December Podcast: Dr. Selina McGee discusses how she tackles dry eye disease in private practice.

Whitney Hauser : Hi, I’m Dr. Whitney Hauser and welcome to Dry Eye Coach podcast. Today I’m joined by Dr. Selina McGee. Selina is a private practitioner and owner of Precision Vision of Edmond and she’s also the president of the Oklahoma Association of Optometric Physicians. Welcome, Selina. How are you today?

Selina McGee :I’m great. Thank you. Thank you for having me.

Whitney Hauser :Good. I love that we both are on the line together talking and we’re both going to have accents, and we just say that right out of the gate. It’s so true. So hopefully the listeners will not need translators for this, but I love having that shared accent with you. We’re going to go ahead and get started. I’m just going to ask you a couple of questions and just to get your perspective on things, I think what’s interesting is a lot of experts in the field, particularly of dry eye, work in a lot of different areas. They work in tertiary dry centers, which I’ve been affiliated with. They work in ophthalmology practices. Some of them work in private practice, but we don’t hear quite as much of that voice. So I’m really anxious to kind of get your perspective on that today. The first question I’m going to jump in with is why, from your perspective, is patient education on dry eye so important? How does that fit into what you do with your patients every day?

Selina McGee :It’s a great question, and I’m glad you led with the fact that I’m in private practice because I think honestly it makes so much sense in private practice, maybe even more so than in a tertiary setting or a co-management setting, simply because most patients don’t recognize their symptoms with dry eye disease and it affects every piece of private practice. What I mean by that is if you have an optical like I do, if you don’t treat their dry eye, they’re going to come back with a glasses RX check. We all know that time is money, and so when you spend that on a glasses RX check and in fact it’s ocular surface disease that we missed, then that’s a huge piece of that. Contact lens patients, lots of private practices have huge contact lens practices, mine included. So if we don’t do a good job of assessing the ocular surface and making sure that is stable, then your contact lens patients are going to suffer and you’re going to spend more chair time doing refits.

Selina McGee :Then if you’re co-managing your surgical patients, and the patients that I work with and a lot of cataract patients these days, they have such good premium options. But if we don’t have a premium surface to deal with, once they get to the surgeon, they’re not going to have a premium outcome. Then of course in private practice, we have patients with glaucoma. We have patients that we’re the first line of defense. So if we don’t do a good job of [inaudible 00:03:06] and teaching our patients what dry eye disease looks like and what the symptoms are, then we can miss a lot of things including even something like a pass down of the disease of Sjogren’s. We know how dangerous that is because those patients unrecognized are much more likely to get lymphoma. So I think there’s such a huge opportunity for private practitioners to really embrace this and set themselves apart.

Whitney Hauser :The education, as I asked that question was really kind of directed at how does education play a role with the patient directly? But really there’s almost two different ways that you can see that question. I think that you sort of embraced both angles of it, which is one, we’re educating the patient in dry eye disease about all the things that optometry can offer to them even if they’re not highly symptomatic. I think that’s an important piece because when you get a patient who gradually becomes very symptomatic, they don’t necessarily think about calling their optometrist. Sometimes they’re going to go down the road of that tertiary center, that ophthalmology practice. I think that proactive education on just what our role is in their lives is important. Then secondly, like you said, educating them on the broader scope of what dry eye means to them. It’s not just about gritty, irritated, fluctuating vision. It also has some very significant systemic effects for some of our patients as well. A really interesting perspective that you lend on that one.

Whitney Hauser :Now, what are some of the specific tactics that you’ve implemented to educate your patients? I mean, let’s get into the weeds a little bit. How do you really dig in and talk to patients specifically?

Selina McGee:We have to create awareness because like most people and my patients, they don’t come in saying, “Oh, my eyes are dry and I need you to help me.” That is hardly ever the case. They come in with-

Whitney Hauser :Wouldn’t you love it?

Selina McGee :Yes.

Whitney Hauser :Would you love if they did, if they came in like wearing a sign around their neck saying, “I have dry eyes.”

