[00:00:00] Chris: Last time we talked. I think you and I, after we’ve had some time to reflect on it, we realize we might have dumped too hard on randomized controlled trials. So what we wanted to kind of come back and talk about was, applying evidence and making those clinical decisions, understanding the limitations of randomized controlled trials, but then also applying what we can know and mixing that with.
[00:00:22] The, uh, patient preference and then our clinical experience. Right. So where do we go wrong in dumping on randomized controlled trials to
[00:00:29] Kyle: too much? Um, I would say, uh, it’s good to, uh, we’ll go back to the three pillars, right? The three pillars, the three conjoining circles that we talked about the first time is, um, those are your patient experiences, right?
[00:00:44] Your, the randomized controlled trial are. And then the, uh, clinical hunch. Right. And we know, you know, we can’t always, uh, lead or make decisions based purely on a patient’s clinical or a patient’s experience, a patient’s preference. Right. Uh, and we talked last time about the randomized controlled trial, which is extremely helpful, right.
[00:01:05] When we think about we’ve all seen that pyramid of evidence where that’s, you know, at the top to give us really good, good evidence, and then. Uh, we kind of picked apart certain randomized controlled trials and how they don’t maybe fit our population perfectly. Um, but we also have to realize that, uh, our hunches as well, the reason we have those, the reason we really have a need RCTs is because.
[00:01:33] Our clinical experience in hunches are off. They often lead us astray as well. So, um, we definitely build that, that builds up over time and we, uh, can improve that through. Through learning through, experiencing through mentorship and all those things. But, um, frankly, we’re just w they’re specific biases that’s coming to account, um, regression to the mean though, those are kind of the two
[00:02:00] Chris: at that for a little bit.
[00:02:00] Cause I think that’s a term that most people have probably
[00:02:03] Kyle: forgotten. Yeah. Good, good question. I, uh, applying evidence regression to the mean is basically a phrase that describes the natural history of an illness. So. You think about any illness, whether it’s dry eye glaucoma or, or anything more generally more systemically.
[00:02:22] Everything has a peak, usually chronic illness and acute that it has a peak and it has a trough, right? So things tend to go up and down, uh, just over the natural course of the, of the condition. And when we see a patient. For that condition. It is often at the peak. So it’s usually in an acute phase. So a great example, dry eye.
[00:02:48] They tend to come in, you know, right at that, that peak moment or a red eye or an infection, they tend to come in at a peak moment. Um, sometimes we, we. We’ll diagnose glaucoma or we’ll see a patient and we hit them at a peak moment. And that’s, that’s why we check pressures at different times of the day and, uh, at different points in time to kind of see that variation.
[00:03:10] But so when we do see patients at that peak moment, Uh, we can get led astray. We can get biased if we give them a prescription for something and they get better, then we just assume our assumption is, well, I made the right decision, right. I, uh, uh, treated them with whatever it was that, uh, that helped them.
[00:03:32] And now they’re better. Well, it’s really difficult to know. Are they better? There’s just really no way of knowing that. Uh, knowing that’s what the
[00:03:40] randomized
[00:03:41] Chris: control trial helps us understand
[00:03:43] Kyle: exactly. Right. Except for when we, you know, take 500 people and we split them in half and we, uh, treat, you know, 250 of them this way, treat the other 250 with the placebo and then watch him.
[00:03:55] And then the difference between the two that’s, whether the treatment worked or not, you know, so. Uh, to put it in terms of kind of, you know, going back to some of our topics, uh, previously, when you look at the, uh, some of the things that are going on in the pandemic right now, that’s where some of those, um, some of the medications early on that were controversial, we can get into that, but they, uh, were very controversial like, um, um, hydroxychloroquine and ivermectin, you know, those, those things, uh, They were working well for a lot of early patients.
[00:04:34] Like there could potentially yeah. Potentially working well. Um, but that’s what a lot of, uh, other people, other practitioners were saying at the moment, it’s like, well, we can’t really decide unless we do an RCT on that. We don’t know if that’s just, Hey, they got COVID and they got. Uh, because that’s a natural history of the, of the condition or do they get better because they had this.
[00:04:56] Why do you
[00:04:57] Chris: think that we apply that, that, um, level of scrutiny collectively to a medication like hydroxy, chloroquine or ivermectin, but we didn’t apply it to things like masking and six feet of social distancing. Shutting things down. Why, why, why the difference? Hello and welcome to the Griswold podcast on I could media today had a great conversation.
[00:05:18] Another followup conversation with Dr. Kyle Clooney about the, about how to navigate uncertainty and also apply, apply our clinical hunches with patient’s preferences. And we’d kind of delved into more of that process. It was a lot of fun as always be sure to subscribe to the podcast, write a review, share it with your friends and support those who support us.
[00:05:40] The MyDay multifocal for a second. It’s just coming out and we have the opportunity to do a preclinical trial with this lens this last summer. And there were a couple of things that I thought were really helpful. The first one is that it is different than a lot of the multifocals that we’ve used before in our practices where patients, especially early emerging.
