Can shifting certain procedures to physician assistants help overcome provider shortages?
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Thumbs up for select oculofacial plastics procedures
Within our current health system, optometry has long served as a physician extender for ophthalmology by providing primary eye care. That said, well beyond the optometrist’s scope of practice is a need for surgeon extenders within certain procedure-based practices such as oculofacial plastics and orbital surgery. Although such discussions are contentious, the realities of modern health care make them necessary. I view the incorporation of surgeon extenders such as advanced practice providers (APPs) including physician assistants (PAs) and nurse practitioners as a means of increasing access while maintaining quality.
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For a procedure-based practice such as oculofacial plastics and orbital surgery, the optometric scope of practice is not an effective service multiplier. If we look at the service lines of orthopedics, otolaryngology, plastics and reconstructive surgery, which are much more similar to an oculofacial practice, these services lines often incorporate APPs. In fact, AAPs have been with incorporated with great success for years. The PA’s core training in surgical procedures allows for an understanding of pre-, intra- and postoperative management and specialty training, as was performed by our PA in oculofacial plastics and orbital surgery, making for an extraordinary partner. The incorporation of a PA into our practice has improved access, quality and productivity. Much like optometry to comprehensive ophthalmology, the PA is a service multiplier.
Additionally, the inclusion of APPs aligns with our evolving health care landscape, and their growth in ophthalmology reflects their growth in other fields. Given decreasing reimbursement and ballooning health care costs, the health care system is driving efficiency. If we look at the behavior incentives, that means the health system wants each provider doing what they do uniquely and do best. For the surgeon, that mean surgeries.
In our practice, the PA is critical to the delivery of our service. In her own clinics, she sees new patients, urgent patients, postops and routine follow-ups. She also is helpful intraoperatively for routine and especially complex cases, serving as a most capable assistant. Her ability to prescribe medications is also helpful. Her integration into the patient experience allows for rapid triage and response to patient needs. She has been trained to manage some lumps and bumps and perform some periorbital injections. As we are part of a large academic institution where I alone provide quaternary oculofacial plastics and orbital care, this improves access in my schedule for higher-order disease.
As a result of having her involved, while historically I was seeing around 35% new patients on a given clinic day, I am now around 45% new patients on a given clinic day. Furthermore, the severity of that disease of new patients has increased. The inclusion of a PA into our oculofacial plastics and orbital surgery practice has resulted in improved efficiency by increasing access and productivity while simultaneously protecting patients by maintaining the highest quality standards.
Mithra O. Gonzalez, MD, is an oculofacial plastic and orbital surgery associate professor in the departments of ophthalmology, oral maxillofacial surgery, otolaryngology, and plastic and reconstructive surgery at the University of Rochester School of Medicine and Dentistry.
Thumbs down for intravitreal injections
Being a retina specialist requires lengthy training.
We go a long way to acquire the knowledge and skills that are needed to diagnose a disease, make the appropriate treatment decisions, and understand the risks and benefits of a treatment. When we perform an intravitreal injection or any other procedure, we want to make sure that we are equipped to deal with any adverse event that may occur. We have a busy clinic, but I am not in favor of delegating tasks such as intravitreal injections to nonphysicians because they have not been through the training to understand the physiology, pathology, and risks and benefits of treatment. We are working on patients’ sight, which is an important sensory gift, and we have the duty to make sure that everything possible is done to preserve that gift.
The number of patients who need intravitreal injections is constantly growing, but we are equipped to accommodate them in our clinic, even with the increase in volume with the possible approval of intravitreal injections for geographic atrophy in the near future.
In some countries, such as the United Kingdom, the implementation of nurse-delivered intravitreal injection services has helped overcome the problem of excessive workload on ophthalmology clinics. It has worked well for them, and I agree that if you cannot meet the demands of the population, task delegation is a possibility. But the U.K. experience cannot be replicated in the U.S. because our health care systems are very different. Based on being in practice in the U.S. for 13 years, I think the model we have here, with intravitreal injections performed solely by physicians, works well, and we can continue to build on that model to make sure all our patients get treatment. We never say no to any patients who need our care, and we always treat them in a timely fashion.
Arshad M. Khanani, MD, MA, is an OSN Retina/Vitreous Board Member.
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