How To Develop a Medical Optometry Practice

At Vision Expo East, Antonio Chirumbolo, OD, sat down with Dr. Patricia Fulmer, Dr. Mark Dunbar, and Dr. Dan Epshtein to discuss how to develop a medical optometry practice.

“I think any practice can be a medical practice,” says Dr. Fulmer. “There’s not a medical patient and a refractive patient—it’s all one patient.”

Dr. Dunbar agrees. “This is a term that’s been thrown around for the last ten or twenty years: the “medical model,” and what does it mean,” he says. “There really shouldn’t be that distinction. If a patient comes in with a problem, it’s our job to fix it.” The dichotomy between the medical model of optometry and traditional vision services, Dr. Dunbar argues, is a created distinction, and optometrists are more than equipped to deal with many types of ocular surface disease and other conditions filed under the “medical model.”

“I would argue that you can’t be the best refractionist if you’re not recognizing those conditions,” says Dr. Fulmer. This would help you address issues with patients having difficulty with refraction when those issues might be arising from ocular surface conditions rather than human error or other issues.

“You don’t need any fancy equipment to start taking care of [dry eye],” urges Dr. Epshtein.

“If it’s that severe, if it’s to the level where I truly can’t get a good prescription, it’s not an option in my office,” says Dr. Fulmer. “The way I approach it, the way I say it to them, is: I want to make sure that when you leave this office that the glasses you’re wearing are the best glasses for you, that you’re going to get the most wear out of them, that your life is going to be improved by them the most. And I can’t do that today because of your ocular surface.” She explains to her patients that while they might not feel what’s wrong, they’ll definitely feel the difference when it’s fixed.

Dr. Epshtein agrees, and urges patient education. Many patients might be skeptical of disease treatment when it seems like simply another added cost, but explaining the benefit can do a lot to encourage buy-in.

Review of Optometry, and the informal resources at NewGradOptometry, are great places to start, says Dr. Epshtein. Journal articles and other peer-reviewed work might be difficult to access for an independent doctor, but there are plenty of CE courses at Vision Expo along with open lectures held by experts like Dr. Dunbar.

But the first step, Dr. Epshtein says, is to make sure you’re all set up with the insurance panels you need. “You can’t treat those medical patients if you can’t take their insurance,” he says, so he urges doctors to look into that first and then while they’re waiting for the paperwork to clear, to search out resources and education.

Dr. Dunbar slightly disagrees. “I don’t think [insurance] should be a barrier to treatment,” he says. “To me, that isn’t a barrier: I see plenty of patients who have dry eye, that I think they need a therapeutic agent and I’ll write a prescription. And I have no problem if they can’t come in in a month or six weeks: I don’t mind seeing you in a year. You provide the education and you talk to them about it.”

For medications topical steroids or other chronic medications, it might be necessary to see your patients more frequently, but for medications like Restasis or Xiidra, having a patient only come in once a year is fine. “Don’t not write a prescription because you can’t see the patient back,” Dr. Dunbar says.

It’s also possible to manage a patient even if you don’t take their insurance. “A lot of their insurances will allow them to file on their own after the fact, too,” Dr. Fulmer points out.

“Eliminate a sample as an option,” Dr. Dunbar suggests. “Don’t let a sample get in the way of writing a prescription.” That will give you the chance to write prescriptions and treat patients. Furthermore, a prescription urges patients to take your recommendations more seriously than a sample they may not understand is medically suggested.

“I think we should take a more active approach, where you don’t treat dry eye like a secondary concern that patients have—you treat it like a primary concern,” says Dr. Epshtein. “I’m taking you seriously, this is what I want you to do, there’s a protocol . . . this is your opportunity to one, have a loyal patient base, but also to fix their problem, which is very satisfying.” Treating issues like dry eye like the chronic diseases they are—and calling them such to the patients—is more convincing in driving home the message that these are chronic conditions that need to be treated.

“I think the other side of [the medical model] is glaucoma, macular degeneration, diabetes, diabetic retinopathy — there’s a lot of opportunities there,” says Dr. Dunbar. “The number I heard is, ten thousand people in the United States turn 65 every day. We know that we’ve got an aging population.” With an aging population comes opportunities and necessities to treat your patients age-related ocular health concerns. These will inevitably go beyond myopia.

“Just starting a medical practice, it’s easiest to start with dry eye,” says Dr. Chirumbolo. After that, suggests Dr. Fulmer, doctors getting into disease care can look to their diabetic patients. “At the base of it, your diabetic care is coming from a really good, dilated fundus exam.”

You don’t necessarily need all of the equipment, like an OCT and a visual field, in-office to manage eye disease. That’s where networking comes in, says Dr. Fulmer. You can send a patient to another clinic for tests while still retaining them for treatment. Eventually you might want to look into acquiring an OCT, but it’s absolutely possible to be a medical optometrist without all the equipment in-house, as it were.

“If you go to your primary cares and say, hey, I’ll see your diabetics, they’re going to jump on that,” says Dr. Fulmer. “And allergy,” adds Dr. Dunbar.

“How many of y’all have had the lovely experience of fixing something that urgent care didn’t treat correctly?” asks Dr. Fulmer.

Patients will go to urgent care with subconjunctival hemorrhages or abrasions, when their optometrists are fully equipped to treat those—in many cases, better equipped than urgent care. This comes back to patient education: it’s important to let your patients know that you’re available to treat eye concerns of many different kinds, including low-level trauma.

“At the end of the day, you are their eyecare provider,” says Dr. Fulmer. “Their whole eyecare provider—not just refractive, and not just from eight to five. And so, if they know that, they’re much more likely to call or to come by.”

Dr. Epshtein agrees, and remarks that many of their patients didn’t know that they could come into a medical eyecare clinic without a referral, and often only came in when they were referred by their primary care doctors. So Dr. Epshtein, and the rest of the doctors on the panel, always make sure to ask their patients if they have any other issues with their eyes, even during routine vision exams.

Find a mentor, urges Dr. Dunbar. “When you’re picking your externships, in your third or fourth year, make sure that you pick a place where you know you’re going to be around good people, that you’re going to see a lot of ocular surface disease, and try to emulate them in many ways.”

He also suggests taking steps to differentiate yourself from your colleagues—for instance, by treating dry eye and other ocular surface diseases!

The best way to start by doing that, Dr. Fulmer says, is by asking the right questions. She always makes sure to ask her patients if they’re having any issues with allergies while she’s getting ready for an exam, since it doesn’t take any extra time but provides an entry point to treatment.