Between the Blinks #005

Blink Exercise of the Week

(Setting) Great Expectations

One of the harder parts of treating chronic conditions is setting expectations for how long it may take to actually see a difference. We’re used to treatments where the feedback is pretty immediate. You have an infection, you take an antibiotic, and a few days later you hopefully feel better. A lot of what we manage in medicine doesn’t work that way, and dry eye is a perfect example.

Many of the treatments I use in my practice are gradual. We may be trying to improve meibomian gland function, reduce inflammation, stabilize the tear film, or improve the health of the ocular surface, and none of that necessarily happens overnight. I try to explain this before we start treatment because the last thing I want is for a patient to get a few weeks into the process, not notice a dramatic difference, and assume that what we’re doing isn’t working.

This is also why I’ve become increasingly particular about establishing a good baseline. If I’m going to tell someone that improvement may take months, I want to have something objective that allows us to see what’s happening along the way. That might be staining, tear breakup time, interferometry, meibography, redness imaging, or whatever else is relevant to that particular patient. The individual test matters less than having something we can repeat consistently and compare over time.

I was reminded of this recently with a patient I had been treating for a few months. One of her main complaints was the appearance of her eyes, particularly the redness, and when I asked how she thought things were going, she told me that she really hadn’t noticed much of a change. This wasn’t the first time I’ve heard that from a patient, and I’m sure it won’t be the last. When you look at your own eyes in the mirror every day, a gradual change over several months can be pretty difficult to appreciate.

Fortunately, we had taken images at her previous visits. I pulled up one of her earlier photos and put it next to the image we had taken that day. Her eyes weren’t perfect, and I wasn’t going to pretend that they were, but there was a very obvious improvement in the redness. More importantly, she could see it herself. The conversation immediately changed from whether anything was happening to recognizing that we were moving in the right direction.

I think we sometimes underestimate how difficult it is for patients to remember where they started. If something improves slowly enough, today simply becomes their new normal. The same thing can happen with symptoms, clinical findings, and plenty of chronic conditions outside of dry eye. Treatment may be working even when the patient doesn’t wake up one morning suddenly feeling different.

That’s where consistent testing and documentation become more than something we put in the chart. Having a baseline gives us a starting point, and repeating the same measurements gives us a way to show progression rather than relying entirely on memory. It also keeps me honest. If the testing isn’t changing and the patient isn’t improving, maybe we need to reconsider what we’re doing.

Not every patient is going to get to 100%, and I think setting that expectation matters too. Sometimes success is simply being able to put two images next to each other and say, “We’re not there yet, but look at where we started.”

When the patient can see that for themselves, continuing the journey becomes a much easier conversation.

Practice Notes

Building Confidence at a Conference

With Academy next week in Anaheim, I’ve been thinking about how much of my practice has actually been shaped at conferences over the years. Obviously, there are the lectures and CE hours we all need, but at this point those are only a small part of the reason I go.

When I was getting ready to open my practice, conferences were where I did a lot of my homework. It’s where I compared ocular surface analyzers before deciding which one I wanted in the office. I spent time looking at EHRs, sitting behind different slit lamps, talking with companies about equipment, and asking other doctors what they were actually using. You can learn plenty online, but there’s something different about having everything in one place and being able to walk from booth to booth, see the technology yourself, and talk to people who have experience with it.

It’s also where I’ve developed a lot of my relationships with industry. You start recognizing the same people, they start recognizing you, and over time those quick conversations at a booth can turn into much more meaningful relationships. Some of the opportunities I’ve had with companies started with nothing more complicated than introducing myself at a conference.

The same thing happens with other doctors. Dry eye can become a pretty small world once you start attending the symposiums, sitting through the same lectures, and seeing the same faces a few times a year. I get to hear how doctors across the country are approaching the same problems I deal with every day, and some of the most useful conversations happen after the lecture rather than during it.

Those relationships have also had a very real impact on my practice. At almost every conference, I meet at least one or two doctors who eventually start sending patients my way. Sometimes they're local, sometimes they have a patient moving to Arizona, and other times they simply remember the conversation we had months later when someone mentions they need a dry eye doctor in the area.

Just last month, a doctor who is planning to open his own dry eye practice flew to Arizona and spent the day with me going through some of the things I learned while opening mine. We talked about equipment, workflow, finances, treatments, and plenty of the small decisions that are difficult to appreciate until you're actually doing it yourself. So, since I know you're reading this, and you know who you are, keep up the good work!

A few years ago, I was the one asking those questions, and I still am in plenty of ways. That's probably my favorite part about these meetings. You can spend one conversation learning from someone who has been doing this much longer than you and the next sharing something you've learned with someone who is a few steps behind you.

Going up to someone you don't know and introducing yourself isn't always comfortable, and neither is walking around an exhibit hall trying to start conversations with people you've never met. I still have moments where I'd rather grab my coffee and keep to myself. But I've gotten too much value out of the relationships I've made at these meetings to do that anymore.

So I'll be in Anaheim for Academy, probably spending too much time in the exhibit hall, making the rounds of conversation with my connections in industry, and trying to keep my finger on the pulse of what's coming next.

If you're there too, come find me and say hi! That's kind of the point.

Life Between the Blinks

A Meeting With the Mouse

I’m heading to Anaheim for Academy this year, and somewhere between figuring out which lectures I want to attend, who I want to meet with, and how much time I’ll inevitably spend walking around the exhibit hall, I decided I’m also going to Disneyland.

I’ve been to plenty of conferences over the years, and I’ve gotten pretty good at turning them into work trips. You fly in, go to lectures, walk the exhibit hall, grab dinner with someone from industry or another doctor, wake up the next morning and do it all over again. By the time you get home, you realize you traveled across the country and barely saw anything outside of the convention center and whatever restaurant was within walking distance of the hotel.

There’s nothing necessarily wrong with that. I’m going to Academy because I want to learn, see what’s new, and spend time with people I don’t get to see very often. But when I realized I was going to be a few minutes away from Disneyland, somewhere I’ve somehow never been despite being 32 years old (in my defense, I grew up in the Northeast so Anaheim was not quite around the corner for me), it seemed a little ridiculous not to make time for it.

I’m not always particularly good at doing that. When you own a practice, there’s always something you could be doing. When I’m not working on the practice, I can work on Between the Blinks. If I’m caught up on both of those, there’s probably an email I can answer, something I can plan for next month, or another project I’ve convinced myself needs my attention. It becomes surprisingly easy to fill every empty space with something productive.

I think that’s part of why work-life balance can be difficult when you genuinely enjoy what you do. Nobody is forcing me to work on these things at night or on a weekend. A lot of the time, I actually want to. The problem is that if you wait until there’s absolutely nothing left to do before giving yourself permission to step away, you’re probably going to be waiting forever.

Sometimes you have to go a little out of your way to make the fun stuff happen. Stay an extra day after the conference. Take the earlier flight. Make the reservation. Buy the ticket before you can talk yourself out of it. There will almost always be a reason why staying at the hotel and getting some work done would be the more responsible choice.

So yes, I’ll be at Academy learning, networking, and doing all of the things I’m traveling to Anaheim to do. But I’m also going to spend a day at Disneyland, eat something unnecessarily expensive shaped like Mickey Mouse, and probably wait way too long for a ride I could have watched on YouTube.

The emails and projects will still be there when I get back.

One Last Blink

Work will happily take as much time as you’re willing to give it. Every once in a while, close the laptop, leave the office, and go do something that has absolutely nothing to do with your career.

See you next week.

Andrew Zagelbaum, OD