[00:05:58] The Oaks really manage the, it didn’t cause a lot of additional, uh, distance blur for them. And the other thing that was really helpful was because we’ve never been involved in a clinical trial before was to understand, uh, the sort of questions that we might ask our patients. And we ask our patients a lot of questions about their patient, about their satisfaction with a contact lens.
[00:06:19] But what we weren’t doing was actually having them score that themselves. So one of the parts of this that was really interesting to me was asking patients on a scale of one to 10, how would they would score their vision, how they would score their comfort in their current lenses, and then how they would do the same on their new lens.
[00:06:37] And it showed me a lot of times where patients would say they were happy white rate their vision as a six or a seven. And, um, and then it also reframe their thinking about their current satisfaction in their lenses and allowed me to open up the door. To offering other solutions. So if you haven’t tried something like that in your clinical practice, I would encourage you to, and I would also encourage you to try the MyDay multifocal for your
[00:07:01] Kyle: patients.
[00:07:02] That is a great question. Um, honestly, like when you look back, I think applying evidence all goes back to, uh, my observation. So I’ll say my hunch here is when you look back to February of 20. Right. When the first information started to come out about, uh, SARS cov two, right. It wasn’t really in the states as far as we knew.
[00:07:29] Um, at that point there was, uh, and you look from February to basically April from the leadership. There was not a great ability to communicate uncertainty there. Um, Like when I think about, uh, my position as a, as an eye doctor, as talking to patients about their risk. And this is exactly what we’re, we’ll get to in a little bit, is that.
[00:08:01] The way that you garner trust the way that you establish rapport with that person and they trust you is that you communicate, uh, what you know, and what you don’t know. Uh, and I, and I honestly, I just don’t think that that was done very well at all. And what it did is it. It polarized, like we’re, we’re already kind of in a, we’re not kind of, we’re in a very polarized situation right now, politically, anyhow.
[00:08:25] Um, but then when you have leadership that is, um, polarized as well. They’re not communicating uncertainty very well about. Essentially mandating certain things that maybe not have the as good of evidence as they’d like it to be. But they’re not saying that those types of things are withholding, that that just doesn’t garner trust, you know?
[00:08:47] Um, I mean, you can’t, no matter what side you’re on left or right. You can’t look back. In my opinion, you can’t look back at the. Uh, almost two years and think that it’s gone well, like, you know, just look at the numbers 750,000 plus, uh, deaths. Right. Um, if you look at that and you just have to say, there’s a, there’s a failure there, right?
[00:09:11] Uh, so, and we know as practice owners is as business owners, like when there’s a problem, it starts at the. 99% of the time, you know, like you can, you can blame people for not listening to you. You can blame people for, uh, just not doing what they’re supposed to be doing. And, um, maybe there’s some bad eggs here and there, but majority of the time, like if you have 50% of the people that.
[00:09:39] Do not listen to you whatsoever and don’t trust you. And then 50% of the people that do like that, that kind of falls on the leader that falls on their ability to communicate well. So in my opinion, that’s where we really, we just have not been able to, uh, communicate from the, get go the amount of uncertainty that’s existed.
[00:09:57] I think if we’d have done that a different way, uh, and not held back, what is the real risk here? Like put it in terms of. Not percentages. Like we talked about last time, but put it in terms of, Hey, one out of 100 or one out of 10 things that you and I, and everybody can see and think, okay, I get that. Like, I can feel that I, uh, you know, there’s, uh, there’s kind of a quick understanding, whereas a percentage improvement, nobody really like, that’s really hard to understand.
[00:10:28] Chris: Yeah. And, and I think, you know, there are things that, um, so if we’re going to apply this to okay. Um, moving forward, when you have uncertainty in clinical practice and you believe in the hunches that you have. Sometimes it’s really hard to, so we want to point to a randomized controlled trial, but one randomized control trial.
[00:10:49] Can’t tell us how to manage all dry eye patients. Right. And he can’t tell us how to even probably manage all dry patients with a steroid because you know, that landmines controlled trial might only last for two weeks or 30 days, or, you know, what have we need to use it longer? Or, you know, so, um, so how do you then.
[00:11:07] Have the confidence to share what you’re seeing with your patient so that they understand that that you’ve weighed the evidence. Well, you’ve weighed your clinical experience. Well, and you’ve, and I think part of the, bringing them into the decision allows them to understand, or at least feel that you’ve weighed their component well, but how do you communicate that uncertainty by saying.
[00:11:30] You know, this is what the evidence tells us. This is what we think. This is what I think is best for you to convey that confidence without being like, well, this might work or that might work or try this or try that.
[00:11:42] Kyle: Yeah. Confidence is the, is the best word there. How do you, how do you get confidence? It really starts, I think, um, break it down to three things that I’ve kind of packaged in my mind of.
