This article is more than 5 years old. Information may no longer be current.

Mutual respect tops OD-MD PRK comanagement wish list

Issue: January 1997

Add topic to email alerts

Receive an email when new articles are posted on

Please provide your email address to receive an email when new articles are posted on .

Subscribe

Added to email alerts

You've successfully added to your alerts. You will receive an email when new content is published.

Click Here to Manage Email Alerts

You've successfully added to your alerts. You will receive an email when new content is published.

Click Here to Manage Email Alerts

Back to Healio

We were unable to process your request. Please try again later. If you continue to have this issue please contact customerservice@slackinc.com.

Back to Healio

Rather than deepen the rift that has historically separated optometrists and ophthalmologists, laser refractive surgery may represent the dawn of a new understanding between the two professions. With perioperative care representing a significant slice of the photorefractive keratectomy (PRK) and laser in situ keratomileusis (LASIK) pie, more and more doctors and surgeons are rubbing elbows at the comanagement table.

Below, several teams of comanaging optometrists and ophthalmologists share their views on what they believe to be the keys to a successful laser refractive surgery comanagement relationship; what they look for in a comanagement counterpart; and what marketing techniques they've enlisted to attract the most important element in any comanagement scenario: the patient. Additionally, the optometrists take you on a step-by-step tour of comanagement from the moment a patient expresses interest in laser refractive surgery through to recovery.

Question 1: What's the most important factor in comanagement?

Randy Andregg, OD: The simplest and most basic element I find necessary for a successful comanagement relationship is a mutual respect for each doctor's ability.

David Lin, MD: Excellent surgical results and a high level of competency on the optometrist's part are crucial. Factors that I look for are knowledge about refractive surgery and a willingness to learn. A willingness to communicate, ask questions and raise concerns is important, as well. I like to comanage with the type of person who treats every case with care and diligence. Almost all of my comanagement experiences have been positive. It's very rare that a patient calls me about something the optometrist missed. But those few experiences have taught me to seek out extremely detail-oriented optometrists.

David I. Geffen, OD: I believe the most important factor in comanagement is educating patients so they understand that, as the optometrist, we will participate in the follow-up of their surgery. When the patient is in the ophthalmologist's office, the patient must realize that he or she will be coming back to me. Patients sometimes have concerns about being "shuttled back and forth." That's particularly the case when the patient is not properly informed from the start.

Michael Gordon, MD: A good working relationship is definitely most important. Optometrists must be comfortable calling me on the telephone, without any hesitation, when there's a question or problem. I think there must be some rapport between the optometrist and the ophthalmologist. Each must have confidence in the other's ability to do what each one of them does.

Terry Hawks, OD: What I consider most critical is making sure the surgeon is qualified, that the lines of communication remain open and that the patient is educated. We employ a refractive surgery counselor to discuss with the patient on a one-on-one basis the details of the surgery and follow-up care. It gives patients the opportunity to ask the personal types of questions they might not want to share in a large group, such as the informational seminars we provide.

Daniel Durrie, MD: To make comanagement work, the doctor and surgeon must trust each other's judgment.

Question 2: What do you look for in a comanagement counterpart?

Andregg: I look for skill and experience in a surgeon. It's difficult for me to determine which is a higher priority because they so often go hand in hand. When it comes to the surgeon's attitude about comanagement in general and working with optometrists in particular, it's important for me to steer clear of the "prima donna" types and instead work with those who value my time, talents and abilities as they do their own.

Lin: When we're choosing an optometrist to which to refer a laser refractive surgery patient, we look for someone who has comanaged before. If it's a new location where I have never comanaged before, and I have to rely on someone new, my staff sends the optometrist a complete comanagement binder that describes what to look for before and after surgery and defines the key points not to be overlooked. Some examples of what the binder includes are instructions on learning to grade haze, making sure the epithelium is healed and checking eye pressures to make sure they are not elevated because of the use of topical steroids.

Geffen: First of all, I look for a surgeon who is highly skilled; that is the most important consideration. I also take into consideration that person's support of comanagement optometry.

Gordon: Probably most important is dealing with someone who will be proactive at providing feedback on the patient's condition. The doctor providing perioperative care should send the surgeon a postoperative report. I think that's something many optometrists don't do. It is important for me to know where the patient is, what he or she is doing and what the refraction is so I can be sure the patient is happy. If there are any problems I can try to solve them.

Hawks: We are lucky in that the surgeon with whom we work has been involved in many of the excimer laser studies and has an excellent reputation throughout the field, so we know we are involved with a qualified person. In most situations, however, you have to look at the surgeon's background, find out how many procedures he or she has performed and evaluate his or her qualifications and previous involvement in comanagement. If it turns out that the surgeon doesn't have much of a track record, you could end up dealing with the patient's tough post-surgical problems.

Durrie: I look for someone who has a good rapport with patients and is willing to put in the time and effort to really understand the procedure and the normal healing patterns. It's also important that the optometrist tries to understand the goals and objectives of the refractive surgery patient.

