Successful neuro-ophthalmology practice requires building trusting relationships

Relationships with other physicians, as well as patients, are needed in a subspecialty that touches upon ophthalmology, neurology and neurosurgery.

Neuro-ophthalmologists serve as a channel between ophthalmologists and neurologists and a resource for both, caring for patients whose ophthalmic ailments derive from neurologic problems. They deal with many aspects of patient care, from interacting with the referring physician to providing lifelong care for the patient.

Because the care they provide can be complex and long-term in nature, it is important for neuro-ophthalmologists to build trusting relationships with their patients and the referring physicians, according to neuro-ophthalmologists interviewed by Ocular Surgery News.

David I. Kaufman, DO, chairman of neurology and ophthalmology at Michigan State University, noted that a large portion of his patient population consists of patients he has been seeing for more than 10 years. To maintain those types of long-term relationships successfully, he said, the subspecialist must be open and honest with the patient.

“You have to supply the patient with information so that they can make educated decisions regarding the treatment strategies they want to proceed with,” Dr. Kaufman said. “The conversations are usually long and involved and important so that the patient has solid information, a solid foundation on which to base decisions regarding their own body.”

Experts in the field of neuro-ophthalmology spoke with Ocular Surgery News about practice management issues in their subspecialty, ranging from initiating referral and communicating with other physicians to building long-term relationships and dealing with managed-care structures.

Peter J. Savino

Referrals

The patient’s relationship with the neuro-ophthalmologist most often stems from a referral from either a general ophthalmologist or a neurologist. Treatment generally begins with collaboration between the two specialists.

“Neuro-ophthalmology seems to be the conduit between the two disciplines,” Dr. Kaufman said. “Many times there’s a nice mix and blend.”

Neuro-ophthalmologists interviewed by OSN said they prefer that the patient be referred as soon as the general ophthalmologist or neurologist feels uncomfortable making a diagnosis or is unsure of the source of a patient’s complaints.

“The bar for that [comfort level] varies from ophthalmologist to ophthalmologist,” said Don C. Bienfang, MD, the chief of neuro-ophthalmology at Boston’s Brigham and Women’s Hospital. “Some of them are more comfortable dealing with neuro-ophthalmic issues.”

Neurologists are often uncomfortable dealing with visual issues, Dr. Bienfang said.

“They’re not trained to decide whether it was glasses, cataract, retina, optic nerve, visual field; all these things are possible in a given patient,” he said. “Particularly in that area, [neurologists are] dependent upon ophthalmologists.”

Peter J. Savino, MD, OSN Neuro-Sciences Section Member, said patients of both ophthalmologists and neurologists would be best served by referral to a neuro-ophthalmologist as soon as a potentially neuro-ophthalmic problem is detected.

“I’m a great believer in going to subspecialists immediately,” he said. “You get to a diagnosis quicker and usually more accurately.”

Barrett Katz

Barrett Katz, MD, MBA, OSN Neuro-Sciences Section Editor, added, “You can sometimes save the patient the expense and aggravation of going through tests that might not be specifically needed in the circumstances.”

The initial referral can be difficult for a general ophthalmologist to explain to his or her patient. The experts interviewed by OSN said patients should be told why they are being referred and what to expect when they arrive for an appointment with a neuro-ophthalmologist.

“You have to say, ‘I’m concerned you might have multiple sclerosis’ or ‘I’m con-cerned you might have temporal arter- itis,’ ” Dr. Savino said. “This way the patient knows why they’re coming to see me.”

Dr. Katz added, “It is useful for the patient to know what to expect when they are seen by a neuro-ophthalmologist, that they’re likely to be spending some time in this consultant’s office and that this person is going to help sort out their signs and symptoms and reach definitive answers and recommendations.”

Open communication

Patients should be sent to the subspecialist with their full array of tests and historical records in hand, several neuro-ophthalmologists said.

“As neuro-ophthalmologists, we all have the experience of having patients show up on a daily basis who don’t know why they’re here, and we don’t have any notes from the referring doctor,” Dr. Savino said.

The passing of records from the referring ophthalmologist to the neuro-ophthalmologist is key to improving patient care and the patient-doctor relationship, Dr. Bienfang said.

“When you refer a patient, would you please send your records? That sounds very down to earth, but it is one of the biggest problems that exists,” he said. “I think that everybody knows how useful those records would be.”

Drs. Bienfang and Savino agreed that precious time is lost when the neuro-ophthalmologist must track down the necessary records.

“We try to get it together while the patient is here, but sometimes it’s just not possible, and we work at a disadvantage,” Dr. Savino said. He suggested that original scans and tests be sent to supplement written reports, which may not always be accurate.

Ongoing collaboration

Cooperation between the physicians often continues after the neuro-ophthalmologist makes a diagnosis.

Dr. Bienfang said sometimes the diagnosis is not serious and the patient is sent back to the referring physician with specific instructions. Other times, the neuro-ophthalmologist becomes the patient’s primary physician.

In the latter case, Dr. Bienfang said he often sends the patient back to the referring physician for some types of care over the course of the patient’s life.

“There could be issues where I turn back to the primary ophthalmologist and say, ‘Mrs. So-and-so has developed a problem that I think is more in your bailiwick now. I’m happy to take care of this part of the issue, but do you feel comfortable in managing her cataract?’” Dr. Bienfang said.

Every ophthalmologist should have a neuro-ophthalmologist to consult, even if it is on a casual basis, Dr. Katz said.

“It is valuable for every practitionerto establish a relationship with a nearby neuro-ophthalmologist that one is comfortable with because such a partner can be helpful to that practice, that provider and that provider’s patients,” he said.

