EYECARE How Comanagement Reinvented Optometry By Michael Riviello, Associate Editor Thursday, October 27, 2016 12:28 AM A pioneer looks back on the conflicts and conquests that unfolded as ODs and MDs established an uneasy new collaboration. The tempestuous relationship between optometrists and ophthalmologists historically favored MDs because of their positions of power and prestige in the medical community. ODs who referred patients to a local ophthalmologist most often lost them as the MD practice—either through willful deceit or just simple inertia—took over. But the tide began to turn in the early 1980s as intrepid optometrists pushed back, demanding a role in clinical decision making commensurate with their ever-increasing skill set and burgeoning ranks. The Omni Eye Centers were in the vanguard, with an audacious business plan that put optometrists in charge—and ophthalmologists on the bench, to be called in only when needed. In an October 1984 profile, “Optometry’s Answer to One-Way Referrals,” Review of Optometry looked at this forward-thinking group just as the concept was taking off. In time, comanagement became a household word among optometrists and the two professions worked toward establishing an uneasy truce and a grudging respect for one another. For this retrospective issue, Review of Optometry sat down with one of its chief architects, Paul C. Ajamian, OD, of the Omni Eye Centers of Atlanta, to reflect on the hard-won gains of recent decades and to speculate on what’s yet to come. Dr. Ajamian has also edited a column in Review of Optometry for more than two decades that seeks to educate optometrists on the ins and outs of clinical collaboration across professions. Dr. Ajamian is, of course, also renowned for his role in continuing education as the chair of the optometric education program at the annual SECO conference. Not surprisingly, his efforts there consistently bring in non-optometric experts from ophthalmology as well as other medical disciplines. Review of Optometry: In 1984, you were featured on the cover of Review to advocate what was, at the time, a novel concept—referral centers in which primary eyecare decisions were directed by optometrists, who engaged the services of an employed MD when they deemed it necessary. It was, in short, a complete reversal of the previous dynamic, in which ODs would refer to ophthalmologists and typically lose the patient. What was the impetus for this concept and how did you and your colleagues settle on that as the business model? Paul C. Ajamian, OD. Dr. Ajamian: Fortunately, the climate has changed quite a bit since the ’70s and ’80s, leading to a better working relationship with many ophthalmologists. Ralph DiIorio, MD, was on the cover of that 1984 issue as well. Early on, he was one of only a handful of allies across the country who truly believed we had a larger role to play. They were criticized and ostracized for “siding” with us, but they stood firm. Today, those beliefs and relationships are no longer an oddity. MDs working closely with ODs in universities and residencies, VA and group practice settings, are exposed first-hand to our training and clinical expertise. It doesn’t take long for them to see how working together can benefit their practice and, simultaneously, our mutual patients. They learn that, to be successful, it is wise to embrace the comanagement model conceived in the early 1980s. If they don’t, their competition probably will, resulting in a career of routine care and occasional surgery. Q: It’s clear that perceptions have evolved since the early days. Has your own way of thinking about comanagement changed since those early years as well? A: Not really. I have never forgotten that the group of Georgia ODs who developed the concept, led by the late Dr. Bill Cuthbertson, established the principle of two-way referrals and mutual respect. The practice was predicated on not doing anything that would compete with the referring OD: no optical, no contact lenses and no primary care. Add to that the automatic return of each patient, a meaningful letter back and ongoing continuing education to move the profession forward, and a transformative model was born. Concurrent with the establishment of the comanagement centers was scope of practice expansion, which allowed that training to be applied to patients, with the center acting as a resource and friendly “back-up.” I caution ODs, young and old, to never forget the era of one-way referrals. If comanagement centers remain strong, the competition will play ball. If not, we could see a return to the old days of ophthalmologists who steal patients and bad-mouth optometrists. Comanagement was on the conceptual cutting edge, and at the time was an “answer to one-way referrals,” as the article in 1984 billed it. We also need to remember that if we don’t practice full scope, and if we don’t stay involved with Medicare, glaucoma and post-op care—someone else will. They will come in and fill the void. And it may not be ophthalmology. Q: Has comanagement helped to elevate the public’s perception of the profession? What about the perceptions of physicians—did successfully pushing comanagement help ophthalmologists see the necessity of the profession? A: It absolutely has. When an optometrist sends a patient to an MD or DO practice that truly believes in comanagement, the optometrist is made to look good, and the patient feels good about the primary care that their doctor of optometry provides. The patient’s perception of us is enhanced when they see first-hand that