When it comes to managing glaucoma patients, do you resist the idea of enlisting help from your colleagues in eye care, particularly optometrists? Were you taught in medical school that you should be able to manage these patients on your own, owing to the chronic and severe nature of the disease along with the potential risk of eyesight loss? Do you fear optometrists will take away a large portion of your business and profits?
If so, a growing number of your peers say it’s time to abandon such beliefs in favor of a more teamwork-oriented approach to glaucoma treatment, for a variety of reasons, especially your own good and that of your patients.
SPECIALISTS AGREE: TWO ARE BETTER THAN ONE
“I was a pilot before I went to medical school, and what I tell my glaucoma patients is that it takes two pilots to fly a plane,” says Rajen Desai, MD, The Witlin Center for Advanced Eyecare, East Brunswick, N.J. “One doctor flies the plane, and the other serves as backup. We work together, so if you need only one or two eyedrops, the optometrist flies. But if you ever need more, I take over as pilot. I’ll be there to take care of you in the OR. You’re not going to go blind on our watch.”
Many ophthalmologists agree, and they lament the resistance some have to sharing glaucoma patient care with optometrists. Reasons range from what some ophthalmologists were taught in medical school to fears of business loss and that patients may receive substandard care, risking damage to or loss of their eyesight.
“We’re taught that we must be capable of managing our own patients and comfortable with all routine and complicated management,” says Brandon Baartman, MD, an ophthalmologist with Vance Thompson Vision, Omaha, Neb. “Most ophthalmologists trained in an era of more traditional incisional surgeries like shunting procedures, where the stakes are higher.”
Constance O. Okeke, MD, MSCE, agrees, noting that, because many of them were trained to follow glaucoma chronically, “some ophthalmologists may feel hesitant to embrace the co-management of glaucoma out of concern about delays in the appropriate timing of referrals from the optometrists.
“On the other hand,” she adds, “some optometrists may be hesitant to refer because they feel threatened that the stable glaucoma patients they feel confident to follow may not return, and that may affect the productivity of their business.”
Dr. Okeke and other ophthalmologists interviewed for this article argue beliefs like these no longer apply — if they ever did — in today’s “real world,” where the number of glaucoma patients is growing exponentially, making collaboration virtually mandatory.
“The baby boomers are aging, and honestly, there are just too many glaucoma patients for one specialist to manage,” asserts Robert Noecker, MD, an ophthalmologist with Ophthalmic Consultants of Connecticut, Fairfield.
Dr. Noecker points out that glaucoma patients fall within various stages, ranging from those with suspected glaucoma to those with active disease and those who only require postop surveillance through routine visits. Many patients also suffer from other eye diseases, such as cataracts or dry eye disease. It’s important, he says, to sort glaucoma patients who require only routine monitoring and treatment with eyedrops from those who require the surgical skills that can be provided only by specialist ophthalmologists. The most important criteria to sort patients are stability and severity of disease, he says, explaining that patients who demonstrate progressive disease under active treatment face a poorer prognosis.
Progression indicates one of three things: the patient is an outlier, the assumptions about acceptable target IOP were wrong or the therapy simply isn’t working. “For these patients who do not have IOPs reduced significantly, a surgical/laser approach is indicated to prevent further progression,” Dr. Noecker says, noting that patients with more severe disease accompanied by significant visual field loss have less margin for error.
“Unlike milder glaucoma patients with whom we have time to work on finding an optimal treatment regimen, patients with advanced visual field loss are at risk of going blind in the near future. As a result, this group as well needs aggressive long-term IOP lowering in order to stabilize and not lose more vision,” he says.
“It’s nice to see relatively healthy people and tell them everything’s great. But that means someone who’s a little sicker may be kept out of my office just because there’s not enough time for me to see them,” Dr. Noecker adds. “Severe glaucoma cases can progress right before our eyes.”
That’s where the advantages of co-managing glaucoma cases with optometrists come into clear view. Noting that glaucoma requires careful attention to vision changes from visit to visit, Dr. Baartman says that in a collaborative care model, “a skilled optometrist can take the time necessary to determine surgical necessity, while surgeons can find their time more effectively spent in the OR.”
Dr. Noecker agrees, noting that technology advances have made glaucoma patient evaluation to become increasingly standardized and amenable to co-management. “Probably 50% of my patients are co-managed to some extent,” he says. “After I can determine that a patient is stable or at low risk of progression, I frequently will alternate that patient’s visits with an OD, often because it is more convenient for the patient. That way, I also have more time to see higher-risk or actively treated patients in my daily schedule.”