Selina McGee :“I have dry eye disease.” That would make all of our lives so much easier, but [crosstalk 00:05:23].

Whitney Hauser :So much easier. This is not allergy. Can I have that on a sign too?

Selina McGee :Yeah. We have to create that awareness, but we have to do it in the way that the patient really hears us. What I mean by that is we have to dig. Specific tactics that I utilize in the clinic, those patients just like we do, we have to hear things typically multiple times to really embrace it. At my front desk, my director of first impressions, she says whenever she’s doing her intake form one in three people have dry eye disease that’s undiagnosed. Please walk through this questionnaire and assess yourself on these different symptoms. Then you guys can talk more about it in the back. Based on that specific questionnaire which has dry eye questions, which also has questions around ocular and facial rosacea and then also have some sleep apnea questions. But that’s the first step is creating that awareness piece. Then once they move to the … When the technician picks them up, then I have a protocol in place. If they answered two or more on the dry eye piece, then they automatically get Osmolarity and InflammaDry before I even walk in the room.

Whitney Hauser :Yeah. Hold right there. Let me ask you a question. You probably have encountered the same thing because I know that you speak a lot about dry eye disease. A lot of colleagues will say someone at the front desk, and I love the title of your front desk as well, director of first impressions, that’s awesome, but a lot of them will say, “My employees don’t want to pass out another thing. My patients don’t want to fill out another thing.” There’s immediate resistance to survey, whether it be a validated survey, a personalized survey that you’re creating. What is your impression or your impression from your staff about the uptake of those surveys?

Selina McGee:Great question because there’s a lot that happens at that front desk. To me that’s the hardest job in the entire clinic. They don’t answer the phone. They’re doing nothing except direct patient communication face to face. There’s no other activity that should be going on there besides that. I’ve empowered my staff to fully understand why that’s so important and I mean, I stand up there sometimes just to see what goes on. Plenty of patients look at this and roll their eyes and like, “Oh, I got to fill out something else.” But when they hear the piece of, “Wait, you said how many people have this?” They’re doing it right in front of us. We don’t get that much pushback. But let’s say that if we have a patient that we get pushback from and they don’t really want to fill it out and they move on with the technician. The wheels start to fall off, but when the technician gets them, then they can ask the questions in a different way. You wind up with a second piece to that.

Selina McGee :Then let’s say that the wheels fall off at the front desk and with the technician. Then when I come in, I still ask the questions maybe similarly, but in a different way. There’s three opportunities there to really get the information you’re driving for. My advice is don’t give up, but don’t ask too much of what your front staff is having. It needs to be simple. Once they understand and are empowered with that information, it tends to go a lot better.

Whitney Hauser :Here’s one of the things that I think I’ve seen over the years as both a doctor and as a patient at different offices. You have these intake forms and as a patient, you sit there and you fill this intake form out and then you get past the front desk, moving through the process like you said, the technician and doctor. No one ever mentions that survey again. In fact a lot of times you’re asked a lot of the same questions a second time, and it’s really frustrating to patients. I think that’s where a lot of their resistance comes from is they do these things and it leads to nowhere. But I think in your practice, you’re actually taking the information and utilizing it. Is that fair to say?

Selina McGee : Yeah, definitely. I like pictures. So I’ve broken up the survey with pictures because I do some aesthetic stuff too. But there’s also a picture of a red eye and a picture of frown lines and check these if these are you. So it’s not super wordy. It’s not really long. It’s very easy and straightforward, but you’re exactly right. If you implement something and then you never touch it again, that’s frustrating for everybody.

Whitney Hauser :Right. I’m probably like a lot of your patients. I would probably like the pictures. Not to sound overly simplistic, but I’ll tell you, you give me a clipboard full of words, all of a sudden I don’t care to even fill it out as accurately as I would otherwise. I think the presentation of the survey is what also leads to engagement. I think that’s a great concept that you have there. What role does your office and team play and dry eye education? We’ve sort of talked about the intake. Where do they take the ball from there?

