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Round table: Pediatric experts tackle conjunctivitis, office efficiency issues
Physicians address treatment modalities, discussions with families and other important topics. Part 2 of 2.
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At the American Association for Pediatric Ophthalmology and Strabismus meeting earlier this year, Ocular Surgery News invited several experts in the field to participate in a round table discussion. OSN Pediatrics/Strabismus Section Editor Robert S. Gold, MD, and Section Members Kenneth P. Cheng, MD, Anthony P. Johnson, MD, FACS, and Scott E. Olitsky, MD, talked about school children with conjunctivitis and tear duct procedures, among other topics. OSN Practice Management Section Editor John B. Pinto also joined the discussion and offered some views on pediatric practices and office efficiency.
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Conjunctivitis and school
Robert S. Gold, MD: There was an article earlier this year in the Journal of Pediatric Ophthalmology and Strabismus about excluding children with conjunctivitis from school. The basic premise was, and I will quote from the conclusion of the article, “Although no current consensus exists among state health officials regarding students with conjunctivitis, the literature supports excluding children with conjunctivitis from school until they are asymptomatic. When patients are treated with fourth-generation fluoroquinolones, the length of the exclusion may be as little as 24 hours in cases of bacterial conjunctivitis, and longer in cases of viral conjunctivitis. Following these guidelines may prevent epidemics of bacterial and viral conjunctivitis.”
What do you think? What do you recommend to your families when they have that type of situation occur?
Scott E. Olitsky, MD: I think it is interesting to see how varied the policies are. The conclusion talks about following guidelines from epidemics, but I think there is also another interesting aspect of this that we do not necessarily think about, and that is the time and cost of keeping a child out of school — a parent who might have to take off from work and daycare issues. So it goes beyond just the health policy with school. It is an issue that affects a lot of people, and not just parents or children at school, but people in the workplace, too. It is surprising to me that there are no good guidelines being used, and ours vary from school to school. Some schools will not let a child back in unless they are on drops. Some will let them come back the next day if I see them at 5 p.m. Others have a much more rigorous policy. And some it does not matter; they can go back on drops or not on drops. I discuss all of those things with the parents. Quite frankly, I do not know what the best situation is for everybody, and I try to make an individual decision with the parent.
Kenneth P. Cheng, MD: I tend to take a harder-line view with the family, and the younger the child, the less likely they are to listen to any type of instruction. I think a high-schooler, who might be trusted to wash their hands frequently and try not to touch their eye, might go back to school more quickly with a potentially contagious disease. Young children in elementary school, you cannot give them instructions like that.
So it comes down to deciding, “Have I really effectively treated the disease or not?” There is no way for you to know, short of culturing, which is not cost-effective in self-limited disease, whether these are bacterial cases or viral cases or a combination of the two. I can think of countless children who have had purulent drainage, and we clear up the purulent drainage with the use of antibiotic drops. Yet they still have an underlying disease, what started out as a viral conjunctivitis. And while I agree with Dr. Olitsky that it is a burden on a family to provide out-of-school care for a child, if it is a contagious issue and it now affects five families in the classroom or their parents, one of whom might be a surgeon or an airplane pilot or a police officer who might be disabled by glare, then it becomes a significant public health issue. So I tell parents that their child needs to stay home until the drainage has significantly decreased. Whether it be clear tears or purulent, I tell them they need to stay home.
Anthony P. Johnson, MD, FACS: My overall view is that this is not so much a medical dilemma as it is a practical and a social dilemma. Because we do not have any defined guidelines about the risk and about who is potentially going to be a factor for spreading it, some of us tend to be more lenient because we see the burden on the family and on society and so forth. Some of us tend to be more hard-lined, and this is what I tell the parents: I tell them that if the school nurse challenges me on this, there is not a leg to stand on. Nobody really knows when is the endpoint. But if someone has a suspicion that this child is truly contagious, short of cultures, there is not an answer. There is not an answer to the culture for several hours or a few days, so that does not help you either. So this is a practical issue, and I think that is why we see so many different policies from all of the states.
Dr. Cheng: There are rapid immunologic tests for adenovirus, but they are costly. And I do not know about all of the reimbursement issues on those yet, so I have not used those in my practice.
Tear ducts
Dr. Gold: I would like to talk about tear duct procedures and tear duct signs and symptoms.
Dr. Olitsky: One of the papers that we presented at the AAPOS meeting looked at the efficacy of monocanalicular intubation tube vs. bicanalicular. This was a retrospective study in which some patients underwent probing and silicone tube intubation with a bicanalicular stent and some with monocanalicular. What we saw was essentially, that as a primary procedure, the monocanalicular silicone tube may have been a better procedure, with no statistical difference between the two procedures.