we do more than prescribe glasses. They learn that we handle all primary care—from red eyes to retina—and that we act as the quarterback in the cases that require a specialist. From the perspective of the MD/DO ophthalmologist, the really talented ones realize that if they want to do what they are trained to do, they need to leave the rest to us. If they want to operate in a clinical niche, they need to let us handle what then lies out of their clinical gaze. Q: Do you have any stories regarding what anyone said to you at conferences or in response to your Review of Optometry column? A: There are lots of stories, and lots of good feedback to the column over the years, because the cases were “from the trenches”—based on comanaged cases that we can all relate to and learn from. One thing I still get asked, sad to say, is “How can I set up an Omni-like center in my area?” When I ask why, it quickly becomes apparent that there are still some who do not have a good working relationship with their small, mom-and-pop ophthalmologists close to town. The local MD tells them comanagement is “illegal and unethical”—a throwback to the ’70s and ’80s for sure! Q: What is the clinical value of comanagement? How can comanagement improve outcomes? A: As a famous poet once said, “let me count the ways!” Let’s use the example of a long-time cataract patient, cared for by one of our many excellent referring docs, with a 30-year history of monovision and toric contacts who wants the same setup after cataract surgery. The OD, who knows the patient much better than anyone ever will, talks to them about the need for a toric IOL and recommends setting one eye for distance and one for near. The patient has received advice from a practitioner she knows and is happy with the plan. That plan is then clearly conveyed to the surgeon, who gratefully accepts and implements it. The result: saving time and confusion, and alleviating the intimidation factor for patients of having to decide during a five-minute first encounter with a surgeon they don’t know. The benefits continue after the surgery, because the patient can get all their post-op care close to home and from a familiar face. From the OD’s perspective, not only do they have a happy patient, but it was also not necessary to introduce her to a competitor with an optical down the street. The value of comanagement has been well proven over the past 40 years, but it has taken some a little longer than others to recognize that it is here to stay. Our first comanagement-themed issue in 1996 tackled a familar concern of the era: how optometrists can survive refractive surgery. To help advance the cause of OD-MD collaboration, this publication launched an annual comanagement issue in 1996 that ran for 20 years. From its inception, the forward thinkers of the profession have spoken on topics such as fee setting in post-op management of PRK patients and maximizing patient outcome through comanagement do’s and dont’s. In fact, the first annual comanagement issue featured a comprehensive how-to within the context of PRK. We’ve since retired the name—but not the coverage—as the concept no longer functions as a responsibility limited to select cases. And Dr. Ajamiam’s long-running Q&A column on clinical challenges—designed to show comanagement within the context of real clinical cases—dropped the overt use of the word comanagement last year. Consider this analogy: in a previous era we may have published an occasional article or two on how an optometrist could incorporate a computer into practice. It was a distinct concept, both intellectually and practically. Today, use of computers is pervasive—and so is comanagement, baked right into the training and expectations of new ODs entering the profession. Contemporary optometrists are (or should be) comfortable ordering an MRI and consulting a neurologist, taking referrals from a pediatrician for childhood vision problems, discussing glucose levels with a patient’s general practitioner or endocrinologist and referring to an ophthalmologist for cataract surgery, with an OD-recommended IOL accompanying the referral. In short, comanagement won. And then we retired its jersey. Q: What happens next? Are there new frontiers for optometry to push, or will it suffice to just continually refine the current model of care? A: New frontiers will always exist, and if the next generation is interested in exploring them, it all starts with membership in their state association and AOA, followed by contributions to local and AOA PAC and the establishment of relationships with state representatives and senators. Remember, we are a legislated profession, and the original comanagement centers were leaders in the effort to educate and then legislate, and still are; but we need every optometrist to get in the game—not just watch events unfold from the sidelines. Q: Does optometric practice in 2016 match what you may have envisioned for it back in 1984? A: Great question. It’s what we dreamed. With a lot of hard work, state-by-state, we achieved the expansion in our scope of practice. I remember the old days of having to refer a patient to an ophthalmologist for dilation. Fast-forward to today, we can dilate anyone—but do we act on our hard-fought rights? Some ODs are actually teaching patients that dilation is a negative by offering a “better and faster” instrument for $40. Let’s use what we worked so hard to get, all of which starts with dilation. This article was originally published in the 125th Anniversary issue of Review of Optometry in July, 2016.