Why Do Different Practitioners Give Different Advice?

 

The other day I had a young patient whose mother wanted to know why I had recommended glasses while my colleague, who had seen this patient 6 months earlier, had said he didn’t need specs and we just needed to monitor. In my mind, with this kid’s prescription and his age, there was no doubt that I wanted to prescribe glasses to avoid amblyopia during his developmental years, but in some situations (evidently including this situation in the other optom’s mind), there is not only one correct course of action.

It is understandable that receiving conflicting pieces of advice from two different practitioners can make a patient confused and nervous about who they should trust and what they should actually be doing. I had one patient who saw me for a third opinion because she got two slightly different scripts from two other optometrists and didn’t know which one she should make glasses from – of course my subjective refraction yielded slightly different numbers again and I had to demonstrate to her that a 0.25DS difference in one eye’s script made very little difference to her final vision, as did a 5 degree difference in axis for her low astigmatism correction.

So why do different practitioners give different advice?

Sometimes it’s a matter of how conservative and risk adverse your optometrist is. The opposite of this might sound bad – who wants a risk-loving optometrist? But for example, take a patient with mild non-proliferative diabetic retinopathy. Assuming reasonable vision and no other odd things going on in the eye, one optom may feel comfortable with sending a report to the patient’s GP and reviewing the patient themselves again in one to six months (even the time of recommended review will differ between practitioners) whereas another optom may decide to refer immediately to an ophthalmologist to be monitored there… a transference of responsibility (and liability), one might say.

The degree of confidence an optom has in their ability will also pull things one way or another. I once worked with an optometrist who referred away any child with a lazy eye. He wasn’t comfortable with treating paediatric problems whereas another optometrist in the same practice was quite happy to diagnose and treat lazy eyes in children by herself (and no, I’m actually not talking about me). Then there are various wild and wonderful diagnostic techniques that they spend about half an hour teaching you in practicals at uni and then you never hear about it again (such as scleral indentation and lacrimal lavage). Only the adventurous dare to dabble in these techniques on real and less-forgiving-than-your-prac-partner patients; the sensible ones refer.

There are a myriad of other reasons why one practitioner will tell you one thing and another will tell you something else. Like most humans on most topics in life, different optoms will subscribe to different schools of thought, or even different attitudes towards referral and treatment. Different optoms will also have had different experiences that have shaped their approach to certain situations, and quite often more than one approach is still acceptable. Whilst all decisions should be evidence-guided, sometimes medical evidence itself just isn’t that straightforward and even research studies can contradict each other.

porque no los dos
Sometimes…

I like to explain to my patients the rationale behind my decision. Sometimes it’s a no-brainer – you’re not meeting the VicRoads vision standards for holding a drivers licence right now so you need cataract surgery – but sometimes it’s a yes-brainer and some careful pondering is required. Just today I had a patient with narrowing of the fluid drainage structures in her eyes, which put her at risk of glaucoma. At the moment her intraocular pressures are still okay as are her optic nerves but she’s on the borderline of something going downhill in the next few years. I had a discussion about referring her for preventative treatment now versus reviewing her again myself in 12 months. I’ve found that different patients will have different attitudes to medical intervention, eg get it over with sooner rather than later vs hold off for as long as possible, and with this particular patient she opted to be referred at this point in time because she expected her life to get busy in the next few years and didn’t want to have to have to think about it later on.

In a nutshell, if you’re confident that your optometrist has your best interests at heart and is reasonably competent, then trust your optometrist. Ask all the questions you need to help yourself understand and feel comfortable with the decision. On the other hand, if you think your optom is just out to make money from you then get yourself outta there!

bye-felicia-001-friday-ice-cube-comment-reply-meme

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