Transcript
Speaker 1 (00:06):
You are listening to The Mod Pod, a companion podcast to modern optometry, the go- to publication for full scope ODs navigating the evolution of our profession. I'm your host, Cecilia Kenning. Join me every month to hear me speak with authors from each issue. We'll talk about their articles, get more in depth about particular points of interest, discuss how to apply tips and suggestions in real life practice and more. Welcome to the ModPod from Modern Optometry, whose new vision is to educate and prepare optometrists for today's practice and the future of eyecare. I'm your host, Cecilia Ketting, and today I'm joined by our guest, Haley Perry. She is at Elite Eyecare in Arden, North Carolina, and we're talking about her article that's in this month's modern optometry called Surmounting the Salesperson Mentality. Welcome. It's such a pleasure to have you on the mod pod.
Speaker 2 (01:06):
Thanks. I'm so excited. I'm so excited to be in modern optometry and I'm so excited to be on the mod pod.
Speaker 1 (01:12):
Yeah. So for those who may not know you yet, can you share a little bit about yourself and your practice?
Speaker 2 (01:19):
I practice in Asheville, North Carolina and I have owned my practice now for I think about 12 years, maybe almost 13. Been in practice though for 16. My oldest daughter is 16 years old. That's how I know how long I've been in practice because I was pregnant with her when I graduated. It's the milestones, right? Yeah. Let's see. We have a heavy dry eye practice. We do primary care ultimately, but we do have a focus on dry eye treatments.
Speaker 1 (01:48):
Very familiar with Asheville. I lived in Virginia Beach. We used to drive out there because it's Asheville. It's beautiful. But living near Asheville and in Asheville, which is absolutely known for good food beer and coffee, would you rather give up craft beer or artisanal coffee?
Speaker 2 (02:08):
I really love both of those things. I don't think I could live. I have many days when I don't drink beer, but I have zero days when I don't drink coffee. So I don't think I could give up coffee.
Speaker 1 (02:24):
I think that's a good way to look at that one. I love it. So let's jump right in. This is a great conversation in your article. I really appreciate it because I think that we as optometrists in general are kind of bad salesmen. And what do you think that is kind of led into this salesperson fear that we have within optometry? Do you think it's something we're taught? Do you think it's something we kind of absorb from other people kind of perpetuating the problem saying, "Oh, we're bad salespeople?" Or what do you think?
Speaker 2 (03:00):
I actually really think we are really preconditioned to just do whatever insurance will cover and we really pigeonhole ourselves into just offering those treatments because we think that that's all that patients can afford. And I don't know that other professions worry so much about their patient's pocketbooks as much as we do. My orthopedic surgeon, I had ran a marathon and I had a knee that needed some help and he gave me a ... His number one recommendation was a PRP shot, which is $650 out of pocket. And he didn't even lead with the insurance covered injections. And so I just think we, I don't know, we get in such a rut of just what medications are available and don't get me wrong, there's nothing wrong with some of these medications, but you just can't let what someone's insurance is dictate what's best for the patient because that's not always what's best for the patient.
(04:08):
So I really blame that.
Speaker 1 (04:10):
It's not just within prescriptions. We do it with glasses, we do it with contact lenses, we do it with all sorts of things. I think we're super empathetic, but almost to a fault, especially when it comes to this, that we kind of sometimes forget to underrecommend some of these really important options as far as treatments.
Speaker 2 (04:34):
Yeah. And I do think that patients see that and being that I have kind of gotten myself out of that pattern, when someone finally lands in my chair, they say things like, "I've been to see five or six doctors before I came to see you. " And we've tried everything. And I'm like, "Well, have you tried these treatments?" And they're like, "No." So it's just that they've just not ... I'm not doing anything magic over here. I just am not afraid to offer what I think's going to work.
Speaker 1 (05:07):
Absolutely. I actually autologous serum is one of those ones where, I mean, a lot of things, I've struggled with this over the years of, well, how do I talk to somebody about this? How do I feel comfortable with saying, "Hey, I have the confidence that this is worth you paying out of pocket until maybe five, six years ago." I really was underutilizing them and saying, "Oh, well, but it's not covered by insurance and I just don't know that they'll want to do that. Well, if I think it's right, I'm going to say that. "
Speaker 2 (05:40):
And then we end up getting these patients that are on these long lists of medications and we're just adding one more. So if you can do something that's as natural as what comes out of your own body or a light treatment, that's just so much safer for the patient too. So yeah, I'm a big fan.
