This week Dr. Chris Wolfe and Dr. Kyle Klute sat down to discuss navigating uncertainty and how that impacts the care of our patients.
You can check out their full conversation here, by searching “EyeCode Media” in your favorite podcast app.
Read the full transcript below:
I tend to be like, just, uh, I love new ideas. I love learning. Uh, I enjoy. Uh, changed to a certain extent. And so sometimes I can get pretty scattered. Like sometimes I lose track of like, what’s my primary aim with that because I just love to listen to, you know, what’s, what’s new out there. What’s, you know, what’s the new podcast, what’s some new article or whatever, and it’s hard for me at times to like, okay, no, this is, these are my values.
I need to, uh, Use these to steer me, to keep me on track, to, uh, point me in the direction I need to continue to going to, to provide value the best way I can. I can just be, I guess. The best way to describe that as I would love to just stay in school for the rest of my life. Like that doesn’t surprise me.
I mean, I’d love to be a career student and just continue to take classes and classes, beauty practice. Yes, it is. For sure. Uh, and so really my, my aim with my practice is to try to mold those two things together. Right. So continue to learn, continue to grow, but yeah. Uh, to enjoy, uh, you know, giving that what I have learned to my patients as well, and to the community.
Um, so. Uh, what I was going to say, basically, we, you know, our core values for our practice. Number one is connect, uh, connect with others, uh, connect deeply. And that’s th these are all four core values that I remind myself of my, uh, myself every day. These are, uh, personally things that I, there may be interpreted a little bit differently, but kind of the big thing is.
Uh, really the same, the message is the same, but, uh, it’s, it’s connect. It’s connect is also like empathy. It’s hospitality. Uh, it’s this, this mindset that we’re here for you, you know, um, the next one is generosity, generosity, you’re giving and not holding back. Um, and that a lot of times we think of generosity in terms of.
Uh, financial, like we’re trying to give a, well, the reality is we’re in a business, you know, we’re not here to give everything away. We need to make money. So, uh, generosity is more of like, The classical understanding of generosity, of more of our presence. Like we’re giving our presence and we’re giving everything.
We’re not holding back any information because at the end of the day, what we’re here for is really just to help people make great decisions, right. That’s at the end of the day, it doesn’t matter how we do that. It doesn’t matter if it’s. There I say online, you know, through tele-health or, uh, maybe not even, uh, you know, using an autorefraction or whether it’s, uh, um, you know, where no matter what it is, As long as we are helping our patients make the best decisions about our eyes and we’re keeping ourselves as that consultant or that expert.
That’s the main thing, you know? So it’s keeping that really big long-term view. And I see that as generosity. Yep. Um, and then the next one is just continuous improvement. It’s growth. It’s a, it’s a mindset of. I may not be very good at something now, but I know that I’m going to put the work in and get better at it.
And I may not be the greatest, but don’t care. I’m going to continue to, you know, incremental improvement. Uh, and then the last one is just celebrate, you know, so, or it’s enjoy celebrate, celebrate, you know, goodness, truth, beauty, wherever you find it. So celebrate when our, you know, neighbors or practice other practices or colleagues are doing well.
Um, celebrate. Uh, and find value in goodness, you know, in the community and all that. So celebrate when you’ve got a great new remodel. Exactly, exactly. Celebrate yesterday. We had our, our one employee, you know, uh, it was her first year. She’s a year for her at the practice. You know, all those things and that’s what makes it fun.
Yep. You know, so, so one of the things that you and I have discussed a lot is the idea of continuous improvement and, uh, and uncertainty. And so, um, I think that applies a lot to clinical practice and a lot to one of my core values, which is trying to make sure that we’re always, as you said, always improving and always in and trying to, how do we push a line?
How do we push a boundary where we’re. Where we can know that patients aren’t in danger, we can kind of sort through what is most likely to occur with this patient and what are, uh, you know, what are the horses and zebras? What w what do we have to worry about that we know? What are the things that we don’t know, and how do we overcome those things so that we can make sure we’re giving good care, but also not just booting up.
