For the next half hour, the stranger sitting opposite me will become the most important person in my life. He will tell me about work, the joys in his life, the problems and roadblocks he faces… he will share his life’s journey. He may have no clue about the condition of his eye health… or he may be able to describe in detail the problems he has… perhaps he simply has a feeling there’s something wrong. For the next half hour his needs and wants are my only priority. Some or all of my prior experience will be critical to solving his vision and ocular health problems. Over the next few years, all of my patience will be required to convince him to stop buying contact lenses online.
Welcome to the world of the nerdy optometrist.
“Eyesight blurry, straining to see and/or headaches? You need glasses.”
Problem solved, my patient is delighted. But I move on. I ask about his family history, covering off macular degeneration, glaucoma, cataracts, dry eye disease, diabetes, hypertension, skin disorders, antidepressants, autoimmune conditions, medications, thyroidism, tumours, colon cancer. And when he asks why, I explain that these are red alerts that all have ocular ramifications.
…cool as can be, you offer this darn elephant the best manicure it has ever had. Calm the beast within and everything will be hunky dory again…
“Wow, I didn’t know an optometrist was involved in checking for all of those things.”
Later in the consultation, I suggest he considers contact lenses.
“Yes please.” For my patient, this is a life-changing moment.
Once released back into the real world, eye problems solved, on-trend specs in hand and armed with the latest and greatest contact lenses, this former stranger is another new best friend. To him, I’m wonderfully clever and ever so helpful.
And so I continue to have this little exchange with my new best friend every year and for several more.
Until the internet makes its presence felt…or the loud girl in the office who holds court at the water cooler proclaims she’s been buying her contact lenses online. She say’s nothing’s ever happened to her eyes… why would it. Then she announces that she’s sick of being “ripped off by the optometrist”.
Enter the Angry Elephant
My patient returns again for his next eye exam. Things start off pleasantly enough, though he is a little more reserved this time. We come to talking about his contact lenses. Are you happy with them? Any dryness, discomfort, redness, any issues with cleaning solutions?
His responses are mostly: “It’s fine.” I make little adjustments to his prescription here and there, recommend he change one or two things to avoid future complications and keep things happy and healthy, and suggest a new contact lens that will improve and solve small issues he’s raised. Then I ask him about lens supply.
“Yes,” he says, “I did buy one year’s supply from you over two years ago…Yes, I do throw them out when I am supposed to…No, I don’t need any more, I still have heaps of contact lenses left at home”.
“Yes,” he says, “I’ve been wearing my contacts everyday”.
They say optometrists only need to know how to count up to two… you know the old line, ’Which one is clearer, one or two?’ Even so, I can tell, something about what my patient has told me doesn’t add up.
Suddenly he can’t make eye contact and turns more than a little frosty towards me. “I just want a copy of my prescription,” he says, his eyes fixed on a point somewhere over my shoulder.
Then the angry elephant in the room wakes up. He confesses, half ashamed, half defiant, “I’ve been buying them online…it’s so much cheaper… my friend at the office put me onto it…” I have to admit, he is polite, but as he drifts off, I can hear him thinking… “You’ve been overcharging me for years.”
And so, just like that, a partnership built on a foundation of professionalism and meeting the best needs of the patient, is completely trampled on by this very angry elephant.
Angry elephants can be menacingly huge. Consulting rooms are very, very small places. In this analogy, the specialty contact lens expert is supposed to be the elephant tamer. Having been in this very situation on innumerable occasions I know very well that at this stage, put a foot wrong and that elephant will just stomp all over me and not look back. Even the best elephant tamers can get trampled into extinction.
Where’s the Loyalty?
An explosion of thoughts came to mind as I considered how to tame this particular angry elephant.
The overpriced Australian dollar… the cost inflation that occurs in a premium first world market when an international supplier ships to a regional supplier, who ships to your little independent local optometry practice, whose left to compete with the buying power of multinationals…the overheads of doing business in a bricks and mortar practice compared to a website run out of someone’s garage in a developing country halfway across the world (but the website has a little Aussie flag in it’s corner so let’s give it the benefit of the doubt…the deal looks too good to pass up!)
