Optometry plays an integral role in the delivery of health care in America. Our optometric education provides us the foundation and ability to address the majority of our patients’ needs—whether vision or medical in nature. Patients often present with multiple conditions that are not just related to their vision, but also may have systemic manifestations. When a condition falls outside the scope of optometry or warrants further diagnostic testing and treatment, your role is to be the quarterback for the patient’s care. The challenge for us, as optometrists, is to further establish and fully integrate ourselves into the health-care delivery for the benefit of our patients.  

Optometrists are familiar with the traditional comanagement relationships with our ophthlamologist colleagues, where patients benefit from the strengths of each profession. Optometric comanagement is a cost-effective means of providing high quality eye care, patient convenience and superior clinical results all in the best interests of our patients. This process is built on the foundation of enhancing patient care and maximizing outcomes.

We refer patients to ophthalmologists for various reasons, including cataract extraction, refractive surgery, glaucoma procedures, retina treatments, lid abnormalities and emergency eye care. Most of us have developed and established relationships with nearby ophthalmologists who will provide patients the best secondary and tertiary eye care available. Patients appreciate that we, their primary eye doctors, are involved, take charge and help guide and direct their treatment. When we take the time to educate them about their conditions, patients gain a better understanding that each specialty contributes to the benefit of their healthcare needs.  

No Lack of Comanaging Opportunities
One common condition that optometrists frequently encounter is diabetes. According to the Early Treatment of Diabetic Retinopathy Study, 50% of blindness caused by diabetic retinopathy could have been prevented with the early diagnosis of diabetes and the early detection of retinal complications.¹ As an example, a patient may present for a routine vision examination with bilateral findings of retinal hemorrhages. Further questioning may reveal that this patient has been experiencing vision fluctuations, increase in urination, recent infections and tingling in his or her hands or feet. Such clues would lead us to the diagnosis of retinal hemorrhage O.U. and a tentative diagnosis of diabetes mellitus. Our treatment would include patient education of the condition, lab testing (complete blood count with differential, fasting blood sugar, glycosolated hemoglobin, lipid panel, etc.), a referral to their primary care physician or an endocrinologist to treat and monitor their systemic condition and re-appointment of the patient to monitor their retina. We need to let our patients know that we are their advocate and that we will promptly send reports to their other doctors. Let the primary care physician, internist and endocrinologist know that you are able and willing to be an integral part of the diabetes care team.² World-renowned business philosopher Jim Rohn once said, “If you just communicate, you can get by. But, if you skillfully communicate, you can work miracles.” By working together and communicating with one another, we will be able to provide the best care for our patients.

The previous example is just one of many different conditions that we may need to comanage with other providers. Patients may have or be in need of the services of numerous other healthcare providers such as their general practitioner, pediatrician, endocrinologist, cardiologist, rheumatologist, neurologist, pulmonologist, otolaryngologist, mental health professional and emergency room staff. No matter the condition, shared goals around patients’ needs and a focus on processes that serve those needs could help transcend traditional barriers.³

Realizing the Importance of Communication
Recently, I was approached by an internal medicine physician who asked how he could improve his relationship with optometrists and ophthalmologists. In his practice, he routinely refers patients to their eye care specialists for eye examinations, but is frustrated by the lack of communication. He refers patients suffering from headaches, eye pain, hypertension and diabetes for additional care; however, he was rarely being informed of the results of this additional care or whether the additional care even took place. Simply put, the internist never received progress reports or findings from the other specialists. I explained to him that our profession is faced with the same dilemma. We often refer patients to various specialists and never hear back from them. Thus, the question that faces us is, “How can we work together as healthcare providers to bridge this communication gap?“

The current trend in health care is to address only the needs of each patient as they present to our practices. If additional care is warranted, some practitioners take a passive role and tell their patients whom they need to see. They assume that patients will take responsibility of their own care and make the appointment with the appropriate providers and that each respective provider will understand why the patient has come to them. By the time the appointment takes place, patients may not remember or understand the reason for seeing this other provider and, in turn, the provider may not understand the exact purpose of the referral. When we take the time to communicate with both patients and other providers, there is a greater understanding of the roles that each of us has in the care of our patients. Referral letters and progress reports are the best form of communicating each patient’s condition, what additional care is being requested and when follow-up appointments are indicated. To promote our abilities and our unique position in the healthcare arena, optometrists need to increase and improve our communication with other specialties. Rather than just telling our patients to go see their general physician or other specialists, we need to take a more active role in ensuring that our patients are getting the best care available.  

Bridging the Communication Gap
The first step in making a referral to another specialist is to develop relationships with other healthcare providers. Take the time to research and find out about the specialists in your area. Ask your colleagues who may already have good relationships with several practices. By establishing ourselves within the community and educating others on what our role is in the healthcare arena, specialists will gain a better understanding of our training and capabilities. We can take several steps to establish and strengthen our relationships with other providers by writing introductory letters to several specialists letting them know that you are available and trained to treat and examine patients with systemic conditions, personally visiting physicians and practices in your area, and sending out invitations to seminars at your office where you showcase your skills and abilities.  

