How Two Surgeons Make Retinal Referrals Work

Mutual trust and frequent contact comingle with a shared priority for the patient’s best interest.

BY Robert Murphy

Here’s a story about a mutual retinal-referral relationship between a general ophthalmologist in Yuma, Ariz., astride the Colorado River and nestled in the state’s southwestern corner, just a stone’s throw from Mexico and California, and a fellowship-trained retina specialist in Phoenix, some 200 miles to the northeast. It’s worth telling not only because of the benefits to the physicians, but more importantly, to the patients. It’s also a story that underscores some useful and commonsense guidelines on how to make such a relationship work.

The whole thing got started in 2008 when general ophthalmologist Patrick Aiello, MD, flew the nest of the Phoenix group practice, with which he had been associated for about 10 years, and struck out for underserved Yuma. Its estimated population of 93,000 contains large numbers of Hispanics and Native Americans, not to mention flocks of winter visitors from all over.

Addressing a Shortage of Care

“I’m in an area where there’s not much coverage,” says Dr. Aiello, owner of Aiello Eye Institute. “I came here four years ago because of a shortage in the area. And I knew even before I was coming here that one of the things I would need help with was retina, because there was a lot of retinal pathology.”

Dr. Pat Aiello’s general and surgical practice in Yuma, Ariz., struck up a relationship with Retina Consultants of Arizona to bring in subspecialist David Goldenberg, MD.

It wasn’t long before Dr. Aiello got the help he desired from Retina Consultants of Arizona (RCA), based in the Phoenix area. Aside from its own in-house eye care, RCA is sort of a subspecialty road show providing retina care to Arizona’s many small and mid-size towns that might otherwise go without.

“We as a group as a whole go out to a lot of smaller communities throughout Arizona, for many reasons,” says David Goldenberg, MD, the RCA associate who consults with Dr. Aiello. “Mostly because there are a lot of patients who need retinal care, and it’s very difficult for them to come see us [in Phoenix] every week or every month. It’s easier to go [to Yuma] and provide care. So establishing a relationship with Pat Aiello certainly made it easier and all the more efficient for patients.”

Getting Started

A clear and linear outline of how their referral relationship works runs up against the fact that all cases are to some degree sui generis, unique in some way. Habitual patterns get tossed to the wind in the face of an emergent retinal detachment or a conversion of dry AMD to its neovascular phase. Still, it’s worth observing how the principal doctors make it work for the patients.

Just how do you initiate a retinal-referral relationship with another ophthalmologist? After establishing his practice in Yuma, Dr. Aiello requested assistance in providing retinal subspecialty service from RCA. Dr. Goldenberg was asked to take on the Yuma retinal coverage. He now visits Yuma once a week, where he can perform various laser procedures, anti-VEGF injections and uncomplicated surgeries for conditions such as vitreous hemorrhage, epiretinal membrane or macular hole.

“But a more complicated surgery such as retinal detachment, a bad diabetic case or recurrent retinal detachment — they might require some advanced things that I need for surgery,” and possibly transfer to RCA’s Phoenix facility, Dr. Goldenberg says. His group tries to facilitate the travel. “A lot of patients in this area are on Medicaid, or are indigent, or have no means of transportation to Phoenix,” he says. “We do all we can to provide transportation for them.” This is especially valuable in the case of complicated retinal pathologies requiring urgent treatment.

As potential new allies, how do a general ophthalmologist and retina subspecialist learn to work together? How do they gain a sense of each other’s personality, knowledge, and skills? What about the personal touch? If one’s counterpart is in some way personally disagreeable if not downright obnoxious, must this by definition rule out a potential mutually beneficial professional relationship?

“To do this, you should find someone whose work you trust, that’s the first thing,” Dr. Aiello says. How on earth can you know? “You’ve got to talk to other people in the area, go into surgery with them,” Dr. Aiello says. “You could refer patients and see if you get them back, see how that happens.” Training, knowledge, and skills top the list of another doctor’s desirable attributes.

Yuma, a Cultural Crossroads

The demographics of Yuma underscore a clear need not only for a general ophthalmologist with Dr. Aiello’s multifacted skills, but also someone like Dr. Goldenberg applying his fellowship-trained specialized retinal skills and knowledge for a sizable retinal patient demand.

On the verge of both the Mexico and southwestern California borders, Yuma’s demographic mix consists of some 60%-70% Caucasian, the rest mostly Hispanic. Native Americans comprise a significant minority population. Thanks in part to retired winter visitors, Dr. Aiello’s practice is about 50%-70% elderly.

Yuma houses a sturdy, if not sometimes stubborn, segment of the elderly population who tend to resist visiting the doctor. Maybe this happens everywhere. “Some of the folks in this area have the mentality that they’re not going to the doctor unless they absolutely have to,” Dr. Aiello says. “Some of the older folks, they’re kind of stoic and wait.” Of course, with many retinal pathologies, waiting is not an option.

Additionally, many in the Yuma area, from all demographics, suffer from diabetes. “There were some figures released a couple of years ago, indicating that of the population that lives here year-round, the population at risk for diabetes is up to 25% of that,” Dr. Aiello says. Is it any wonder Dr. Aiello presciently foresaw the need for a collaborative retinal service?

