The expert view: Pointers on new tech

Ophthalmology Management: Thank you for joining us. Our topic is incorporating new technology, such as premium products, into the practice.

William J. Fishkind, MD: At the recent ASCRS meeting, the big talk was about MIGS, and the Raindrop (ReVision) and KAMRA (AcuFocus) inlays and so on. We need to think about how to incorporate such new technologies into our practices. How do we evaluate them; determine if we want to do them; and then prepare to do them? And of course, not all new technologies work out; as a reference, remember conductive keratoplasty? How do we avoid mistakes like that?

Dee Stephenson, MD: First, how do we separate ourselves from other colleagues, and what do you do in your practice that makes you unique? There are all kinds of technology, but you have to pick technology that’s going to be good in your hands and that fits into your practice. You have to do some work before you get to your technology.

That includes your advertising or your website. What kind of packages for cataract surgery or femto do you offer? Do you do patient mailers? Media? There are some other things I think you need to think about before you step off into some of this.

Now, for me, I bought the first ORA (Reichert) in 2009 so I had the first install for ORA, which was big technology to step off on and many people poo-pooed it. In fact, some ophthalmologists are still not 100% involved with it, and for as good as it has made my results, it wasn’t simple.

But in my community it has made me kind of an expert in post-refractive cataract surgery. I do a lot of glaucoma surgery. I stay up with the MIGS technology and have been to Santo Domingo to learn new techniques with Juan Batlle, MD, on the Hydrus. The best advice I can give a new ophthalmologist is to find what’s good in your hands. Just because it’s new technology does not necessarily mean it’s going to be good in your hands.

Sohail Khan, MD: A few points I want to throw in. Number one, look at the data. Just because it’s new doesn’t mean it’s better. Look at the peer-reviewed literature.

Number two, learn as much as you can when you’re in residency or once you come out, and stay involved with residents or a training program. That way, you’ll see what they’re doing differently from when you trained and that will give you constant exposure.

It helps to look at old things that can be new again. I’m a retina specialist. Scleral buckling, for instance, is not really taught anymore in retina fellowships, and I was fortunate to learn it. A lot of folks in practice, at least recent graduates, do not do scleral buckling. The reason that it’s problematic for those folks who don’t is you get these young people — I had a case a few weeks ago, a 13-year-old with a detachment. And you try to get in there and do vitrectomy, you get a posterior vitreous detachment, it’s very challenging. If you can do a buckle, which is not exactly a new technology but it’s something few can do anymore, it’s proven. That’s one way to distinguish yourself. Because some folks would absolutely benefit from scleral buckle. My point is to learn all those different ways when you’re in training.

Dr. Stephenson: I think those are really good comments, because I had the pleasure of being with Blake Williamson on a symposium and he learned femto in his residency. He put Crystalens (Bausch + Lomb) in, he put some low-add multifocal or some multifocal lenses in. In my residency, I didn’t do that. Femto wasn’t around when I trained. ASCRS is a great place to learn things, the different labs and things you can do hands-on.

But I also think seeing a colleague who’s an expert at something, watching him do surgery, seeing how he runs his operating room, for instance, when you take on a new technology for cataract surgery. That old adage, “see one, do one, teach one” holds true here.

Dr. Khan: One avenue we have now that we didn’t have before is YouTube. Before that, you would read about the procedure or you would go to a mentor to learn it. Now, you read about the procedure, get all the steps in your head, but then you can go to or Eyetube and look at a video of someone doing it and it makes it so much easier.

Recently, I did sulcus sutured lenses, sutured IOLs — with the Gore-Tex suture — and it’s so much nicer. When you read about the procedure, then watch it on video, when you actually perform it, it’s as though you’ve been doing it for years because you’ve seen the proper technique.

Dr. Stephenson: Yes I think that’s an invaluable tool, YouTube — Eyetube as well. I go many times to watch the difficult cases, you know, Steve Safran, MD, who has all kind of techniques for explanting IOLs, ASCRS and AAO have complex cataract cases that I also look at to learn. And I think the generation of doctors coming out of residency now really want everybody to do well and you share your knowledge. It’s not like you don’t want to share your technique because the guy down the street is going to make more money than you. You want to share your technique so that the best treatment is given to the patient.

Dr. Khan: Correct.

