Premium surgeons face many challenges on a daily basis, from managing patient expectations, managing the ocular surface and treating corneal astigmatism to calculating proper IOL powers, but the most daunting challenge is learning about and/or implementing a new surgical maneuver or device. Wikipedia describes the familiar expression “a steep learning curve” as intended to mean that the activity is difficult to learn, although a learning curve with a steep start actually represents rapid progress. Either way the steep learning curve is interpreted, the premium surgeon has to encounter it, whether it be starting femtosecond laser-assisted cataract surgery, managing astigmatism and knowing his or her own surgical induced astigmatism factor, adding intraoperative aberrometry, and/or implementing any or all of the tiers of advanced/premium IOLs, such as aspheric, toric and presbyopia correcting.
When implementing any or all of these aforementioned technologies, it usually involves a multifaceted approach and not just the surgeon learning his or her part of the procedure. It starts with proper front desk scripting, proper inclusion and adjustment of flow for new diagnostics that pertain to the new device/procedure at hand, technician training, surgery counselor incorporation of the new products and pricing with advanced beneficiary notices retooled to maintain CMS guidelines for Medicare patients, and lastly billing department involvement in the latter and description of co-pays and deductibles if applicable.
When it comes to front desk personnel, assigning roles for individuals to create databases via spreadsheets for potential patients to undergo a certain new procedure will help ramp up volume and minimize the learning curve. Proper scripting that drives patients in to the office for evaluation should be the key messaging so the technicians and surgeon can give the proper clinical information to prospective patients. If certain technologies are to be added to the surgical armamentarium, such as the anticipation of the Kamra corneal inlay (AcuFocus) in the coming months, diagnostics associated with such technology, such as the AcuTarget HD, must be implemented ahead of time in terms of EHR integration and device training.
With the addition of femtosecond laser-assisted cataract surgery, there was extensive OR preparation in terms of planning flow issues, engineering needs for the laser such as Internet access and special electrical requirements, proper integration of the financial approach to the patient for such technology, and lastly the surgeon’s preparation to use the femtosecond laser properly, from capsulotomy creation, fragmentation options, understanding OCT/Scheimpflug imaging, and astigmatic incision creation in terms of radius, arc degree and axis. The latter requires vector analysis through websites such as www.lricalculator.com, with the caveat that the surgeon knows his or her own surgical induced astigmatism (SIA). Taking it one step further, each surgeon should know his or her SIA for right vs. left eyes. The website www.sia-calculator.com by Warren Hill allows for easy calculation of an individual surgeon’s SIA for each eye, making astigmatism management for either astigmatic incisions and/or toric IOLs much more accurate. Then there are the guidance systems linked with each femtosecond laser, such as the Cassini with Lensar (Lensar), Cirle Surgical Navigation System with Victus (Bausch + Lomb) and Verion with Centurion (Alcon). These guidance systems must be mastered as well as part of the learning curve.
Simply adding toric IOLs to the mix in a surgical practice now requires understanding posterior astigmatism as well and obtaining devices, such as Cassini, that measure this, in addition to knowing one’s SIA as previously described. The CMS guidelines on managing astigmatism must be followed, so appropriate advanced beneficiary notices must be signed before surgery so patients know that this technology is not covered upfront and they will be responsible for it in whole. The practice then may want to incorporate financing options, which then adds another layer to the learning curve. This process is no different when adding presbyopia-correcting IOLs such as the Crystalens (Bausch + Lomb), Trulign toric (Bausch + Lomb) or the newer Tecnis multifocals ZLB00/ZKB00 (Abbott Medical Optics).
Implementing intraoperative aberrometry adds another layer to the learning curve process by having staff learn to enter preoperative data online so it is available in the OR for the specific patient, and the surgeon must learn how to use the device, especially the Verifeye with the ORA system (WaveTec Vision) for toric IOL axis confirmation.
The theme remains the same no matter what technology or device is implemented in a practice: There is a learning curve. How steep the premium surgeon wants this to be will be determined by his or her dedication to the overall process from front desk to the technicians to the billing office and ultimately to the surgeon. In the end, it is worth it because outcomes will be much better in the long run despite the learning curve.