LETTER TO THE EDITOR

To the Editor,

Among the major issues facing the medical profession is that of comanagement with other health care providers. A full and balanced airing of the concerns surrounding this sensitive topic could help your readers understand better the challenges related to it. Unfortunately, “Is Comanagement the Future of Retinal-disease Management?,” which appeared in your March issue, was a lamentably unbalanced discussion of the issue of comanagement. As elected organizational leaders in the retina community, we believe that the article, instead of presenting a full and fair picture of the issues, reflects only a single point-of-view and contains inaccuracies that we find very disturbing.

The retina community has a strong record of advocating and acting in the best interests of its patients. It is a record to be admired, and it is a record well worth maintaining. We believe that comanagement raises serious questions about patient safety and standard of care. Failure to raise these issues does not allow your readers the opportunity to hear both sides of the case. To dismiss our point of view as “traditional educational bias,” as do the opinions expressed in the article, betrays an understanding of our concerns and trivializes the fundamental questions of training adequacy, demonstrated competence, quality of care, and patient safety.

The article relies upon a single optometrist and a single ophthalmologist to summarize a complex and controversial issue. The sole retina surgeon quoted in the story in fact works at an optometric-led comanagement practice. The optometrist Center Director (on that practice’s website) describes it as “a referral, comanagement and consultation center complementing the expertise of optometric doctors and other referring physicians.” As such, it is hardly representative of the vast majority of vitreoretinal subspecialists.

The sole optometrist quoted in the article states “Comanagement allows us to, in a sense, control our patients.” We find that attitude disheartening.

The article also states that “there are no mandated or recommended guidelines from any professional organization for comanagement between optometrists and ophthalmologists.” This is simply not true. A joint position paper (http://www.aao.org/member/ethics/upload/joint_position_paper.pdf) issued by the American Academy of Ophthalmology and the American Society of Cataract and Refractive Surgery states that comanagement, while a useful approach, must not be practiced as a matter of routine policy on all patients. Comanagement must not be for economic reasons, such as an inducement for surgical referrals. Besides being unethical, this is also illegal in some jurisdictions.

A critical element of this previously issued joint position paper is the affirmation that any transfer of care must not occur unless it is clinically appropriate and in the patient’s best interest. Further, the ophthalmologist should confirm that the comanager is legally entitled and professionally trained to provide the particular services. Vitreoretinal issues are frequently medically challenging and involve complex decision-making. For this reason, the typical modern vitreoretinal subspecialist completes 2 years of fellowship training after 4 years of residency and after medical school.

Finally, to engage in gratuitous stereotyping about the nature of ophthalmologists, as this article does, is a true disservice to the profession. To suggest, as the opinions expressed in the article do, that we are less alert to patient issues, such as compliance, and have more distant relationships with our patients dishonors the commitment of medical professionals who have spent years training for and serving the needs of their patients.

We recognize that comanagement is a controversial topic and that there are deeply held opinions on both sides of the issue. As a fair and respected publication, Retinal Physician should have reflected the range of opinions in your article. As your readers, we find it very disappointing and unfortunate that, in this instance, you failed to meet that standard.

      Sincerely,

Julia A. Haller, MD

President, American Society of Retina Specialists

David W. Parke II, MD

President-elect, American Academy of Ophthalmology

Michael T. Trese, MD

President, Retina Society

C. P. Wilkinson, MD

President, American Academy of Ophthalmology

George A. Williams, MD

Past-President, American Society of Retina Specialists

Lawrence A. Yannuzzi, MD

President, Macula Society

The views stated are those of the individual signatories and not necessarily of their listed organizations.