[00:11:53] Okay. This is, this is the process that I would, that I would consider every single time. And number one, really. You, you gotta have your own confidence in the treatment. So, uh, it’s more personal leadership. This is like, before you get to the patient, before you have the patient in your chair, you, the three things I would go to as a assess, right?
[00:12:15] You got to assess the evidence, right? Okay. You need to articulate in certainty and then you need to document if you can do those things, those three things really well. I think you’re going to be really successful and garner that trust. You’re going to have, you’re going to have the confidence to move forward with a patient because they’re going to trust you.
[00:12:32] You’re going to trust that, that process and they’re going to trust you. So that first one, uh, like I said, it’s kind of. It’s an everyday grind. It’s an everyday consistent practice that, uh, if you want to continue to improve as a doctor, you got to do it. And that’s really just to assess the trials yourself.
[00:12:49] So don’t take, okay. Our reps are great, right? The industry vendors. Everybody’s great. They give us a lot of information, but go to the study yourself and read it. Um, don’t be intimidated by it. Yeah. There’s a lot, you know, I feel like we tend to make things way too. Uh, we want to be like statisticians. We don’t have to do that.
[00:13:13] You know, you don’t have to know really like thoroughly understand P values and you don’t have to just like what we talked about last. Look at the study, like assess the study yourself. So read through it and does this apply? So it’s compare, it’s understand the chances and then find some consistency. So it’s, does this study compare to, like we talked about last time, does it compare it to my patient base?
[00:13:36] Uh, what’s the absolute risk reduction in the number needed to treat and just understand those things calculate that, that every, every time. Um, so it’s looking at the studies it’s, uh, also if you. If you want to understand more about. Other clinicians are doing as well. Like you, you’re not only looking at the RCTs, but also clinical hunches.
[00:13:59] Um, read review articles, read, uh, two of my favorite applying evidence journals, hands down, review of ophthalmology and current opinion and optimal. Uh, those are great places just to get like, Hey, major review on macular degeneration and you’re going to get every, like every study. They’re just, you know, somebody doing the work for you, and you’re going to read that and you’re going to see the combination of clinical opinion and the RCT.
[00:14:26] So that’s a great, that’s a great thing to look at another awesome resource, uh, our resources, our, uh, clinical practice guideline. That, uh, AOA puts out or the academy of ophthalmology puts out a preferred practice patterns. So they’ve, I mean, if you haven’t gone there, it’s a great place to, to go to start.
[00:14:48] Cause I mean, they’ve have, you know, uh, preferred practice patterns on a higher or a open-angle glaucoma center. On ocular hypertension on a primary open angle, glaucoma on dry eye, on, uh, macular disease, you know, macular holes and or peripheral retina. So that one of my favorite documents is reading their preferred practice patterns on peripheral retina.
[00:15:12] You know, I mean, that’s, that sounds silly, but, um, it it’s great information, you know, it’s the reason why I’ve set up my protocol. If somebody has flashes. Uh, I’m going to have them, obviously you’re going to see them right away. If I don’t see any retinal abnormality, what that protocol says is you need to have them back in a month, right.
[00:15:29] Because if somebody is in your chair with flashes and floaters in that moment, there’s about a 15% chance that they’ve got something. Okay. Uh, if, if, if, if you find nothing, then there’s about one to 2% chance that they may still have something happen in the next month, four to six weeks. So you have them back and forth to six weeks, you know?
[00:15:49] Uh, so it’s just a great place to go for those things. Um,
[00:15:55] Chris: well, it’s nice because, you know, In your vernacular. The part that you’re talking about with talking to patients is, um, when you can say either, okay, the, this study tells me this and it’s going to apply, but if you can’t say that, you can say based on our clinical practice guidelines, and as long as you’re saying it accurately, we’re going to do X, Y, and Z.
[00:16:16] And the other part that I think is interesting to bring into this is the idea of billing. And I often, as you know, I often consult with. Different companies and different practices, as well as just talk about billing and coding. And one of the most common questions I get is, well, Chris, what am I going to have to worry about an audit?
[00:16:37] And that usually comes when we’re talking about managing a patient with glaucoma and having to run three or four fields in a, in a course of a year for one individual. And they, they think that that is going to trigger somehow this massive audit. And by being audited, you’re going to be like, everything is going to get, like, everything’s going to collapse in you.
[00:16:58] And so there’s this fear of, well, okay applying evidence. I’m worried about that, but, but like if you’re following the clinical practice guidelines and as you rightly point out, if you have a patient, I, I, I say this off the top of my head, but if you have a patient that has severe glaucoma. It’s not unusual to want to run a field three to four times a year on that patient.
[00:17:17] In fact, that’s what our clinical practice guidelines would suggest. It’s also not unusual. Our clinical practice guidelines and preferred practice patterns would tell us that within the first two years of diagnosis, we want to have six fields, correct to six fields and it blows your mind. And so, so like, um, So, okay.