And still more reasons…globalisation… the list goes on.
I reflect on all those wonderful studies by Hanks, Ritson, Brujic and Pier… the studies that promise CL patients are much more loyal, refer three times more new patients to your practice, spend more in your practice, and return more often than spec patients do?1, 2, 3, 4 Not if they no longer trust their optometrist…welcome to the internet age.
According to Professor Fiona Stapleton, online contact lens sales continue to grow. “Originally, early studies showed a 4 per cent rate of penetrance into the market. Four years later, online supply was 11 per cent, and two years ago the rate was 18 per cent. Now some optometrists in the field say rates are higher than that,” she told me.
Sadly, there’s only half an hour for an eye exam, and quite frankly, I’d much rather use that time to do an eye exam than talk to my patient about the realities of globalisation and retail economics.
And anyway, in my experience, it’s only the most staunch diehard supporters, that really, really adore me who allow themselves to understand that long-term, “If I don’t buy my contacts from here, and no-one else does either, this business will cease to exist and I won’t be able to return for my eye exams in the future”.
What’s the Solution?
In my opinion, there’s no strength in playing the pity card. Don’t believe me? Think of those poor sods hamming up soccer injuries on the football field.
When the elephant raises its foot with menace, the way you manage the situation will have a profound effect on whether you quash the issue, or become squashed.
Everything rests on this moment. If you communicate the right message you rebuild the relationship, and by weathering the storm, the relationship may even become stronger. This is where, cool as can be, you offer this darn elephant the best manicure it has ever had. Calm the beast within and everything will be hunky dory again.
Where to Begin
Any interaction between two people with very strong opposing views is challenging and difficult to manage. To successfully handle the elephant, you need to put the patient’s needs first – completely put aside your wants, your needs and your opinions. A lot of this strikes right at the heart of why we initially become optometrists: to benefit our patients and help others. Patients need to be able to tell their eyecare professionals the truth. React angrily, or with resentment, and your patient has already mentally left your practice for good.
This is something we focus on at The Eyecare Company. All new customer care staff and optometrists are trained on our strategy for conflict resolution within the first week of coming on board. The strategy is really very simple and yet it defuses almost any conflict situation. I feel quite chuffed because it is one of my rare original thoughts: set an example and ‘LEAD’ the path to successful resolution: Listen. Empathise. Accept responsibility. Deal with it with decisive action.
The truth hurts but it’s always better to hear it than not.
Only Human
Patients are, of course, only human and, therefore, by nature governed by direct self-interest. Successfully winning my patient back, then, is all about education, and leveraging the value of my consultation and expertise over the false idea that Internet purchases deliver better value.
There are several strategies to be implemented. The first, and I believe most successful is to demonstrate, with a scientifically proven methodology, that there is a clear and tangible risk that comes with purchasing contact lenses over the internet. (All other strategies can sound like they might have hidden self-interest from the optometrist.)
A well-hidden gem of a study by Professors Brien Holden and Fiona Stapleton et al. published in the journal Ophthalmology provides unquestionable data that supports the argument that purchasing CLs over the internet is linked with a far higher risk of microbial keratitis.5
Fiona’s research found that online purchasing of contact lenses via the internet and mail order resulted in the risk of microbial keratitis that was 4.76 times higher than those who purchased prescribed contact lenses from their optometrist.5
Another strategy you require is to develop a sales system that suits both the patient and the practice. UK specialty contact lens fitter Brian Tompkins direct debits and delivers his patients their contact lenses each month, and offers 24/7 optometric care. Past president of the British Contact Lens Association (BCLA), Shelly Bansal, charges an annual fee for specialty contact lens examinations and specialty dry eye assessments. In return, patients have access to contact lens prices that rival those online. At The Eyecare Company, our contact lens care plan bundles specialty services for all contact lens consultations with contact lenses and care products in an affordable, tailored pricing plan. For us, this is very successful and gets us fiercely loyal patients.
Essentially, every successful contact lens practitioner has their own system. Developing that recipe for success is your hidden bottle of nail polish for that initially intimidating elephant in the room.