Clinical Examples

The heart of the matter, clinically, lies in the types of conditions for which this kind of collaboration may be well-suited to serve patients’ needs. While they try to stick to a certain protocol — for instance, Dr. Goldenberg devotes one day a week to Dr. Aiello’s Yuma office, and both physicians understand each other’s scope of practice—sometimes the idiosyncrasies of a case call for innovation and mutual trust. Trust and open communication emerge as the sine qua non of any retinal-referral relationship.

The most common conditions Dr. Aiello refers to Dr. Goldenberg are retinal detachment, neovascular macular degeneration and diabetic retinopathy. While retinal detachment calls for urgent transfer to Phoenix for surgery, the other two can be managed in the Yuma office. Dr. Aiello may call upon the retina specialist to confirm a diagnosis, such as conversion from dry to wet AMD, as well as other tricky calls as to whether urgent treatment is indicated.

The terminus of the general ophthalmologist’s clinical and procedural comfort zone marks a milestone where Dr. Goldenberg takes up the case, almost as a bus or trolley might complete a nightly commute after a subway ride. “I treat diabetic retinopathy and sometimes AMD, if it’s a garden-variety case,” Dr. Aiello says. “Then I feel comfortable treating, with minimal to moderate pathology. A severe diabetic retinopathy with proliferative changes that is going to need vitrectomy, I can’t provide that.”

Mutual Respect Of Skills and Knowledge

Dr. Aiello’s training and experience amount to an impressive scope of expertise and skills. In an area under served not only for retina care specifically, but more generally for a broader spectrum of eye care, his services satisfy an unmet need. Among other clinical procedures, Dr. Aiello performs laser procedures on diabetic patients. While he refers to Dr. Goldenberg for laser treatment for neovascular AMD, Dr. Aiello can administer anti-VEGF injections for these patients, as well as for diabetic retinopathy.

Over time, both doctors have come to respect the other’s skills and knowledge. “You want to refer patients to a doctor you trust, and [who] is going to continue that excellent care,” Dr. Goldenberg says. “Pat and I have that great relationship. He’s a great physician, he’s a great surgeon. So when I send him a patient, I know they’re going to be in excellent hands, and I don’t even have to worry about it.”

Postoperative and follow-up visits vary not only in their timing but, depending on the circumstances, in terms of who sees the patient. Generally, Dr. Goldenberg sees surgical patients one-day postoperatively, after which the frequency and duration of post-op and follow-up visits—and who will handle them—may vary according to the case.

For example, here is how they handle a retinal detachment: “If a patient presents with a retinal detachment, I’ll diagnose it and send it on to him,” Dr. Aiello says. “He’ll let me know if he does surgery. I might see the patient the next day for convenience. But I won’t resume the care until the patient is all done with whatever is going on.” In other words, when the eye is stabilized.

Dr. Goldenberg encounters a full plate during his weekly visits to the Aiello Eye Institute, with doctor and patient consultations, challenging fundus evaluations, anti-VEGF injections, laser procedures for AMD or diabetic retinopathy, and more. Then there are the selected complicated surgeries best served in the Phoenix office. The added benefit of transportation that Dr. Goldenberg’s practice arranges gives perspective to the sense of dedication to patient convenience and well-being.

As for the financial arrangement, Dr. Aiello notes, “It’s not like a traditional co-management relationship.” He does not take a percentage of fees. Even so, Dr. Goldenberg’s group chips in with the general ophthalmologist’s rent and equipment payments. “We’ve got to pay rent and for the equipment in our office space, so I’m just giving up space that I’m not able to use,” Dr. Aiello says. Don’t call it a quid pro quo — more of a friendly mutually beneficial alliance.

Fulfilling Obligations

With stakes as high as visually threatening retinal disease, failure ranks no better than a worst-case scenario. But what about a referral relationship between a general ophthalmologist and a retina subspecialist? Are seeds of failure lurking beneath a seemingly glowing surface?

Mostly, this is not the case. “I think it all comes down to the quality of care for your patient,” Dr. Goldenberg says. “When the two physicians think alike, they’ll get along personality-wise. That’s going to happen the vast majority of the time. I haven’t seen it not work in the 3½ years that I’ve been with this group.”

Dr. Aiello attributes a hypothetically failed referral relationship to negligence by either doctor to fulfill the obligations to which one or both parties had acceded. “One thing that would cause the relationship to fail would be if, for example, the group wasn’t responsive, and if they weren’t providing the service they were contracted to deliver,” Dr. Aiello says. “And also it would fail if I wasn’t responsive to their needs, and wasn’t providing what I said I would deliver, mainly the office space and the equipment.”

With regards to equipment, Dr. Goldenberg requires an indirect laser to treat retinal tears in the far periphery. These cases had been brought to RCA’s Phoenix office, but Dr. Aiello’s Yuma practice recently purchased one. Besides the chance for more prompt care, it also relieves his patients of a three-hour drive.

Advice for Newcomers

Whether you’re new to a town or new to ophthalmologic practice, it may be worth establishing viable referral relationships with retina specialists. In a place like New York City, this may amount to little more than a walk around the block. In a place like Yuma, it helps to have longstanding retinal associates, as Dr. Aiello did.

For Dr. Goldenberg’s part, patients are well-served by his weekly visits and willingness to treat them either at the Yuma office or RCA’s Phoenix office when the condition may demand it.

“That’s why Dr. Aiello and I get along well, because we both put our patients’ needs first,” Dr. Goldenberg says. “Our priority is to take care of them and I think that’s why we have such a great relationship. If I didn’t believe in Dr. Aiello, and vice versa, I don’t think it would work well.” OM