We’re back with another installment of the Future of Canadian Optometry. Joining us today is Dr. Richard Maharaj, who expressed that the original six conversations did not fully represent the perspectives of optometrists across Canada. In this episode, Dr. Maharaj dives into the perspectives that many non-business-owning doctors have about our profession's current and future status. He also shares a perspective of a growing area of the industry that he calls the Independent Specialist. You don’t want to miss out on the incredible exchange of insights and ideas by tuning in to this episode with host Harbir Sian.
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The Future of Canadian Optometry - Dr. Richard Maharaj, The Independent Specialist
Here's a very big Happy New Year. Welcome to the year 2023. This is our very first episode of the New Year. I'm excited for multiple reasons for this to be the first episode of 2023. If you've been tuning in to the show, you will know that in 2022, I did a series of interviews, which was called The Future of Canadian Optometry. I did 6 interviews with 6 different guests to explore where the profession is heading in Canada. Through those interviews, I had conversations with many colleagues.
I got lots of amazing feedback. I learned that there were certain aspects of our profession that we missed and didn't cover. I didn't want a big portion of our colleagues to be left in the shadows and not discussed the opportunities that they could have to grow, and for the profession to grow. The perfect person for this conversation or the person who brought most of this to my attention is this man right here, Dr. Richard Maharaj. He's no stranger to the show. Welcome back, Dr. Maharaj. I'm so happy to have you here.
Harbir, thank you for having me. I'm looking forward to the three-peat. I'm excited that you asked me to come back. This is going to be a great conversation.
I jumped into introducing you without giving you a true intro. Even though you've been on the show a few times, it's important to give everybody a little bit of context as to why you're the right person for this conversation. Previously, we have had CEOs, vice presidents, or presidents of these different groups. We even had Dr. Kerry Salsberg give the private practice owner's perspective. You have a unique perspective on this. Independent specialist is the term that I love that you've coined that we want to explore here.
Just so everybody knows who you are, you are the Director of Interventional Dry Eye Services at the Prism Eye Institute, which is a leading medical and surgical eye care and research institute with multiple locations in the Southern Ontario area. You are the Chief Education Officer at MyDryEye.ca and the Cofounder of the Dry Eye Summit, which has very quickly become one of the most recognizable names in dry eye education and innovation here, not just in Canada but across North America.
You're the perfect person for this conversation. I'm blessed to have you and your insight here. Why don't we share how this came about? I released those six interviews. You are kind enough to listen to all of them and even more generous to give me your honest feedback on them. You shared that although you felt that there was a certain light shed on conversations that needed to be, there was a good portion of our population and our colleagues that were not represented in those discussions. I would love to hand it over to you and tell me what you think about that.
Thank you. I'm fortunate enough to have both live and digital relationships with a lot of colleagues from across the country, young and old, and from all walks of life. One of the points that came back to me quite often was from some of the younger colleagues that describe themselves like, "I'm not a practice owner. I'm not part of a corporate entity. I'm just a person or an optometrist."
Those optoms that have been in contact with me generally are interested in dry eye and how to integrate it into their practice or how to do it stand alone. What I found from the conversations and what I was hearing from other colleagues was that the perspective of either the corporate owner or the private practice owner was adequately explored, and then some. The independent specialist or the independent associate whose voice certainly outnumbers the voices of practice owners is vacant. Where does the future of optometry exist if not with the individual?
Where does the future of optometry exist, if not with the individual.
If those voices are saying something but are not part of a larger group, then that message gets left out. I'll put my bias out there front and center. I don't think it's any secret, but I've been behind the movement toward the specialization of optometry in Canada for the last decade. The one thing that became a common theme in most of these conversations was the conversation around the comprehensive eye exam. How do we utilize that? How do we optimize that? What is the value of it? How does that impact eye care, eye care consumption, and the market in general?
I would submit that looking at the comprehensive eye exam is a sliver that is hyper-focused. I just don't think I've lived it. My involvement now with the Prism Eye Institute and the movement toward specialized optometry clinics within the Prism Eye Institute and our groups, which are growing nationally, suggests that there's a market in and of itself that exists outside the comprehensive eye exam and outside the traditional retail optometry space. That's where we can frame this conversation and see where it takes us.
Canadian Optometry: There's a market all in and of itself that exists outside the comprehensive eye exam and outside the, the, the traditional sort of retail optometry space.
That sounds good to me. I have to admit. I agree that is a lot of what happened there, whether it was by having my blinders on or the way that the conversations went with the different guests. Being a business owner myself and a practice owner, I was coming from that perspective. I'm guilty of not sharing or at least addressing to some degree that the vast majority of our colleagues who are not business owners and their associates are practicing some other form.