Getting the Message Out There
Within our own optometric industry, we have the Optometry Board of Australia (OBA) and Optometrists Association of Australia (OAA) to protect us, speak for us and also protect the interests of public health and safety. As the regulatory framework, the OBA’s role is to work with the Australian Health Practitioners Regulation Agency (AHPRA) to protect the public and guide the profession. The Optometry Board has done amazing things to achieve therapeutic prescribing rights for appropriately qualified optometrists, which in turn has brought about considerably improved access to advanced eyecare for the general public. With this change, optometry is asserting its position appropriately as an emerging and vital part of the medical profession.
So isn’t it time we worked collectively on the governance of safe contact lens supply?
Genevieve Quilty, chief executive officer of OAA said it’s on the OAA’s radar. “The increased challenges that global online retailing have posed to the optometry profession in many countries, including Australia, is an issue that the Optometrists Association Australia has and will continue to monitor and assess on behalf of the profession and our members,” she told me. “We have committed to the development of a range of resources and tools to help members meet these challenges. We continue to strive for optimum regulatory and legislative settings, remuneration models and recognition for optometrists and the work they do, including the provision of high quality and safe contact lens care for Australians.”
One of the resources and tools of support she referred to is the Contact Lens Hub, a collaborative effort from the OAA and Johnson and Johnson Vision Care. It’s a huge online project that encompasses strategies for contact lens success in optometric practice as well as marketing support. There are pages upon pages of sound practice building advice and mentors available who offer candid strategies on how to build successful practices. This year, the Cornea and Contact Lens Society of Australia (CCLSA) is rolling out a pre-followship program and Masterclass, aimed at contact lens education for optometrists to really sharpen their skill set in contact lens practice.
But is what the OAA doing enough? At every seminar I attend, I still meet at least one optometrist who does not charge for their contact lens consultation. Nor do they manage to convince their patients to purchase their contacts from them. Some never charge, some only under certain circumstances. Some don’t even realise, until I bring it to their attention, that these patients are not supporting their practice in any financially tangible way whatsoever. In my opinion, there is no shame in keeping your skills sharp, delivering an exceptional consultation to your patients and expecting to be well remunerated in return.
The stirrer that I am, I asked Genevieve whether the OAA has done enough to achieve this goal?
“The Association is keen to ensure it supports members in continuing to provide the eye health and vision care the community requires,” she replied.
While the efforts of the Association have been commendable, we need more action.
Waiting for effective change in contact lens-related legislation, particularly when the ears that need to bend are governmental, and particularly when it comes to new emerging arenas like the internet – forgive the cynic in me, but I won’t hold my breath. I’d rather focus my attention on things that are within my practice and on business strategy – things I can control and tweak to perfection in an imperfectly competitive market.
Learning from Similar Industries
Meanwhile, the General Optical Council in the UK – the regulating body of the UK optical profession – has taken a multi-layered approach to dealing with the sale of illegal contact lenses online. One layer encompasses following up complaints about those that sell contact lenses without a valid prescription. Another is promoting public awareness of the need for proper contact lens consultations and aftercare advice. There are more. On its website, the General Optical Council makes it clear these measures are being employed to reduce the risk of public harm arising from illegal practices. I like where this is going and hope our relevant bodies follow suit.
Here in Australia, with its strong lobbying clout, The Pharmacy Guild has taken an authoritative position on the online sale of medications. It has effectively lobbied government to ensure patients who purchase medications online do not benefit from the PBS safety net and it has produced a public document explaining its official position.
An official press release from the Guild states, ‘Buying medicines over the internet can pose a serious risk to your health’ and outlines valid concerns over quality and safety.
Mainstream news media were quick to jump on the bandwagon and wrote follow up articles about the risks to public health and safety from medication sourced from purchasing over the internet.
Buyer Beware
A quick Google search for ‘buy online medication’ proves illuminating: key words that jump out at me from official looking websites are: danger, careful, danger, illegal, danger, unreliable. On top of this are constant media warnings about online medication purchases. Compare this with a Google search for ‘buy online contact lenses’ and the buzz words are ‘cheap, cheap, cheap’…the silence about public health and safety is deafening.
