At the Rosenberg School of Optometry (RSO) at the University of the Incarnate Word (UIW) in San Antonio, all fourth-year students participate in a mandatory perioperative care rotation—to my knowledge, the only such program in the country. The goal is to expose 100 percent of optometric interns to the clinical and business concerns involved in comanaging surgical care.
Knowledge of perioperative care is essential for those who want to practice full-scope optometry or plan to work in an OD-MD group practice. At minimum, a primary-care optometrist should be able to advise patients on their options and make a referral to a good surgeon. It is even better if the optometrist can actively participate in their patients’ perioperative care.
During their fourth year, students participate in two external clinical rotations as well as one semester in-house, which includes the perioperative rotation at Parkhurst NuVision, an independent cataract and refractive surgery practice that leases space inside the UIW Eye Institute (see Figure 1).
During the four-week perioperative rotation, students have the opportunity to observe cataract surgery, laser vision correction (including the new small-incision lenticule extraction [SMILE] surgery), as well as other forms of refractive surgery, such as corneal inlays and phakic intraocular lenses (IOLs).
Students may also participate in the care of patients undergoing Nd:YAG capsulotomy, phototherapeutic keratectomy (PTK), corneal crosslinking, selective laser trabeculoplasty (SLT), or implantation of a trabecular microbypass system for the treatment of glaucoma. The practice is a busy clinical trial site, so students sometimes get to work with new technologies prior to U.S. Food and Drug Administration (FDA) approval.
With the supervision of RSO faculty and Parkhurst NuVision Greg Parkhurst, MD and Bobby Saenz, OD, interns conduct preoperative and postoperative exams, which allows them to hear directly from patients about concerns and motivations prior to surgery. Postoperatively, interns see firsthand the impact of surgery and patients’ reaction to their new vison. I am convinced this experience is far more valuable than watching hours of surgical procedure videos.
Parkhurst NuVision is a referral-based surgical practice that doesn’t offer primary care or optical services. Here, students are exposed to elective refractive patients who are often paying out of pocket, have high expectations, and have been referred by private-practice optometrists. When those same students rotate through RSO’s outpatient surgery service, they have the chance to see patients in another location, an underserved part of the city with patients exhibiting advanced cataracts and complex disease states.
For many students, the perioperative rotation is their first exposure to new technologies revolutionizing cataract surgery, such as multifocal and extended-depth-of-focus IOLs and precision surgical tools like femtosecond lasers. Faculty stresses the importance of primary-care optometrists learning about these technologies so ODs can better counsel patients and set expectations for the surgery center.
The rotation may also be the first time students have been required to have a “medical mindset.” Students must be available for patient questions or emergencies in the evenings and must set aside time on a Saturday morning to see Friday’s surgical patients, rather than limit appointments to traditional business hours.
Patient communication is a huge part of what we teach students and one of the most valuable lessons they take with them from the program. I tell students that their foremost role at every postoperative appointment is to reassure the patient. What is routine to us as practitioners is a once-in-a-lifetime event for the patient, who may be extremely anxious.
For example, we saw a patient who had 20/20 /J1 vision one week after implantation of a presbyopia-correcting IOL but was worried that something might still go wrong. She breathed a sigh of relief when the doctor told her, “Everything looks great.” That is why it is important to reassure patients that their eyes look good and their symptoms (if any) are normal. If anything is not normal, we want the patient to know we can identify the problem and have a plan for managing it.
The business of comanagement
Helping young optometrists understand the ins and outs of the business relationships they may have with surgeons is just as important to the program as imparting clinical knowledge.
I tell students to keep in mind that they cannot legally be compensated for a referral alone, but they absolutely should be compensated for legitimate perioperative care.
1. Contact Lens Wearers Insight 2012 Survey. Jobson Research. Available at: http://www.jobsonresearch.com/scripts/prodList.asp?idCategory=18. Accessed 05/17/18.