Selina McGee :through the office. Then the technician knows, okay, I need to do these other couple of tests before he or she sees myself in the room. It really is a team effort. I mean, if you try to implement anything on your own, you’re going to be super frustrated and it’s going to fail epically. You have to empower your team and they have to understand the why of this so that they can help you. I’m a huge believer of let’s talk about this. Let’s walk through the scenario. Let’s implement it whether it’s perfect or not, and then revisit it in four or six weeks. What worked about this? What didn’t work?

Selina McGee :Actually, I mean, this intake form that I’ve done, I think I’m on the third or fourth revision just this year because when you try something once, it’s not likely going to work as well as you want it to. I rely heavily on my team and I listen to them when they tell me this is not working. We have to find a different and better way. So you just have to really make sure that the people that you surround yourself with can help you see your patients in an effective manner and communicate what you’re trying to communicate to your patients. That’s easier said than done, but you cannot go this alone.

Whitney Hauser :Well. I love a lot of what you’ve just said there because it is a team effort and to a degree over the years you hear the word team and it’s sort of drilled into people about being a team and so forth. But particularly with dry eye disease, it is a Herculean effort sometimes. For the doctor to do all the listening in the exam room, you’re right. It’s going to be an epic failure. It’s just not going to … Especially if you’re looking at things like thermal treatments, intense pulse light. Moving the needle at the end of the road is really hard to do, but when you have that sort of incremental build throughout the patient experience, I think you’re going to have a much better conversion, much better uptake of things.

Whitney Hauser :The other thing that you said that is incredibly valuable and I think a lot of practices probably don’t embrace this the way that they should is be willing to fail, be willing to be open to revising. What I really liked about what you said, and you kind of snuck it in there, was in four to six weeks … You give it a timeline. Give it a timeline to reassess this. Because what a lot of doctors do is they start and then they kind of get distracted by the next thing they’re doing or by the things they used to do and they don’t revisit things in an orderly fashion. If you don’t go back and look at it, you’re never going to make those revisions. You’re never going to have that opportunity to improve.

Selina McGee :Absolutely.

Whitney Hauser :That’s great advice that you’re providing. I guess, a lot of times we look at things and we see all the opportunity for treating dry eye for both our practice and our patients. What are some of the biggest misconceptions that your patients have when it comes to dry eye disease? What are the things that they’re missing?

Selina McGee :I think that they miss all of the pieces that really affect their day to day lives. I think if we don’t do a good enough job educating them, they miss the fact that this is a chronic disease. They miss the fact that, “My contact lenses or are just not comfortable. I need something different, Doc.” That one’s huge. I still hear, “My vision is just not as clear as I want it to be. Can’t you just sharpen up my glasses a little bit?” Lots of misconceptions there. Then since I’ve treated dry eye for so long, I think one of my biggest frustrations is they get to feeling better and then they stop what they’ve been doing and now we regress.

Selina McGee :I’ve gotten better at trying to tell that story to my patients at the beginning so that they hear it. Your temptation was going to be that when you do start to feel better, you’re going to get lax on some of these things. Because I mean, this is really truly a lifestyle change. We’re not going to do one or two things forever and that’s going to continue to hold you and then not do anything ever again. Because there are so many treatments. I mean I offer thermal pulsation. I have IPL. I have all of these pieces in my practice. So we really have to tell that story on the front end that we’re not going to get instant gratification. We did not get here overnight. We’re not going to fix you overnight, but I promise you I will be in this journey with you together and we will step by step take care of you. I think that’s the biggest misconception is they want something quick and easy and fast and done.

Whitney Hauser :And permanent.

Selina McGee :Right.

Whitney Hauser :What I also hear you saying is that our patients tend to sort of silo their symptoms. So if they have trouble with their contacts, fix my contacts. If they have trouble with how their eyes feels, fix how my eyes feel. If they have refractive or visual changes, fix those things. Aesthetics. The other component of dry eye that’s very commonly overlooked by practitioners is patients don’t like how they look. Their eyes look red or glassy or things along those lines. They’ve got all these different complaints. They want you to go fix that one compliant. It’s really our job to see it’s the overarching dry eye that’s really at the root of many of their complaints and educate on it. That’s a tough education probably for some of the patients to take in.

