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.

image of page 1 of 3

image of page 2 of 3

image of page 3 of 3

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. 

This tweet that Dr Hom posted this past week, and our exchange of responses that followed, is what inspired us to start this blog on how best to have Eye Care Providers (ECPs) work together. Although micro-blogging with Twitter can provide some instant feedback, many potential great learning moments can just go unnoticed in that medium. Hence, the chance to continue where we left off by having people add their comments.

My view as an ophthalmologists, sub-specialized in glaucoma, may differ from that of other ECPs. For me, if I receive as part of a consult request, a series of appropriate tests, it would make me think highly of the skills of the optometrist. But is also must be recognized that not every optometrist is going to have the latest nerve head imaging device or perimeter if they do not have to deal with a lot of glaucoma patients themselves. Therefore, knowing when a patient is at risk of having glaucoma is also something that would rank highly in my books.

Having a good working relationship with optometrists can help assure good pre-consult testing is performed. For example, in my practice, I do offer optometrists the opportunity to send patients in just for diagnostic testing with the Heidelberg Retinal Tomogram (HRT) or standard automated perimetry (Medmont) if they would like to order those tests but do not feel they have enough information yet to warrant sending the patient in for consultation. As the tests can be fit in most every day, the patient does not wait 4-6 months to get to see me only to have to perform these tests once or twice more to reach any conclusions. Once the optometrist has the benefit of the proper diagnostic tests over enough time to look for stability or change, then they are in a better position to refer appropriately.

By working together, Eye Care Providers can assure timely assessment and interventions for patients with glaucoma.

As a investigator and grantee for the past five years, I have studied the issue of improving the access of appropriate eye care to a broad spectrum of patients.  Specifically, eye disease is commonly not found soon enough and patients may needlessly suffer loss of vision because of this phenomenon. 

There are many players in the maelstrom of eye health care.  While the numbers may be plentiful to patients, accessing the appropriate level of care is not so easy.   Asymptomatic patients may see the optometrist for spectacles or contact lenses and may discover that they have an eye disease. Or similarly, a visit to a primary care physician may also detect a similar eye problem.

Whether in Canada or in the United States, definitive care may delayed for a variety of reasons. Sometimes it is a miscommunication amongst providers and sometimes it is the patient who cannot appreciate the severity of their problem and sometimes. 

Minimizing sight loss, therefore, may require an elevated sense of cooperation that might not exist today.  As in the United States, individual eye care providers may have excellent relationships with one another, but this level of relationship building isn't sufficiently institutionalized or formalized to guarantee that any patient seeing any kind of eye care provider will receive the most appropriate care 

Suffice to say, there is a risk writing about this subject.  My goal is to overcome the suspicion and skepticism that surrounds cooperation between all eye care and primary care providers in optimizing the eye health of our citizenry.   This first post will serve as a my foundation for writing about this subject and will be a pro forma mission statement.   In the following installments I will offer models of cooperation, specifically between optometrists and ophthalmologists to answer the deeply held beliefs that may have served to separate rather than join the professions together.