referrals
REFERRALS: Examine the Evidence
Remember these key points before entrusting your patient to a surgeon.
DANIEL J. SCHIMMEL, O.D., Brentwood, Tenn.

Optometric referral centers (ORCs), created in the 1970s, have set the standard of care for a working relationship between optometrists and surgeons. I believe ORCs have been an asset and an ally to optometry on many levels and have been good for patient care. However, never lose sight of the fact that referral centers are businesses that strive to be profitable.

So how do you evaluate a center to make the best decision for your patients?

ILLUSTRATION BY GARRY NICHOLS

How to size up an ORC

At the very least, you should refer patients to one of the better surgeons available in the area. This is your responsibility as a doctor. Realistically, no surgeon is going to question his own surgical skills. Therefore, you should base your referral on your personal clinical judgment of an individual surgeon's surgical outcomes.

Typically, an ORC hires a surgeon who fits its particular need for a specialty or subspecialty. It may hire a surgeon based solely on availability or because the surgeon accepts the proposed compensation package.

While ORCs check credentials on paper, actual observation of surgical techniques or review and verification of surgical outcomes may not be addressed when these surgeons are hired. Ask the ORC not only what this doctor's resume looks like, but if anyone watched him perform surgery. Does the center know this surgeon's complication rate?

You should observe, in a clinical setting within one week post surgery, how well your patient is recovering. Get hard statistics from the surgeon regarding his complication rates as compared to that of the national average. Most surgeons usually give you an estimate or "feel good" number. The better surgeons do track this statistic and will gladly share it with you because it is a reflection of their superior skill.

Check for safeguards

Researching statistics is a good starting point in determining the quality of surgery you expect and the quality of the ORC. Also, check if it has one of the top surgeons in the area; if not, then why?

Most centers employ good surgeons. However, you expect the best, and so does your patient who has put her trust in your clinical decisions. At an ORC, once a "good" surgeon has performed many procedures, it's almost impossible to replace him with another surgeon with outstanding surgical skills and outcomes.

Yes, referral centers have replaced surgeons for various justifiable reasons. The issue, though, is the time that passes between recognizing the problem and finding a replacement.

Does your ORC give back?

But the surgeon isn't the only factor to consider in choosing an ORC. I like to examine the center's commitment to organized optometry as well.

Does it offer continuing education on its own or is it in competition with the state organization? Does it give financial support to the state optometry association or to the American Optometric Association? Will the referral center and the surgeon support optometric-friendly legislation?

Remember other options

I have been directly associated with referral centers for 12 years and believe that they have raised the standard of eye care. I also believe that just because a referral center exists, your referrals to them should not be automatic.

If there is a surgeon who is independent and provides all the things a center does, even though there is not an optometrist as a center director, then your referral may be based upon sending your patients to the best surgeon for your patient. If you don't send patients to other surgeons to see what kind of outcomes they might have, you will never discover if a better alternative is available.

Dr. Schimmel is a member of the American Optometric Association and the Tennessee Optometric Association. You can reach him at 3 Maryland Farms, Suite 120, Brentwood, TN 37027.