Our society has the misconception that optometrists only perform vision examinations. Despite recent improvements in interprofessional understanding, conflict and confusion regarding the scope of practice of various disciplinary delineated roles persist and continue to hamper interprofessional communication.⁴ Some progress has been made in this area; nonetheless, confusion about the unique expertise and knowledge of each profession still exists.⁵

Once you have established relationships with other healthcare providers, it is important that you schedule the appointment for the patient to them. A referral request letter helps each specialist understand the exact intention of the referral. Provide any recent, pertinent patient notes and let them know that you can comanage these conditions. For referrals to ophthalmology, inform the ophthalmologists of everything you want them to do. Is the referral for all care to be taken over by the specialist or for testing only? Or is the referral for a second opinion to confirm your findings or current treatment for your patient? Lastly, do you wish to comanage the patient whom you are referring? If our orders and intentions are not conveyed to the specialists, they may assume that the patient is beyond our level of care.    

Our staff plays an integral role in ensuring that all referral notes, progress reports and documentation is sent to the appropriate provider. Office communication protocols should be established within each practice and a team member or members should be assigned to this task. Additionally, letters and reports should be sent in a timely manner either through fax, email or standard mail.  

The Beginning of a Beautiful Relationship
Whether manually written or dictated and typed by a transcription service, certain details should be included in every referral letter. Use business letterhead with your name and practice location. Your letter should include all relevant medical details, referral date, the patient’s name, date of birth and gender, in addition to your patient’s contact information, including telephone numbers. According to Stephen Scoper, M.D., the most important aspects of a referral letter are your diagnosis and recommendations. “Keep it short, sweet and to the point,” he advises.6 Often, referral letters contain too much information from the examination. Present only the key findings of your examination, your diagnosis and your recommendation for the specialists. State the diagnosis in one to two sentences, informing the specialist the reason for the referral. Additionally, keep your recommendation to a minimum of two to three sentences explaining what tests you feel are appropriate, along with when you plan on seeing the patient again. Your ability to effectively and briefly communicate through writing will help to improve efficiency and save valuable time for all parties involved.   

To establish good professional communication, practitioners should implement the seven Cs of business communication, which aid in improving both the efficiency and efficacy of interactions with other healthcare providers.^7–9

• Conciseness – Referral letters should be short and to the point.
• Correctness – Accurately state the facts; check your grammar.
• Clarity – Make it easy to understand.
• Completeness – Cover the essentials to get your intended response.
• Consideration – Put yourself in the place of the receiver.
• Concreteness – Be specific to reinforce confidence in your skills.
• Courtesy – Strengthen your relations.

I’d like to add an additional “C” to the list: Consistency – Make it a habit in your daily practice. Just as we appreciate referral letters from our colleagues, we should do our best to provide letters for all mutual patients. Referral letters are most effective when the receiver understands the same meaning that the sender intended to convey. By utilizing these attributes, your intentions and expectations will be effectively conveyed.  

Staying Involved in the Care
Many optometrists have had at least one experience where they make a referral to a specialist who evaluates their patient and refers the patient to another provider. By the time we find out what happened to our patient, he or she has already been seen by another provider and we may not see that patient again. The best way to ensure that we, as optometrists, remain actively involved throughout each patient’s care is to communicate with the referred specialist and the patient. Whether the specialist is someone with whom we are familiar or an established provider for our patients whom we do not know, our ability to communicate with other healthcare providers helps to establish our roles in the overall delivery of care. Whenever we see patients who are referred by their physician, take the extra step and send progress reports and letters to communicate your findings. It is also important to educate and schedule your patients with follow-up examinations. Doing so further helps our patients understand that they are supposed to continue to see you. Furthermore, our communication will demonstrate to the comanaging provider that we are well informed and competent in addressing our patients’ eye care needs.       

It is essential for optometrists to develop referral relationships with a variety of medical specialists. While your patient’s primary care physician should be intimately involved in the process, direct referrals to a variety of medical specialists can result in more rapid and efficient care. Familiarity with the local healthcare system, including one-on-one relationships with medical specialists, can enrich your professional life and serve as a great aid to optimal patient care. 

Dr. Whitley is the director of optometric services at Virginia Eye Consultants, in Norfolk, Va., a tertiary referral care center. He is an adjunct assistant clinical professor at Pacific University College of Optometry, The Pennsylvania College of Optometry at Salus University and Southern California College of Optometry.

1. The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993 Sep 30;329(14):977-86.
2. Chous P. The new fundamentals of diabetes. Review of Optometry. Available at: www.revoptom.com/continuing_education/tabviewtest/lessonid/105080/ (Accessed January 23, 2011).
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5. Verhovsek E, Byington R, Deshkulkarni S. Perceptions of interprofessional communication: impact on patient care, occupational stress, and job satisfaction. The Internet Journal of Radiology. 2010; 12(2).
6. Personal communication with Stephen Scoper, M.D. Virginia Eye Consultants. Norfolk, VA.  
7. Cutlip SM, Center AH. Effective public relations: pathways to public favor. Englewood Cliffs, N.J.: Prentice Hall, 1952.
8. Root G.  7 Cs of effective business communication. Available at: http://smallbusiness.chron.com/7-cs-effective-business-communication-114.html (Accessed January 22, 2011).
9. The Seven C’s of Effective Business Communication. Available at: http://notesdesk.com/notes/business-communications/the-seven-cs-of-effective-business-communication/  (Accessed January 2011).