Unnecessarily, and there is a fine line. Um, and I think understanding that line and finding it continuously allows for continuous growth, which allows you to better care for your patients in the short-term and the long-term. And, um, but it’s a real challenge to know, uh, how do I mitigate or how do I navigate.
The uncertainty of practice. And when I look around at my mentors, the, the guys that I really feel like they’ve got it, they’ve figured that out. They figured out how to navigate uncertainty in a clinical situation. So tell me about that great question. Uh, this is kind of a little pet project in mind, just because I, you know, I just talked a little bit about.
hello and welcome to the Criswell podcast. And I could meet you today. I had a great conversation with Dr. Kyle QD about how to manage uncertainty in our practices and our lives. How do we evaluate things like. Randomized controlled trials, as well as our clinical experience and align that with patient preferences, it was a ton of fun to talk to Dr.
Clooney. I have a conversation with him on a weekly basis. Please enjoy our conversation as always be sure to subscribe to the podcast, write a review, share it with your friends and support those who support us, a growing number of children with myopia. If you’re coming through the doors of our practices in recent years, optometrists across the country have answered the call to provide true.
Conditions instead of vision correction alone through workshops, like the brilliant futures acceleration program practitioners have had the opportunity to share their perspectives and support those who are implementing the myocyte one day lens into their practices. Some of the tips that resonated with me include educate early and often with your patients.
Talk about this all the time, offer a myopia consultation, visit assign a myopia management team member. Somebody who’s going to own myopia in your practice. And advocate for this to patients as well as you communicate consistently with families. And there’s great templates at my site, pro.com and emphasize comfort and ease of use for more information on successfully implementing my site one day into your practice contact your CooperVision sales representative, or a myopia management specialist.
It’s kind of a little pet project of mine, just because I, you know, I, I just talked a little bit about, you know, core values and how I need them to keep on track. Equally. I feel like I’m always trying to, I think a lot about how do I make the best decision, you know, how do, how do it just like you’re saying is how do we, how do I know, how do we know something?
You know, the, the, uh, the word for it is like a piston ecology. That’s the, that’s the study of, of how do we acquire knowledge? You know? So it’s more philosophical, but really. Um, how do I make the best decision for my patient when it comes down to it? And what evidence do I need in order to do that? And the thing that I keep coming back to, uh, I guess I’ll say this first, my, my, um, my disposition.
Is always to try, like I just said a little bit ago about academia. I love being a student. My, my disposition is to lean very heavily towards a randomized clinical trial. Uh, and I think that’s a good awareness of the space medicine. Evidence-based, that’s one of the three things. Yeah. Yeah. And that’s what I want to say is that, so if you break it down, so evidence-based medicine, that’s a, that’s a loaded phrase.
Right? Right. I think. I think we all have when we hear that some of us cringe, some of us, some of us get angry, some of us pushing the signs, clinicians, for sure. Um, but the reality is, is I think that, like there was a Oxford professor that he’s one of the founding fathers of, of evidence-based medicine. Uh, David Sackett is his name.
And he proposed that there’s a triad within evidence-based medicine (allows us to navigating uncertainty) and we’ve probably all seen it. If you can picture it in your mind, three conjoined circles. Uh, the top circle is, uh, compose of patient experiences, patient values and experiences. The bottom left. I mean, knowing in no particular order, but the bottom left there, usually how it’s presented or the randomized clinical trials and then the bottom right.
Is a clinical experience or what I’d like to think of it as hunches. And that’s not disparate to disparage like, experiences. Like that’s really what it is. It’s like when we really come down to. Our experiences give us hunches and those hunches may be true or false. Right. Uh, and knowing that, understanding that, that it really is just a hunch, uh, is actually kind of freeing, right?
Don’t you think? Uh, but embracing it, embracing this is freeing you, understanding that not every. I think the, the gut reaction for a lot of us is that, well, if I don’t know what this is, I’m going to send this to somebody else who’s going to know. And most of the time, those people don’t know any better than we do.
They just understand how to figure out the uncertainty and how to start navigating uncertainty. Yes, precisely. And this whole model of those three. When you think about those three pillars, when, um, when decision-making breaks down, It’s when we start leaning too heavily towards one out of the three or two out of the three and we neglect the other.