[00:17:36] Let’s say that triggers an audit. Well, it probably shouldn’t be every single patient that has a diagnosis of mild, mild, or low risk glaucoma suspect. That’s getting six fields in two years, but you might have a patient that is that right. You might have a patient that is that. And so understanding those clinical practice guidelines, not only allow you to know how to communicate to your patient and how you should follow up with those patients, but it also should give you confidence in what you’re doing and how.
[00:18:04] How you’re billing
[00:18:04] Kyle: for something. Right. And one of the reasons, I mean, just to get into the weeds a little bit on that, uh, the, this is another, uh, practice guideline that I’ve been through that I’ve read through. And, uh, most people might think that’s kind of nerdy, but, uh, is the European glaucoma society also has, it’s an amazing document for applying evidence.
[00:18:23] Yeah. 60 70 pages or I forget, or maybe more. Uh, and it just like, it’s like taking glaucoma one-on-one again, going through there. And, uh, one of the primary reasons that they site for. Performing that, that a visual field six times in the first two years is because there was a study that showed, um, are there there’s at least evidence, I should say that 10% of new glaucoma patients are rapid progressors.
[00:18:50] So, uh, so if one out of 10, I mean, and that’s a conversation you have with a patient, right. Is like, Hey, you know what? We just diagnosed you with glaucoma. There’s evidence that about 100. Patients, uh, do rapidly progress in that first two years. So we, we’ve got to have you back, and this is my plan for you for the next two years.
[00:19:08] So you’re going to get really used to this, this clicker test. I know you don’t enjoy that. It’s not very much fun. Um, but that’s what, that’s what the guidelines show us. That’s what the evidence shows us. Uh, so that’s the decision we’re going to make. ’cause the last thing we want is to, for you to come back in, you know, just to set up the six month return, I’m going to see you maybe two or three times next two years.
[00:19:28] And all of a sudden two years from now, you’ve, you know, you’ve gone from a mild to severe, you know, that’s what we don’t want whatsoever. Um, and that’s not only good patient care, but that’s also reducing your liability.
[00:19:41] Chris: Right. Right. And part of that reduction of liability, and you mentioned this before, and I want to come back to it is the documentation component.
[00:19:47] So, you know, I think the other part of uncertainty is. Well, how much should I put in my chart? I need to be like, is it okay for me to put that I’m unsure about the, the state of this patient’s condition. And if I am unsure, do I need to have somebody else give me a second opinion,
[00:20:09] Kyle: right? Yeah. That’s uh, I think that documentation is the, probably like the most important besides understanding and assessing, and, and obviously you got to communicate that, but documentation basically seals it all together.
[00:20:22] It seals the deal for you. Uh, because you’re going into the chart and it’s essentially, if you, if you’re documenting this, that means that you do know the studies that you have articulated it. But basically you’re just saying, uh, say that glaucoma patient, you are saying that, um, for example, for, uh, ocular hypertension patient, I’m going to say, uh, patient educated on oats trials, uh, patient perceived, understanding.
[00:20:53] And educated on risk of treatment versus no treatment I’m going to put down on every single time, every single chart that I’m going to do that for patients. Uh, and then you, like I said, you want something in there where it actually says that patient seemed to understand what you were saying. Uh, so that, you know, and they know that like, Hey, this is, this was communicated while this is articulate.
[00:21:15] Um, and you can even put in there, like you said, uh, for example, for the oats, I always tell patients, we put it in that kind of number needed to treat mindset or that one out of whatever mindset and that’s, Hey, if we treat you, uh, you have about a one in, you know, a, what is it? One in 10 chance? Of getting glaucoma in five years.
[00:21:34] If I don’t treat you, you have about a one in 20 chance of getting glaucoma in five years applying evidence. That’s really what the oats shows us. As long as you fit in that category,
[00:21:42] Chris: right across the board, average patient thin exactly high, you know, higher
[00:21:47] Kyle: IOP’s. Right. Um, so document that. Right. So, um, and then after that, then patient prefers this.
[00:21:59] Patient direct, you know, period, patient directed to this, and then you can then list out what you’re gonna do, you know, for the next three to six months in your, in your plan. Uh, and that’s, I mean, there’s so many benefits to that beyond liability, beyond patient education. I mean, it’s a great. Having that full documentation so that when you come back, you have a idea of what you did talk about.
[00:22:24] Then you can reinforce that same topic. You’re probably going to have the same exact discussion again, cause a patient, you know, that’s going to go over their head. Um, but one point that I think is really important when we, when we educate. So when we articulate kind of going back to, um, when we’re articulating these things to the patient, Part of, um, part of articulating uncertainty to patients.
[00:22:48] Like we tend to be in a real marketing driven world right now in marketing tells us that we have to simplify, simplify, simplify, everything. I don’t think I, I could be wrong, but I personally don’t think that’s how we should be. Um, we should be educating our patients. Uh, that’s, that’s a tool to help you buy something, right?