Dr. Stephenson: I think that is a really nice thing about you Millennials — how you share that technology.

Dr. Fishkind: I’m listening to the two of you, and the way I see it is there are two kinds of new technology. One is expanding what you’re presently doing. If you’re a cataract surgeon, it’s incorporating new technologies of cataract surgery into your procedure, i.e., becoming a refractive-cataract surgeon where you pay more attention to the refractive status and outcomes using diagnostic technology and using maybe new implants or new stabilization techniques to make what you’re doing better. You go to meetings, see what people are doing and see what’s new. Then, once you determine that, you read about it, you can go on the computer and look at YouTube, you can go and work with a colleague and do a mentoring type situation with somebody who can take you through it step by step.

And the second is new technologies that require totally new skills, things like KAMRA, or Raindrop or, if you are a newer retina surgeon who doesn’t do buckles, buckles. Those totally new skills are a bit more daunting, because they require you to move out of your box to a greater degree. You go to the meetings, you learn what looks like it’s going to work, you take the courses conducted by the developer of the technology. You can then do the exact same thing: Go to YouTube, mentor, get it all down and then decide, “Do I want to bring this into my practice?”

Dr. Stephenson: That said, the one thing I do as a refractive-cataract surgeon is databank, databank, databank. You’ve got to know what your outcomes are. You’ve got to know where you start so you can improve because you can step up in technology, but if your outcomes are not good with that technology, you can’t follow them and actually measure the quality of your surgery by the outcomes.

Dr. Khan: Absolutely. Know what you’re delivering, know what your goals are but also, I would say don’t be the first and don’t be the last. Know what you’re getting into. Once you get a feel for it and you’re offering it to patients, then as you see the outcomes and the results coming back and they’re positive and you offer it more, you’re not the first one out there who gets burned and you’re not the last one in town who still doesn’t do Procedure X or Y.

Dr. Stephenson: There are some things that you can be first in, but first in your area doesn’t mean you’re first in the world to do it. I’m in a small group called the Cedars Aspen Group. There’s about 40 to 50 of us. One of us will ask a question, and we send it to everybody on that list and you get a response on what would you do. It’s amazing, my colleagues have such depth and breadth of knowledge. So, if you trust a group of people and you call on them, it’s a nice way to have your hand held, if you will, and have 50 people that back you, or 50 people that give you 50 opinions so you know what your thought processes are.

Dr. Khan: Yes, absolutely. If you go to those kinds of meetings or if you can cultivate and maintain the relationships that you develop as you’re a resident or as you get out in the world, you’ll find there are groups of like-minded people who have the same kind of goals. You can bounce ideas off of them so you can say, “That’s a good idea,” or, “Maybe you should do it this way,” and you can never stop learning. Maximize those relationships you’ve developed with your mentors because they love to hear from the people they’ve trained and they love to stay in touch and it’s actually helped them take better care of their patients. That’s very gratifying on both sides of that table.

Dr. Fishkind: So, the process is a continuing process. You decide you’re going to start the technology. You do all the things that you need to do. You start to do it, and then you have to go into outcome analysis so that you know if you’re doing it well. Then, you still will meet with your colleagues, or with other experts so you can share what you’re doing with and see improvements and fine tuning, etc.

Dr. Stephenson: Correct.

Dr. Fishkind: Once you’ve done all that, do you advertise? Because, Dee, you were talking about that. Do you start saying, “Now we’re offering this new service?” Do you advertise it by the newspaper, or radio, or television, or social media? How do you get the word out that you’re doing this procedure and that it improves patient outcomes?

Dr. Stephenson: I have a really great website, thanks to Glacial [Multimedia]. You put your own videos on there. You advertise it and patients look at the videos on the website. So, you have patient testimonials and reviews on what you do and what technology you have. I think you have to do it piecemeal, if you will. You can’t just put a website up and advertise everything in the world, but you advertise the things that are successful, or what is coming to your practice. I let people know what meetings I’m attending, what talks I’ve given. I advertise on my website and then by word of mouth and also do some direct patient mailings.