And I mean, where you could go into. As we do on our Tuesday morning runs, uh, where you could go into what’s going on in the world right now with a pandemic and you could evaluate it through those three pillars. And I think there’s a lot to say about that, uh, for good and for bad. Uh, but when that breaks, when that decision-making breaks down, I think you’re probably in a position where you’re neglecting one.
And like I said, my, my inclination or my, uh, my leaning is always, I always lean heavily towards the randomized clinical trial because that, for me just provides a lot of, lot of, lot of, um, uh, just. It mitigates a lot of my doubts or maybe helps my insecurities about, uh, hunches that I don’t maybe experiences that I don’t have.
And that’s okay sometimes. Right. Uh, to lean towards that. But the reality is is every single one you lean towards every, any one of those three, they’re all, they all can be weak. They all have weaknesses. Right. Randomized clinical trial, like what are the weaknesses of a randomized clinical trial? Yeah.
There’s people that aren’t included in that trial that you can’t apply precisely which makes it difficult to start navigating uncertainty. Right. And we forget about that. We do, for example, hypertension treatment study. Yes. You know, you got pressure at 22, not in the trial. Yup. Right, exactly. Right. We’re at 35, not in the trial trial. Yeah, for sure. Well, the other one too, that, uh, I like to bring up is this Scott, you know, the, uh, steroids for trial and we constantly, maybe I’m being too dramatic here, but I feel like we constantly use that to explain what we should do for corneal ulcers.
But when you look, do you know, I mean, have you seen what the, the data, like, if you look at the S the 500 or 500 patients within that? Yup. Okay. Uh, 320 of them. So well, over half of them, uh, were manual labor, uh, either agricultural or nonagricultural workers that had a foreign body in the majority of them are foreign body induced infections now from outside.
Yep. Yep. Now I’ll try that to your practice, right? That’s not my practice. That’s not your practice. I mean, we constantly teach that in schools here, but in the typical. You know, primary care ODI practice in, uh, in America. What are you seeing? I mean, I’ve personally contact lens, well, contact lens. I mean, we rarely see them anymore.
Right, right. It’s contact lens in my, in my patient demographic. And what are you and what are you seeing? What I’m seeing is I’m seeing peripheral, peripheral infiltrates. It’s infiltrates. It’s not also, it’s not ulcers. Yep. And so. That completely that’s completely different. You know? So I would say nine times out of 10, if I’ve got a, a co a corneal ulcer, which is really, isn’t an ulcer truly, right?
It’s an infiltrate. Um, then I’m hitting the steroids and the antibiotic is not necessary. So we can’t even apply that. And when you look at it, like the, the, the group that was used for that, for that RCT that we constantly build up, there are eight contact lens wearers, right? Eight out of the 500, right.
Yeah, it’s really not like, how can you really apply it? Yeah. But yet we, we use that and we praise it so well, you know, to, to kind of come back to the other, um, the other push on patient preference, you know, um, Dr. Lindsey in our practice, she had a patient, she’s got a patient right now that, um, is a patient longtime patient of my dad’s.
And she’s just, just four-plus SPK patient, bad, dry eyes. She’s got Parkinson’s. So she barely blinks her eyes. Um, can’t put any drops in her husband can’t get any drops in. She doesn’t want to do any procedure-based treatments. Right. So LipiFlow is out. IPL is out. Uh, she does, she has horrible inflammation, but what, how do you control it?
Right? She’s got all these other. Systemic diseases her, I can’t remember if my point is, is even her she’s so concerned about changing anything, right? Like even omega threes to try to reduce inflammation. Um, they’re not going to do that because of the amount of vitamin D that could impact some of our other medications.
So she’s just really concerned. So. So then you get to the point, it’s like, you know what he got left, right. I mean, and, and that’s, and that’s where patient preference goes so far in one direction. Right? And then you, your hands are sort of tied. Like I think yesterday she plugged her just a 10 day plug just to make sure we’re not going to make inflammation worse, but she also thought one let’s improve symptoms.