Speaker 1 (05:59):
And the cost burden builds up each time you add something on. So this might only be 30, this might only be 50, but when you've got multiple of those at the same time, you may even be hitting to the point where, like you said, you're just controlling it versus doing something that might actually get a better response and at the end of the day, may actually cost about the same as all their copays for all the prescriptions you're giving them.
Speaker 2 (06:25):
Yeah. And that's the number one thing. When I talk to patients about these treatments that I offer in my office, I'll say, "Well, all of these dry eye medications, all of them are copays every month from now until forever. We are on these for maintenance. These are not antibiotics where you go on it and then you go off of. " And I'm specifically obviously talking about dry eye. And so when it comes to going on a treatment is expensive upfront, but in the long run of your lifetime, you're spending less oftentimes, unless you've got this just really amazing insurance plan where you're $0 out of pocket and if the $0 out of pocket is the one that works.
(07:14):
So that's where very often I'll just kind of lead with like, "We'll take your lead. I want to do what you think is best for you. I'm just working for you. This is what I think is going to be best. It'll be more expensive upfront, but it may be less in the long haul." And then I let them make the call. So that's how we've been pretty successful with it because a lot of times some patients will want to go on medications and then they see what I'm talking about like, "Oh, this is 40 or $50 every month." Whereas these treatments are expensive, yes, but have this also sometimes have this happy accident of making your aesthetic a little improved.
Speaker 1 (07:56):
None of my patients ever complain about that. Yeah.
Speaker 2 (07:58):
Yeah. Right. So anyway, that's what's going well for us.
Speaker 1 (08:03):
So what was your aha moment? What was your proverbial light switch that made you kind of feel more comfortable with this and get to the point that you just stopped under recommendating these things and just kind of started pushing forward?
Speaker 2 (08:19):
I'm not going to list any specific medications, but there's some that have been out for a very long time that did not really have the efficacy. I never really felt that the efficacy was there. Signs, yes, symptoms, no. And so you just end up plugging and chugging. One thing that bothers me a lot that I think that we don't do is I don't think that we prescribe a med and actually have the patient come back to see if it works. It's just sort of this like, "Here's your medicine, good luck. I'll see you next year," kind of thing. And very often there's dropout throughout that year. So anytime I prescribe something new, you're coming back and I'm retesting to see if it works and we're going to talk about your symptoms. And so when you plug and chug through some of these medicines, you kind of get to a point where none of those work.
(09:11):
And at that same time, you realize that what you've just put the patient through, like how many hundreds of dollars did they just spend if you would've just recommended this from the get- go? And so I really think that was sort of the turning point for me that was like, quit being a baby about it and just tell what is best for this patient. And as it turns out, what is best for the patient is also best for the practice. I've heard doctors all over the place
(09:41):
Because I did feel, if I'm being completely honest, I completely sympathize with doctors that think, "Oh, this feels like I'm selling this for me, the doctor." And I get that, but at the same time, it's like you're just not really thinking about all of those copays and the additional medication in addition to the list that they're already taking and remembering to do one more thing in their day, there's just all these different things. It's like if you really think about it, it's
Speaker 1 (10:10):
Really- And it's not selling, it's treating, right? You're treating the problem and there's no need to apologize, right? It is. Yes, it's not covered. And here's the reasons. And we shouldn't be saying sorry is a thing that needs to move its way out of a lot of our vocabularies, myself included. I find myself doing it more often than I should and I know I don't need to apologize for telling my patient what I think is best. It is unfortunate that some things aren't covered by insurance, but that's again, going back to the copays and things, it all racks up anywhere you look at it.
Speaker 2 (10:50):
Yeah. And I do think that I am a good educator. I'm just going to educate this patient of how this drop works, how this drop works, how this treatment works. And then I always say, "I'm working for you. So we're going to do, based on what I've just told you and what you know, also I'm trying to give them proof. I'm not just trying to tell them something and they're hopefully believing me. I'm doing my biography. I am doing a tear film stability. So doing things that I can measure and we can talk about each time. And so then I let them make the call and we're going to go with whatever they decide and it just so happens that when they know all the options, they can change their mind later down the road.
Speaker 1 (11:38):
Now, how do you do that without necessarily overwhelming the patient when you're presenting all of these options?