The second study was something that had interested me a lot, and that is the patient who undergoes a probing and silicone tube intubation and the parents come back and say, “There is still tearing with this in place.” A few years ago, Gregg Lueder, MD, of St. Louis showed that many of those patients who were still tearing seemed to do fine. I had been using monocanalicular silicone for a while, and I wanted to know if that same thing held true. Theoretically, with only one tube going down the tear duct, maybe there is more room and we would see less tearing overall. What we found was in the children who did not tear at all, they were cured when the tube was removed. The majority of patients who were tearing also were cured when the tube was removed.
Dr. Gold: Again, we all know that whatever modality is used for tear ducts seems to work well. Dr. Olitsky has advocated the monocanalicular tube as a primary procedure. I know that there can be a difference of opinion about this, and I would like to find out what you do.
Dr. Cheng: I have not put in a bicanalicular stent in many years. I think that the advantages of the monocanalicular stent and ease of insertion, more importantly ease of removal, are significant oftentimes in young kids. It prevents the second trip back to the operating room to remove the tube. It also has an added element of safety because a child cannot grab the end of the tube from the nose, pull and create canalicular damage, which can be permanent. So I do not see any indication for doing a bicanalicular stent.
Dr. Gold: What is your primary procedure? Do you do that as a primary procedure or do you do that if a patient has failed?
Dr. Cheng: I only put in a stent if the patient has failed probing. Unless I feel significant stenosis, I do not put in the stent.
Dr. Johnson: I have continued to do probing up until age 1 year. No matter what age, if they fail, then I will put in the bicanalicular stent. If they are older than 1 year, depending upon the amount of obstruction, even if it is a primary procedure and I am concerned about the success rate, I will frequently put in a bicanalicular stent at that time. I have put in a few monocanalicular stents, especially when they have an absent punctum or for various other reasons. And I have been pleased with those and noticed that it is more popular. I may consider doing that as the secondary procedure and not use the bicanalicular.
But dating back several years, H. Sprague Eustis, MD, suggested — when I was telling him some of my frustrations with bicanalicular stents more than 10 years ago — tying the stent over a 3-mm silicone sponge and allowing it to retract beneath the turbinate. So I have not had trouble with the child pulling the tubing out. I rarely ever take them to the operating room to remove the tubing. I just remove the tubing in the office. Anything that makes it easier just makes more sense.
Dr. Gold: I do a regular probing, sometimes up until 18 months, maybe up to 2 years. My second procedure, if the obstruction is not in the superior or inferior canalicular system, is to do the balloon dilation with Lacricath because I do not want to have any tubing anywhere. I do not want to be woken up in the middle of the night if I put a binocular stent in and have someone pull the tube out, which, of course, is alleviated with the monocanalicular tube. So when someone fails a probing in my practice, I usually will do the Lacricath. But it is interesting to see that there are more possibilities and more things that we can put in our armamentarium.
Office efficiency
Dr. Gold: I would like to talk a little bit about some practice management issues in pediatric ophthalmology.
John B. Pinto: It used to be that whether you were in general ophthalmology or pediatric ophthalmology, you could earn a great living if you were only 50% or 60% efficient. We are now in an era where if you are not 80% or 90% efficient, there are going to be some financial punishments with that. We are moving toward an era, because of rising practice costs and falling reimbursement, where if you are not using your facilities, staff, equipment and yourself at something approaching 100% of full capacity, you are going to fall behind financially. So it is a challenge for all ophthalmologists to try to increase utilization and increase how many patients they are seeing at a given time.
But it strikes me that this is especially poignant in the pediatric space, where traditionally the thought has been, “We just can’t see as many patients as those other kinds of doctors can.”
Dr. Olitsky: Having a protocol in the office about which patients can be dilated before we see them has improved efficiency a great deal for us. It has also helped parents see the movement of traffic through the office. We are essentially an open-access clinic, so we schedule patients within 24 to 48 hours. So that has eliminated a lot of headaches with no-show appointments, scheduling them at the front desk, referrals. I think that adds to the efficiency of the office. Although at the beginning it seemed like an insurmountable task, it has been pretty easy to keep up with. In some of our busier places, it helps to have somebody scribe for you. Those are three things that we have tried to do to help make our practice more efficient.
Dr. Johnson: I think that it is an intriguing idea to have open access. I have tried to envision that for our practice. I am in a large group, with multiple subspecialists of ophthalmology and several comprehensive ophthalmologists, and we have a long way to go to be able to accomplish that. But I have no doubt that that would be beneficial on many different levels.
