Talking with your patient

So, rush over to visit the guidelines in full text that are now in press, then hurry back here to add your comments and lets get talking!

While I have your attention as well, for those who have not seen it yet, please read about my new sub-reddit for Talking About Glaucoma where I post links to new glaucoma articles on the web. 

Ever since AB 949 was approved in 1997 or so, glaucoma care has been constrained by an complex set of requirements and processes that led only 250 of the state’s optometrists to being certified, less than 10% of the state’s number of optometrists.  The new SB 1406 law that is the basis of the new regulations will vastly streamline this process and thus will expand the number of optometrists who can become certified to manage glaucoma.

There is a strong foundation for optometry and ophthalmology collaboration in the California and it is unlikely that this will change dramatically with the new regulations.

What is best for our patients needs to be our guide with respect to managing patients with glaucoma. What should this model look like? Is it a collaborative model between Optometrists and Ophthalmologists or competitive? When should Optometrists check with Comprehensive Ophthalmologists or Glaucoma specialized ophthalmologists when caring for glaucoma patients? Should the model be different for rural vs urban centres and how are these defined? Should only Ophthalmologists provide initial glaucoma therapeutic recommendations or Optometrists as well? How do we know what is best for our patients - longterm progression outcomes? Cost analysis?

All of these issues have been debated in different forums in Canada, mostly within Optometry and Ophthalmology associations and colleges. The result is many differing opinions on how best to handle glaucoma care. The challenge now is to remember to keep care focused on the patient and not on turf wars as we begin Optometry/Ophthalmology discussions on how to achieve these goals.

No win situation? (photo from zazzle.com)Putting money where my mouth is, I am deeper into this process at the federal and provincial levels. I was involved in helping develop the recommendations from the Canadian Glaucoma Society as to how glaucoma sub-specialized ophthalmologists see this model of collaborative care. This is now in the hands of the Canadian Ophthalmological Society and they are in dialog with the Canadian Association of Optometrists. I have been appointed by the BC College of Physicians to the pharmacy advisory committee of the College of Optometrists of BC. I am hoping that discussions can prove helpful to our patients but worry about the risk of a no win situation for patients, optometrists, ophthalmologist and myself. I’ll keep you posted with updates to this article but will not be able to post any confidential information.

What are your opinions on this subject? Please add your comments to share in this discussion.

Please visit the British Columbia Association of Optometrists website to read a very important posting regarding new regulations set to be implemented in our province that will serve to blind our population by ignorance. The change in the Health Professions Act will permit opticians to dispense glasses or contact lenses without the need for anything more than computerized eyesight testing to estimate the required strength. By no longer requiring a proper examination by an Optometrist or Ophthalmologist, the people of our province will no longer be screened for asymptomatic eye diseases like glaucoma, retinal tears, and other conditions that will lead to permanent visual loss if not found and treated early.

Unfortunately, this is a bigger crime that the government is pushing through our legislature than the much publicized Harmonized Sales Tax (HST.) The cost-benefit analysis of the HST is something the government of BC may indeed be correct about, but the concept that both Health Services Minister Kevin Falcon and the right honourable Premier Gordon Campbell have stated that there is no such thing as an asymptomatic eye condition has no basis on reality and is blatant ignorance of how the eye gets ravaged by diseases that can sneak up on us all.

As a glaucoma sub-specialized Ophthalmologist, I see the devastating loss of vision that can result from inadequate screening eye examinations. Glaucoma is asymptomatic until half the optic nerve is destroyed and the irreversible process is well under way. By no longer requiring an eye exam by an Optometrist or Ophthalmologist for a prescription, there will be more patients not presenting with glaucoma until they become symptomatic - which means not until they are already partially blind. If detected on routine eye examination, this would not happen.

Keith Gordon, the Canadian National Institute for the Blind (CNIB) Vice President Research and Service Quality sent a letter to Minister Kevin Falcon, with a copy to Premier Gordon Campbell on 8Apr2010 that emphasizes the need for routine eye examinations and references the Canadian Ophthalmological Society policy on routine eye examinations.

Thomas Freddo, Professor and Director of the University of Waterloo School of Optometry has also sent a detailed letter, containing other key references, to Mr Falcon and Mr Campbell. He goes into detail to explain that allowing just sight testing and not even requiring proper full refraction means that patients will not even be getting acceptable measurements for glasses prescriptions. As for awaiting the presence of symptoms for conditions that afflict the eye, he states this is “an unacceptable standard for any health care system in any jurisdiction in a developed country. If one only considers glaucoma, the risk should be deemed unacceptable. In its most common forms, symptoms only occur very late in the course of glaucoma, when nothing can be done to regain what has been lost and little can be done to prevent patients from losing their remaining vision.”

