“All in the family”

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• Paul B. Freeman, O.D.

This past February, at SECO International, I had the opportunity to speak about a theme that has puzzled me for years. Along with 4 outstanding speakers, our charge was to make a presentation about the value of referrals to optometric colleagues when appropriate, or as the title for the lecture suggested, keeping the referrals “All in the Family.” Physicians (MDs, DOs, DMDs, DDSs) are not at all reticent about referring to their colleagues when a patient presents with symptoms or a diagnosis that is out of the realm of comfort or expertise for that practitioner. Optometrists as well seem to be comfortable referring to these physicians for much the same reasons. Why, then, is there a reluctance or even a resistance to intra-refer? One might conjecture about the potential multitude of reasons that, I believe, on closer examination, would reveal themselves as outdated prejudices.

Although we consider ours a primary care profession, there are certainly areas of interest or emphasis (one might even use the “S” word) within the profession that some practitioners endeavor to pursue. This suggests that there are patients who might receive a more in-depth evaluation and therapeutic management for a particular problem by those optometrists, rather than by clinicians who do not have the same level of interest or skill. Indeed, some of our colleagues do postgraduate residencies to further their diagnostic and treatment skills. Additionally, there are many other means by which to cultivate a particular area of interest such as coursework at meetings like the one where this presentation was given, as well as Optometry's Meeting®, along with the AOA's sections, the College of Optometrists in Vision Development (COVD) meeting and its Fellowship curriculum, and the American Academy of Optometry's meeting and section and Diplomate programs, to name but a few. Of course, independent study is always an option. As an example, our presentation at SECO covered some of the possible intra-referral avenues for infant assessment and management (Andrea Thau, O.D.), binocular vision evaluation and management (Leonard Press, O.D.), advanced contact lens and dry eye evaluation and management (Jack Schaeffer, O.D.), glaucoma evaluation and management (Joe Sowka, O.D.) and vision rehabilitation evaluation and management (me). While each one of these topical areas is familiar to all optometric practitioners, not all practitioners are comfortable with delivering those services. However, familiarity with the range of services available, consequently, means that those patients who are in need of such specialized care should get that necessary care provided by the most qualified practitioner for that condition. And just as when referring to health care providers outside of the profession, no optometrist should feel the anxiety of not knowing everything about everything or being able to treat everything along the entire continuum for a given diagnosis. In fact, a recent article stated, “Previously, we acted as if physicians could accumulate all the knowledge they needed and carry it around with them. But the amount of relevant information for making clinical decisions now far exceeds the ability of one brain to hold it.”¹ (Certainly, this concept of brain saturation can be extrapolated to many aspects of today's complex life.)

In our presentation there was never a suggestion of “inferiority” of care by a primary care practitioner who might refer to an optometric colleague, but rather the emphasis was on the need to offer patients the best possible care when more specific expertise is necessary to provide that care. In fact, colleagues who receive referrals typically speak well of the referring doctor to the patient for not only being able to recognize a situation that warrants a referral, but for going the extra mile to make sure that the referred patient is properly managed by the professional who can do it best. (Appreciate that this dialogue is common in most any referral scenario.)

As I mentioned at the outset, I have always found it curious that optometrists as a group infrequently refer to one another. Perhaps it is because the initial referral for a problem is typically for treatment outside the scope of optometric practice, or to rule out a medical condition that might then need treatment beyond the scope of optometric practice (i.e., a patient with diabetic retinopathy who might need laser treatment before beginning vision rehabilitation, or a sudden-onset strabismus that might require medical treatment prior to or in conjunction with vision therapy). But especially in these cases, when a practitioner knows that the patient will ultimately benefit from additional optometric intervention, it is in the patient's best interest to outline to that patient a plan that addresses all the aspects of care that will be required, often necessitating referral to several different practitioners both within and outside optometry. As our SECO panel discussion sought to demonstrate, optometric colleagues with interest and experience in specialized areas of care are comfortable working in conjunction with other medical specialists. Because of that, there should never be a struggle with a perceived conflict of where to send the patient.

As an important aside, referrals are a 2-way street. Wanting to refer is one thing, but the ease of the process of making a referral is another and should be facilitated by the doctor to whom the referrals are directed. Additionally, the doctor to whom the patient is referred has the obligation to keep the referring doctor apprised of the results of the interaction as well as the management plan, recognizing that the referring doctor is still the primary source of eye and vision care for that patient.

When thinking about the concept of referrals, whether it be inter or intra, I might suggest that one think about the question, “If I do not address the patient's needs and don't refer the patient for additional services, what will the quality of life for that patient be?” as if that person were a family member or close friend. One might even conjecture “if it were me, would I want my doctor to present me with all of the options and help me make informed decisions about consulting with other practitioners?” Thinking about the referral process this way, the answer, I trust, becomes most obvious.

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Reference 

1. Bakhtiari E. Time for ‘Dr. Next?’ HealthLeaders Media, July 2009. Available at: http://www.healthleadersmedia.com. Last accessed March 5, 2010.
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