At this point, our approach has been to schedule appointments as much as a year ahead of time. At one time, I thought that would never make sense, especially in pediatrics, knowing the transient population — families are moving all of the time and phone numbers are changing. Every day I see a number of patients, and I will notice that it is within a day or two of the exact date the year before. Of course, there is a no-show rate as well, and we just factor that into the schedule. On the days when all of the scheduled patients show up, then you really have to run fast. But I count on about 15% no-show rate every day.
A scribe is so valuable to get you in and out of the room. And I am speaking about a practice without electronic records. I assume that with electronic records that same scribe would also be the one doing the data entry. But on the days that my scribe is limited or interrupted, it changes the flow dramatically.
I agree with the protocol for dilating patients. They can be dilated ahead of time. That makes a world of difference.
Dr. Cheng: I am probably a practice dinosaur because I practice solo pediatric ophthalmology. My schedule is opened up between 2 and 3 months in advance, so I am somewhere in between an open schedule and scheduling a year in advance. I probably have the worst aspects of both.
But in terms of office efficiency and seeing more patients, the final common denominator is always the doctor. And the one tip that I would have that works in my office is to try to minimize on-staff costs. What I do is I find people who primarily want to work on a part-time basis, not so much a set number of hours, but less than 40 hours a week. On days when I am not in the office, when I am in surgery or traveling, there is always someone in my office to answer the phone. And the rest of the staff has free time to do whatever else they want to do. I have been lucky enough to find high-quality people this way, who oftentimes do not have this as their only source of income for the family. It has allowed me to hire a higher level of employee. All of my employees have college degrees. More than half of my employees have master’s degrees. I pay them more than the standard rate for an office staff, but my actual staff costs are the same because they are not working when I am not working. I am also not paying benefits, as my employees are part time and have spouses who provide their benefits, which is a huge cost savings.
Dr. Gold: I also schedule up to a year in advance. In our situation, where I live in Central Florida, the waiting time for those who need routine examinations is too excessive. Our no-show rate is not as high as Dr. Johnson’s, but it is part of pediatric care.
One thing that we have instituted, and I think we do a pretty good job, is a triage system in our office for those who need to be seen promptly. That starts from our front office and goes to our ophthalmic technicians, who are empowered to get patients into the office. If there is any question at that point when the patient should come in, then the doctors get involved in that type of decision-making. Specifically, when a pediatrician calls and needs to get a patient in, we get them in because that is part of our business, that is who we take care of. So we have tried to continue that good relationship with our pediatricians, and we always have places for emergencies to come in.
Mr. Pinto: There are half a dozen or so dependent variables that go into making an efficient clinic: the numbers of rooms that you have to work out of, the quality of the staff that you have, the harnessing of technology. But 80%+ of the effectiveness comes down to the doctor. I saw a pediatric ophthalmologist in Paris many years ago, a solo female practitioner, who was seeing well in excess of 100 patients a day, on her own, with no back office assistant. Of course, this may have been an environment where the medical records standards and the rest are less, but I dare say she would still be seeing nearly 100 patients a day if she was practicing here with American standards. I have seen pediatric ophthalmologists who struggle to see 20 to 25 encounters in a day. That is the prominent difference up and down the specialty and subspecialty ladder. Those doctors who are just naturally able to accommodate a much higher patient volume, they are the ones who are able to make the higher levels of income.
Dr. Gold: I would like to thank you for bringing this. It is refreshing to have, in a pediatric ophthalmology round table, discussions that are practical to real world situations that we are all involved in.
For more information:
- Kenneth P. Cheng, MD, can be reached at 1000 Stonewood Drive, Suite 310, Wexford, PA 15090; 724-934-3333; fax: 724-934-3371; e-mail: kpc123@verizon.net.
- Robert S. Gold, MD, can be reached at 225 W. State Road 434, Suite 111, Longwood, FL 32750; 407-767-6411; fax: 407-767-8160; e-mail: rsgeye@aol.com.
- Anthony P. Johnson, MD, FACS, can be reached at 601 Halton Road, Greenville, SC 29607; 864-458-7956; fax: 864-458-8390; e-mail: apj@jervey.com.
- Scott E. Olitsky, MD, can be reached at Department of Ophthalmology, Children’s Mercy Hospital, 2401 Gillham Road, Kansas City, MO64108; 816-983-6777; fax: 816-855-1793; e-mail: seolitsky@cmh.edu.
- John B. Pinto can be reached at 1576 Willow St., San Diego, CA 92106; 619-223-2233; fax: 619-223-2253; e-mail: pintoinc@aol.com.