I hope we can address some of it here. As I've been sharing these episodes, I want to make sure that this conversation about the future of Canadian optometry doesn't just get buried with those six interviews I did. I want this act to be an ongoing thing. I plan to have multiple more interviews with different guests to make sure that we continue to see the different aspects of our profession and hopefully, bring to light some of the potentially negative things that might be happening but more importantly, the positive things. When people ask me, "Give me a quick summary of those six interviews," I'll say, "Generally speaking, everybody I brought on says that they think that the future is bright and that our profession has a lot of good things going for it." I hope that we can see that and come together.
The other message I share with everybody is it's going to be super important for us all to work together to make sure our profession stays strong. The majority of our profession is practicing not as business owners. We need to make sure that the masses are hearing the message and working toward greater goals and pulling in the same direction to some degree.
Why don't we do this? I'll ask you some of this so we can keep some structure to the conversation. Otherwise, we will just banter back and forth. I'm sure that will still be valuable, but there's still some structure to the conversation. I'm going to ask you a couple of the same questions that I asked the other guests. I would love for you to put your spin on it or your perspective on it. The first question I ask everybody is this. In your opinion, what is the current state of optometry in Canada now?
The way I see it, we're currently in a state of transition. One could argue that we're always in a state of transition. It just depends on how close to the lens you want to be. If we're zoomed in super close, that tends to happen when we're highly stressed, highly anxious, and highly worried for whatever reason, competitive reasons or otherwise. If we zoom in, we will see that our traditional competitive landscape is right in our backyard.
That's the entrance of new players like Specsavers and also the existing other corporate entities like FYI and the other folks that were generous to share their perspectives on your show. That’s in the backyard of this competitive landscape of what I would describe as retail products, as well as the eye exam itself. It was Dr. Daryan Angle that brought this up. I completely agree that if you zoom out, you're going to see that optometry is thriving if you compare where we have come from and where we are now.
From a regulatory perspective, we are legislatively at the pinnacle of where we have been, at least in Canada. We're not yet at the space in which some of our surgical colleagues in the US are, but we are approaching that. From a regulatory and legislative perspective, we're probably the most advanced that we have been. From a market share perspective, we're also occupying the largest market share that we have ever had as a profession. There was a time when we fought to be recognized as a profession.
Zooming out, you're going to see that we are at a precipice of a very exciting time. I would agree with every other of your guests that this is an exciting time, but it does depend on where you are in your career, how seasoned you are or how new you are. That can be burdened with fear for various reasons. If you're a new grad, you're thinking about where you're going to work.
If you're a soon-to-be-retired optometrist, you're thinking, "How am I going to reap the rewards of this nest egg that I've built up over the years? How am I going to transition?" It does depend, but it's super important that we zoom out and remember that this is and will always be the most exciting time in optometry. The day that you ask that question will always be the most exciting time.
I hope that's the truth. I hope that's the case, that our profession continues to grow and our scope continues to broaden or expand. Every time you ask that question however many years down the road, it will be potentially the most exciting moment in the profession. There's no downhill trend at some point due to various forces or whatever they might be. That’s a good piece of advice there is for us to zoom out. It's tough to do sometimes.
Maybe I can clarify. Exciting doesn't always mean great. Exciting means that we are in the midst of change. As you've noted and as we have all experienced in the last couple of years, change is uncomfortable. It depends on where you are. We're very much a cyclical profession. If you look at any emerging profession, there are cycles. We are in one of those cycles. The discomfort is part of that change. At the time, it may not seem exciting from a happy perspective. When I say exciting, it's like you're about to get on stage to do that talk, and you've got those goosebumps and bubbles in your stomach. It's that kind of excitement where it's a nervous excitement. That's how I frame that.
Exciting doesn't always mean great. Exciting means that we are in the midst of change and change, as you've noted and we've all experienced in the last couple years, is uncomfortable.
That's fair enough. What do you see as some of the potentially disruptive forces? Disruption doesn't necessarily have to be a bad thing either. Sometimes that word tends to have a negative connotation. What are some of the driving forces that are changing the profession? We're in somewhat of a transition phase here, whether it's specific players like Specsavers, potential legislative changes on the horizon, or expansion of scope in medical opportunities. What are you seeing happening? What are some of the few key forces in there?
This topic was interesting. The independent specialist in optometry has the potential to be a true disruptor. This is not necessarily a practice owner, corporate, private or otherwise. A lot of the conversations talk about specialty eye care services as an adjunct or as an addition to primary eye care or comprehensive eye exam services. I would offer that that's perhaps a bit of a limited view given the demanding aging population that we're seeing, the increase in various chronic diseases, our ability to treat those diseases, and more importantly, our appetite, especially from newer grads that are being trained at such a heightened level.
