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I sense that as ODs, we do not get much training or even discussion on the concept of clinical failure. We are taught treatments for a given pathologic process, and we initiate them. As interns, if we are lucky, we get to see the patients back and get a sense of what works and what doesn’t. Compare this to the MDs, who are immersed in a hospital setting where treatment failure is almost a given. A medical intern on Day One probably sees a patient transferred from cardiac telemetry to a critical care unit, based on worsening results. The concept of treatment failure is ingrained in the MDs psyche from the beginning.

From there, pharmaceutical product lines aren’t usually integrated in a vertical fashion. Meaning, there is seldom a discussion from a manufacturer whose product does not get desired results. It’s on to the next product in a method that may not be much better than trial and error. When was the last time a company representative gave an evidence-based discussion on what to do when the represented product fails? (Wouldn’t it be interesting if Allergan’s possible purchase of Shire goes through? Restasis and Xiidra on the same plate?)

As with life in general, the key is to be prepared.

Treatment failures are going to occur, even if diagnoses and treatments are executed perfectly. That’s the beauty of medical care, as there is mystery in even the most straightforward of cases. Think through your next step in any pathology or visual disruption that you may treat. Will you go to a stronger version of the same therapy, or will you change tracks entirely? Or, will you maintain the original treatment and add to it?

As Yogi Berra famously said, “90% of this is half mental.”

The point here is not to suggest that you won’t go to the next step appropriately. Rather, it’s that your confidence and lack of hesitation will go miles to reassure the patient who is disappointed in your early results. Hem and haw, or project doubt, or turn to Dr. Google, and you’ve jinxed the patient’s upcoming results even if you’ve made the ideal therapeutic choice.

Your clinical acumen is the key to anticipating less-than-perfect results. When do you discuss the possibility of treatment failure with a patient? Acute conjunctivitis would not be the place to start unless we are dealing with a florid case of EKC. Show Hamlet’s self-doubt over treatment of an uncomplicated red-eye, and you’ve lost the game before the patient gets to the pharmacy. It’s the more chronic diagnoses that should lead you to review possible endpoints of your prescription and prepare the patient accordingly.

Do some of our own behaviors lead to failure?

I often lecture on uveitis, and audience members invariably tell me that they follow-up in “a day or two.” Here’s why that approach will fail you, and you can generalize it to any number of follow-up scenarios. Pick a follow-up interval that will be not too long, but especially NOT TOO SHORT. The patient implicitly expects improvement, and will inevitably be disappointed at receiving the same clinical report. Uveitis simply doesn’t resolve that quickly.

An audience member recently asked, “If you are waiting 5 days to follow up on an iritis, what happens if they get worse in the meantime?” Our door for emergency care is always open. Increased redness and swelling, pain, or blurry vision would lead them to call before the scheduled follow-up, and they’ve already been reassured that they can get in “sooner if needed.”

Insufficient dosing is more common than a true missed diagnosis. Hit pathologic conditions HARD, especially if steroids are involved. Tentative efforts designed to “avoid side effects” tend to result in even higher doses of steroids being employed.

As optometrists take on chronic care in diseases of the ocular surface and glaucoma, we have to increasingly deal with treatment failure. These are lifelong, progressive illnesses whose care has huge commercial influence. It’s always interesting to hear a colleague assert that “my approach is best,” yet the reality is that approaches to both disorders are all over the map. Standardization is lacking, despite efforts to categorize diagnosis and treatment.

Keywords that come to mind are confidence, open-mindedness, and exit plan.

Knowing when you’ve done the best you can do within your scope of practice, and knowing when it would pay to have a second opinion, all serve in the patients’ best interest. Convey confidence and don’t expect poor results, but embrace failure as a fascinating part of optometric practice!

Bill Potter
Associate Editor, Dugout Dirt Editorial for Dr. Bill Potter is the senior optometrist at Millennium Eye Care in Freehold, New Jersey. Millennium is a multi-subspecialty optometry/ophthalmology practice, where Bill has practiced for 31 years. Prior to this, he served for 3 years as a Captain and optometrist in the U.S. Air Force. Bill is a graduate of the University of Pennsylvania and the Pennsylvania College of Optometry. He serves as a member of the Review of Optometry’s Editorial Board. The Primary Care Optometry News honored Dr. Potter in 2016 by listing him as one of the “PCON 250” top leaders and innovators in his field. Dr. Potter has a special interest in uveitis and other ocular inflammatory diseases and has lectured and published many articles in this area. Most recently, Bill’s CE article on “Red Disease in Glaucoma” appeared in the March 2017 Review of Optometry.