Let’s get down. You know, she’s not going to do goggles. She’s not going to, it says I’m not going to do scleral lens is not. It’s like, all right, well, we’re, we’re scraping the bottom of the barrel. And so I totally see where, uh, where you can flip and push to these other areas. Right? I know. Yeah. The, the, the one, the example that I think about all the time for patient preferences is, uh, I have two, uh, two glaucoma patients that I’m managing data completely opposite, uh, and opposite in their disposition.
Hmm. One of them has a incredibly asymmetric, uh, IOP where she’s constantly in a ride. I at 30 to 34 and in her left eye, she’s between 22 and 26. Mm. Uh, nothing to explain for it. It’s just, that’s just the difference. And, uh, she absolutely does not want to be treated whatsoever. She is very, you know, SLT, nothing.
She does not want any drops. She has 0.2 nerves. I, and I always tell her, I S I S a, I won’t use her first name, but I always just say, Brandy Brandy, uh, you, you know, the conversation we’re going to have, if you go to you can, you know, if you went to 10 other doctors, uh, and they didn’t know you, as well as I know you, they were probably like forced treatment almost.
Not really. I mean, but they would really recommend that. Yeah. Again, the main thing is that your nerves are healthy. We’ve, you know, I do. As long as you keep coming back to me, like as long as I see you every six months and we do OCT visual field. Uh, and check your pressures and I don’t see any changes on that OCT your visual field, then we’re totally fine.
And she just loves that. She’s loves not having to be treated flip side. So that’s definitely like I’m using evidence-based medicine because, uh, I don’t know how much clinical experience I’m adding to that, but you know, the randomized clinical trials would say, I need to treat her right. Or even my clinical experience would say, I need to treat her, but the patient value and expectation is no.
On the flip side, I have a patient who she’s probably equal age, probably in that, uh, early fifties range where healthy nerves, uh, borderline IOP is 21, 22 is their max. And she wants to be treated because her sister has glaucoma and to have, has had bad glaucoma. So she just wants nothing to do with it.
She, and she’s anxious every time she comes in, uh, You know, um, I’m willing to do that willing to prescribe and that’s, that’s the, that’s the art. Yes, right? Yes. That’s the, that really is the clinical experience. That really is like the, uh, the essence of why we are in the position we are in. And you can’t just plug in these randomized clinical trials to computer to make the decision for us.
Right. Yeah. Because it takes so much more than that. We’ve talked about that before, too. It’s like, It really just comes down to trust. Like if you are. If you’re leaning really heavily towards the hunch side or the RCT side without the patient side, people are not going to trust you. Yeah. Yeah. I think that’s true.
And I think, um, your, uh, it’s nice to be able to, you know, I probably geek out a little too much when I’m talking to patients about what, what studies tell us. Yeah. But I do think that. That being able to articulate that, plus being able to say, this is why it’s going to apply to you or not apply to you.
And we could do this or that, then it does bring in the patient preference. It’s like, you know, and I’m going to bring in the pandemic because it’s fresh in my mind. But, um, there’s, there’s all these hunches that are being articulated. And then there’s this misuse of randomized control trials that occurred.
So, you know, the, the headline is, you know, you can reduce your risk of contracting infection by 95%. What type of risk are they talking about? They’re talking about relative risk reduction, not absolute risk reduction. Precisely. So, um, so one of those things that was right on my mind was, was recently about.
Um, uh, masking for kids and, you know, you can look at a bunch of studies and it’s probably safe to say that there is some benefit and there’s a, there’s a big study that I think is still under peer review in Bangladesh. And you and I talked about this a little bit and essentially what, what that study found was that if you wear a surgical mask, not cloth mask, but surgical mask, Um, and again, they had training on proper wear and all this sort of thing.
Then you could, um, reduce the, so the headline is surgical masks, reduce risk of COVID infection, and then you read and it reduces it by about 11% and then you keep reading. And you find that that’s the, that’s the relative risk reduction. And you find that the, the people who were wearing the surgical masks had a point over the course of eight weeks, had a 0.6, 8% risk of contracting COVID in this specific population. This makes it difficult to start navigating uncertainty.
And in a 350,000 people randomized into, I mean, it wasn’t blinded of course, but randomized into masculinity masks. And then the people who weren’t wearing masks had a 0.7, 6% to 0.7, 6.08% difference is your absolute risk reduction. So if you flip that obviously, and you, and you figure out your number needed to mask your one in 1,250, so you’re masking 1,250 people to prevent one symptomatic or asymptomatic infection.