Speaker 2 (11:44):
Well, so the other thing that I think because we're so worried about people's pocketbooks and also time is we try to do everything in the comprehensive exam. And I do think that it's impossible because you are overwhelming them when you're talking about their glaucoma and their AMD and their dry eye and all the necessity of doing all of those, trying to do as many of those tests in one visit as you can. So I mean, I just kind of treat dry eye like I do glaucoma or like I do macular degeneration and that is, we've identified this problem. I want you to come back. I want to take some images of the glands that help you make tears and then we're going to talk about it. And so they're coming back for a problem focused visit just around dry eye so that gives us the time to go over their pictures and talk about all the different options.
(12:38):
So we're not talking about everything at once. We're just talking about their dry eye, whatever's going on with their ... Because not everybody is a candidate for treatment. Some people really are a better treated doctor.
Speaker 1 (12:50):
And that is a big thing too, is recognizing when someone is a good candidate for which treatment and that it's a multifactorial disease and a lot of times it means more than one thing needs to be done.
Speaker 2 (13:04):
Exactly. So that gives us the time to sit and really dissect this problem for this person. I really love doing it that way just because they get to ask their questions and I still end up inevitably getting behind because I like to talk, but it does help.
Speaker 1 (13:24):
That's a win-win for your practice, right, for you to not have complete decision fatigue from treating 15 different things all at once. You have the time to set aside and it's a win for the patient to have a little bit more of your time to spend to understand what you're going through and the treatments that you're offering.
Speaker 2 (13:45):
Yeah, exactly.
Speaker 1 (13:46):
Yeah. Well, a lot of great pearls today in such a short amount of time. I really like this discussion. To wrap up, we like to ask a question on the mod pod and I'd like to ask you, what's something in practice that you've changed your mind about over time other than what we're talking about today or something that's in conjunction about what we're talking about today?
Speaker 2 (14:09):
Something that I've changed my mind about over time, I'm going to say AI because- Yeah, me too. It used to be like, what is it? SkyNet that was like from Terminator two that, oh, it's going to come. It's going to take your job. And I've just really leaned into that as well as far as using it for data analytics for the practice. And I just love and so excited about the predictive capabilities of some of the new tech that's coming out in iCare. And so yeah, that used to be a big, scary thing for me and I didn't think it was real. And then when you see what it can do, you're like, oh my gosh. So that's something I'm really passionate about right now.
Speaker 1 (14:53):
I have AI answering all my emails. It's phenomenal. So for those who want to know more and hear more from you, where can they find you on social media?
Speaker 2 (15:03):
You can find me on LinkedIn just from searching HaleyPerryOD and then I also am on Instagram at HaleyAperryOD altogether.
Speaker 1 (15:11):
Wonderful. Thank you so much for joining us on The ModPod. It was great having you.
Speaker 2 (15:16):
Thank you so much. I enjoyed it.
Speaker 1 (15:18):
So everybody stay on. Join us after the break for chat with Kiana Swanson. Welcome back after the break. I am here with our colleague, Kiana Swanson, who is optometry resident at Associated Eyecare in Stillwater, Minnesota. She is here. We're chatting about her article on ocular manifestations of cancer medications and she wrote this alongside our good friend, Jake Lang. Welcome. It's a pleasure to have you on the ModPod.
Speaker 3 (15:52):
Thank you for having me.
Speaker 1 (15:54):
Absolutely. So would you mind telling our listeners a little bit about who you are and what you do?
Speaker 3 (16:00):
Absolutely. So I am the current ocular disease resident at Associated Eyecare, which yes, is located out in Stillwater, Minnesota. It's awesome because I am originally from Minnesota, so it's great to be back and practicing in my home state, but my residency ends in just nine to 10 short weeks, which is crazy that it's flown by so fast. I'm so fortunate to have had the experience that I've had, but moving forward, I just recently accepted a job offer at the University of Minnesota. So I get to stay in my home state, which is awesome. That's something that I've always been looking forward to. And then yes, I went to the Illinois College of Optometry for my optometric education. I
Speaker 1 (16:45):
Know you did, which is why my question, because I grew up in Missouri, St. Louis, and so very big fan of Chicago. It was always the big city. Deep dish actually the best Chicago pizza, or is that just what the tourists think?