Building trust

The long-term relationship between the neuro-ophthalmologist and the patient begins with the initial testing and diagnosis and continues through potentially life-long treatment.

“You have to be open with the patients,” Dr. Bienfang said. He suggested explaining to the patient the possible diagnoses, in order of importance, before sending them for confirmatory tests.

“By the time they go off and get their testing and come back, they’ve had the chance to mull over the implications of what you’ve told them,” he said. Many times, he said, the patient will have also researched, via the Internet, what the neuro-ophthalmologist has told them.

“The Internet is a blessing and a curse,” Dr. Savino said. He cited a recent study that estimated that only about half of the medical information on the Internet is accurate. Experts agree that part of the neuro-ophthalmologist’s job is to answer all of the questions that this information and misinformation may raise.

“The most comforting thing you can do is to be right,” Dr. Bienfang said. “That’s the most confidence-building thing you can do. The next thing is to show the patient that you’ve thought about the case, considered a variety of possibilities and done the appropriate tests to reach a logical conclusion, or at least a logical plan.”

This plan comes into play when the neuro-ophthalmologist must explain to the patient that there is no cure for his or her disease.

“If you give somebody bad news, you also have to outline for them a plan of therapy,” Dr. Bienfang said.

Dr. Katz added, “We can share with them what their prognosis is, counsel them on appropriate expectations and help them recognize that, while not every disease is curable, most diseases are treatable.”

Dr. Savino said explaining an inability to cure is the hardest thing to do in a neuro-ophthalmology practice.

“That’s the toughest thing I do,” he said. “Fortunately, that’s just one instance in the day. Usually at the end of the day, the positives far outweigh the negatives.”

Maintaining a relationship

Once a diagnosis is made and expectations are set, the neuro-ophthalmologists often must maintain a relationship with a patient over a long period of time. Vital to maintaining these relationships is proper communication, both with the patient and with cooperating physicians in other disciplines.

Physicians interviewed by OSN recommended that, at the end of each session, a letter should be dictated to the patient and the referring physician detailing what was discussed that day. This provides the patient with a complete record of his or her medical treatment and should lead to fewer questions later.

“The other benefit that you don’t realize is that the patient now knows that you’re not telling their doctor anything different than you’re telling them,” Dr. Savino said. He said he did not realize the importance of this until his office administrator pointed it out.

“If they get the same letter as their doctor, they know that you’re telling them everything,” he said. “I had not realized that previously, but it’s critical.”

This is one aspect of the open communication that Dr. Kaufman said is necessary to build an ongoing relationship.

“Communicate with people during their visit with you, and approach them in a way that makes it quite obvious that you are there to educate them, provide them with options and help them decide what to do with their body rather than perhaps making pronouncements,” Dr. Kaufman said.

He offers his home telephone number and reassures patients that he is available when they need him. He said patients rarely call at inappropriate times; on the contrary, he said, their calls have helped him provide more timely treatment when necessary, rather than waiting until business hours.

“One of the major things in terms of engendering trust to develop a trust relationship with a patient is that ability to communicate your skills as a person, basically your humanity. Are you able to project that to a patient?” he added. “Most times the patients will sense that and feel that they’ve got somebody that’s really there for them.”

Changing scope

Dr. Savino said taking a patient from the initial referral through a complex or lengthy treatment is becoming harder as more demands are placed on patients and physicians by the insurance industry.

“In the past, it’s been our tradition that when a patient is sent to us, we’d take care of the patient. We were not just consultants,” he said. “We can’t do that anymore. It’s changed my practice a lot, from being total care for every patient who walked in the door to being a largely consultative practice. I don’t like that, but I can’t control it.”

This is a reality of the neuro-ophthalmology field and all other fields, Dr. Katz said. He pointed out that patients can be forced to switch physicians if they change insurance plans.

“I think that it’s a problem for both patients and physicians,” Dr. Katz said.

Dr. Savino said such changes can result in misdiagnoses or the inability to accommodate a critical patient in need of specific tests. He added that at times he has been frustrated by not being able to refer patients to the best specialists in the area, but instead being limited to those in a particular insurance provider’s network.

“It is detrimental to patient care, and this is one of the frustrations that you will see among neuro-ophthalmologists,” Dr. Katz added. “If we as subspecialists could help change that system, such changes would be cost-effective, as tertiary providers would be most able to order the right tests at the right time, avoid repeating scans that were not focused upon the area of most relevance and perhaps obviate unnecessary tests. Ideally, the tertiary care consultant would get the right workup done the first time.”

For more information:

• David I. Kaufman, DO, can be reached at Michigan State University, Department of Neurology and Ophthalmology, 138 Service Road No. A217, East Lansing, MI 48824; 517-432-9277; fax: 517-432-9414; e-mail: kaufmana@ht.msu.edu.
• Don C. Bienfang, MD, can be reached at the Department of Neuro-ophthalmology, Brigham and Women’s Hospital, 75 Francis St., Boston, MA 02115-6195; 617-732-7491; fax: 617-732-6083; e-mail: dbienfang@partners.org.
• Peter J. Savino, MD, can be reached at Wills Eye Hospital, Neuro-Ophthalmology Service, 840 Walnut St., Philadelphia, PA 19107; 215-928-3130; fax: 215-592-1923; e-mail: pjsavino@aol.com.
• Barrett Katz, MD, MBA, can be reached at Fovea Pharmaceuticals, 3-5 Impasse Reille, 75014 Paris-France; 011-33-1-44-16-42-42; fax: 011-33-1-44-16-42-40; e-mail: katz@fovea-pharma.com.

• Katrina Altersitzis an OSN Staff Writer who covers all aspects of ophthalmology.