practitioners within our respective disciplines for the realities of modern eye care.

Collaborative Partners in Education

Figure 1. The educational component of the rotation includes review of active cases as well as interaction with staff of Parkhurst NuVision, as depicted here, where Dr. Parkhurst is introducing optometry students to critical components of ocular anatomy.

Starting in 2014, the Rosenberg School of Optometry at the University of the Incarnate Word and the Parkhurst NuVision clinic began a collaborative educational partnership. Under the program, all fourth year optometry students are required to participate in a nearly 1-month rotation at Parkhurst NuVision, where they are fully immersed in refractive surgery clinical operations, from performing patient encounters to observing surgical procedures. Depending on annual class size, more than 60 students each year are afforded access to this enriching educational experience (Figure 1).

Through exposure to the hundreds of patients who would typically cycle though Parkhurst NuVision during a 3 to 4 week timeframe, students are exposed to the variations in corneal appearance before and after various surgeries; they gain an understanding of how to perform various measurements; and they get to see firsthand how various clinical scenarios are managed, among other things. Students are trained to think like independent practitioners throughout the rotation. They interact with patients, conduct slit-lamp examinations, and formulate treatment plans for each encounter. The students also perform the necessary testing during the preoperative assessment of cataract and refractive surgery patients, working up patients for follow-up appointments, and literally holding their hands in the operating room. This approach allows the student to gain valuable insight from one-on-one patient interaction while preserving the patient’s high expectation for service.

Thus, the potential to impart valuable clinical lessons is abundant. For example, when students are tasked with building a management plan based on their findings during a patient encounter, they receive immediate feedback on their clinical judgment when their plan is reviewed and used as a teaching point by a senior optometrist at Rosenberg. As well, students get exposed to a gamut of refractive surgical procedures, including corneal inlays, crosslinking, refractive cataract surgery, refractive lens exchange, phakic IOLs, SMILE, PRK, and LASIK, and so they start to gain an understanding of the procedures, how demand for those procedures will benefit their patients and their practices, and how they can be applied (Figure 2).

Figure 2. Students from the Rosenberg School of Optometry watch as Dr. Parkhurst performs laser cataract surgery (A). The Refractive Surgery Grid helps students determine what surgical procedure is best suited for each patient (B).

But the teaching moments go beyond the obvious. By actively participating in clinical scenarios, students are introduced to the sort of autonomy that will be necessary to thrive in clinical practice. We also like to think that they are learning the awesome responsibility involved in caring for patients’ vision. The obligation to be available to the patient, perhaps past regular clinical hours, can be conveyed over and over in the classroom or during didactic lectures. That first time students get a call about a postoperative pressure spike at midnight, however, is when those lessons finally crystalize.

Practical Applications of Theoretical Knowledge

If the program described above sounds like an integrated model of education, that is because that is precisely what it is. In many ways, the rotation of fourth year optometric students through a busy refractive surgery clinic is intended to mirror experiences in the real world. The booming demand for eye care services (both surgical and nonsurgical), as well as the looming potential for a shortage of providers, suggests a need to improve how patients are managed. Integrated care is a plausible way to do just that, but growing that model will require education that prioritizes understanding patients’ needs.

This last point is conveyed nicely by Timothy A. Wingert, OD, dean and a professor of Optometry, Rosenberg School of Optometry, “We highly value the relationship we have with Parkhurst NuVision and the educational opportunities it offers for students in our program. The rotation immerses our students into a situation where there is a seamless integration of the professions with each concentrating on taking care of the patient. The rotation removes some of the mystery as to when surgical approaches can best serve the patient and how to counsel the patient during the process.”

One of the other valuable exposures students get in our program is that they hear firsthand and listen to the perspectives of patients prepping for surgery, including not only their excitement, but also any anxieties and fears they may have. They also get to talk to patients after surgery and hear about their success stories. In our minds, those types of experiences lend themselves to creating better doctors, because if students get to understand what a patient is going to go through for surgery—what their anxiety level is, and how they anticipate going into surgery—it affords a view from the other side of the slit lamp, so to speak.

Although we are aware of several opportunities for optometry students to participate in externships at ophthalmology clinics, we believe our program is one of the first formalized approaches to training. Beyond the interest of teaching best practices for the perioperative care of refractive surgical patients, it is our contention that our program also delivers practical lessons in building relationships that complement and add to the theoretical knowledge students gain in school. Our particular model is successful because of the proximity of our respective offices, and it is already serving as a model for other optometry schools.

There are many ways we can measure outcomes of our program, and we are actively gathering data that will hopefully guide us on ways to refine the experience for students to make it even more beneficial. We have received feedback from several students who have passed through the program, many of whom have expressed gratitude for the experience. Some never knew they wanted to work with surgical patients until the rotation, while others have learned an equally valuable lesson when they realized that managing perioperative patients would not be their professional ambition.

There is another metric of our program that, although anecdotal, is something that makes us particularly proud. Many of the optometrists who practice in and around San Antonio direct referrals to the Parkhurst NuVision clinic not only because of the elegant surgical outcomes they have come to expect, but also specifically because they know how patients will be treated in our collaborative care model. In studying those referral patterns, we have learned that many community optometrists know their patients are going to get excellent care, and with informed consent of the patient, they are assured of being returned back for postoperative comanagement. Many have also told us that they refer to us, in part, to support the continued education of their profession.

This last point, we believe, is extremely important. Ophthalmologists and optometrists each take an oath to always maintain the best interest of patients, promising to advise all patients fully and honestly of all which may serve to restore, maintain, or enhance their vision and general health. Yet, while unspoken, there is also an implied duty for those in eye care to be stewards of their profession, including attending to the training of the next generation. The integrated model of eye care is a relevant practice model in which all sides benefit, especially the patient. We believe the adoption of formalized training programs that advance evidence-based practices within that model will serve to produce practitioners more versed in its nuances, ultimately laying the groundwork for even better delivery of eye care in the future. n

1. American Optometric Association. State of the optometric association: 2013. Available at: Accessed May 4, 2017.

Gregory D. Parkhurst, MD
• founder and physician CEO, Parkhurst-Nuvision, San Antonio, Texas
• (210) 615-9358;;
Twitter @PNuVision and @gregparkhurstmd
• financial disclosure: consultant to Alcon, Johnson & Johnson Vision, ReVision Optics, Staar Surgical, and Zeiss.

Kyle A. Sandberg, OD
• senior clinical instructor, Rosenberg School of Optometry
• financial interest: none acknowledged