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Subspecialties Professional Development, Imaging & Diagnostics, Refractive

Focusing On Fundamentals


There are no shortcuts. If you want to build a successful clinic, you’ve got to do it right. You need to start with a good, solid foundation laid by good clinical decisions in the best interest of the patient – you can’t focus on generating income. I have a clinic manager who takes care of the business; he makes sure we stay afloat, especially in tough times. But all of the clinical decisions are mine. I have no problem seeing 10 patients a day and referring nine away because they aren’t good candidates. I make my decisions based on the patient’s suitability, and it’s not an issue if we don’t treat everyone we see. I’ve not got anyone looking over my shoulder saying, “Hey! We didn’t get enough patients today!” Why don’t we have a high-pressure selling environment? Because we operate on word of mouth. It’s the most valuable thing a practice can have. But there is only word of mouth if the patient’s experience is consistently good.

As for the last few years of austerity, I suppose our biggest feat is surviving. It’s been tough in Ireland, no question about it. But we’ve got through it well and things are definitely turning around. One thing we learned from the recession was that we needed to diversify more. We were doing an awful lot of LASIK and less intraocular work, but I think now the balance is about half and half.

We also put emphasis on following outcomes. When our general manager, Ed Toland, joined us he asked me what our conversion rate was and I asked, “What’s that?” What you don’t measure, you simply don’t know. Now, we let the numbers talk. We have a very good idea of how we drive nomograms for LASIK, or of what’s working in our clinic and what isn’t. When we try a new procedure, I’m not the judge; the patients are. If enough of them are satisfied, we keep doing it, and if they aren’t, we stop. It’s not rocket science, just good clinical practice.

We treat people individually – we don’t have a protocol to work through. We sit down and listen, then give them the best advice we can. If someone isn’t a good candidate for LASIK and there’s an alternative, we offer that too. It’s always good to have different solutions available. Also, I think something that’s quite unique for a big surgery like ours is that I see all of our patients preoperatively, perform the surgery, and follow up with them postoperatively too. I don’t just do the surgery and let someone else do the rest; I stay heavily involved. So we actually work in a small, country practice style, just on a bigger scale.

My advice is, to be successful, focus on your patients and their experience in your clinic. Do that properly, and the rest will follow.

… and promoting it

We’ve tried traditional marketing, advertisements and so forth, but we didn’t like the way it worked. We got some people who would come in because they’d seen our advertisements, but they weren’t really interested. For me, it’s all about word of mouth. If you make decisions based on your patients, eventually you’ll build a base of patients who would use you again and recommend you to others. About 30,000 patients have had LASIK in our clinic, and the vast majority are good word of mouth proponents because they’ve had a good experience. That’s how we build our reputation.

Alternatively, if your patients are unhappy, word of mouth can turn against you – negative comments spread farther and faster than positive ones. In terms of online restaurant reviews, one critical comment can negate 11 good reviews. If you don’t do things right, word will spread quickly, and you will not be successful.

Investing wisely in new technology

We’re always on the lookout for new innovations that could benefit our patients. Our mission statement says that patient satisfaction is our top priority. When something new comes on the market, I ask, is it interesting, and is the science behind it reliable? If the answer is yes, I’ll usually speak to the company’s CEO or CTO, and find out how it works and who’s used it before. It’s important to get as complete a picture as you can before you invest your time and money. Even then, you need to be careful not to make promises to patients that just aren’t true and have not yet been validated. We’ll only make a final decision to try something if we have a need for it – if it will benefit our patients or our practice, rather than just buying it as a toy.

We’re not always the first to adopt new ideas. Often, we’ll note new technologies early on and keep an eye on their development. I was very slow to come on board with femtosecond lasers, for example. At first, all they were doing was making flaps, and I couldn’t see the value. But they developed into a fantastic cutting tool. When femto started doing things like channels for rings, pockets for corneal inlays, and penetrating and lamellar keratoplasties, it became a much more interesting option. I got my first femto in 2010, about a decade after they entered the market.

If you want to try new things, they’ve got to make economic sense too. So when I want to try something new, I run it past my clinic manager and say, I’m thinking about this new technology and here is the cost, and because he understands the field, he won’t just look at the monetary return. He’ll look at what it could do for the clinic, and for the patients. Technology may be expensive, but it might also offer your patients more options and add to their perception that your clinic always does its best.

The next (potential) purchases

Cassini is a very nice tool that I’ve enjoyed getting to know over the past year, and I’m thinking seriously about getting SMILE; I’ve been hearing a lot of good things about it, and I think it’s going to be part of the future. But some of the things I’m most excited about at the moment are actually homegrown projects. Our clinic has a very strong academic link, despite being private. Someone who’s had a big influence on my interest in science is Michael Mrochen. He’ll say, “Hey, look at this cool new idea; what do you think?” and we’ll go through it from a clinical perspective.

Some things we’re working on now include an ocular biometer that combines a Purkinje imaging method with an OCT device to measure many aspects of the eye, including things like posterior cornea and the geometry of the anterior and posterior crystalline lens, which gives us really precise predictions of IOL power. So this device has the potential to make it much easier to choose a lens, even with difficult eyes. Michael presented some of the preliminary results at Winter ESCRS recently.

Another example is a device capable of mimicking any optical solution – any through-focus curve. It can therefore allow the patient to preview any trifocal, bifocal or extended depth of focus IOL, as well as other presbyopia solutions. So in theory the patient arrives in the clinic and puts this helmet on, and it gives them a live view – not a simulation – of what it would be like to look through any optic before they make a decision; it gives the patient a better idea of what to expect. It’s all about managing expectations, as any refractive surgeon would be well aware.

Keeping things interesting

Back in South Africa before I relocated to Ireland, I had a senior colleague say to me, “You know, your enthusiasm is fine, but you’ve only been in practice three years. Wait until you’ve been doing this 10 years – you’ll be as bored as anything.” And I thought to myself, it’s taken me a long time to get here; I don’t want to get bored!

I’ve discovered that the best way to stay engaged and excited is to always be involved in the search for the next solution, the next leap forward. The entrepreneurial, start-up side of my work has kept the day-to-day much more fun. If you go in every day and think of your work as just a job, then maybe you’ll get bored. But if you’re continuously looking at new things, evaluating them, considering them, discussing them, it keeps things interesting. So I love the research side of my work – it’s fabulous. It breaks up your time in the clinic so that when you do see patients, you’re fresh and enthusiastic. It’s so important to enjoy what you do.

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About the Author

Arthur Cummings

“I started my career in South Africa as a retinal surgeon, and developed a special interest in the anterior segment,” says Arthur Cummings. Today based at the Wellington Eye Clinic in Dublin, Cummings is an internationally renowned expert on customized laser treatments having performed upwards of 25,000 LASIK procedures and 5,000 cataract and other IOL procedures. His research interests include refractive surgery, cataract surgery and corneal surgery for keratoconus.

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