OPHTHALMOLOGY
Where Eye Care Fits In Bridging specialty and primary care GARY S. SCHWARTZ, MD, MHA
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hen I was in medical school and matched in ophthalmology, a friend who is now a urologist started referring to me as an “eye dentist”. His logic was that because my patients would not need to undress and could be examined in a chair rather than a bed, that my practice would look more like a dentist’s than a physician’s. We laughed about this at the time, but throughout my training and career I have been repeatedly surprised by how often the truth behind his joke has shown through. As with other specialties, the clinical, surgical, and business aspects of eye care have changed dramatically in the 30 years since I matched. Cataract surgery is still the most commonly performed surgical procedure in the United States, now is usually performed in physician-owned ambulatory surgery centers rather than hospitals. The use of lasers to “cure” patients of their dependence on eyelgasses has not only been proven effective and safe, but has also moved from the fringes of the eye care community to the mainstream. And advancements in eye care have not solely been surgical. For instance, there are now dozens of well-tolerated eyedrops available for
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the treatment of glaucoma, while in my residency there were only two or three, and each of these had its list of troublesome side effects. Despite all the medical and surgical advancements, eye care delivery is still fundamentally a combination of preventative and specialty care, where the concept of the “eye dentist” is at the root of the question, “Where does eye care fit into a patient’s overall health care?”
Eye Care as Primary Care I am occasionally asked whether I consider myself a specialist or primary care doctor. I answer by saying that I am a primary care doctor for my patients’ eyes. In this regard, patients do not need to be referred to see me as they do for other types of specialists. Think about it – a patient with cardiac symptoms will usually be referred by their primary care provider (PCP) to a cardiologist. Likewise, a patient with GI symptoms will usually be referred by their PCP to a gastroenterologist. Although many patients are referred to me by their PCP’s, at least as many will find me on their own through advice of a friend, relative, or a Google search, and their PCP may never know that they were seen by me. Why is this? I believe the answer to this question has to do with why the term “eye dentist” resonates. Most Americans know to see their dentist twice a year for cleanings and to give their dentist the opportunity to look for potential problems. Most of us keep to this schedule even though we are almost always asymptomatic. We also understand that what our dentist provides us is separate from and parallel to what our medical PCP does. They both take care of the parts of us that they are responsible for, usually without communicating with one another. There is a good chance your PCP does not know who your dentist is, and your dentist does not know who your PCP is.
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For many of my patients, I perform the same type of service for their eyes that their dentist does for their teeth (minus the cleaning). Patients return to me on a schedule that I deem appropriate without either of us seeking input from their PCP. I update glasses and contact lens prescriptions (similar to a hygienist’s doing a cleaning) and look for signs of eye disease (much like a dentist’s looking for cavities). I usually will not send a letter back to the PCP for this type of service, and if I did, the PCP would likely not devote a lot of time to reading it. My patients remain fully clothed and are examined in a chair instead of a bed, exactly as my urologist friend predicted.
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Another parallel with the dental profession lies in our ability to help PCP’s predict systemic disease. For instance, the status of the gums and teeth can allow dentists and hygienists to give feedback to PCP’s about their shared patient’s cardiovascular status. As eye doctors, we can do something similar. When we examine the posterior segment of a patient’s eye, it is the only time that a doctor can directly view that patient’s vascular system in vivo. In this way, we can often help diagnose vascular conditions such as hypertension, atherosclerotic disease, and diabetes mellitus before they even make it onto a patient’s problem list.
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JANUARY 2021 MINNESOTA PHYSICIAN
