The key features of any comanagement scheme are communication and education. There must be clear guidance on what is expected of the comanaging eye care provider, not only in terms of patient assessment but also in dealing with routine situations. Optometrists must, of course, work within the recommended guidelines. If we encounter any adverse issues beyond the realm of our clinical capabilities, we must have established, open channels of communication with the treating surgeon in order to ensure patient safety.
GAINING EXPERIENCE AND RESPONSIBILITY
At London Vision Clinic, we have an excellent team of experienced optometrists, most of whom have more than 7 years of laser refractive surgery experience. Because we are all under one roof, we have a close working relationship among team members, with a strong sense of mutual respect. London Vision Clinic prides itself on having extensive standard operating procedures (SOPs) to ensure that each patient is given the best quality of care—from the initial phone call to the clinic visit and through the final postoperative appointment. This also results in consistent medical and psychological support being offered in an equitable format by everyone on the team. We have weekly clinical grand rounds meetings for our optometrists and surgeons to discuss everything from new advances in the field, to the latest on our own research, to new or updated SOPs, to interesting patient presentations.
Every new optometrist at London Vision Clinic completes an intensive training program in which he or she observes all aspects of the patient journey, from the initial screening to informed consent and surgery to subsequent postoperative visits. We spend weeks reading, learning, and understanding the SOPs. We then work under the supervision of our more experienced colleagues for a period of 6 months to get up to speed to run our own clinics for pre- and postoperative patient appointments. With experience comes more responsibility, and working with the surgeons we are able to comanage more advanced therapeutic patients, such as those referred for rehabilitation due to previous suboptimal surgical outcomes.
PATIENT COUNSELING
A large part of my role, in addition to the clinical aspect, is counseling patients before they proceed to refractive surgery. This discussion takes about 45 minutes for a typical patient and allows us to establish what he or she hopes to achieve from surgery and to discover any particular occupational or sporting requirements he or she may have. We focus on aligning the patient’s expectations with reality in terms of the typical timeframe for recovery and what occurs during each phase of healing.
The full 2-hour preoperative optometric consultation also includes a comprehensive ophthalmic examination with dilated fundoscopy, along with a discussion of the patient’s treatment options. These initial visits are quite intensive, and they set the tone for a strong future relationship with the patient as we establish continuity of care throughout the postoperative visits on a one-on-one basis.
Patients want to feel comfortable within the clinical environment, and they expect professionalism, high standards, and good advice from a consultation. We always aim to deliver on all of these aspects while being open and honest about patient expectations and surgical options. Many patients have unrealistic expectations of refractive surgery, so we spend ample time addressing their concerns, realigning their expectations, and confirming that they accept what is achievable before they meet the surgeon. This, in turn, alleviates any additional stress patients may have at their forthcoming surgeon consent consultation, so that the surgeon can concentrate on making final clinical measurements and gaining any necessary additional information.
In 2012, I underwent refractive surgery for high myopia (OD: -5.50 -0.25 X 133º; OS: -9.00 -1.50 X 160º). This has given me great insight into the procedure from the patient’s perspective and has proved to be invaluable in daily practice, as it allows me to empathize with my patients in many areas of their care.
THE FUTURE OF SHARED CARE
Shared care is vital for the future of refractive surgery and indeed many other aspects of medicine across many disciplines. Well-trained comanaging optometrists can ease the pressure on surgeons by carrying out the necessary clinical tests, counseling the patient, and answering his or her questions in advance. The patient then has an established connection with a clinician other than the treating surgeon as a point of contact to help him or her through the postoperative period.
There are already well-established comanagement pathways within optometry for glaucoma and diabetes. Many optometrists would relish the opportunity to expand their knowledge and participate in such schemes. The future of optometry looks to be heading in that direction, at least in this country, as increasing numbers of optometrists in the United Kingdom are furthering their education with clinical masters courses or postgraduate courses such as independent prescribing. This can only be beneficial to the field in the future.