Question 3: How do you address marketing — both internal marketing to existing patients and external marketing to potential patients?

Andregg: Our first approach to promotion was through external marketing almost exclusively. We tried a very simple, almost over-used, approach to external marketing through complimentary seminars. The seminars were presented by the surgeon and perioperative care doctor together and were fairly successful. I think there was a market that was definitely ready for laser refractive surgery, though not to the extent that the laser sales representatives suggested. That's why we reached out to the general population via external marketing, rather than relying on the prospects within our internal patient pool. We've been providing PRK for almost 3 years. Idaho is unique in that as an optometrist I can provide both the procedure and the perioperative care.

Lin: My practice is almost completely comanaged; nearly 90% of my Canadian and U.S. patients are referred by an optometrist, so I don't need to do any marketing. I was one of the first ophthalmologists in Canada to do PRK 5 years ago. I did have to market that aspect of my practice back then because there was no public awareness. But after 5,000 cases, there's so much word-of-mouth referring. We do a patient satisfaction analysis on each patient, and those surveys have shown that more than 30% of our referrals are generated from word-of-mouth recommendation to a comanaging optometrist who then refers the case to us.

Geffen: We send out newsletters that discuss information about glasses, contact lenses and refractive surgery, and we provide free consultations to patients interested in refractive surgery to help them learn about it. Another tool that we use is the patient presentation at the end of each exam. I discuss glasses, contact lenses and refractive surgery with each patient after the exam. I explain why he or she is a candidate for any or all three. I'm in a unique situation in that I'm in practice with two ophthalmologists, so most of the marketing I do is directed at my patient base. But we also do some external marketing through newspaper advertisements. I don't promote seminars outside of my patient base because the surgeons do, but I do give some of those seminars.

Gordon: We hold seminars here in our office. We do some newspaper advertising promoting those seminars and we've also done radio advertisements. Another method that we use is advertising in the office. We display cards with information about laser refractive surgery in the waiting area so that patients are exposed to information about these procedures while waiting to be seen. At this point, the bulk of our patients hear about us through word of mouth. That's an important source of referrals.

Hawks: We've been refractive surgery consultants for years, so we've been educating patients about these procedures for a long time. When patients come in, they fill out a form that asks if they are interested in refractive surgery. If they respond positively and we find them to be a qualified candidate after examination, we send them directly into a counseling session. We don't do any external marketing for refractive surgery — or anything else. We're in a refractive surgery group that markets externally; as a group we rely on word-of-mouth referrals and seminars that are strictly for our patients — unless they bring a along friend.

Durrie: We found that the best thing to do for marketing is provide education. Rather than marketing the procedure or the physician, we like to market the idea that we are a source of education about all types of refractive procedures so patients can make informed choices.

Question 4: For optometrists only — What is entailed in the process of laser refractive surgery comanagement from initial patient interest through surgery and recovery?

Andregg: If someone expresses interest in laser refractive surgery after one of our seminars, we usually suggest that he or she come in for a complimentary screening. If it's an existing patient, we'll review the ocular history and discuss overall health and use this information to evaluate the patient's eligibility for excimer laser surgery. If the patient will have the procedure done here, we schedule an appointment. If the patient will need correction for higher degrees of myopia and is going to Canada for the procedure, the patient schedules the appointment. Once the procedure is scheduled we can determine when to see the patient for preoperative and postoperative care.

Geffen: Once a patient expresses interest in refractive surgery, we spend some time explaining the pros and cons for that individual under his or her circumstances and the one or two or three procedures that you deem to be in the best interest of that patient. There are many things to consider beyond the shape of the cornea. You must assess the patient's needs in respect to his or her psychological state. The question to ask yourself is: "Will this patient be happy if the result isn't perfect?" because we can't guarantee all of these people crisp, 20/20 vision. Once a patient is considered a good candidate and is interested in having refractive surgery, we set up a no-charge consultation with the surgeon. Patients who are 4 D or up are offered a choice between either PRK or LASIK. We have a comanagement checklist of things to do that the patient can read to learn exactly what to expect. The ophthalmologist does the first two follow-up visits, and then we do the remainder to make sure the patient's vision is staying where it should and to follow the progress of the healing. In that way we monitor the situation. I usually get the patient back at the 1-month visit; see the patient again at 2 and 3 months and again at 6 months.

Hawks: First I review the chart and tell the patient which procedure best suits him or her. If the patient continues to show interest, he or she goes to a counseling session. If the patient decides to have one of the procedures, we perform cycloplegic refraction and corneal topography. If the patient wears contact lenses, we instruct him or her to go without the lenses for up to a few weeks and monitor changes in refraction until their vision has stabilized. We schedule the 1-day postoperative exam and then, depending on which type of refractive laser procedure was performed, we determine a postoperative follow-up schedule through to recovery.