PHOTOGRAPHY: DAVID SPARKS

When Thomas M. Aaberg, Jr., MD, founded Retina Specialists of Michigan in January 2009, his goal was to create a practice that focused on patient satisfaction through exceptional clinical and interpersonal skills. He gives much of the credit for allowing him to achieve this goal to staff training.

“A well-trained staff translates into happy patients,” says Dr. Aaberg.

In fact, a Survey of Ophthalmology study showed that greater patient satisfaction is linked with increased patient adherence to recommendations, greater patient retention, and decreased malpractice suit rates, as well as increased patient referrals. (See bit.ly/3kUnHLt for the full study).

“Our staff has been trained to make patient encounters informative and pleasant from the time a patient calls us to make an appointment, throughout their initial work-up and retinal imaging, to their encounter with the physician, and to the point of checking out,” Dr. Aaberg says.

He notes this training has helped enable the practice to expand over the last 12 years from himself and one ophthalmic technician in 2009 to six doctors, four locations, and 35 allied staff members today.

Here, Retina Specialists of Michigan staff explain how they accomplish patient satisfaction and excellent outcomes by focusing on several areas of staff training in each of the practice’s five subspecialties: comprehensive retina, inherited retinal disease, ocular oncology, uveitis, and pediatric retina.

Retinal disease education and more

The practice focuses on education through didactics and educational materials, such as videos and courses from BSM Consulting, to enable staff to learn about the retina, how it functions, and how diseases disrupt its function, explains Jessica Norkus, COA, a technician supervisor at Retina Specialists of Michigan. “We also have an education fund to be used for remote learning, attending conferences, or purchasing textbooks,” she says.

However, the practice’s education program covers more than just the different types of retinal diseases. It also teaches about different patient personality types, communication skills, and how to handle emotionally charged situations, as many of these conditions can be sight threatening. For example: “Handing the patient a box of tissues when the doctor delivers difficult news, and knowing when to leave the exam room and say, ‘I’m going to give you a few minutes to absorb all this,’” Ms. Norkus says. (See “Enhance communication with patients,” p. 13.)

In addition, training focuses on anticipating patient questions and allaying fears, says Ms. Norkus.

Educating the patient

In addition to educating patients on the basics of their condition, Retina Specialists of Michigan staff provide information customized to the subspecialty. For example, for ocular oncology patients who require life-saving enucleation, the practice’s surgical schedulers “walk patients through the entire process to make sure they understand what is going to occur,” Ms. Norkus says. The schedulers provide an information folder that, among other information, contains post-surgical resources — such as a book that discusses the expectations, challenges, and strategies needed to live with single eye vision — the names of ocular prosthetic specialists, and, most importantly, an email to which they can send any unanswered questions or concerns, she notes.

In the pediatrics subspecialty of the practice, staff explain to parents what the workup entails, what their child can expect, and how they or their child can inform staff of concerns so any issues can be rectified, says Olivia Rainey, OCT-C, COA, the practice’s director of photography. Additionally, allied health staff learn what to say and how to say it to young patients to increase the likelihood of cooperation, notes Ms. Norkus.

An example: “Today, we’re going to take a photo of your eye. This machine is going to have a target that you’re going to look at, and the target will stay the same. The machine isn’t going to come out and poke you or anything. It’s important that you sit still like a statue because that’s going to give me my best photo. Does all this make sense? Do you have any questions?”

Further, the staff is trained on how to deliver positive reinforcement, by saying things like, “You’re doing a great job! I’m almost done. Keep up the awesome work!” Ms. Norkus explains.

Education on diagnostic devices

Retina Specialists of Michigan employs fundus autofluorescence, fluorescein angiography (FA), electroretinography (ERG), OCT, OCT-angiography, ultra-widefield retinal imaging, and ultrasonography to aid in the diagnosis and management of patients’ eye care.

Ms. Rainey says that she provides education on both the operation and related nuances of accurately capturing pathology. Typically, Ms. Rainey says she spends a week with each new staff member but will continue one-on-one training well beyond the usual training months. The education includes: how the device works, what normal anatomy looks like, and how to recognize and capture anything that looks different compared to the surrounding area. She also emphasizes that “staff do not diagnose and how important it is to have this provided by the physician.”

Ms. Rainey says she has created imaging acquisition protocols for certain conditions. She explains the importance of a technician understanding why these protocols exist to ensure they are capturing what the physician needs. Again, the education piece is so important, says Dr. Aaberg. For example, for vitreomacular adhesion, Ms. Rainey says she trains staff to acquire scans that have smaller spaces between them to ensure a small break is not missed, possibly revealing a small macular hole.

When it comes to employing autofluorescence on patients who have inherited retinal disease (e.g. Stargardt disease, Leber congenital amaurosis, etc.), Ms. Rainey says she educates staff that the protocol is to minimize the use of the particular test because the frequency of light used for those images may cause damage to the retina when it is in a vulnerable state.

Joseph Boss, MD, a specialist in uveitis and pediatric retina at the practice, adds that staff also have benefited from outside training on more sophisticated testing, such as echography and ERG at different academic institutions.