Speaker 3 (17:00):
Okay. I think it is so delicious. My body processes lactose so terribly, so I might not be the best person to ask about it, but I have heard that Piquad's pizza in Lincoln Park is probably the best deep dish pizza. I, however, spent a lot of my time in Chinatown trying different sushis and hot pots and Korean barbecues, but I know that the pizza scene is huge and everyone really loves it.
Speaker 1 (17:32):
You are talking my love language here. I am very happy with this. So a little bit more serious note because it is a little bit of a serious article. It's actually a great article. These are a large part of my patients that are referred into my clinic are actually in referrals from oncology, so I work very close with them. When you're managing ocular toxicity from cancer therapies, how do you decide when to treat through and keep them on the medication versus when to push for modifying or pausing the drug? I mean, this is a thing I think a lot of us struggle with.
Speaker 3 (18:12):
Absolutely. And I'm really glad that you asked this too because I think it's probably the toughest part to consider, especially when there are adverse effects of a medication and that medication is potentially saving a patient's life. I think the decision to push through likely varies per provider, but for me, there's two important things that I take into account and first being, I think ultimately the most important thing is to involve the patient in their own treatment plan. So the goal is to maintain and manage comfort without changing the systemic medication. I think yes, overall the goal is what can we do and how much can we do without changing the systemic medication? But one of the biggest parts is what is the patient willing to endure? Are they willing to continue ocular therapies? Do they want to adhere to a topical regimen? Are they willing to be patient with their eyes to give their overall body a chance to benefit from their systemic medication?
(19:23):
But I think second, we have to be mindful of the severity and the potentially permanent complications from surface toxicity if it gets to a point where there is a perforating ulcer or something that's going to be detrimental to the vision long term. But I think when we're at a point where the cornea is likely going to demonstrate some permanent damage, as long as the patient is well aware and the patient's oncologist is roped in, I think making a decision as a team of three is the most important way to handle things, but mainly informing the patient about all treatment possibilities and kind of letting them guide their own treatment path.
Speaker 1 (20:12):
I mean, that's absolutely true. I know that's a big thing that I try to do with my patients, especially if they're ongoing treatment, right? It's not post-treatment and we're seeing damage that is there afterwards. If it's ongoing treatment trying to say, "Hey, how are you doing? And here's the risk we're at. This is a point we're at." But especially if they get a worsening of the diagnosis because maybe the cancer has spread or it's not responding, it's kind of a hard thing.
Speaker 3 (20:41):
Exactly.
Speaker 1 (20:42):
So with our colleagues, if they're kind of delving into this or dipping a toe or they have a patient, what are some of the early ocular surface signs? And they're all a little bit different depending on the chemo or ADC, right? What do you think the most commonly missed are and how can we better catch them before they're severe?
Speaker 3 (21:04):
So I think the earlier symptoms that a patient would experience would be things like tearing, foreign body sensation, light sensitivity, and then potentially blurry vision. But things that we as eyecare providers should be looking for would be things like conjunctival hyperemia, tear film insufficiency, superficial punctate keratitis, and even microcystic corneal changes or corneal deposits. But it's not necessarily that we are missing these signs. I think because there are so many novel systemic cancer medications, we might just not be making the connection as to what is causing the underlying cause. So I think the overarching message would be stay informed as much as you can about novel medications that have very well known ocular toxicities, but also don't be embarrassed to Google something too if it's a medication that you don't know. A medication that I recently Googled that's not a part of this article is a cancer medication called Keytruda and actually on their website they have a step-to-step approach for how to move forward with these side effects and clinical signs that we are seeing.
(22:26):
So honestly, sometimes Googling is awesome and going on the actual medication website, it just really, really helps you guide your management and treatment. But again, it's not necessarily that we are missing these things, but maybe not making that connection as to why it's happening.
Speaker 1 (22:44):
I agree. Our brains can only hold so much and there's things always changing. So it is okay to look. It's also okay to say, "Hey, I don't feel comfortable dealing with this or managing this, so I'm going to refer it to someone who does." In patients who develop severe ocular surface disease or what I see a lot of times actually neurotrophic keratitis short-term and long-term, what does your escalation ladder look like from artificial tears all the way to things like biologics, regenerative therapies? How do you navigate this?