I really have little more to add to this debate that is not already very well stated by Keith Gordon and Thomas Freddo in their statements. The only point I might add is that Dr Freddo may have offended our colleagues in developing countries, many of which have eye care at least as good as ours. Perhaps Premier Campbell’s own words can also help illustrate how he and Minister Falcon show a complete lack of understanding of the evidence of the importance of proper eye examinations. His own words are contained below in an email that he sent to a patient this week in response to her concerns over this change in the regulations that is scheduled to be implemented May 1. To highlight Gordon Campbell’s own words from this message, “I can assure you Ministry of Health Services staff have examined the medical evidence and have determined there is no strong evidence to suggest regular eye examinations for asymptomatic individuals aged 19 to 65 improve health outcomes.”

As a glaucoma sup-specialized Ophthalmologist, I can assure you that the Ministry of Health Services staff never examined the correct medical evidence and have absolutely no medical evidence to base their decision to impair the health of British Columbians. This is a grave dis-service to the public good that will result in permanent visual loss to our citizens. The extra burden on society in lost productivity and extra health care costs to treat patients not presenting until they have symptomatic eye disease is completely preventible. The government must not be allowed to outlaw routine eye exams for patients who want to buy glasses and contact lenses from on-line companies. There is no cost-saving to British Columbians by government enabled blindness.

On Sunday 11Apr2010 I had the opportunity of speaking with a fairly large gathering of Optometrists from across British Columbia at a conference they were holding at the UBC Eye Care Centre. I was invited to talk about how best to work together in caring for patients with glaucoma as well as an update on my practice. This was an exciting opportunity given my involvement with this blog that Dr Hom and I started that deals with that very subject, as well as my work on the Canadian Glaucoma Society’s (CGS) subcommittee on Inter-professional care of patients with glaucoma.

I am including the Keynote slides that I used for the talk below but what was far more important was the interaction with the audience for this session. The CGS guidelines are still in draft form and took the committee headed by Dr Marecelo Nicolela at Dalhousie University more than one year to get to this far. They have been approved by our committee but await discussion at our CGS Annual Meeting in June 2010. That being said, it is vital to be in constant communication with our Optometric colleagues in order to keep our glaucoma patients at the centre of their care.

After introducing the topic, I led an open discussion with the audience to better understand the practice patterns of current optometrists in our province as it pertains to the care of patients with glaucoma. As expected, there is quite a lot of variability likely dictated by two key factors: urban vs rural and Canadian vs American training. Perhaps oversimplifying our discussion, those Optometrists practicing in a rural setting are often not able to get patients the care they need for their patients because there are fewer ophthalmologists and no glaucoma specialists at all. Those Optometrists who trained in the United States were more likely to have a background in therapeutics whereas this has been less emphasized in Canada. Another statistic tossed around related to the decreasing role of Optometrists in dispensing glasses but this was a bit harder to measure with many Optometrists giving up the dispensing but practicing inside or directly next door to a major optical chain.

Patients who are suspected of having glaucoma or who have early glaucoma that is stable, especially if they live in a rural setting, are likely to need Optometrists to be intricately involved in initiating glaucoma therapeutics due to limited access to general and sub-specialized Ophthalmologists. As it is now in BC, they are either not receiving any initial therapy or some Optometrists have a close relationship with Family Doctors who they ask to initiate therapy until the patient can see a nearby general Ophthalmologist.

Patients in urban settings in BC, that is, Vancouver, are more likely screened by Optometrists and referred to glaucoma specialists. With our aging population, this may not be a sustainable model. As we have discussed in this forum before, Ophthalmologists are needed for the more advanced stages of the disease and if they spend too much time screening or treating patients very early in the course of glaucoma, they will not be available to handle the patients who need surgery.

We did discuss though an interesting conundrum, and perhaps those reading this article would like to add their opinions in the comments section. In order to adequately treat someone with a medical condition such as glaucoma, it is important to be very familiar with not just the diagnosis of disease and its progression, but also with the treatment options at different stages of the disease. An Optometrist in the audience asked where I fit Selective Laser Trabeculoplasty (SLT) into the treatment regimen. Laser is alteration of tissue and therefore it is surgery; this is not going proposed as a modality of treatment that Optometrists will provide if/when they get therapeutics. As myself and other colleagues do perform SLT as first or second line therapy, should an Optometrist be presenting this as an option as a first or second line therapy to their patients? Absolutely! Patients need to be aware of ALL reasonably accepted options for treatment, their side effects, and the alternatives including what would happen if they were not treated. For those treatment options that they cannot provide themselves, they need to refer to someone who can…whether this is a general or sub-specialized Ophthalmologist or a treating Optometrist. (We will likely see in Canada some Optometrists comfortable with medical treatment, some specialized in Glaucoma, and others who are not comfortable with initiating treatment.)