KEY TO CO-MANAGEMENT NO. 1: EDUCATION
Developing a collaborative approach to glaucoma care with optometrists doesn’t have to be complicated. Much of it comes down to organic growth, says Dr. Noecker. “Our business is word of mouth, and sometimes it’s just proximity to other practices.” Going beyond that initial contact, however, requires intentional effort.
Dr. Okeke says she has found a focus on continual education, an openness of communication, and an ability to trust to be critical ingredients of effective co-managing relationship with optometrists. On the first point, she says, glaucoma specialists must continue to educate the optometrists with whom they choose to partner.
“There’s the basic education they get through their optometry school to get their degree, and then there are the COPE (Council on Optometric Practitioner Education) credits that they need to take as a requirement to keep up,” she says. But ophthalmologists can and must provide ODs with additional information specific to their own practices as well as to updates in technologies or procedures, such as minimally invasive glaucoma surgery.
For example, Dr. Okeke says her practice hosts seminars for ODs on glaucoma, as well as other conditions, for them to become certified in co-managing patients with her practice. The training extends to co-managing actual patients on a case-by-case basis to build capability as well as communicating one-on-one through e-mail and phone calls to address questions the OD may have about when to refer. Optometrists are also encouraged to “shadow” ophthalmologists as they see patients in the office.
“As you see that optometrists are appropriately finding pathology and referring, you get a sense that they have a good understanding of when to refer. You can then feel more confidence that they will refer appropriately,” Dr. Okeke says.
Co-management: An optometrist’s point of view
By Robert Vandervort, OD, FAAO, Dipl ABO
As both ophthalmologists and optometrists are coming under pressure to examine and treat more patients per hour, co-management offers each profession the opportunity to do what they do best with better outcomes for the patient.
Optometrists have an excellent track record of exercising good professional judgment on behalf of our patients. That said, the overriding factor for all optometrists is to act in the best interest of their patients. As a profession, we tend to be very conservative in managing these cases; when in doubt, we refer the patient. No doctor of any stripe has any desire to manage or treat patients who are outside his or her comfort zone with respect to education, training and experience.
Co-management, therefore, is often tailored to the best fit between optometrist and ophthalmologist. Like their MD counterparts, many ODs specialize in different aspects of eye care. An optometrist who focuses on ocular surface disease may choose to refer glaucoma patients to an ophthalmologist. Another optometrist may manage the medically related glaucoma treatment and refer the patient only when surgery is required, resuming care once the patient is released postoperatively. Both situations require communication to delineate the expectations of each side and the level of detail each doctor desires to properly care for the patient.
The ultimate goal is for the patient to receive the best care in the most time- and cost-efficient manner. It takes work for both sides, but in the end everyone wins, especially the patient.
Dr. Vandervort is an optometrist and founding partner of Heartland Eye Consultants, LLC, Omaha, Neb.
KEY TO CO-MANAGEMENT NO. 2: TRUST
“As my practice is built on relationships with optometrists, I also work on developing those relationships at annual meetings and regular seminars and even visits to their offices,” Dr. Baartman says. “I like to talk about the technology they have and how they can best use it to care for patients.” Dr. Baartman says this kind of relationship building develops trust that the optometrists he partners with can “help decide when it is appropriate to send in, and [that I can] reassure them that, when doubt exists, to err on the side of referral.”
KEY TO CO-MANAGEMENT NO. 3: COMMUNICATION
The importance of communicating with each other cannot be overstated, according to Dr. Noecker. “Basically, the optometrists communicating what their questions are [and identifying when] they need to refer a patient,” Dr. Noecker says. “Talking and direct communication between providers is always the best way both to grow and to strengthen the referral network as well as to improve patient care.”
He says he likes to begin treatment of a new patient with an initial phone call to the patient’s optometrist as well as a written referral letter for reference in the future. “Many times, the phone call is nice to address concerns that are not evident in the formal referral letter and get a feel for the referring doctor’s comfort level dealing with the patient’s problems. But, once care is established, I just generate the most recent note from the EHR so that we’re all on the same page,” he says.
KEY TO CO-MANAGEMENT NO. 4: PUTTING THE PATIENT FIRST
And therein lies the fourth key: always putting glaucoma patients front and center, which means embracing the practice of collaborating with optometrists — for the patient’s good and your own. “There’s really no wrong way to co-manage glaucoma. The only thing wrong is desiring a monopoly in a referral territory,” says Dr. Desai. “Make the patients’ vision first and your sense of exclusivity last, and patients will be better off that way.” OM