Satellite clinics and other strategies to enhance rural ophthalmology 

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Subspecialist ophthalmologists in rural areas face unique geographical challenges that often require innovative approaches to providing patient care. Proactive communication with referring doctors and maximizing efficiency of patient visits are essential pillars of success, ultimately enhancing the quality and accessibility of eye care services in remote areas and improving practice satisfaction from critically important optometric referral sources.

Proactive communication, effective collaboration

The cornerstone of a rural subspecialty ophthalmology practice is fostering timely and clear communication channels. I’ve practiced in rural locations in the Rocky Mountains of Montana and Rim Country in Northern Arizona, where many of my referring doctors are 2 to 3 hours away. Most recently, I established the Northern Arizona Retina Division at Barnet Dulaney Perkins Eye Center, based in Flagstaff, Arizona. At that time, there were a handful of outside referral doctors who would send patients in for retina care. Most urgent retina referrals were sent to Phoenix simply due to a lack of reliable retina care in the northern part of Arizona.

Understandably, and ultimately due to convenience, retina patients were generally referred to our main offices in Phoenix for both urgent and nonurgent care—it would take too much time and effort for rural referral optometrists to know when the next available retina clinic would be.

Shortly after I established my retina practice in Northern Arizona, I began to reach out to various optometry practices and optometrists methodically, sharing my personal information (cell phone number and email address) in the hopes of establishing an expanded referral network. I asked everyone I spoke with to call me by my first name as a collegial gesture, something my fellowship mentor, Steve Charles, MD, encouraged. I would like to believe that my personal approach helped me quickly establish a comfortable relationship with dozens of referring doctors scattered throughout Northern Arizona as well as Northwestern New Mexico and Southern Utah.

I currently practice across 4 fully equipped satellite offices. Regardless of the distance between these clinics, my referral physicians knows that my cell phone number is a 24/7 direct line of contact to me. This ensures that referring doctors can reach me promptly—even on the rare Sunday morning. It’s also an excellent way to triage retina patients. Not all potential retina patients need to travel to see me, and recommendations for ongoing retina screening can be facilitated by their optometrist after a quick discussion (ie, nonsurgical macular puckers, diabetic macular edema not yet requiring treatment, diagnosis of vitelliform macular deposition, etc). In nonurgent cases, the referring doctor and I can decide next steps and when the patient should either be referred to me or continue follow-up with their eye physician close to home. Open and reliable communication can minimize the need for patients to travel hundreds of miles.

A proactive approach to communication not only expedites patient care, but also ensures all stakeholders are on the same page and, most importantly, fosters trust and ongoing collaboration. Doctors feel more confident referring patients knowing that they will receive timely reports regarding assessments and interventions. Their patients will return to them as soon as possible, and their patients feel reassured that their doctors are working together to provide efficient care.

Brendan Girschek, MD, FRCSC, FACS, treats a patient in office at a satellite clinic location. Providing services to patients in these clinics allows them to receive treatment locally, hopefully leading to a better follow-up rate and closer monitoring of conditions by reducing patient treatment burden.
(Image courtesy of Brendan Girschek, MD, FRCSC, FACS.)

Maximizing efficiency with advanced technologies

The first visit with a patient in my retina practice sets the tempo for care and informs the patient of treatment goals as well as how to best
involve their local eye doctor. I strongly recommend patients bring someone who can accompany them in the exam room to act as a second pair of ears. Optimizing the efficiency of clinic visits therefore is essential to minimize the need for patients to make multiple trips to a practice or satellite clinic.

A comprehensive approach during the initial visit is key. Whenever possible, I like to schedule a complete diagnostic workup and an initial treatment during a patient’s first visit to reduce the burden of travel. It’s too easy to visit with a new retina consult, schedule them for an advanced diagnostics workup such as angiography, and then schedule them for another visit for a procedure.

Although my offices are more than adequately stocked with the latest in diagnostic imaging, injectables, and laser delivery options, it is critical that all equipment is maintained to ensure reliability. Many of my rural patients present with an urgent need for retina surgery. Having a faulty or unreliable B-scan ultrasound machine can completely change the expectation of same-day urgent referrals for surgery if not available.

The most important tool a retina specialist has in their clinic or satellite location, however, is a laser. I try to get as much laser treatment possible on a first visit. It’s not uncommon for me to perform bilateral panretinal photocoagulation laser treatment or intravitreal injections on a patient’s initial visit.

Advantages of a portable, reliable laser

My most prized item remains my portable and reliable laser delivery systems. I use the Norlase LION and LEAF lasers for all my slit lamp–based and indirect-based deliveries. In my opinion, these lasers represent the pinnacle of portability, reliability, and functionality in retina laser delivery. The last thing any retina specialist needs is several patients referred for retinal breaks when a laser is nonoperational. Considering my unique practice setup, I’m grateful that I have yet to give a second thought about my lasers not working.

The Norlase lasers are adaptable and space-saving. My offices have different types of slit lamps, and the LEAF laser adapts to all without difficulty. The LION, owing to the Keeler foundational indirect ophthalmoscope, is often the brightest and clearest indirect in all my clinics. Additionally, I fly to my most remote satellite office on a 10-seater twin-engine turboprop plane once a week. Traveling with both Norlase lasers takes minimal effort.

Collaborative care goals

Practicing at satellite clinics in rural areas requires careful planning and collaboration with local care providers to determine an agreeable scope of service and patient care schedules. As simple as it may sound, a smartwatch that forwards phone calls and texts has been indispensable for communicating with my referring doctors who don’t have to wait more than 1 or 2 minutes for me to respond about a retina patient, who is often still sitting in their chair.

Being able to immediately triage and schedule urgent follow-up has been the most important aspect in growing my rural practice and saving patients the added time and inconvenience of traveling to a larger metropolitan area. Many of our surgical patients get gas bubbles, and doing surgery at elevation means the difference between the patient going home an hour after surgery and staying in a hotel for 4 to 5 days postoperatively as their intravitreal gas bubble resolves. I often schedule surgical patients to present “nothing by mouth” with expected same-day surgery after an initial consult to enhance efficiency. For me, being able to operate in the same facility as my clinic is a luxury that helps minimize travel with surgical patients.

Additionally, the ability to phone a referring doctor later in the day to discuss their patient is appreciated. It’s ironic that practicing with referring optometrists who are hundreds of miles away can establish and encourage superior communication to that experienced in a metropolitan center.

Conclusion

Proactive communication with referring doctors and leveraging advanced and portable technologies equip subspecialist ophthalmologists in rural areas with the necessary framework to deliver patient-centered, timely, and high-quality care, overcoming the challenges associated with health care delivery in remote settings.

Brendan Girschek, MD, FRCSC, FACS

E: bgirschek@gmail.com

Brendan Girschek, MD, FRCSC, FACS, is a retinal specialist at Barnet Dulaney Perkins Eye Center in Flagstaff, Arizona. He did not acknowledge any financial interest in the products or companies mentioned.