Selina McGee :Yeah. That comes back to the team piece and they really have to hear it more than once.

Selina McGee :Yes.

Whitney Hauser :Right.

Selina McGee:It’s just that journey and walking them through it.

Whitney Hauser :Right. All right. We’re going to say you’ve walked him through it, you’ve done the team component. You started the build from the front of the office all the way to the back of the office. They get to you, you make the diagnosis of dry eye disease. How do you now educate them on the treatment options? You’ve already said that you’ve got thermal pulsation, you’ve got intense pulse light. I’m sure you’re writing ophthalmic prescriptions and so forth. How do you now begin that education process? Because frankly, a lot of practitioners are daunted by having so many tools in the toolbox now.

Selina McGee :Sure. It can be overwhelming. Let me take a step back because I kind of start that process through the exam. It’s a really key piece that I have found very helpful. It’s easier for patients to understand something when they’re the ones that bring it up. So my key questions that I ask and I’ve tried to train myself to do this, when I think I’ve asked enough questions and I need to ask one more, and that’s kept me sometimes out of trouble. One of the things that I love to ask is, walk me through your typical day. I need to understand how you utilize your vision through your day. That way, I get to know how they’re using their eyes, what that looks like for them because everybody’s individual. Then I ask them, do your eyes ever itch? Do they water? Do they burn? I used to stop right there.

Selina McGee :Now what I do is I ask, tell me about that. Do you use any drops? If so, what drops are you using? Then the clincher is, do they help? The patient always says, “You know what? They help for a little bit,” because typically they’re on something we don’t want them on Vizine, Clear Eyes, whatever it is on the market that we don’t want them on. That’s what they’re utilizing.

Whitney Hauser :Yes.

Selina McGee :When you ask that question of, do they help, then they have come up with their own solution right there. They’re like, “You know what? It doesn’t help. I need something more.” So that’s the ophthalmic prescription comes in. When they say that, now I have a good opportunity to talk about, “Okay, you know what? This is a disease. We need to treat inflammation that’s causing this problem.” I write lots of prescriptions for Restasis, and I do not wait. If they have symptoms and they have even stage one level clinical signs, which is [inaudible 00:19:13], then they get a prescription that day. I’m not waiting to treat this down the road.

Selina McGee :But what I have found so helpful when I don’t get push back is that last question, is what you’re doing helping? Because it’s not. So my patients will leave with a prescription for Restasis. They’re doing home heat therapy. If they’re not on a good Omega-3, then we add that or we may switch what they’re doing if it’s not something that I want them on. Then just teaching good habits. If they have a lot of computer time, blink reflex, get up and take a break. Sitting is the new smoking. Then I recheck them in four weeks and that key piece. I walk them through this of, “This is going to be steps. We’re going to start here. We might need to build on this. This may be enough, but we’re going to start here and then we’ll step it up if we need to as we go.”

Whitney Hauser :What I like about what you’re telling me is not only how you’re getting the patient to sort of acknowledge the limitations of things like artificial tears, but also that you give them a more kind of a horizontal perspective, if you will. Because a lot of doctors, I’ve had the pleasure of sort of sitting in with some of my colleagues over the years and watching them educate patients as the consultant, and they don’t give a very definitive path a lot of times. They also don’t necessarily always say, “This is not something I can sure fix. There’s no magic bullet for it. However, here’s my longterm plan for you and we’re going to start here.”

Whitney Hauser :I think having that longterm plan established, and you certainly don’t have to tell them every detail of what you’re going to do over the next 20 years for them, but at least saying, “Here’s my short term and mid term objectives for you.” I think that matters. I think that helps to reinforce the chronicity of it. I like what you’re saying and how you’re doing that with your patients. I think it’s really important and often overlooked.

Selina McGee :I mean, and this has all come about because I failed early because if you don’t do those steps, then I would have patients that would come back and they’re like, “Oh, well now I have to do more? What? How long am I going to have to do drops?”

Whitney Hauser :Right.

