Evidence-Biased Medicine: Part 2


GerdWe posed the question in Part 1 as to why so many pediatric ophthalmologists harbor a bias against office-based vision therapy, discouraging the patient from undertaking it despite the striking evidence-based medicine of the CITT.  We provided some clues from the work of Professor Gerd Gigerenzer, director of the Max Planck Institute for Human Development in Germany.  The fundamental issue, and the challenge to both Optometry and Ophthalmology, is how we help guide patients toward making good decisions.  There is one inescapable conclusion: the evidence bias against the cost and time involved in doing office-based therapy is outweighed by the value judgement of the doctor that it simply isn’t worth it.  A frank double standard.  While it was fine for Frank Sinatra to boast that he did things “My Way”, that simply isn’t good enough for eye doctors cloaking themselves in mantles of scientific concern.

 

gerd 2But let’s go beyond the obvious evidence-base for CI about which there is absolute certainty.  How do eye care practitioners typically handle other conditions such as strabismus and amblyopia about which there may be less certainty?  Gigerenzer offers insights about such heuristics from his Edge conversation: “Still, medical societies, individual doctors, and individual patients either produce the illusion of certainty or want it. Everyone knows Benjamin Franklin’s adage that there is nothing certain in this world except death and taxes, but the doctors I interviewed tell me something different. They say, “If I would tell my patients what we don’t know, they would get very nervous, so it’s better not to tell them.”

Take for example a recent case in our office involving refractive amblyopia.  The parents of a child came to us, referred by other parents in their neighborhood, regarding management of their son’s amblyopia.  He had previously seen a pediatric ophthalmologist who prescribed glasses for him having two significantly different powers between the eyes, accompanied by a patching regimen but no therapeutic activities.  I reviewed my findings with his parents at a separate conference during which I laid out the treatment approach of moving beyond patching and into MFBF techniques to bridge binocular integration, and then onto binocular activities to maximize outcome including depth perception.  The child’s parents seemed to grasp the difference in the optometric approach from the ophthalmologic, and proceeded to schedule vision therapy.

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At the first vision therapy session the child’s father seemed conflicted.  After our conference he went back to the pediatric ophthalmologist who said that his son was making fine progress with patching and that no other treatment was necessary.  For good measure, she increased the power in the lens of the amblyopic eye, further exaggerating the difference between the two eyes, though the family didn’t feel it was important at the time to mention it.  The father asked: “Do you really think my son needs vision therapy?  I want to do what’s best for him, but it’s very expensive and I want to make sure you feel he needs it because Dr. X said he didn’t.”

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This child’s first progress evaluation seemed to turn into a debate over whether this young boy was making progress demonstrable by “empirical evidence”.  Matters devolved from there into his parents becoming passive aggressive toward our staff, and I was left to wonder how much the pediatric ophthalmologist’s voice was in their head.  Can we graph out data and spend considerable time at each progress evaluation, or in this case even toward the end of a therapy session?  Of course, yet there has to be a happy medium between no evidence and smart clinical heuristics, in Gigerenzer’s terms.  I would love to have been a fly on the wall in the ophthalmologist’s office when she presented the data to the parents that they were demanding of us.  Did she review the PEDIG trials to establish the optimal number of hours for patching?  Was she conversant with the rich body of literature in ophthalmology journals over the past several years showing functional deficits in amblyopia that arise when visual acuity is used as the sole index of visual function, and its implications for therapy beyond patching?  Did she review the application of computerized methodologies for amblyopia therapy as pioneered by Dr. Jeffrey Cooper?  Where was the empirical evidence that the ophthalmologist’s approach was doing anything that would alter the Rx required to attain optimal outcome?  Was she conversant with the rationale that we were pursuing regarding reverse engineering hyperopic anisometropic amblyopia, as I have documented in the ophthalmic literature?

Presumably the ophthalmologist presented some sort of evidence to the parents, but exactly what it was we’ll never know.

 

 

 

 

4 thoughts on “Evidence-Biased Medicine: Part 2

  1. Dear Lenny,

    Some thoughts regarding this misuse of power and the facts. I recently used two quotes by Mark Twain in a presentation. The first was that “There are lies, damn lies and statistics” and the second was “Get your facts first, then you can distort them as you please” In your case, it is obvious to me that the pediatric ophthalmologist played the credential game. It is the MD versus OD degree, which is the ultimate deciding factor. Physicians are notorious for bullying their patients into following their recommendation. They have also raised the question of doubt, which is then impacted by the cost of therapy. Amblyopia has always been defined as more than decreased acuity in the text books and in research but doctors continue to focus only on acuity. What about the patient’s accommodative, ocular motor and binocular skills? What about the impact of the condition on the patient’s academic or work performance? What about the reality that it is rare to have only one lazy eye? The patient really has two lazy eyes but one is just more lazy as measured by acuity. I doubt that this ophthalmologist was even interested in the PEDIG studies. The change in prescription was another tactic to undermine your recommendation. Why would you want to increase the anisometropia if your goal was to achieve binocular function? The achievement of binocularity would also limit the potential of any regression in the acuity of the child’s amblyopic eye. I doubt that this doctor had any of these concerns on their radar. They just wanted to maintain control of the case and undermine your approach.

    Wishing you the best of luck in managing this case. In my experience, it is often a lose, lose situation. The true loser is the patient/child, who does not receive the appropriate treatment because of this ongoing conflict between medicine and optometry. It should also be noted that we are not the only non medical provider, who has been treated as second rate providers by the medical community. Insurance companies, who are strongly influenced by medicine, also go out of their way to create an uneven playing field.

    Richard

  2. Well-stated, Richard. Not sure why it’s in my DNA, but I refuse to believe that there aren’t a cadre of caring professionals who can rise to the challenge of admitting that vision therapy can be a public services, and that it isn’t an inherent weakness if they admit that optometric vision therapy is synergistic to their knowledge and skill set as opposed to a threat to it. In fact, I’m working on such a project right now.

  3. Hi Len,
    In my mind it is always easier to recommend something which is less involved. It is just easier to explain and carry out.

    For myself, my parents had a similar decision. At the time it was much easier to patch continously for three months and then go back in for a recheck with our pediatric ophthalmologist. They knew of another boy who was provided optometric vision therapy. It was, however, much more involved. Except after three months of continual patching my lazy eye had become the good eye and the previous good eye was now lazy! This situation reversed a couple of more times until the ophthalmolgical patching was considered unsuccessful.

    Case closed until I was provided binocular optometric vision therapy by developmental optometrist, Dr Bill Ludlam. Gradually my stereopsis improved and so did my ability to remember better and process faster.

    I find my story being repeated over and over even today! My story occurred 52 years ago! To me it is amazing I remember this because my folks passed 37 years ago!!

    Thanks to people like you, Len, for getting the optometric vision therapy story out to the masses! It is taking time but as Napoleon Hill said, “Do not wait; the time will never be ‘just right’. Start where you stand, and work with whatever tools you may have at your command, and better tools will be found as you go along.”

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