Dr. Fishkind: We’re in a small city that has 60-some odd ophthalmologists doing various things, and we advertise. We do a lot of radio advertising, very little newsprint. We do the same with the web page. We put information on our web page, but we do it with what we call blitz advertising on the radio, which has been very good for us. And we’ll run an ad that’s more entertaining than it is lots of pounding the facts, but it gets the point across about a new technology. It’s a 30-second or a 60-second spot on a lot for two weeks and then we’re done. We’re on different stations, including the public stations, and after a couple of weeks we stop for about one month and then we advertise a couple of weeks again. So, we’re kind of always in the public eye with entertaining, not hard-core, ads. They get to understand our brand and that we are the progressive ophthalmologists, doing new things and bringing new techniques and technologies to our patient.

Dr. Khan: A friend of mine in Dallas was a resident under me. He opened an office and he was the first in his area to do DMEK. The local news people heard about it and had a little two-minute bit on what is DMEK and this and that and they came to his office and he showed some very nice OCT images for the lay person; he showed them what is a cornea transplant, what is a PKP, what’s a DMEK and why is this different, why is it better. When that little segment aired, he had a big jump in his referrals. So, I think if you could somehow finagle the local news media to give you a little bit of air time, they’d probably be happy to do that.

Dr. Fishkind: Yeah, that’s great and you absolutely can. You send press releases to the television and radio stations and if you know somebody, if you know the science editor, you can write them, or call them and say, “Hey, you need to know about this. This is really a cool technology.” Frequently, that’s the kind of thing that will happen and it’s very powerful.

Dr. Stephenson: I agree. In my community, we have a local magazine and it always has a section on medical stuff. You can either write an article about a procedure or they interview you about it. And these little blurbs, that’s more bang for the buck in my community than radio, because there are 20 doctors. I live within walking distance of my home and my office and between, if I drive it takes me 30, 45 seconds to get there; I’ve heard three radio ads about ophthalmologists.

Dr. Fishkind: If you’re going to do something that’s really new, and very different, you’d better be prepared if there’s a problem for how you’re going to deal with it and who can help you deal with it in the community.

OM: Do patients come to you with new technologies or new techniques that you’ve barely heard about or you’re not quite sure of yet?

Dr. Khan: Patients sometimes ask me about macular translocation, which is not new but it’s not done that commonly. I tell them I don’t do it, but they do it at Duke [University]. Go there or go to California for the implantable, the work that Dr. (MS) Humayun is doing with retinal implants and things like that. People are always wanting those things and I say, “Well, these things are still mostly experimental. They are FDA approved but not being done in lots of locations, so please, if you have the resources or are able to go.” So, I just kind of direct them to the appropriate location.

Dr. Fishkind: That’s when I may come and make some statements we’ve made (here), that is, this is a new technology. It’s untried. We’re watching it, and we’re waiting to see if this technology is going to pan out, if it’s going to be as good as we think it is and if it’s going to be as safe as we hope it would be. And, before I can recommend that to a patient, I want to be sure that I’m not going to recommend something that’s going to make them worse instead of better.

Dr. Stephenson: Absolutely, because patients will come in and say, “Well, how come you don’t do this, and that?” And I always have a comeback: “In my hands right now, it’s not tried and true yet. I don’t have enough experience with it, or I haven’t seen enough of the surgery to offer it to my patients because I don’t want to cause them a problem.” So, I think being really honest is the correct course, because patients are educated and they’re on the Internet and half the time part of their information is truthful.

Dr. Khan: We didn’t talk about the cost, or the insurance aspect, or the billing for these procedures, but I would say just make sure that before you begin offering it, know what it’s going to cost you in terms of the time in the operating room or time in the clinic that you’re going to be spending additionally and, of course, look at what it’s going to cost the patient. Is it covered by insurance, is it not, what is the cash rate? What is the allowable? Again, I just want to get back to hammer home the point that you have to know, whether it’s a new technology or an old technology, you have to be able to decipher an EOB like you dissect the nucleus and know exactly what each field means because that way you can make yourself whole. Just make sure you’re staying ahead of the billing.

Dr. Fishkind: And if you don’t know, I’d be sure that someone in the office does, whether it’s an administrator or bookkeeper or the doctor.

And actually, if you’re doing something that’s an operating room procedure, you need to go into the operating room ahead of time and train the scrubs and the staff of the operating room as to what you’re going to be doing and what they can expect and how it works so that they’re prepared for it. OM

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