That appetite to engage in specialty eye care services from our perspective is there. The demand is there. It's important to recognize that we do have to continue to market to the end user who is our patient that we are comprehensive in nature. We will provide you with a general physical examination of the visual system and ocular health. However, that is not an exclusion or isolation of other specialty services. Where I see the difference from the previous colleagues that you had on the show is that the over-reliance on the comprehensive eye exam has resulted in it becoming a commodity.
Whether anybody wants to acknowledge it or not, the commoditization of anything doesn't generally yield a solid outcome or a positive outcome for the provider of that commodity. When we talk about the eye exam, we have to have the latest technology and make sure we have imaging, OCT, and all these other things. If you think about it, what we're doing is we are inflating the value. Some of my colleagues talked about the perception of value. We will get to that.
We perceive the value to be greater by including these other things in it. To me, that seems to be backward because if you look at our 4 years of training, and then if you did a residency afterward for 1 or 2 years, of those 6 years, the majority of that time is spent learning how to diagnose and treat diseases. It's not to say that dispensing eyewear and treating visual conditions is not part of it, but we spent a lot of time treating diseases.
If we look at the percentage of time we spent learning and the percentage of our revenue earning based on that same ratio, it's inverse. If we're going to expand the comprehensive eye exam to include this, we also need to acknowledge why it's being positioned that way by some of the leaders that we had previously. I would submit that we are creating momentum toward making the eye exam a loss leader.
Another bias aside, I practice in Ontario. I can certainly attest to the devaluation of the eye exam because of OHIP's remuneration being below the cost of delivery but we can't keep on doing that. That's where I see the disruption being necessary. It’s to not just invest but put into the commonplace language in optometry that the independent specialist or independent specialization in optometry is not just a possible path forward but a necessary path forward.
To digress a little bit, you flipped it. You said, "We spent all this time learning the medical but that ends up being a small portion of what we do." It reminded me of something I heard on even my very first day of optometry school. It was the first week. One of our professors stood up at the beginning of the lecture and gave a ratio of 90% and 10%. He said, "90% of what you do is going to be refraction and 10% is going to be medical." I was wondering what you would say to somebody if you happen to be in that lecture reviewing it or auditing it. Would you stand up and say something to that professor? What would you say?
I would tell him, "I hope that's how it goes." I agree with that proportion of learning. I'm still baffled to this day that the proportion isn't reflected in our earnings. Spelling out a little bit about my history, I started from scratch with a referral-based practice in Ontario, which relied almost primarily for a time on referrals from colleagues from ophthalmology and optometry. It was unheard of at the time. I was focused specifically on the ocular surface treating a particular medical disease nonetheless.
I put my money where my mouth is and said, "I'm going to rely on the training that I've had." I did a fellowship, so I invested further time. I said, "I'm going to put my money where my mouth is. I'm going to invest in relying on that acumen, expertise, and specialized knowledge to generate the very revenue and value that I can bring to the profession and my patients." Reflecting back on things that I heard from colleagues, it’s either I'm crazy or it's never going to fly. It won't work in Ontario. I got slapped on the wrist by some colleagues. I thought, "How backward do we have it?"
What I would say to the professor that you mentioned is that we need more people and voices saying that we were trained for this. We're being trained at even a higher level than both you and I were. I'm twenty years out now. We are being trained at a much higher level with more focus on diagnosis and treatment. While legislatively provincially, at least I can speak to that, we still have some catching up to do on the billing side. We better invest in showing our patients what it is that we're best at and then, more importantly, valuing that.
Canadian Optometry: We better invest in showing our patients what it is that we're best at.
The word value is a tricky word that came up a lot. As open and transparent with each other and everybody else here, we don't need to beat around the bush. One of the big elephants in the room here was Specsavers. A lot of colleagues are worried that their presence was going to devalue the eye exam. We have been putting hyper-focus on the eye exam. That's what we have been trained to do. That's what we do as eye doctors. We do comprehensive eye exams.
We have been in the collective voice. It seems to be that we're worried that our bread and butter or the cornerstone of what we do day in and day out is going to be devalued. Therefore, patients are not going to look at what we do with as much respect as they previously may have. Do you think that's true? In response to that, we're trying to inflate the value of the eye exam and add in the OCT, the Optum map, and this thing. We add value to it, but in what other ways can we add value to what the patient sees in what we do then?
The one thing that I would say is to stop trying to add value to it. The value needs to be specific there. What I see that we're doing is we're leaning into optometry psychology of being less than or perceived as less than. I've talked about the psychology of optometry for a long time. I have done a lot of research on this. Our pervasive personality type is an ISFJ, which has us being anti-competitive or at least competitively shy. What we do instead is we try to inflate. We figure out ways to do that. As a profession, I can say that we have done that. This is one clear example where we inflate.
