As I See It

A Catechism of Best Practice Patterns

By Paul S. Koch, MD, Editor Emeritus

A year ago in this space I told the very happy story about how a handsome private equity firm swooped in and bought my practice. Since then, they have teamed us up with others, and at the conclusion of month 12 we find ourselves with 13 locations, four dozen doctors and a cast of hundreds.

From my perspective it’s been beyond wonderful. My bosses are wonderful. Work that used to cross my desk now crosses theirs. Problems get channeled elsewhere. I hesitate to let them know it, but being an employee is a bit like being on a brain vacation. I understand now why so many people support the concept.

My clinical work has been cut back a bit and shared with our very excellent younger surgeons. In its place, I’ve taken on the role of medical director of the whole kit and caboodle.

As one of my friends told me, “There comes a time when you should get paid for what you know instead of for what you do.” I guess my crop of gray hairs fooled them into thinking I actually learned some lessons over the years. (Shh, mostly by making bad decisions. Don’t tell them.)

20 Different Answers

One of my ongoing projects is to develop and monitor a program in Best Practices. Ultimately, we seek to have a network where patients can come and expect a certain and excellent level of care no matter which of our locations they visit or which doctor they see.

The problem, as loyal readers will anticipate, is that each doctor has different and unique education, training, experience and opinion. Naturally, all believe their life’s path gives them the best solution. Were we to ask 20 doctors how to approach a problem, we would get 20 different answers. After considering them, I generally find that almost all are reasonable approaches, except for a few at which I can only shake my head.

This then puts me in a dilemma. Should I recommend that every doctor in each location follow his or her own unique and different path? Or, should wee seek a common pathway, that all can agree upon? Further, how often should we follow that route, considering the individual needs, resources and ambitions of each patient?

Studying Their Catechism

Finally, how could I gather dozens of bright minds to come to a consensus on the path forward? The concept of a cookbook in medicine is more distasteful than it is in gastronomy. Still, there must be a standard we can select that we can all agree is a Best Practice, even if we cannot practice it on all patients.

Enter here the hard work and research of many learned committees, putting together community standards that experts can agree are excellent. The American Academy of Ophthalmology’s Preferred Practice Patterns, along with the Clinical Guidelines of the American Optometric Association, turned out to be valuable resources for what we were trying to accomplish.

All our doctors had heard of them, yet almost none had actually read them. Exceptions were rare, and even then only within the doctor’s specialty. We quickly seized this opening. I positioned these publications as the “Catechism of Clinical Practice,” the repository of the basic tenets that we should all accept.

Monthly Brainstorming Sessions

Monthly, we work our way through them, together as a group, and come to a consensus as to how we should handle most clinical situations. I find myself particularly lucky because these publications speak for themselves. I have no cause to impose my opinions on others, and little need to referee disagreements.

I do not like everything about our Academy, like when a contemptible trustee will hire himself out to testify for the plaintiff in a case outside his area of expertise. But when it comes to the Preferred Practice Patterns, I am a big fan. OM

Paul S. Koch, MD is editor emeritus of Ophthalmology Management and the medical director of Koch Eye Associates in Warwick, RI. His e-mail is paulkoch@kocheye.com.