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Sharpen your diagnostic and prescribing skills in three steps
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The ability to diagnose medical eye problems and prescribe therapeutic pharmaceutical agents (TPAs) is crucial to providing primary care to our patients. If optometry is to become the primary entry point for eye problems in managed care settings, practicing at this level is essential. It is also very rewarding both professionally and financially to the optometrist to care for the patient with eye disease. Managing patients before and after surgery, handling red eyes and caring for the long-term needs of the glaucoma patient establishes strong bonds between the doctor and patient.
The scope of eye care that you deliver should be dynamic and always changing. Adding TPAs widens your scope of practice so that you can handle a wider variety of patient problems. Just like prescribing contact lenses, TPAs become another important facet of the care we provide. You will develop a comfort level with different types of eye diseases. The complexity of ocular conditions you elect to treat and manage will increase with your confidence. For example, a corneal ulcer could be outside your current comfort level but may be inside your scope of care next year.
Expanding optometry’s scope of care by managing ocular disease does not mean the profession is de-emphasizing optometry’s strengths. Optometry’s unique ability to understand the visual system and prescribe corrective spectacle and contact lenses to maximize binocular vision remains the cornerstone of the profession.
Hurdles to prescription writing
Despite having the availability of TPAs in many states for a long time, many optometrists have not incorporated the management of ocular disease into their practices. Even though optometrists comprise the largest group of eye care providers, they write only about 5% of ophthalmic prescriptions. What are some of the hurdles that face optometrists?
Restrictive state laws or inability to get access to Drug Enforcement Administration (DEA) numbers can limit progress with therapeutics.
Managed care contracts may allow ODs to provide only "routine" eye exams and may require referral to ophthalmology for medical eye problems.
The public may be unaware that ODs can treat eye disease because they have been referred out of optometrists’ offices for so long.
The biggest hurdle for optom etrists is their lack of confidence in managing eye disease. There is a big gap between learning therapeutics (the science of drug therapy) and doing therapeutics (the art of treating). Due to the small number of pathology cases in optometric offices, it is difficult to achieve comfort levels in treating various disorders.
Take the following steps to get started on implementing TPAs into your practice.
Get proper training
Step 1 is to get the proper training. Getting TPA certified was only the start. You need the hands-on experience that can only be obtained by visiting the office of the ophthalmologist to whom you refer, a local medical college or a referral center. Guidance from and interaction with experienced peers is invaluable in giving you insights into medical therapy that textbooks cannot.
Spend 1 day per month or 2 half-days in these settings for the next 4 months until you start to feel more comfortable expanding your scope of practice. After that, continuing education for you and your staff should be an ongoing commitment.
Action Plan: Call a local ophthalmologist or referral centers and schedule 1 day or 2 half-days per month from Feb. 1 through June 1.
Make a treatment binder
Step 2 is to start a primary care treatment binder. Buy a 5" x 7" ring binder with alphabetical tabs. Using blank, lined filler paper, make an entry for each of the common disorders you are likely to encounter. Describe the disease by its clinical symptoms, signs, and treatment. Include important drug information, like dosage, size of bottle and concentration. Add a disease once a week until you have compiled a comprehensive manual.
If you read about a disease in a journal or attend a continuing education lecture, add it to your book. You will have quick access to the most important information about a disease. I keep my binder in my briefcase so that I even have access to it at home. That way, if a patient calls me at home, I have the necessary information at my fingertips.
Along the same lines, it is useful to keep a pocket-sized ophthalmic drug guide that lists commonly used eye medications, size of bottles, concentrations and dosages. See the example of an entry in my treatment binder.
Action Plan: Obtain small ring binder and start by making entries for viral conjunctivitis, bacterial conjunctivitis, anterior uveitis and glaucoma. Add one disorder each week.
No more samples
Step 3 is to stop giving away samples and start writing prescriptions. It is only natural for ODs to think they should give away free samples of medications. We do it all the time with contact lens solutions, disposable contact lenses and artificial tears. But it is these habits that are causing market data to underestimate the number of prescriptions prescribed by ODs, and drug companies will not support this type of sampling. Apart from glaucoma, their products are largely used for acute conditions on a one-time basis.
Patients will take your treatment more seriously if they walk out of your office with a prescription rather than with a sample. It is only necessary to give samples to glaucoma patients to determine the efficacy of a particular medication, to try different types of artificial tears for dry eye and to indigent patients who are unable to afford their treatment.
Action Plan: Get a blank prescription pad for use with ophthalmic medications. Do not order any drugs for office inventory. Become familiar with the proper way to write a prescription.
For Your Information:
- Dave A. Ziegler, OD, FAAO, is the senior partner in a group private practice and is an associate clinical professor at the Southern College of Optometry. He can be reached at 2400 South 102nd St., West Allis, WI 53227; (414) 541-2100; fax: (414) 541-2377. Dr. Zeigler has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.