[00:23:09] When you simplify something, it’s like making something black and white, it’s like, you know, you’re either going to have this life or this life. If you buy our product, right. That’s marketing, that’s not really medicine. Medicine is about, uh, really are articulating well, the complexity it’s okay. And I think it’s ideal relate this back to what we did, what we talked about previously about COVID our COVID response.
[00:23:35] I think it’s okay. And really wise to unpack the complexity of it. Right. Because it puts the patient in a position where it’s like, okay, I see where they’re coming from here. I trust them that this isn’t just. He knows exactly what we’re going to do, and it’s just going to, things are going to be solved and then I’m gonna move on in my life.
[00:23:56] You know, think about this in the terms of dry eyes. Yes, uh, 85% of dry eye patients. It’s my Bowman gland. Dysfunction is underlying reason and 15% it’s, you know, decrease or aqueous deficient. But is that really true? I mean, that’s kind of what dues one lettuce, but then. Clinically, like, it’s so much more of a mix than that.
[00:24:19] Right. Um, we, we know that when we’re, when a lot of us that treat a lot of dry eye, it’s way more complex than that. And I honestly say that to every patient it’s like, this is kind of how we tend to categorize. But it’s like, it’s hard. It’s like, this is a chronic condition and it waxes and wanes, and these are the things that we kind of know.
[00:24:39] But, um, so some of these are things that we have good evidence for. Um, but communicate that complexity. I think patients deserve that and they respect that well, and
[00:24:50] Chris: I think it, it comes full circle. Right? You you’ve understood the evidence. You then applied your clinical hunches to, to the evidence that you have and that individual patient’s situation and preferences.
[00:25:04] And then by articulating it, you’re gaining trust. You’re building trust. So that patient, when they need to potentially wonder about something or when, when you can’t fix something right away or something isn’t getting better, as you would want it to get better, or the patient might want it to get better.
[00:25:20] And then you’ve documented. I mean, at least the patient has, I mean, it’s, it prevents all of those things are, are going to prevent all the stuff that you don’t want to have happen. Losing patients, uh, you know, having bad outcomes, uh, having, um, having malpractice lawsuits brought against you. Right. Even if you, you know, if you put in your chart, all of the things you’re talking about, and let’s say that patient did in fact have glaucoma and did in fact progress and their glaucoma.
[00:25:51] On the one hand, it’d be really hard for them. I mean, if you’re monitoring them closely, it’s probably not going to be a rapid. And, um, and so if you’re following our clinical practice guidelines and you’re following what the evidence tells us, we should do, and we’re not worried about, you know, getting audited because somebody might, you know, come down and look at our charts, then that patient’s going to come back in six to 12 months.
[00:26:13] Right. Let’s say they’re let’s if. 22. They’re probably going to come back in six months. If you look at our clinical practice guidelines, maybe, maybe you’ve, you’ve established that they’re stable over years and you can push it out a little further. But, but the point is, is that a patient with a pressure of 22 at almost any age is not going to lose significant vision from glaucoma in a year, right?
[00:26:33] Uh, are. And so, so if you’ve done all those things, you’re going to follow that patient and they’re likely not going to get worse. And then you’ve built in trust with the patient. So they’re going to come back and even if they don’t come back, they’re going to, they’re not going to want to go after you from a malpractice standpoint because they’re going to have, they’re going to remember.
[00:26:53] Oh yeah, yeah. Maybe I went, I didn’t went someplace else cause I got a better deal. Or I went online because I, you know, I knew that Dr. Clooney talked to me about other stuff I knew he had. Worried about this, I should have known better. And then even if it gets to that point, your chart has, has described all the thought that you’ve gone through and, and start applying evidence into this individual case.
[00:27:14] And I, like, I also think. That, you know, as we get into busier clinical situations, it can be easier to not chart as well, but that only punishes you later, right? Because if you chart well, as you said, you know, I can look at my charts now and look at what my plan was from six months ago, three months ago, a year ago.
[00:27:33] And I can know exactly what I was thinking and exactly what I wanted to do. And the only difference is on that specific visitor is if there’s something new that has been brought to the table that I have to. Otherwise it’s it’s okay. This is what my protocol was. This is what I was thinking about this.
[00:27:47] Is there anything different about that? No. Okay. This is what we’re going to do. Right? Right. So that, that simple, it actually simplifies your life in a busy practice.
[00:27:55] Kyle: It really does. And that is the common pushback it’s like, okay. I gotta, I have to document all of that in it is, it is. Um, It is tedious at first, uh, to really like, if you aren’t documenting like that to really get into it and do it, but once you you’re exactly right.
[00:28:15] Once you start doing that on a consistent basis, it really does, uh, pay off big time in the long run, um, spending that extra, you know, 60 seconds really in each chart at the end, summarizing in a story. Cause really that’s like. I don’t know a lot about audits. That’s not my area of expertise, but from what I have heard, like, I mean, these are these people that are auditing auditing charts.
