July 1, 2020
By Gary Gerber, OD
My optometry training at the State University of New York, (SUNY) College of Optometry, included a lot of time learning about vision therapy (VT), or at that time, “vision training.” After I opened my practice a few years later, armed with all that VT knowledge, and having seen more patients at SUNY’s VT clinic than any other discipline at the college, when my first prospective VT patient came to my practice, I didn’t take care of them.
Here are the three reasons why I made that decision:
- Not treating was my way of providing the best clinical care for that patient.
- While I had the academic theoretical training to take care of this patient, I lacked practical, non-school real-world clinical experience.
- I did not have the proper diagnostic or treatment technology to care for the patient.
With all that SUNY VT education, I did the absolute best thing for the patient and did not treat them. Instead, I referred them to a colleague who was an expert in the discipline.
If I wanted to build a VT practice, I had to start somewhere. But I did not have that desire. If I did, in the best interest of patients, a better place to start would have been to work for or spend time in another VT practice, which already had real-world VT figured out.
Thinking back, perhaps I could have just taken more straightforward cases and treated them with minimal technical requirements. But that approach would have required compromises with patients’ well-being becoming ocular collateral damage. For example, what exactly was an “easier” case, and what were the best “minimal technology” requirements for such cases, if they even existed? Or what if I started taking care of a kid and what I was doing was not working, and the solution required an escalation in treatment protocol and equipment I did not have? That sounded inherently unfair to the child’s outcome, let alone the parent’s wallet.
I referred the next VT patient and the next one and the next one. In fact, throughout my career in private practice, I am proud to say I referred hundreds of patients for VT. I am also happy to report that with most of these patients being kids, their parents were very appreciative of the referrals and stayed with my practice for years as loyal primary care patients. What I learned was, there is no shame and only the creation of goodwill when we make an intelligent and necessary referral to another doctor who has the requisite education, experience, and technology to care for our patients better than we can. Cardiologists refer to cardiac surgeons, dentists refer to orthodontists, and primary care MDs routinely refer to a host of sub-specialists for that exact reason – the person they are referring to is better suited to care for their patient than they are.
However, for reasons still not clear to me, when it comes to intra-professional referrals in optometry, and myopia management in particular, this referral paradigm is challenged by many self-proclaimed “experts” in our profession. They claim that all ODs can provide myopia management. To which I say, “I agree, all ODs can! And they should, provided the patient receives complete scope expert care.”
Another common refrain from those advocating not referring is that myopia management is a fundamental optometric procedure, akin to primary care. To that point, I say, “I agree! Provided the patient receives the same high quality of care they’d receive at a practice that specializes in myopia management!”
It is quite simple. If you want to bring myopia management into your practice and have never treated a single patient or attended courses on the topic, you should pursue it! But do it with the same intensity and commitment you did when deciding to provide a high-quality primary care examination. With the proper education, technology, and dedication you had in deciding to excel at primary care, you can readily accomplish the same thing with myopia management. Your primary care practice is configured such that you do not cut corners in caring for a hyperope. You do not only take care of “easy hyperopes.” Why do that for a myopic child? You would not withhold a cylindrical correction to an astigmatic presbyope because your phoropter does not have cylinder lenses. Why would you attempt to treat a myopic child with only off-the-shelf, non-customized orthokeratology lenses? You would not treat a glaucoma patient without measuring IOP. Why treat a myopic patient without measuring axial length? Similarly, you would not withhold a second medication to a glaucoma patient who needed it. Why would you withhold a second treatment method to a myopic child whose axial length was progressing faster than it should with a single device or pharmaceutical agent?
The referral discussion with parents is as straightforward as referring to a cataract surgeon. “Mom, I’m referring your son to an expert colleague across town who is a specialist in treating myopia, which means your son’s eyes are too big from front to back. The symptom of that is blurry distance vision. Glasses will take care of the blurry vision but not the size of his eyes. Left untreated, myopia will usually progress and may go on to cause significant ocular health problems later in life, especially since you and your husband are also highly myopic.”
From there, mom will undoubtedly pepper you with questions since the topic is likely new for her. The doctor you’ll be referring to should train you and your staff on the best responses, or you can do some very high-level research on your own to help answer the most common questions (usually “how is it treated, and why haven’t I heard about this before?”)
With myopia management, if you choose not to get immersed in the discipline by obtaining the requisite education, technology and making the mandatory changes to your practice paradigm (for example changing up your scheduling template to allow more time for visits, genuinely committing to training your staff, creating proper treatment protocols and the associated fees, etc.), then refer these children to a trained colleague. The kids and the parents will thank you many times over. You are not less of an optometrist for referring to a colleague who is an expert in myopia management, or dry eyes, or scleral lenses, or VT. You are a better one.
Gary Gerber, OD, is a co-founder of Treehouse Eyes, a company dedicated to providing expert myopia care for kids. You can learn how to bring this expert care model into your practice by contacting him at firstname.lastname@example.org.