“We have paid for flights and training, which is a huge investment, but, obviously, it’s worth it to ensure we get the most accurate data,” Dr. Boss says. “This is practice-driven. Typically, we identify staff capable and interested in learning how to perform and understand sophisticated testing, and then we make sure they are trained in the best possible fashion.”

Regarding ocular tumor imaging, Dr. Aaberg says the staff are trained that the type of tumor and the tumor’s location dictates the imaging protocol. For example: patients who have iris tumors shouldn’t undergo dilation before seeing the doctor, as it may distort its appearance; allied health staff may need to physically position patients to obtain the image the doctor needs, but they should ask the patient for permission and keep the patient’s comfort top-of-mind; and, despite everyone’s best efforts, the technician may need to improvise in situations in which regular patient positioning may not be possible for tumor image acquisition.

“I must brag about our staff. We have a culture that fosters innovation and education,” Dr. Aaberg says. “As a result, our staff has developed very innovative ways to capture tumor images or any ocular pathology for that matter. Then, those innovations are quickly disseminated to other staff members.”

Another example of training is in the patient workup for uveitis. These patients may be unable to see well enough to fixate on the device’s target, due to the condition’s inflammation, pain, and/or photophobia. In such cases, staff perform a “sweep,” directing the uveitis patient to look up, down, left, and right to enable visualization inside the eye, offers Ms. Rainey.

“In pediatric patients, we often use the ‘flying baby technique,’ where we remove the device’s camera head, chinrest, and face plate to get the baby or child as close to the camera as possible, and then we have the parent hold the baby or child on their stomach and kind of fly them close to the camera,” she explains. “Capturing a good image is all about timing, so right when the patient gets close and the staff member can see the child’s eye on the screen, that’s when the photo is taken.”

When it comes to the use of ultrasonography, as in the ocular oncology subspecialty of Retina Specialists of Michigan, for example, Dr. Aaberg says staff training is lengthy.

“Many facets of ultrasonography must be taught in order to accurately image an eye. These include probe orientation and directionality, to gain adjustment and pathology identification,” he explains. “If not done properly, tumor dimensions are inaccurate, retinal detachments can be missed, and critical areas of vitreous traction can be overlooked.”

Information acquisition education

The practice educates staff on the information needed from patients, such as past medical history, past ocular history, family medical and ocular history, social habits, and a generalized review of systems. This information, more often than not, becomes important in the management decisions of the doctors, notes Dr. Aaberg. Specific questions, such as, “Does anyone in your family have a history of issues with their eyes?” are designed to elicit answers that the doctors need, Ms. Norkus points out.

“A review of systems is particularly important with uveitis, for example, as uveitis may be linked to disease that affects other organs; for example, ankylosing spondylitis may damage the lower spine, Behcet’s disease and multiple sclerosis can damage the brain. In turn, this helps to direct the laboratory work-up, so the patient doesn’t have to undergo every blood test under the sun,” explains Dr. Aaberg.

Patient interaction education

Retina Specialists of Michigan staff shadow the doctor and scribe, so they can see how the practice expects them to interact with patients. This is particularly important in the pediatric subspecialty where staff must be “comfortable, confident, and capable,” says Ms. Norkus.

“So, having staff observe the doctors and senior techs in the trenches, so to speak — how they get a toddler to fixate, and how to distract with a toy, as examples — works well to get them acclimated to working with these patients,” she offers. “Kids are super intuitive, so if the staff member is nervous, the child is going to be nervous, and the appointment won’t go well.”

Ms. Rainey says she uses FA as an example of the importance of observing seasoned staff.

“With FA, there’s a risk of nausea and sometimes vomiting,” she explains. “It’s one thing to hear about how quickly a patient could feel this, but it’s entirely another to actually witness it and see firsthand how senior staff reassure patients that the reaction is normal and will pass.”

The practice then has staff rehearse their diagnostic device, patient history, and interpersonal skills on fellow staff members while senior staff observe.

“We come up with various patient scenarios to encourage learning, questions, and preparation,” Ms. Norkus says. “For example, a staff member may play the role of a patient who is having trouble sitting still, fixating on a target, or who has just received difficult news.”

Ms. Rainey adds that this training is also beneficial for the trainer, who gets a taste of what retinal disease patients go through and thus encourages empathy, as the fellow staff members are temporarily putting themselves in the shoes of those patients.

Education should never end

Dr. Aaberg stresses that staff training is ongoing, with didactic lectures, a staff retreat, and cross-training.

“We have a full staff meeting every month and sometimes every two weeks, and it includes a 10- to 20-minute didactic lecture on a specific retinal disease,” he explains.

The retreat, which Dr. Aaberg says takes place annually off-site for a half or full day, includes additional staff education, along with reviewing administrative tasks, the practice’s LEAN processes, and team-building activities.

Ms. Norkus notes that staff also undergo cross-training, so they can step in for a colleague when needed and keep the schedule on track and patients happy.

“There’s honestly not a day that goes by where a patient doesn’t thank us for the care we provide, whether it’s their first retina appointment or their fifth,” Ms. Norkus says. “We’ve worked hard to give them an exceptional experience. It’s just so gratifying hearing, ‘Thank you for spending the time to explain that to me,’ or ‘Thank you for helping me.’” OP