[00:28:45] They’re not medical experts. Right. So, if you can write in the story, rarely, rarely, but, so if you can tell a story, right? Like, you know, that that is marketing in a sense, you know, uh, we’re all very in tuned to stories and when you have a good story, uh, that seems like it’s pretty methodical and well thought out then.
[00:29:08] I mean, that’s going to be, uh, going to be really, really helpful, uh, in those situations, I would think at least. Um, but yeah, I th I think it really, uh, it, uh, whatever you are, the amount of time you’re spending on the backend, that extra 60 to 90 seconds, like you said, you are saving on the front end the next time you see that patient, uh, cause you can train your staff just to go in.
[00:29:33] And I just, I just say. You need to click on these tabs and go right to my, uh, my summary right there. And you’re getting everything you need to know about how are handling this patient, all the tests we’re going to do next time. You know? So that’s, that’s what they do is they just my technicians, they come in and they look at that.
[00:29:51] They read that and they know exactly what we’re going to do, and they learn something about, about the patient and our decision. Uh, another word on that too, is what I’ve found with documentation. So say there’s a situation where you don’t know what that we’re, we’re, we’re all we’re always talking about.
[00:30:06] We, we have been talking more about, we know what the diagnosis is and now we’re just trying to figure out what treatment, right? Right. Well, when you don’t know the diagnosis, that’s a whole different thing document that, right? Well, yeah, we
[00:30:18] Chris: did. Yeah. So we didn’t get into that. So, so talk about that. If. Um, cause that’s the other part, is that okay?
[00:30:25] Well, we’ve got ocular hypertension versus glaucoma, but that’s kind of similar, right? We know how we can manage that uncertainty, but I don’t want to put in uncertainty when I see some patients that have corneal infiltrates, but I don’t know maybe this is her Pedic or maybe it is, um, or I don’t know.
[00:30:46] Yeah. So what do I do? So the natural reaction is to just get rid of them. Let somebody else take a look at them in hand. Right?
[00:30:53] Kyle: Right. Um, it’s to it’s the walk walk, I walk it through with a patient. Just, just like I was talking about before is I, I just out loud and a lot of times I come into my conclusion by talking it through to the patient.
[00:31:07] I don’t know if you do that as well, but sometimes it just makes an understand their preferences. You start to feel like. Uh, if they’re worried about it, you start to feel their level of anxiety. And if they’re really anxious and you have no idea, then maybe you need to have a second opinion. Right. Um, but for the most part, it’s just walk through, Hey, it could be this or this or this, you know, you’ve got these, you know, sometimes a lot of times corneal issues.
[00:31:32] I mean, they’re not textbook, you know, the cornea is difficult. That’s why we have specific people that are specialized in that. Right. And we should be to optometrist. I mean, that should be our bread and butter as well. Um, but it’s to walk through, uh, each of the options and to articulate the complexity of that, just to say, Hey, we usually, you know, for, uh, for your example there, well, I would articulate it could be a virus.
[00:32:00] Okay. But what viruses, the textbook view of a virus, a textbook example of a virus is to have these little, we call them. But I’m not really seeing that, but sometimes when it’s really early on, they’re not quite formed yet. The dendrites aren’t quite formed. It’s more punk date. It’s more kind of like a little, little, you know, spots.
[00:32:18] Uh, so that, and that’s kind of what I’m seeing today, or there’s this other thing that we kind of think is. Um, but it, but it doesn’t really usually happens in kind of a white and quiet. I, and that’s, that’s similar to what you have. So I, I mean, I just walk them through that whole thought process, uh, and it just, it lets them in on the complexity.
[00:32:39] Um, and then I document that, I usually say patient educated on a potential differential diagnosis, and then I put a colon and I just list them this versus this, versus this versus. And, and then I just say, based upon the discussion, we’re going to initiate. Topical steroids. Right. You know, um, we’re gonna, we’re gonna initiate.
[00:33:00] Well, it does make me
[00:33:01] Chris: more, more, um, make it more likely that this is the diagnosis, but we’re going to be aware of these other diagnoses precisely. And that’s how, and so we’re going to watch closely for resolution or
[00:33:12] Kyle: progression. Yep. And then I would say, you know, we’re going to return, have the patient patient understands the risk and we’re going to return the, have the patient return to office in one to two days.
[00:33:22] Or sooner patient was educated that if anything changes list the things that you told them, that if these specific things change, then they’re going to call you. You know, you can even a lot of times I’ll just say Dr. Clooney gave them. Uh, gave patient direct number or mobile phone number to call him with any changes after hours.
[00:33:44] And so just like, okay, you’re just presenting the case that you’re here for the patient. You’re not doing something. Careless. Right, right. Uh, you’re spending time and thinking through and, and the art of it. And even
[00:33:57] Chris: if you miss thought something like, like the, the reality is, is that malpractice doesn’t mean you can’t make mistakes.
[00:34:04] It just means, it just means it can’t be like patients can’t be like catastrophic harm by those mistakes or even significantly harmed. I mean, I’m not a malpractice expert, but the reality is is that like, there’s very few, uh, Very few times where if you’re listing all those things out, let’s say there was a whole other differential that you weren’t even considering.
