Q: I have a headstrong cataract patient. Ive recommended a surgeon at a large multispecialty practice across town, but the patient is against traveling far for treatment. Mind you, this patient drives a full hour to go to his weekly poker game. How can I persuade him to go to the surgeon I recommend?

Impress upon him that cataract surgery is not just a minor procedure, says optometrist Robert Vandervort, of Omaha Eye and Laser Institute, a comanagement center in Omaha, Neb.

Patients who have friends and family with good surgical outcomes may conclude that any surgeon can perform cataract surgery with no complications. Even optometrists can get lulled into the false sense that, because the operation has become so refined, anybody can do it well, Dr. Vandervort says.

Patients have only one chance to have their cataract surgery done right. So send them to the best surgeon.

But a high volume cataract surgeon at a large center will probably have more consistent results and a significantly lower complication rate than the general ophthalmologist down the street, Dr. Vandervort says. There are still a lot of 40-minute-a-case surgeons out there. Plus, the busy surgeon is more likely to be supportive of your expertise as a primary care optometrist.

In any comanagement arrangement, your primary goal is to achieve what is in the best interest of the patienteven if the patient sometimes doesnt see it that way.

I tell patients, You only have one chance to do this right, and its going to impact you for the rest of your life. Ive worked with this surgeon [at the farther center] for many years. This surgeon does much more cataract surgery than Dr. Jones [down the street]. Im sure Dr. Jones is capable, but I want you to have the best, Dr. Vandervort says. Besides, you will be receiving your post-op care in my office, so you wont have to make a lot of trips across town.

Many times optometrists do not exercise the control that they are capable of, or need to, in directing referrals to the best source, he says. Our profession has become so patient-friendly that weve almost let the pendulum swing too far, and sometimes we dont act like doctors by taking control of the situation. Thats not acting in the best interest of the patient.

Q: I finally persuaded the patient to see the high-volume surgeon across town. But the patient has to see his primary care physician before undergoing the procedure. What if the PCP questions the patient about my referral and suggests Dr. Smith down the street again?

A: Lay the groundwork beforehand, Dr. Vandervort says. Sit down with the local PCPs in your area and explain who you prefer to work with and why.

If the PCPs understand that you want your patient to get the best care, they will be less likely to discourage the patient from going to the surgeon you choose. In addition, take the time to schedule the surgery before the patient sees the PCP. Its less likely that a PCP will interfere at that point, he says.

Perhaps go a step further and get the eye surgeon and PCP together for lunch, so that the surgeon can explain his or her relationship with you, the doctor of optometry, Dr. Vandervort says.

The bottom line, he says: Is what I am doing in the best interest of the patient? In most cases, the optometrist will say, Yes, Im his primary eye care provider, and I understand this patients personality and vision care needs better than anyone. It is in his best interest to obtain specialty care with the experts I am most comfortable with.

Vol. No: 142:8Issue: 8/15/2005