Now, the question that I would ask is. Some people would look at that and say, that’s still worth it. And other people, other patient preferences would say no way, it’s not worth it. Right. But, but the problem is getting to that point to at least have that conversation is so difficult that, and then once you get there, Again, now we can start talking about preferences.
Now we can start talking about, well, what is important? Like apply it to a school population in Omaha, Nebraska, and you can say, okay, well, in our school, in our particular school where our kids go, it’s about 900 students. Well, over the last eight weeks, they’ve all been masked. And the assumption is from administration is that we’ve done good because the studies tell us that we can reduce the risk of contracting COVID if we wear masks, except that over the course of eight weeks, a randomized control trial tells us that we need reading to mass 1,250 to prevent one symptomatic.
And we don’t have 1,250 students. So the chances are we haven’t done any good. And so, but the point is, is like getting to that conversation. So difficult and then we can have, and then, but once we do, then we can have discussion about preferences. So anyway, I think it’s just, um, and we have a real conversation about those preferences.
Yeah. And what means something? I mean, that’s largely my, uh, worry, not worry. I’m not worried about it, but that’s. Largely my concern. Like if you, if you think about those three, the patient values and preferences, you think about the RCTs and you think about clinical hunches and the bedrock of all those things are trust.
Right? We’ve talked about that. It’s, uh, none of them work if the patient doesn’t trust you. Right. And because it’s all, it’s always like the whole, the whole picture. Well, and if you don’t trust the patient, that’s the other thing that patient that you were describing that has a pressure of 34. If you don’t trust her to come.
The intro, then you’re going to say, I’m going to prescribe this medication for you, and then you don’t really care anymore if she, if she comes back or if she doesn’t listen to you because you’ve already done the precisely. And is she just gonna go and leave and come back in three years and then she has full blown glaucomas.
She’s lost vision, all of that. And then, yeah, I mean, you could go down the road with what happens to. Um, but yeah, it’s all built on trust, uh, because the reality is, is that we’re just trying to figure out how to make a decision when there’s a lot of uncertainty. Right, right. We are fooling ourselves. If we think that we have it all figured out.
Yeah. Um, we just, we just talked about how RCTs are helpful, but they’re not always helpful. There’s a lot of problems with them. Even in that one, our hunches, there’s a lot of problem with problems with our hunches. We have a lot of bias and the reason we have our CTS is because to try to mitigate some of the biases that.
Uh, when we’re with our clinical experience, you know, so then do you always need, so that’s the other thing, and we see this a lot with macular degeneration is, and I was like this, you know? Um, so how much do we need to know how much is a randomized control trial needed to tell us? To solve those hunches.
And how can we know whether or not that randomized, like where would you look to say this control trial? Isn’t going to tell me the stuff I need to know about early intervention or, you know? Yeah. Yeah. I mean, if I’m looking at a, if I’m looking at a trial and I’m or at a paper and trying to articulate or trying to understand it better to apply it to clinical.
There’s really three things that I’m looking at. One is our comparisons. Like, no, the comparisons, you know, we just talked about that. The Scott, like, is it, is, is that patient population that they did that trial on really compared to mine? Right? No, not really. Same thing is, uh, that’s the, that’s really the main number, one thing that you really have to like.
Uh, another example of that is the dream study with omega3s, in my opinion, I mean, in my opinion, there’s a lot of different issues with that. A lot of issues people have had, honestly, at the end of the day, it’s a well designed trial. I can, they did a good job and it really did show the results showed what they set out to do. This also makes it difficult to start navigating uncertainty.
Right. But the problem is, is in my opinion, I am rarely adding. And in a lot of the patients I’ll make it threes. We’re at. Because the patients were already being treated for something. So, uh, but the main thing for me is they treated moderate to severe patients. And I am rarely adding omega threes to a moderate or severe dry eye patient.
It’s usually the mild. And so I know that makes it way more difficult to run an RCT, but I think you have different results if you do that. That’s my hunch. My hunch is that. They didn’t specify specifically, look at patients who had inflammatory markers or, I mean, you would assume that moderate to severe patients would, but they didn’t specifically look at those, you know, um, inflammatory markers.