[00:34:25] I don’t know what it would be, but, but maybe there was something right. And some, some, you know, most experts that would come in and look at that case would probably say, you know, I don’t know that I could, I could fault him for what, the way he was thinking, because I understand the logic that he’s presenting.
[00:34:41] Right. Very few doctors are probably doctors out there, but there’s very few doctors that, uh, won’t get. Clinicians the benefit of the doubt, especially if there’s, if they’re well articulated in their documentation. And they’re, well-reasoned like maybe there was a zebra there that you’re not considering that is going to wind up harming that patient again.
[00:35:00] I don’t know what it would be, but what the point is is even if you miss that zebra one, you’re having the patient backs. To, uh, your, your articulating the things that are going through your head and the complexity that’s going through your head and why it’s reasonable for you to think that this is the, the, the thing that you’re dealing with.
[00:35:23] So then, then we’re, you know, and then every time you have that patient back and you’re monitoring that patient, you’re you’re wondering, okay, is this still reasonable is okay. Cause it’s, it’s getting better just as we expected to get better, as opposed to now it’s not getting better. And I don’t know what, what, the other thing that I’m missing is that makes sense, right.
[00:35:42] When you can’t figure out what you know and what you don’t know. That’s where you have to to think, okay, what, what am I missing? Who do I need to bring in Chris’ case to, to help me clarify that,
[00:35:54] Kyle: right? Yeah. That’s a great point is like, yeah, if you do have you
[00:35:58] Chris: articulated a patient, sorry, but that this might be, you know, when we were running last time you articulated a patient that, um, had his.
[00:36:06] Uh, prior history. Yeah. So go ahead. You were going to say
[00:36:09] Kyle: something and then I’ll, I’ll talk about that. Yeah. So interesting case I have a, uh, patient he’s he’s about he’s our age. She’s, uh, late, uh, early, late thirties, early forties. And he’s had, um, plaque psoriasis for 15 years and he has not treated it whatsoever just because he’s in, uh, because it can cause issues with.
[00:36:32] Um, some of the heavy treatments for, and he would need some pretty heavy treatments. So, um, and he had, when he was he’s an attorney and when he was in law school, uh, he had, uh, a histoplasmosis infection. And, um, so his right eye, when you look at it, he’s got the classic histo spots, but he’s got peripapillary atrophy.
[00:36:52] That’s significant to the, to the point where it took out about 40% of the macula. Okay. So when you look at those photos, you’re like w and he’s 2020. Okay. Where’s contact lenses, 2020. Uh, so seeing really well, but man, any more and he would be dramatically losing vision in that, in his right eye. And so he we’ve been talking about it for several years.
[00:37:16] He’s been, uh, in terms of him trying to initiate treatment for his plaque psoriasis and I, and I told him every time. Those are immune modulators. Okay. And theoretically, if you go on something like that, uh, prior infections or, you know, latent infections, uh, could resurface. I mean, it’s theoretically, I don’t know how I never, you know, when I told him that I was just like, this is all theory.
[00:37:41] I have no like data. How many of this times this happens, I’ve no study or anything like that, but we just have to be mindful of that. So when you do decide and see your rheumatologists, do you do decide to do. Uh, you need to let me know, and then we need to figure out a plan. And so he did, it was a couple of weeks ago he texted me and he said, Hey, we’re going to start this medication.
[00:38:00] I just want to make sure it’s okay. And so I, um, excuse me, I. Uh, obviously texted him back and we talked about it a little bit, but it was one of those where I emailed, um, our, uh, one of the local retinal specialists here and we have a pretty good, uh, rapport or a relationship where he’s, I just said, Hey, this is the case.
[00:38:23] Just like I just presented it. Here’s the photo. And have you. Had any cases where toxo or not toxo, histo, um, reactivates. And because I don’t, I mean, I’ve seen maybe I, you know, less than 10 in our, in our demographic, in our area right now. And he said, I’ve seen, he said, I’ve seen one patient. I have one patient that has had a histo reactivation.
[00:38:48] I, and none of them is because of this. So, and he said the same thing. Is it possible? Yes. Theoretically possible. Is, is it really rare? Yes. Uh, but this is the plan I would make is we would do this. And so, um, so I said, okay, great. That’s excellent information. That’s kind of what I was feeling as well. So we made up.
[00:39:10] Uh, with this patient. Okay. Once you start that in about six weeks, we’re going to have you come in, we’re going to do an OCT and, uh, give you an Amsler grid. You’re going to look at that at home. And then about every two to three months for the next year of treatment, that you’re going to be on a, we’re going to have your.
[00:39:27] And just do an OCT just to be sure that we’re not losing anything, there’s no reactivation or anything. So, I mean, that’s like, there’s no study as far as you know, that’s totally just like, Hey, this is our hunch. We should probably watch it this way. We have these tools to evaluate, uh, this, uh, this tissue and it’s all based upon theory, but.
