Should your group add pediatric ophthalmology?

Kids bring fun — and other family members may follow.

By Amir Arbisser, MD

About the Author
	Amir Arbisser, MD, is a pediatric ophthalmologist and the founder of Eye Surgeons Associates, a multi-location practice based in Bettendorf, Iowa. His e-mail is aarbisser@usa.net. Disclosure: Dr. Arbisser has no financial relationships with any of the companies mentioned.

As a pediatric ophthalmologist, my knee-jerk response to the question posed in the headline ought to be an unequivocal “YES!” But three plus decades on the clinical front lines slightly tempers that autopilot answer. Today my answer would be, “It depends.”

Pediatric care: not for everybody

If you envision a boutique, discretionary-expense, elective practice, pediatric patients simply may be inappropriate.

Patients seeking the hushed reassuring comfort of a facial plastic spa or the efficient professional precision of a refractive surgery center might not embrace the unpredictable pandemonium children and their families bring. You, your staff and your patients might dislike noise, rug rats to trip over, cartoons and toys in reception areas plus — one of my personal all-time favorites — soiled furniture.

When did you last stock wet wipes and a range of diaper sizes, much less dispose of them or discover abandoned soiled diapers in the bathrooms during clinic hours? When did your staff last face protective and occasionally loud caregivers arguing about refraction fees, this week's excuse for late arrival or their forgotten Medicaid cards?

Providing the right environment

If you fantasize about maximizing office economics by efficiently filling unscheduled appointments with pediatrics, please realize you need more than a receptionist, an unoccupied tech and an empty chair to serve children.

John Frederick, MD, performs a muscle balance test on cooperative young child.

Your facilities may require physical modification beginning with reception and waiting areas. Both adults and children appreciate separate spaces. Our children's areas include Plexiglas-walled play areas to contain children and whatever diversions they bring with them. The play areas contain the tumult and feature blocks, Legos, continuous loop cartoons, books and appropriate furniture. They are easily visible to accompanying adults in adjoining comfortable seating.

The pediatric units are generally located some distance from our refractive surgery folks. I haven't attempted electronic sound suppression yet but I know that technology works well in another non-medically related venture.

Next, you'll need long examination lanes (24 feet) to deliver optimal strabismus service. Two typical long lanes occupy the space of three or four of our classic exam rooms. Don't forget fixation devices and portable equipment like slit lamps, loose lenses and prisms.

If you and your patients and staff really don't enjoy children or lack patience, sell vitamins or hearing aids instead.

Embracing pediatrics

If your group seeks population or managed-care contracts you must provide a broad menu of ophthalmologic services. Carving away subspecialty care such as retina or pediatrics may cost your group money or even the contracts themselves.

The word in some quarters is that, increasingly, subspecialty fellows actively seek affiliation with large multispecialty groups as medicine lumbers from fee-for-service, where specialists thrived, toward comprehensive population contracts. Remember that cost-effective population care entails a team approach led by the ophthalmologist or specialist.

The new patient typically receives an initial comprehensive examination and is then fielded for routine care and scripted follow-ups to protocolled extenders such as knowledgeable optometrists, nurse practitioners, orthoptists or technicians. The specialist obviously intercedes with necessary procedures, and the staff must be astute in identifying and treating amblyopia, among other diagnoses.

Pediatric specialists are a practice resource

Pediatric ophthalmologists offer your group multiple important resources and benefits, including the very real possibility that other family members may follow the kids into your practice once they recognize that the children are happy, comfortable and in the care of highly skilled professionals.

Behavioral assessment techniques refined through years of examining non-verbal or pre-verbal children enable and enhance the pediatric specialists' evaluation of neurologically impaired patients.

The author keeps a ready supply of finger puppets in his pockets to amuse his young patients and keep them focused while he is performing vision tests.

Because we practice daily on moving and uncooperative customers who can present challenges that I enjoy overcoming, we often display advanced refracting abilities.

For example, I often serve colleagues' advanced technology refractive surgery patients. I see pre- and postoperative refractive surgery patients with their high expectations and periodically help associate surgeons avoid or escape refractive pitfalls. If glasses are a discretionary income center in your group, you can benefit from those refracting and patient education skills.

Neurology skills are critical to pediatric ophthalmology practice. Do you routinely order diagnostic scans for complaints of diplopia because you've lost your neuro-ophthalmological skills and want to avoid anxiety insomnia?

Many are unnecessary, and MRI and CT scans drain precious dollars from managed-care contracts. We can help and knowledgeably explain to patients and referring physicians why they may not always get their expected scan.

Speaking of diplopia: Pediatric ophthalmologists are skilled with Fresnel prisms to ameliorate diplopia. Those same skills further reduce annoying and potentially expensive optical shop re-dos.

Mood and attitude

Pediatric patients and their entourage (I've had up to five accompanying siblings and peers attend quick checks with one harried caregiver) infuse optimism, vitality and fun into potentially mundane clinical life.

Diagnostic equipment in pediatric lanes resembles adult lanes except for longer length for distant fixation testing for accurate muscle measurements.

The kids create and share their artwork, and they wear holiday costumes and favored garments. In response, our comprehensive practice reacts with sometimes outrageous Halloween costumes and competitions. When was the last time you and your assistants dressed as Boris and Natasha, Rocky and Bullwinkle, Papa Smurf or Fred Flintstone? (I actually purchased an awl and sewed my own genuine coyote skin outfit.) When was the last time you handed out Halloween candy in the office to patients?

Pediatric waiting areas require multiple engaging toys appropriate to patients' ages.

Children who are comfortable with the office staff want to play and tease. Some play hard to get, which warrants a myriad of fixation targets; I have at least a dozen finger puppets in my pocket at all times, plus magical illuminating thumbs.

The fun and costumes, of course, are the icing to our clinical cake. The practice cake itself achieves greater texture, complexity and interest for all involved by adding the pediatric component.

Our practice began with pediatrics

My multispecialty group practice began with a single pediatric exam lane inside a general surgery office in a relatively modest Midwest Mississippi River community. Most pediatricians and family practitioners in nearby larger communities soon preferred referring their patients to a private pediatric ophthalmology practice instead of the established and geographically accessible academic center.

Satisfied with both office efficiency and clinical outcomes, the families and their physicians soon inquired what other services were available. They were delighted to bring grandmas a distance to a friendly welcoming office for cataracts, ptosis repairs and elective blepharoplasties.

From that humble beginning, our group evolved into a 20-plus doctor, eight-location, bi-state entity. Pediatric lanes exist in three of our locations. Our medical world is changing, but patients' basic preferences remain unchanged. They seek appropriate care and outcomes. They expect respectful treatment with understandable costs. They generally enjoy humor and a good time. Pediatrics can infuse much into your practice life if the expectations are appropriate. OM