SLT Blog by Dr. Savak Teymoorian

03 September 2018

If SLT is Right for the Doctor as a Patient, Shouldn’t It be an Option for Every Patient?

I have the pleasure of giving many glaucoma lectures to fellow eye doctor colleagues at different venues. Recently, however, I have noticed an interesting trend which greatly puzzles me. Consider the following situation: the audience is presented a straightforward high-risk ocular hypertension or early primary open angle glaucoma patient. They are asked for their typical treatment plan. Most individuals respond with the usual prostaglandin analogue of their (or actually, insurance) choice.

I have the pleasure of giving many glaucoma lectures to fellow eye doctor colleagues at different venues. Recently, however, I have noticed an interesting trend which greatly puzzles me. Consider the following situation: the audience is presented a straightforward high-risk ocular hypertension or early primary open angle glaucoma patient. They are asked for their typical treatment plan. Most individuals respond with the usual prostaglandin analogue of their (or actually, insurance) choice. The question is then repeated with the same profile but a different scenario whereby the doctor is the patient. Their revised response may surprise you as it did for me the first time I asked it. In fact, I had to repeat this question over several meetings to make sure it wasn’t a one-time fluke. Most doctors would rather have SLT used as first-line therapy for themselves despite stating that they would utilize a prostaglandin analogue on their patients. But why? Where is the disconnect in practice patterns? Shouldn’t the algorithm be the same if the patient and their presentation is identical?

I’m still trying to figure it out. The answer appears to be multifactorial to my best understanding. Let’s take a deeper look into these reasons. First, we all know and agree that time is valuable and finite, especially in the office setting when we are seeing patients. The everchanging medical landscape continues to increase the challenges it presents to us when trying to care of our patients. The downstream consequence is not only less time for every appointment but also more requirements to fulfill other duties that are not directly doctor-patient oriented. Actual face-to-face doctoring time ends up being reduced. It is just so easy to tell patients to start a medication as this is typically what occurs in many other settings throughout all of medicine. Patient comes in with a problem and they leave with a prescription for drugs. Anything that goes against this trend will require an input of time. Despite these external pressures, however, we shouldn’t sacrifice our patient care for what is simple but rather do what is right. We need to figure out a means to create more time or identify other solutions where time can be saved. The valuable time spent together needs to be protected because this is what we would want if we were the patient.

When you think about it, this invested time leads to more available time in the future. How can that be? If doctors would prefer starting with SLT before drops, then there must be some intrinsic value to this choice. SLT provides a method to reduce IOP but it also removes the biggest issue with drops – noncompliance – and also the next one – side effects. Any method that removes these two problems will result in better patient care and reduce demand of the doctor’s time in the long-term. The little extra time spent with the patient will save the doctor multiple fold in the future.

Second, there is an inherent struggle with patient perception about using a “laser” on their eyes instead of drops as the former sounds more invasive. These preconceived beliefs become a barrier that providers must first overcome before patients will elect to proceed with SLT. In the physicians’ minds this obstacle means more time needed to be spent to educate patients. This again brings up the issues stated earlier with the lack of available time during doctor-patient interactions. However, with adequate effort spent to build our patients’ knowledge, these perceptions can be changed. This is not to say that all patients will initially elect for SLT because some will still want to try drops first. What is important to remember is to keep the option of SLT open and available to patients later on because their desires may change after they experience firsthand the effects of using drops. These include routine issues that lead to non-adherence of cost, side-effects, and daily (or multiple) dosing. They should always know their options so review with them over certain intervals to ensure they understand.

Third, there maybe limitations to access to a SLT unit. The major driver for this involves the cost of the capital equipment. In eye care we are fortunate to have many technological advances in both diagnostics and therapies, especially for glaucoma. Unfortunately, these don’t come free. Each physician along with their practice must balance the benefits and costs to any new piece of equipment. I have discussed in other blog entries the wide range of clinical application for SLT that allow most physicians to not only provide this additional, beneficial level of care but also do so over a large portion of their patients. Any individual taking care of glaucoma patients should either personally own or have readily available to them the option of SLT.

At the end of the day, regardless of why this disconnect occurs, shouldn’t we as providers strive to provide patients with the care we would give to ourselves? If it’s a time issue, then we need to either provide more time personally or figure out an effective mechanism to create it. This goes the same if the issue is misinformed patient perception based on lack of knowledge. And if it’s a deficiency in having the equipment, it’s about time to get it. The successful provider views this challenge as an opportunity for growth in their practice and improvement for their patients, instead of obstacle that gets in their way. Let’s break this disconnect and put patients on our own playing fields.

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