In some ways, the relationship between optometry and ophthalmology is a tale as old as time. I would encourage you to listen to Celine Deon and Peabo Bryson’s hit song "Tale as Old as Time" to set the stage for this piece. As time moves forward, there continues to be the newest incarnation of this relationship in which optometry and ophthalmology must look past their differences in order to accomplish what is in the best interest of patient care.
Before we discuss the current state of collaboration between optometry and ophthalmology, we have to take a brief step back to realize how we got to where we are today. First, it is important to remember that optometry is a legislated profession—there was a point in time when optometrists had to refer a patient to an ophthalmologist for dilation. It wasn’t until 1971 that Rhode Island became the first state to allow optometrists to use diagnostic pharmaceutical agents.
Fast-forward to 2020 and, thanks to the tireless efforts of volunteers in the American Optometric Association and affiliates, contemporary optometry looks much different. States continue to modernize their scopes of practice to reflect what is being taught and tested in optometry schools.
The collaborative relationship between optometry and ophthalmology, too, looks much different today than 30 years ago. Historically—and occasionally, still today—an optometrist would refer a patient for surgical or medical care and, often, through one mechanism or another, the ophthalmology practice would end up taking over the long-term clinical care of the patient.
This one-way referral system led to frustration. In the early 1980s, however, a group of pioneers developed the concept of a two-way referral system built upon mutual respect and structured in such a way that ophthalmology would not compete with optometric practices providing primary eye care services. Thus, the comanagement referral center model was born. Since the inception of this concept, other models of comanagement have developed, and the landscape of collaborative care has evolved into what we are familiar with today.
WHY INTEGRATED EYE CARE?
So, what is integrated eye care, and why is collaboration so important?
The American population is aging, and with that aging comes an increasing demand for optometrists not only to serve as primary eye care providers but also to manage an increasing number of patients with complex eye diseases. By 2030, approximately 72 million Americans—one out of five—will be aged 65 years or older. The group aged 85 years and older is now the fastest growing segment of the population.1 As the population ages, the prevalence rates of cataracts, diabetic retinopathy, glaucoma, and low vision are all expected to increase.2
Although all of this means that there is an increasing demand for surgical intervention, the number of ophthalmologists is essentially fixed. There is also an increasing number of ophthalmologists retiring,3 and there is a trend toward more ophthalmology trainees completing additional fellowship training, meaning fewer are going into general ophthalmology.
Conversely, the number of optometrists graduating each year has increased over time, and the number of optometrists completing postgraduate residency training has also increased. This shift requires practices to adopt a model that promotes efficiency, and integrated eye care models have attempted to do just that.
Integrated eye care models are shaped around the concept of different doctors working together for the common good of the patient. There are currently four basic integrated eye care models:
1. Optometrists who work in private practice and actively comanage patients.
2. Optometrists who partner with, employ, or lease space with ophthalmologists.
3. Optometrists who practice in a vertically integrated setting.
4. Optometrists who work directly with ophthalmologists in a referral center.
In each of these models, optometrists and ophthalmologists collaborate during the various stages of patient care to best serve the needs of the patient.
THIRTY YEARS OF EXPERIENCE SPEAKS
I recently had the opportunity to discuss this topic with Christopher J. Quinn, OD, founder of Omni Eye Services of New Jersey and New York, the New Jersey Center for Cornea and Refractive Surgery and Essex Specialized Surgical Institute, where he serves as president. Dr. Quinn has been a president of the American Optometric Association and the New Jersey Society of Optometric Physicians. He is on the medical staff at Robert Wood Johnson University Hospital and has spent the past 30 years fostering a collaborative and respectful relationship between optometry and ophthalmology with an unwavering commitment to high-quality patient care.
Q: How can optometrists foster a healthy collaborative relationship with ophthalmology?
A: A healthy interprofessional relationship can be based only on mutual respect. Finding a surgeon who is not only a quality provider but who also understands and respects you as an optometrist may not always be easy. You can foster this type of relationship with open and honest communication when sharing in the care of your patients. If the respect and quality is not there, move on to another provider who can meet your needs and the needs for your patients.
Q: How has the comanagement model evolved, and in what ways does it improve patient care?
A: Comanaged collaborative care is increasingly being recognized as improving both patient outcomes and provider productivity. Patients benefit when the focus is on the patient and not on territorial or ego-driven considerations. Collaborative care benefits the patient with improved access and allows the patient to benefit from the expertise of multiple members of the care team. Despite the benefits of collaborative care initiatives, many in the ophthalmology community continue to oppose comanagement of postsurgical care by optometrists. After more than 35 years of successful comanagement between optometrists and ophthalmologists, it is hard to understand why there is not greater acceptance of this collaborative care model.
Q: What is one thing every optometrist should know about either comanagement and integrated care or just collaborative relationships with ophthalmology in general?
A: Many ophthalmologists are excellent surgeons and also understand and respect optometrists. At the end of the day, both physician types, optometrists and ophthalmologists, must remain respectful of each other and patient-centered. Respect that comes naturally, a focus on high-quality patient care, and open communication are the keys to an excellent collaborative relationship.
Regardless of the mode of practice, there are a few key concepts that are required to promote healthy collaboration. First, open communication between parties is key to promoting enhanced patient outcomes and patient experience. Second, building these relationships requires engaging with colleagues in ophthalmology. To do this, make an effort to connect and build a working relationship with different specialists, and attend continuing education meetings and social events with them. Third, optometrists should practice to the highest level that their scope allows and, when a condition is either out of their scope or comfort level, consult with a specialist they have built a working relationship with. Avoid blindly referring patients. I recommend referring to a specialist who is clinically proficient and supportive of optometry.
An ever-evolving relationship
Collaboration is going to be key to addressing the demands of the aging population. Personally, I believe that the tale of the relationship between optometry and ophthalmology is going to evolve to enable ophthalmologists to do what they are skilled at doing—surgery and managing complex cases—and optometrists to serve as the primary eye care providers, managing the growing need for medical and postoperative care.
- 1. Dramatic changes in U.S. aging highlighted in new census, NIH report: Impact of baby boomers anticipated [press release]. National Institutes of Health. March 9, 2006.
- 2. Klein BE, Klein R. Projected prevalences of age-related eye diseases. Invest Ophthalmol Vis Sci. 2013;54(14):ORSF14-ORSF17.
- 3. Cunningham DM, Whitley W. What is “integrated eye care?” Review of Optometry. March 15, 2012.