Communication, respect essential for successful comanagement

Jonathan Stein

J. James Thimons

There was a time when comanagement between optometrists and ophthalmologists was a topic of great controversy. Today, it is a commonplace occurrence and growing increasingly relevant as demographic demands for ophthalmic surgery and care rise.

MarketScope recently estimated that demand for ophthalmic surgical procedures will increase by about 45% by 2020, and the need for management of chronic conditions such as glaucoma and age-related macular degeneration will increase by more than 20%. The ranks of ophthalmologists are not growing fast enough to keep pace with such demands alone, so we need to find out how to best utilize the skills of all eye care providers.

We comanage many cases with each other and, as a referral practice, comanage extensively with external practitioners who send us patients for surgery, corneal consults or advanced imaging services.

Our comanagement model is designed to capitalize on the strengths of each provider, support and utilize existing doctor-patient relationships and, most importantly, provide patients with better care. Comanaging for purely financial reasons is never appropriate; neither is it helpful to get caught up in turf or political concerns. What is helpful is to stay true to the simple principle that the care of the patient comes first. With that as the foundation, everything else falls into place.

A successful relationship

Communication and respect are the essential ingredients for an effective comanagement relationship. Because we practice together, we are constantly exchanging information — both about individual cases and also about our general approach to new technology.

With referring clinicians, we have a highly evolved communication system. We send follow-up letters every time we examine or treat their patients; however, one-way communication is not enough. Each visit with a comanaging clinician generates a full postoperative form that is faxed back and reviewed by us. One of us is also always on call for referring clinicians.

Respect, of course, is built over time and requires confidence in each other’s professional skills. To this end, we organize educational programs in our office and elsewhere in the community that allow us to build relationships with referring clinicians who are both professional and collegial. We share our results with clinicians throughout our local community so they can better understand what our practice offers for their patients.

Referring clinicians who want to comanage with us come to the office for a day of follow-up visits with postoperative patients. Trust is a huge factor, regardless of the letters after one’s name. If you cannot trust the comanaging clinician to see your patient, the relationship will not be successful.

Adding up to better care

Ideally, two practitioners who comanage can build on each other’s strengths and add value to the patient experience. With surgical comanagement, the surgeon gets far more information and a better prepared preoperative patient than he or she would otherwise, and patients are reassured to be able to have most of their follow-up visits with someone they already know and trust.

It certainly helps if both clinicians share some common clinical protocols and concepts of patient care. For example, we both believe that a healthy ocular surface is important to surgical outcomes and take similar approaches to dealing proactively with dry eye. At the same time, our different training perspectives and viewpoints are more valuable to the patient than a single thought process, especially in complex surgical cases or with patients who have multiple ocular conditions.

Refractive cataract surgery

When considering a premium IOL, it is invaluable to receive some history from a primary eye care provider who knows how the patient’s visual performance has evolved, what his or her visual needs are now and whether the patient’s expectations can be met with a multifocal or accommodating IOL.

Moreover, when the patient has a long-term relationship with a family eye doctor who understands the new lens options, that patient comes in far better prepared for the premium IOL discussion in our office. The primary eye care provider can help guide the patient through any initial discomfort or neuroadaptation and ease the transition period before the second-eye surgery. The result is that the surgery is much more likely to successfully meet the patient’s expectations.

There are inherent challenges in the comanagement of premium IOLs. The primary care clinician is uniquely suited to the role of patient advocate throughout the pre- and postoperative period. But he or she also has a much larger and more complex knowledge base to acquire for successful management of premium IOLs, compared to LASIK. Multifocal lenses, in particular, create an entirely new optical paradigm that has to be well understood to provide appropriate counseling to the patient, to perform differential diagnosis when there is a problem and to determine when an enhancement might be beneficial.

No matter how good the surgeon, some premium IOL patients will absolutely require refinements to achieve the desired refractive endpoint, so the availability of and cost structure for excimer laser and other enhancements is another big challenge. If these are not well defined in advance of premium IOL implantation, it can place tremendous stress on the patient and the comanagement process.

Good comanagement is needed now more than ever. Practitioners who take the time to get it right will find that the team approach works well for everyone — especially with the complex decision making surrounding premium IOLs.

For more information:

• Jonathan Stein, MD is in private practice at Ophthalmic Consultants of Connecticut in Fairfield, Conn. He can be reached at (203) 366-8000; Web site: www.occeye.com.
• J. James Thimons, OD, is in private practice at Ophthalmic Consultants of Connecticut in Fairfield, Conn. Dr. Thimons is a member of the Editorial Board of Primary Care Optometry News. He can be reached at (203) 366-8000; Web site: www.occeye.com.