My patient’s view is understandable. “The online boxes are the same as the ones you sell me. Surely, if it’s unsafe to buy contact lenses over the internet, the government, the TGA or some regulator somewhere would have shut it down?”
According to Professor Fiona Stapleton, “when it comes to prescription medical devices, the role of the Therapeutic Goods Authority (TGA) or Food and Drug Administration (FDA) is to govern product use. It does nothing to govern the avenues of supply”.
In my interpretation, this means caveat emptor, or, ‘buyer beware’… if you choose to run the risk of buying your contact lenses online, or, for example, you purchase your medications from the internet, the TGA or the FDA do not have a role in regulating who you purchase your prescription product from. Their role is to simply advise you on how to use that prescribed product. Interestingly, no one doubts the dangers of purchasing their medication over the internet – so why do sellers of contact lenses go unquestioned?
Recently, I was taken on a tour of Bausch+Lomb’s warehousing facilities. Freshness of the product, sterility and safety, and shipping methods carefully temperature controlled for temperature sensitive cargo such as contact lenses were all emphasised. Companies have to be absolutely compliant with strict warehousing and supply laws to be signed off for Australian standards and the higher costs expended on these standards are of course passed on to consumers that purchase from bricks and mortar optometry practices. Despite the little Aussie flag waving in the corner of the webpage, overseas online companies that ship their products to our patients in Australia simply do not have to comply with these regulations.
Time to Change the Framework
In my experience, every time I’ve diagnosed microbial keratitis, mucopurulent, ridiculously painful, potentially blinding eye ulcer that it is, there has always been an associated high risk behaviour. Fortunately, despite the considerable numbers of patients I see, it remains a very rare occurrence. However, every time I’ve seen it, the patient and I agree they wish they’d had – or listened to – more professional advice about prevention and about the risks of buying contact lenses off the Internet.
Fiona explained to me the concept of population attributable risk percentage, which is the amount of disease that can be reduced by getting rid of that risk factor. A risk that occurs because of a certain behaviour, and thus, can be eradicated through proper education to modify that behaviour – convince everyone to stop smoking, for example, and you’ll see a decline in lung cancer. In my opinion, the purchase of contact lenses online is a risk that occurs because of a certain behaviour – a risk type that can be minimised by changing the framework in which the risk exists. Each time I see a patient with microbial keratitis, I can’t help but think of it as a failure somewhere in the collective framework.
And I think we are finally ready – ready to change the framework. It’s time we have a strong, united effort on multiple fronts, from optometrists, from our representative bodies such as the OAA and OBA, and collective agreement amongst the contact lens manufacturers about instituting some regulatory change. This simply has to occur in an effort to improve and safeguard public safety, and to ensure the sustainability of the optometric industry.
Winning the Patient
So what do I say to my patient? I conduct his eye test. I show him studies. I show him some Google images. I patiently explain.
And… he wants to come back. He’s mentally filed me back to my old ‘best friend’ status. Maybe even a promotion to ‘BFF’ status.
Some of our patients are so familiar with contact lenses that they forget they are wonderfully ingenious, prescription only medical devices put into the most sensitive and arguably one of the most important parts of your body – the eyes. Use them with inappropriate care, and without professional consultation, and the devastating risks are certainly there. Yes, truly, your patient could lose an eyeball.
As a specialty contact lens optometrist, I’d much prefer my patients use them with proper care, and appropriate professional guidance, and have them change their life in an amazingly uplifting way. You cannot put a price on vision.
It’s useful to gently remind them all of this when they forget.
My elephant struts out of the consulting room with an amazing shade of electric fuschia on its nails. I wish you well with yours.
Margaret Lam is an optometrist and owner of four eye care practices in Sydney that operate under the banner of The Eyecare Company. She qualified in optometry from the University of New South Wales in 2001. Ms. Lam has a special interest in successful patient communication, specialty contact lenses (including orthokeratology and keratoconus), contact lens management and retail aspects of optometry.