From our open discussion, we were in agreement that any eye care professional needs to know what they are comfortable treating and when it is time to refer onward either for confirmation of the current management or additional medical or surgical therapy. I did point out a bit of irony in that these guidelines to date were drafted by a group of glaucoma sub-specialists, to suggest how Ophthalmologists (never specifying glaucoma specialists) and Optometrists should work together in keeping the glaucoma patient in the centre of a model of inter-professional care. However, no general ophthalmologists or optometrists were involved yet in these guidelines. That is of course why these talks are now beginning over the next few months to open the dialog between Ophthalmologists and Optometrists. On reflection, it does make sense that we had to start somewhere so getting our CGS group to put together this initial draft does make sense.

In order to standardize the care, the guidelines do propose some minimum skills for eye care professionals involved in caring for patients with glaucoma. This includes performing Goldmann-type applanation tonometry as the accepted gold standard (likely Pascal will also become acceptable) but that Tonopen and pneumatic tonometry are not acceptable. Gonioscopy and stereoscopic assessment of the optic nerve are both minimum required skills in diagnosing patients with glaucoma. Furthermore, an understanding of what constitutes progression on Visual Field testing is vital to know if a glaucoma suspect is progressing to glaucoma or a patient with established disease is progressing. Full threshold testing is required so that those Optometrists who just have FDT machines can only screen but can’t diagnose new disease or look for progression. We discussed that those Optometrists who have one or more of these minimum skills are certainly qualified to diagnose patients and follow patients early in the course of glaucoma. 

As the glaucoma staging moves from screening, suspecting, early glaucoma and more advanced disease, the need to consult with an Ophthalmologist increases. There are differing degrees of Ophthalmologists involvement proposed depending on where in this continuum the patient lies. This section of the guidelines serves to put into words what would seem to be intuitively obvious to both Optometrists and Ophthalmologists. That being said, there will still be a lot of variability based on urban vs rural and Canadian vs American training. These guidelines are still in draft form and are, just that, guidelines. We need further input from those not yet involved in this document’s creation, namely Optometrists and general Ophthalmologists. This process is underway and your comments on this blog would be very helpful to help us better care for glaucoma patients.

To add further insult to injury, our health minister was recently quoted as saying on national radio that there are no eye diseases that are asymptomatic so our province is looking at no longer covering routine eye examinations. Kevin Falcon clearly knows nothing about glaucoma; screening can detect disease before it becomes symptomatic so our patients need never lose vision to glaucoma. Sadly, our best data is still that half of patients with glaucoma don’t even know they have it. We need to be able to work together as eye care professionals to care for patients with all stages of glaucoma.

The Alberta College of Optometry (ACO) has submitted to Alberta Health & Wellness (AHW) a Proposal to amend the Optometrists Profession Regulation Respecting the Authorization to Perform Restricted Activities  to include such things as manage patients with glaucoma without any involvement of Ophthalmologists including prescribing medications and performing laser iridotomies and trabeculoplasties. I would be interested in feedback regarding this issue from both Optometrists and Ophthalmologists who care for glaucoma patients and how this effects inter-professional collaboration for the best care of our patients. 

Clicking on link in paragraph above or on any of these thumbnails of the individual pages all downloads the same three page PDF file of the proposal.

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The visual field, either by frequency doubling or the traditional white on white static techniques has quickly become a standard part of the optometric examination. While the first visual field may be atypical or even abnormal, the iterative intellectual process follows the traditional optometric paradigm of collecting sufficient information before concluding that (a) the atypical finding is not indicativie of a disease or (b) there is sufficient rationale for more testing.

In the model of optometry that I had posted previously, the optometrist may either follow the “detect and refer” model and immediately refer the patient or attempt to discern whether there are additional findings that might further define this as a patient with a risk for glaucoma or one who has a high likelihood or even a diagnosis of glaucoma.

To many ophthalmologists, they may see or even wish that optometrists would immediately refer any patient who demonstrates any risk for glaucoma and I would agree that probably the majority of optometrists would do that.

However, in the last ten or even twenty years, optometrsists have either gained the legislative privilege and educational preparation to diagnose and manage most of the common forms of glaucoma. The ophthalmologist might find it heartening then, that a referral from a more progressive optometrist might not be a false positive referral (one that is assumed to have glaucoma but doesn’t require medical treatment). In these cases, the optometrists will liekly refer a patient who may have an advancing form of glaucoma that may not be amenable to a single or even dual topical therapy.

It is sometimes a difficult choice for some optometrists to choose which ophthalmologist to send a patient. Although it may be optimal to refer the patient to the best qualified medical practitioner, there might be alternative factors that dictate the referral.