And I think if they had an excluded patients, so again, figuring out what’s the mechanism that you’re trying to control for and trying to treat. And, and being more focused on it. So like, like you, I don’t, I don’t usually a shotgun omega threes. There are very specific, um, player in my armamentarium exact first stage. This makes it difficult to start navigating uncertainty.
Right, right. And, um, and even for me, it goes further. Cause it’s first stage in patients I suspect are inflammatory. So I think that, that if we had done that, um, I think that we probably would see. Maybe we’ll we might see something different. Right. But, um, so anyway, uh, I think that, that helps us. So my point, yeah, so you, you brought up the dream, you were going to say the other, the other point.
So my hunch is that that’s how I would apply the dream is not to probably treat anybody that has. Yeah, yeah, yeah. For sure. I think you have to be way more selective. I think you, you know, the other thing too is not to labor on this, this study. What does it look like when you are using, uh, the meibomian gland evaluator?
You know, what does it look like for maybe you just choose nonobstructive MGD patient. Um, or obstructive, you know, um, you know, those are the little nuances there that are kind of glossed over it’s and that’s the problem with an RCT, you know? So, um, and you have to be aware of those things. They don’t always apply.
Uh, another thing I’m looking at in a study is just what we talked about with, with statistics, with risk. Is, are they reporting absolute relative or the number needed to treat? You know, if, if they’re glossing over that, that’s a big sign. That’s a big issue that you got to look into. Sometimes you can’t, it’s hard to find it and figure it out yourself. This makes it difficult to start navigating uncertainty.
Mostly sometimes you have to reverse engineer it, you do. And the root problem that a lot of like you, if we take this issue with looking at it, looking at a study and. Put it in the context of the broader issues right now with the pandemic is the media has, is always reporting the relative risk reduction.
Yeah. And the reality is, is we are just terrible at understanding risk. When we see percentages, that means nothing to us. Like percentages really. It means something, but it’s incredibly easy to mislead with a percentage. And so, um, The majority of the time that you’re seeing something in a publication, uh, it’s, there’s a ton of bias within it.
There’s selection bias. There is confirmation bias. Uh, you know, so most times, or I want to say like, like 50 to 75% of negative trials aren’t even reported. So you don’t even see. Uh, so I guess we’ve gone back to a study. Those are the, the main to, uh, compare. Well, uh, no, your chances, right? Uh, we’re back to like Jordan Keith’s, uh, oh, a lot of his talks on that.
That’s about knowing your chance. Chances. That’s really good, but even if you, sorry, go ahead and consistency. Right. So consistency means has, can this be repeatable? Right. Yeah. Is this something like, when I think about the, my side data, um, when we’re looking, looking at that lens, I think there’s, it was done really well.
I think it’s really valuable. I think it’s great information, but to me, the reason why it kind of tipped me over the edge in terms of, uh, treating myopia control or myopia management is because it basically confirmed. A lot of other previous trials, very similarly, like that 50% or so of reduction of, uh, of progression.
And it did it in a way that was well-run well-designed and then when you’re confirming a lot of previous studies, then it’s like, well, we have consistency now. And those are the things you got to look, look for. Yeah, totally. You can’t just one off you. Can’t one off, you know, RCT. So, well, I’m going to stop it there so I can be respectful of your time.
We will probably have to pick this up again. So many things, and it’s never boring to me. That’s the fun part is that we have these conversations for at least an hour, uh, on runs every week. And, um, we should probably just make it friends. I’ve tried it, it doesn’t sound good. Doesn’t know. It’s hard to edit that out.
There’s probably more like, uh, like riffing and, uh, probably things that we talk about that probably. It should be more edited then. Yeah. Yeah. But I also think that that’s, that’s, what’s fun to listen to is that sometimes it’s like, wow. Uh, some of the off the cuff things are probably more interesting, but nobody wants to be more vulnerable. This makes it difficult to start navigating uncertainty.
Yeah. That’s true. That’s true. Which is sometimes. Yeah. Well, thanks man. Appreciate it.