Speaker 3 (23:18):
Right. I think when you're having these side effects from a cancer medication, you would treat it even like something like neurotrophic keratitis and escalate as you see fit. So starting from things like tears to incorporating topical steroids to bandage contact lenses, autologous serums, amniotic membranes, you could even go as far as lid tarsorphy. But I think what's different about the treatment with these cancer therapies is that you could even consider something like a myotic. I know we didn't touch about this in the article too, but we recently had a patient who is having Elahere infusions and 12 hours before an infusion, she instills one drop of brimonidine and one drop of brimonidine 12 hours afterwards just to decrease the bioavailability of the drug and to prevent it from or to minimize the drug delivery to the eye itself. So I think your treatment course looks very similar to how it would for a more advanced dry eye or keratitis, but with an addition of myotics, I think that's what makes it unique.
Speaker 1 (24:32):
Well, and I think that some of these drugs, especially the ADCs, have protocols that already exist as far as start this five days before and five days after, eight days before and eight days after. So they already exist, but I think that there's some hesitation from some of us to say, "Oh, I'm going to add on to this and feeling okay with doing that.
Speaker 3 (24:58):
" Absolutely. I feel like, and again, it's one of those things, and I don't mean to talk myself in a circle, but inviting the patient too to make that choice as well. If I tell a patient, "Well, we could do this myotic or this topical therapy, and it might be an additional thing that you have to think about when you're going for your cancer therapy, but it's something that has been proven to help. And if that's something that you wouldn't like to incorporate into your therapy, then let's try it. " I think, yes, I understand that there is maybe a concern or a hesitation about adding to someone's treatment, but I think as long as you are informed and the patient feels well informed and comfortable with the treatment they're given, then I think that hesitation is appropriate to have but might not be necessary.
Speaker 1 (25:48):
I like that approach of putting a little bit of control back in the hand of somebody who's going through something where there really just inherently is a feeling of lack of control. Many of our listeners know I've gone through cancer, I've been there, it really sucks just to be frank. And so having that empathy from a doctor and the taking the time to have those conversations I think is really important. I'm glad you've learned it already at such an early stage in your career. I think that's amazing.
Speaker 3 (26:28):
Good. Absolutely. I think the psychology that goes on in exam room is huge. I think making a patient feel as comfortable as they do and as in control as they do in terms of a therapy that's helping them stay comfortable during a devastating time in their life is absolutely important.
Speaker 1 (26:51):
Well, was there anything else? I mean, you did a great job. We didn't talk about the specific medications you did during the article. I know they can go read that and I highly suggest that to get some of these specifics about different drugs, absolutely go read the article. But is there anything else that you wanted to say in the article that you didn't necessarily have the space or time or wasn't the place to that you would like to hear?
Speaker 3 (27:15):
Not necessarily. I think the big part I wanted to make sure people knew was about the myotic therapy. That was just not something that made its way into the article, but also I know articles too can come off very objective and I think having this podcast to show the emotion behind decision making too is very important. I think again, it's so much of our job to inform and be honest to the patient so that they can feel like they are managing things in a way that's manageable for themselves is why I think that's so important, just having so much patience and grace for themselves too going through this process.
Speaker 1 (27:58):
To wrap up, I'd like to ask you, what part of eyecare excites you? You're the new generation, the next generation. What is exciting to you?
Speaker 3 (28:08):
Okay, this is weird and I find it comforting, but it's the unknown. I think it's so intimidating but so rewarding to walk into an exam room and have no idea what's coming for you. There could be that sudden acute unilateral vision loss and is this going one way or another way? Is this going to be something new that I'm learning today or is this going to be something routine? I think showing up to work as a resident, especially when I'm doing an urgent care-based residency, talking with a patient and having no clue where it's going is what I found is comforting at this point, which I never thought that I would say that or I think going through school and you're learning so many things I find comfort in the things that I thought I was most knowledgeable about, but now I'm finding that it's just the complete opposite.
(29:02):
The unknown is very exciting.
Speaker 1 (29:05):
You sound like me. I say find the comfort and discomfort because you know what? It's how we get better. I love it.
Speaker 3 (29:13):
Absolutely.
Speaker 1 (29:14):
Well, this has been phenomenal. For those who want to know more and hear more from you, where can they find you on social media?
Speaker 3 (29:21):
So you can find me on LinkedIn just under Kiana Swanson. Otherwise, you are always welcome to email me directly at kiswanson@associatedicare.com. Otherwise, if you want to search and find my Instagram, I'm always happy to talk there too.
Speaker 1 (29:38):
Well, thank you so much, Kiana, and good luck and welcome to the other side.
Speaker 3 (29:43):
Thank you so much for having me. I really appreciate it. Hello.