These will be covered in a later post, but it is sufficient to say that an ophthalmologist who openly or covertly suggests that a particular optometrists should have sent the patient to them simply on the basis that the optometrist doesn’t have the capability to treat and manage a patient will not likely be high on the list of a referral regardless of the skill of that ophthalmologist.

Most, if not all optometrists are quietly proficient and even humble about their role in glaucoma management. This approach has helped promote optometric/patient relationships where the pace of a traditional ophthalmologic office might not provide that kind of atmosphere. Respect runs both ways. They will respect ophthalmologists who aren’t overly condescending. They would hope that they will be treated like a colleague who welcomes pointers and clues to better care for their patients. Respect after all, is one of the few human qualities that produces many returns for both the optometry and ophthalmology.

Sounds simple and straightforward, right?

Ask a dozen physicians and I would bet about a quarter will know what an optometrists is trained to do or is allowed or licensed to do. 

What is confusing is the natural compulsion of physicians to feel that if you're not a physician, you can only do assessment. That means only a physician can assess and treat.  But what makes optometry a bit of a different kind of profession is the extensive, albeit focused, education that recent graudates have undergone.  In recognition of this wider and deeper education, individual states in the United States have set the boundaries of optometric practice. The concept of legislative definition of scope of practice is an anathema to some physicians.

But other differences, some less obivous, further differentiatle the optometrists from the normal model of a physician.  First, optometrists see mostly healthy eyes and people. In that group or segment, the optometrist isn't preoccupied so much about finding a signficant pathology, just because it probably isn't any.  By attending mainly to healthy people, the optometrists is adept at practicing anywhere in the continuum of care. That continuum spans refraction to disease management.  However, the ophthalmologist will probably lean more to unhealthy eyes that require surgery. Like surgeons, if an ophthalmologist sees something wrong, they will recommend medicine or surgery.

Up to now, the division standing between the refracting optometrist and the ophthalmologist has been stark, but easy to comprehend. The responsibilities were clear, The authority was unmmistakable.  Optometrists detect and refer and ophthalmologists treat.

Simple then, but not so simple now.  With nearly half or more of all optometrists still detecting and referring, that proportion clashes with perception. For an ophthalmologists, that question may either be a preumptous one, or one that doesn't need asking. Either way, most opthalmologists generally view or want to confine optometry to that traditional model of detect and refer.

In summary, the traditional image of an optometrists has unfortunately hobbled the collaborative nature between the two professions. I even think that most optometrists pine for those older days past when such distinctions prevailed. For collaboration to advance, there must be some recognition that optometrists are no longer willing to be confined to the model of "detect-and-refer". In fact,  It is a double edged sword, though, because most optometrists probably are themselves struggling with the pervasive notion that they are only "detect-and-refer" optometrsits, something that doesn't smack of collaboration but of unwilling servant.  Much needs to be done still.

But first, a backdrop needs to be in place. If either eye care provider (ECP), ophthalmologist or optometrist) reads their professional organization's public relations literature, you might believe that there are never any good working relationships between the two ECPs.  For many ECPs, that belief is so strong, that it might blind either side that the patient's well being is missed.

I think one of the first steps in opening dialogue between the two ECPs is meeting your colleagues face-to-face at least once.  I know there are some who believe that the words that flow from their mouths are golden and probably are unalterable truths. What one finds, though, are elements of kindness in either that makes them worthy doctors to their patients.

Tapping into that self dignity, then it is possible that if we can look at one another and ask ourselves what is the best for the patient? It's possible.  What we forget is whether we are talking about Canada or the United States, there are obviously situations where there are more patients than there are ECPs.  In these circumstances, it just makes sense to work together for the patient's benefits.

On the one side, the ophthalmologist might feel that their judgment is above reproach and unquestioned.  On the other side the optometrist might feel unappreciated. Neither side holding fast these views will be obstacles to collaboration.   Therefore, trust must be built between the two. The ophthalmologist must trust the optometrist that no harm will come to a patient under joint care.  The optometrist must trust the ophthalmologist that the patient won't be hijacked. If either feels that these are unalterable obstacles, then the preexisting struggle of the two ECPs will persist.

I think the professional organizations that each of us belong are capable of overseeing the benefits of the professions as a whole, but those efforts will fail to address the day-to-day minutiae of practicing in our offices and dealing with our patients.  I know that such viewpoints will be difficult to appreciate, and maybe unreachable, but each individual ECP has the prerogative and capability of making such a gesture. After all, the patient is the beneficiary, isn't it?

My next installment will begin to unveil what optometrists do? I think that some in the medical profession have viewpoints that may have been shaped by personal experiences or by anecdotes from colleagues.  They may or may not be true today.