[00:39:48] It’s all documented. Right? We talked about it. The patient prefers this patient. Doesn’t yeah. And
[00:39:52] Chris: you can also put in there, look, you know, discuss the case with Dr. So-and-so and he agrees with the plan that we laid out. I mean, you’re not trying to throw him under the bus. What you’re saying is like you’ve added complexity to your thought process, by the way.
[00:40:07] Then you can, you can bill for that outside consultation, right? Correct. Either in your number of data that you’re considering, or the amount of data you’re considering or in a separate consultation. But I think the point is, is that, um, you’ve, you’ve managed uncertainty. Yeah,
[00:40:24] Kyle: yeah, yeah. Again, going back to it’s okay.
[00:40:28] To communicate complexity. It’s okay to do that. Um, you got to, I, you look back at just like the art. I said that I used that word earlier. There’s an art form and a science. There’s an art form to doctoring. And that is just being. Comfortable with that. You’ve got to learn to be comfortable with that. And I think the way to do that is just to understand big picture wise.
[00:40:52] Like there is a lot of uncertainty, there’s a lot of things that we are totally uncertain about and nothing is really that. Um, perfectly well-designed in terms of treatments, um, yes. Some things kind of help some things kind of don’t. And when you kind of get to that point, I guess, in your career, or in that point of understanding the evidence enough, that there’s just a lot of uncertainty, anyhow, it actually gives you confidence, like, okay, then it’s really just down to it’s under my control to just communicate that really well.
[00:41:24] Uh, and paint that picture really well with patients to, to realize like, You know, this isn’t a perfect solution. There’s no silver bullet or very few, I should say very few in medicine. What’s up.
[00:41:38] Chris: I think one of the things that before we wrap up, but I think one of the things that always helps me clarify my thinking is, especially in uncertain situations is to try to step back and say, What’s the stuff I really have to worry about.
[00:41:55] You know, what’s, what’s the threat to vision. What’s the threat to life in this specific place, especially, you know, we had a patient that came in and in Awana being just a really big subconjunctival hemorrhage in a patient who has had lots she’s on 23 different medications, a couple different anticoagulants, but the, the notes in the, in the triaging, when the patient called was she’s got a bloody nose, bloody tears and bloody.
[00:42:21] Right. So immediately, uh, Dr. Lindsay and I were kind of talking, talking it through well, okay. So you’re starting to think, well, what could this, like, what could cause all three of those, what are the things we really need to worry about? And what are the things that, um, like if it’s just winds up being a subconjunctival hemorrhage, fine, but like, W what’s the really, and you can do that on a number of things, you know, a patient comes in with this symptom or this finding.
[00:42:47] Okay. I’m not sure exactly what this is, but I will feel much more comfortable if I can understand what’s the really bad stuff I’ve got to worry about. Correct. And then I can figure out if I’m really worried about it, or if, even if I’m not, how do I eliminate that from the thing I’ve got? I’ve got. Uh, I’ve got to lose sleep over in terms of uncertainty.
[00:43:07] Kyle: Yeah. That’s yeah. So well said. Yeah, just understanding what’s the worst case scenario in this, in this situation, you know, um, it’s, it’s just checking those things off the list. My top thing that I’m really, really worried about. I gotta look for that first and if it’s not that, that I’m gonna just check down the list and then it’s getting to the point of realizing, okay.
[00:43:25] Whatever the worst case scenario is here. Am I willing to sit on that and embrace that? Right? Am I able to own it? Am I going to own that? Yeah. And so what are you willing to own? And I, and gosh, you know, we could talk for hours on this cause we usually do when we’re running, but, um, as ODS, man, we got to own so much.
[00:43:45] Oh, yeah. You know, we, we, uh, we’re just in such a position where, and that’s why I’m passionate about, uh, decision-making clinical decision-making and understanding uncertainty, both just in our practices and in light of what’s going on, uh, in the pandemic is, um, we’re we have such an opportunity to, because we’re with people every single day with our patients every single day to, to like own this.
[00:44:10] To be the best at communicating this to be the best at understanding the evidence. Uh, because there have been some major failures, like we alluded to before. Um, in how this has been communicated to the public. And so if we can, uh, just do, do better and continue to, to improve on that and our own growth, our own selves and our own practices, talking to our own patients, uh, that just puts us in a better position to, uh, to earn their trust.
[00:44:42] And, you know, it all comes. The thing I was thinking about before is like, Talk about practice management. Oh yeah. This is the practice builder. I mean, I mean, if you just want to look at like dollars and cents at the end of the day, this is, this is going to establish you and this is not why we’re doing it.
[00:45:00] It’s a by-product, but it really does grow your practice. And, uh, it grows your reputation. Uh, people respect you. It helps the profession tremendously and just puts us in a position to. No matter what competition we have online or whatever, because we’re maintaining that position as the experts, as the go-to for anything AI-related, you know, from here on out.