Selina McGee :Lots of questions. So I’ve learned the hard way and failed a few of those to get this conversation right for the patient.
Whitney Hauser :Well, the other thing that it does is it says that you acknowledge that you have other tools at your disposal that you can use if needed. It also acknowledges the customization of the treatment that you’re providing, that it’s not a one size fits all. Finally it says, “I’m not just guessing at this.” I think a lot of us unfortunately come across as just throwing things at the wall and seeing what sticks. I get that it’s very different patient to patient and there’s a difference between being customized and guessing. Sometimes that perception for the patient isn’t always there. I love what you’re doing about how you’re giving a little bit of a detailed explanation for how you see their care going.

Selina McGee :Definitely. You have to say it with confidence. That’s something that comes with working with patients and getting some wins. But if you don’t believe in what you’re talking about, the patient knows that. They’re much more apt and I’m sure, like you just said, if you sit in and watch people talk. I’ve had plenty of people sit in and watch me and I’m like, “Please critique.” The biggest takeaway is you have to say it with authority and you have to say it with, “I know what I’m doing.” Like you just said, “I’m not guessing at this, and we’re going to do this. If this doesn’t work, then we’ll do X, Y, and Z. Here’s the path we’re going to go on, but we’re going to do it together.” I just think that’s hugely powerful. Typically just as a profession we’re sometimes, and myself included, we’re not always maybe as confident as we should be but our patients know that. So I think that’s an important piece to practice.

Whitney Hauser :Well, I think you raised an excellent point. I often tell practitioners that I consult with, “When you’re not confident and you haven’t worked out your presentation skills, it is like blood in the water. It is a feeding frenzy at that point. They know that you don’t know what you’re talking about or they suspect that you don’t. Immediately you’re going to lose conversions on whatever it is, whether it’s them even up taking an ophthalmic prescription or doing something that’s an out of pocket expense to them.” The presentation skills, I mean what you just said, most people would disagree with. You said, I want somebody to come in and critique me. Most people, that’s their greatest fear is that someone will come in and critique them.

Whitney Hauser :But through that awkward, uncomfortable role play scenarios, you really learn how you’re saying things wrong. Once we leave school, no one’s listening to us anymore in the lane. That door is closed and it’s up to us to either sink or swim. You get sort of into these habits of how you present things to patients. I think it’s a wonderful idea to have staff listen to you, a colleague, a friend, a spouse, and present whatever you choose in your office to present, whether it’s a nutraceutical or thermal pulsation, and then start to really learn how you could be doing that better. Because I think that we avoid that pain point that you sort of embrace and you’re a rarity with that. Even I think that role play is pretty tough. But you learn so much from doing it.

Selina McGee :Definitely. It’s never easy, but that’s the only way that you’re going to get better. One thing that I love, and especially if you’ve work in a practice with other doctors, just go scribe with them for a couple of patients and listen to how-

Whitney Hauser :Right. Oh, yeah.

Selina McGee:Hugely helpful.

Whitney Hauser :It is. It is.

Selina McGee:I catch myself saying stuff that I learned 20 years ago and I’m like, “Is that really relevant? Surely there’s a better way by now.”
Whitney Hauser :Right. No, it’s true. I mean, I still say like a phrase or two from my preceptor when I was an extern because it resonated with me at the time and just think that’s your last time to shadow people.

Selina McGee:Yeah.

Whitney Hauser :Now if you take that opportunity and go in and take away some positive from a colleague, that is a great opportunity. Well, Selina, I really appreciate your time in joining us today for the podcast.

Selina McGee:Thank you, Whitney. I had a good time.

Whitney Hauser :You bet.

Selina McGee:Hopefully everybody took something away.

Whitney Hauser :Well, I did. If nothing else, I took plenty away. We’d like to thank you all for joining us as well for Dry Eye Coach Podcast. Join us again soon. We’ll be bringing more to you on iTunes. Thanks so much.

Selina McGee:Okay, that was awesome. That was so-

Dry Eye Coach
December Podcast: Dr. Selina McGee discusses how she tackles dry eye disease in private practice.