Does the Integrated MD-OD Model Represent the Future?
Greater collaboration between these eye care specialists will have a growing role in the management of glaucoma patients.
Everywhere, it seems, are data indicating the burgeoning number of people with glaucoma. The volume of patients seeking care should also grow based on implementation of the Patient Protection and Affordable Care Act. The number of ophthalmologists and glaucoma specialists currently in practice and the number of training positions to create future providers appear inadequate to handle the increasing demand. Without a paradigm shift in glaucoma care, those in need will be underserved.
An unlikely solution to this problem is the discovery of a cure for glaucoma in the next 5 to 10 years. The alternative is to add providers to the system. Given the inadequate pool of providers in the allopathic and osteopathic systems as well as the limited funding for medical education, not enough physicians will be available to fill the need. Other fields of medicine have bridged the gap with physician assistants and nurse practitioners. Similarly, in the field of ophthalmology, a fair number of ophthalmologists have successfully integrated optometrists into their practices. It helps to approach the process with an open mind and a respectful professional manner.
INCORPORATING AN OPTOMETRIST INTO AN OPHTHALMOLOGIST’S PRACTICE
It would be unreasonable to expect to find an optometrist who is already fully trained in glaucoma and in the way the ophthalmologist(s) likes to practice. Rather, the key is to find someone with a solid foundation in ophthalmology and glaucoma, basic intelligence, an interest in learning, and an ability to learn. Because glaucoma care is a labor of love, it is also important to find an optometrist who has a genuine interest in the field.
Clearly, optometrists and ophthalmologists have very different educational backgrounds and training. At the Cincinnati Eye Institute (CEI), where I practice, optometrists have worked alongside ophthalmologists for years. After initially collaborating with cataract surgeons, optometrists began to work in the glaucoma, cornea, uveitis, and, eventually, retina and neuro-ophthalmology services. CEI has an accredited, 1-year, optometric residency that trains enrollees in all of the subspecialties offered at the institute. A benefit of this program is that all of these residents also learn how CEI’s ophthalmologists and optometrists practice, and it allows us to identify residents who we feel are highly capable and compatible.
Although an additional year of training such as described is helpful, an alternative is for ophthalmologists to take the time to teach an optometrist exactly how they like to manage various types of patients. It is reasonable to expect in return some time commitment from the optometrist.
The optometrist with whom I work, Brian Kuhlman, OD, completed the CEI residency just when I needed help. For the first 6 months, Dr. Kuhlman only saw patients on my schedule in a capacity similar to that of a senior resident or fellow. Then, we gradually created a separate, limited, schedule template for him. I began by having some of my glaucoma suspects, patients with stable ocular hypertension, and those with mild to moderate glaucoma see him for follow-up appointments.
In the beginning, I felt uncomfortable telling patients that they would see someone else at their next visit, but the transition slowly became easier. I would explain that the optometrist and I would share in their care and that they were always welcome to return to me if they wished. At the outset, Dr. Kuhlman and I alternated visits. Eventually, however, I became comfortable having him observe any patient indefinitely.
For the first 1 to 2 years that he had his own schedule, Dr. Kuhlman and I sat down for up to an hour at the end of each clinic day and reviewed the charts of all the patients he saw. I would offer comments on his management. This process allowed our managerial styles to become more similar, and it gave me much greater confidence in him.
Today, any time I begin to perform a new procedure or decide to modify my approach, Dr. Kuhlman and I discuss the matter in clinic. In addition to the patients on his schedule, I have always and still will bring him in to see patients who present with interesting findings or whose cases make management complex. Dr. Kuhlman does not hesitate to request my advice or to ask me to see a patient about whose case he has questions. Importantly, he recognizes when he needs help. Over the years, our mutual trust and confidence have grown. That and open communication are crucial to the success of our relationship.
EFFECTS ON THE OPHTHALMOLOGIST’S PRACTICE
As ophthalmologists grow busier, it will become increasingly important for them to allow others to deliver certain aspects of care. The MD-OD model allows me to see more patients. My patients are very comfortable with the model and almost never resist seeing the optometrist.
An upshot of the MD-OD model is that my schedule focuses on time-consuming cases such as those involving patients with advanced disease, those who require laser therapy or surgical intervention, and patients whose postoperative care would be better handled by the doctor who performed the surgery. This restructuring can allow an ophthalmologist to have a higher volume of surgical procedures relative to the number of patients he or she sees.
An alternative is not to create a separate schedule for the optometrist but for him or her to facilitate workups and clinical flow to make the ophthalmologist more efficient. Which approach is chosen will depend on personal style and preference.
Many optometrists are not used to or interested in seeing patients with severe pathology every day. Although some optometrists work full time in a subspecialty, many at CEI either spend part of their time working in outside optometric practices or in another subspecialty at CEI for a change of pace. This approach helps to prevent burnout and allows them to maintain their skills in primary eye care.
The number of people requiring glaucoma care is on track to outstrip what ophthalmologists can provide. Collaboration between ophthalmologists and optometrists and their mutual respect are paramount to facing the challenges to come.
Anup K. Khatana, MD, is director of the glaucoma service and glaucoma fellowship at the Cincinnati Eye Institute and volunteer clinical assistant professor of ophthalmology at the University of Cincinnati College of Medicine. Dr. Khatana may be reached at (513) 984-5133; email@example.com.