References:
1. Hanks AJ. The practice viability of contact lenses vs. spectacles. Contact Lens Spectrum. May 1988
2. Ritson M. Which patients are more profitable? Contact Lens Spectrum. March 2006;38-42.
3. Brujic M, Miller J. The business of contact lenses. Review of Cornea & Contact Lenses. January 2008;37-40.
4. Pier MD. Profitability potential…contact lenses or glasses? Contact Lens Spectrum. December 1991.
5. Stapleton F, Keay L, Edwards K, Brian G, Dart JKG, Holden BA. The incidence of contact lens related microbial keratitis. Ophthalmology 2008;115:1655-1662
6. Marketing data on file, Johnson&Johnson
7. http://www.guild.org.au/docs/default-source/public-documents/issues-and-resources/Fact-Sheets/risk-of-buying-medicines-online-.pdf?sfvrsn=0
8. http://www.smh.com.au/news/national/warning-over-online-medication-purchases/2008/01/26/1201157740353.html
Manufacturers‘ Binding Predicament |
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In our bid to find the culprit behind online sales of contact lenses, it would be easy to point the finger at the contact lens manufacturers – after all, they’re the ones supplying the internet businesses. However, as I found out, contact lens manufacturers do not have full decision-making rights over who they choose to sell their products to. Certain Australian Competition and Consumer Commission (ACCC) laws mean contact lens companies are not able to exclusively sell to one group of individuals, such as, for example, bricks and mortar businesses. To my non-lawyer ears, this makes enough sense… however, to the optometrist in me, I find this pretty disheartening. Of all the places that the regulatory framework governing contact lenses is the strongest, it winds up being in commercialism – and the pursuit of the dollar. The four major soft disposable contact lens suppliers maintain a strong consensus around recognition and support for bricks and mortar optometry practices. Some have differing strategies on how to offer support, but essentially there is universal agreement that optometrists are the ones best placed to provide eyecare and products that meet the highest public health and safety standards. “For public health and sustainability of the contact lens industry, it is critical that we have a strong independent optometry sector,” said Brett Elliott, who heads up Alcon Vision Care Australia. “It is bricks and mortar optometry that screens for eye disease in the community, detects patients in need of visual correction and recommends the most appropriate solution for patients’ needs. Optometrists also invest the time to ensure patients are assessed properly and offer effective follow up aftercare. “When bricks and mortar optometry drive the uptake of contact lenses, they ensure the value provided to patients – through eyecare and breakthrough technology – far outweighs any saving that may be redeemed from an online supplier.” Rhonda Keen, who heads up Bausch+Lomb, says only by purchasing contact lenses through an optometrist can a patient be assured of product integrity. “Consumers are guaranteed they are purchasing authentic Bausch+Lomb product when they are purchasing through optometry practices. This means it meets all the regulatory and clinical standards required of an ophthalmic device. These products are backed by the support of Bausch+Lomb for manufacturing quality and comfort. “Best patient outcomes can only be achieved when a qualified eye care professional manages a contact lens patient’s visual outcomes to ensure overall eye health and comfort is maintained.” At CooperVision, Greg Sampson, General Manager for Australia, said patients who buy contact lenses from their optometrist build an invaluable long term relationship. “In the end the only place a patient can have their contact lenses prescribed and fitted properly is a bricks and mortar optometry practice… Buying their lenses from the same optometry practice is the only way for a patient to be absolutely sure they are wearing what their optometrist prescribed. Also, in the unlikely situation where something needs to be checked or is not right, the patient can go back to the best, and only professional that can assist them; their optometrist.” All of the big four have unique strategic support for encouraging optometrists to develop their contact lens business. Johnson and Johnson Vision Care, for instance, has worked collaboratively with the OAA at a national level to develop the Contact lens hub I referred to earlier. The other three have strategic support but also internet pricing strategies to support bricks and mortar optometrists. |
Step by Step |
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Listen: Empathise: Accept responsibility: Decisive action: What I am presenting here is a strategy to leverage trust and expertise based on a priceless consumer insight discovered by contact lens companies from extensive consumer surveys: the vast majority of patients prefer to purchase their contact lenses from their optometrists, as optometrists are perceived to be a far more trustworthy source for their contact lens supply.6 |