This perhaps might come from my close proximity to ophthalmology now, especially with my work with Prism. They're a group, and ophthalmology is a group that can hang up their shingles and open up. They have a waitlist right out the gate. With that comes a certain bravado, tempered arrogance, and sometimes more arrogance. There's this BDE or Big Doctor Energy. I have to put that for the PG group. That comes with that.
There are no apologies because they're not in a position where their patients have to perceive the exact value that they're paying. They get a remunerated service. The way I see it is let's not inflate the eye exam because we're deflating the service by doing that. Let's provide the eye exam and services that are needed and necessary for the population. It's no surprise to anyone. There are demographic prevalence studies on the increasing aging population. We know that AMD, glaucoma, dry eye, and myopia are going up. We know low vision is going way up in numbers. Specialty contact lenses and all these areas are expanding. The need for that is expanding.
Let's not inflate the eye exam because we're deflating the service by doing that. Let's provide the eye exam and provide services that are needed and necessary for the population.
Do we need to leverage the eye exam to get the patient there? No. I'm going to speak very plainly. We need to market the fact that this is what we do. We provide these various subspecialty services. Not just that, we recognize that internally. Imagine this to the public. I'm sure you get this too, Harbir. Doing dry eye as long as I have, I have patients that say, "I went to a dry eye specialist." They use the vernacular specialist, but in Ontario, we can't. I believe in BC you still can't.
That boggles my mind because I don't believe that it protects the public if they don't know the difference between a specialist and a generalist in our profession. I don't think it serves them well because they can go to anybody that says they're providing dry eye services and think they're a specialist. I would imagine the same could be said about low vision and other subspecialties.
What we have done is we have forced or painted ourselves into a corner. I've decided to take a step out of that corner and step on the paint. I'm leaving some footprints but I'm hoping some people follow me because that's the path forward. That also gets us out of chasing a fixed market share. The only way that we're going to increase capture for glasses and contact lenses is by forcing need, so telling them they need multiple pairs or decreasing the time between their eyewear purchases.
It's 2.7 years between eyewear purchases. That's Specsavers' model, but we can decrease that to once a year. The way we do that is by decreasing prices maybe. That's one method, but unless we increase pairs sold per visit or decrease the space between purchases, we're chasing a fixed market. I don't know about you, but I would rather be a true disruptor and define a new market.
I like that. We're going to hold onto that for a second. Let's make sure we get to that disruptor thing. I want to reiterate why you're the right person to talk about that. You're saying it's a fixed market. The interesting thing was when I was speaking with Rick Gadd who's the President of Essilor Canada, his business is selling lenses. He felt that there were still a lot of opportunities to penetrate different parts of the market and it wasn't saturated. It wasn't the number of people who were glasses.
Let's say we reached some threshold there, but it was that there are so many different types of lenses that we could be offering these people. We have been offering them basic single vision this whole time. Maybe we need to offer them task-specific lenses and anti-fatigue in the second pair potentially. In that regard, there seems like there's still quite a bit of opportunity. I do think it's not the same as what you're saying. We do have to change our perspective still. Otherwise, it seems like that Einstein line. The definition of insanity is doing the same thing over and over and expecting a different result.
We have been doing the same thing over and over and then getting upset that somehow the business is not growing, or somebody is taking away the market share. If you start to offer higher-end, more unique, and more specific types of options in the refractive and optical ophthalmic sense to patients, all of a sudden, you can grow your offering and then hopefully, increase your revenue and that kind of thing. It still sounds like there are a lot of opportunities for us in that more traditional sense. I don't know if you have any comments on that.
I don't believe that the glasses, contact lenses, and eyewear market is saturated necessarily. Any system has a peak efficiency. I don't think we're ever going to get to 100% efficiency. That's impossible. Let's say we can get to 60% efficiency, which we're still not there. How do we get there? What do we give up of ourselves as clinicians to get there? I'm going to say things that are perhaps a little unpopular.
I would expect nothing less from you.
The protection of our eyes from blue light and blue light-filtered glasses. The science is pretty clear to me that there's a lot of fear in a lot of the marketing that's out there for that. We're creating a market. Let's call it what it is. Our patients see it and hear it. If that's the mechanism to drive toward that 60% efficiency of a system, that's not a mechanism that I want to partake in.
I'm calling it out. We are a part of that system but we're a cog in a much bigger wheel. With any certainty whatsoever, I can’t rely on my colleagues or blame my colleagues for spinning that wheel. Some of us have looked at the science and heard the marketing. That makes sense to them. That's what they're going to carry through, but we also have to be cognizant of the why.
Simon Sinek talks about your why. What's the why of your practice? If we're driven toward the commoditization of an eye exam, then we shouldn't be surprised that we're going to start to commoditize various components of our practice. We need to separate and tease that out because the market is already straying that way. The entrance of Specsavers reveals that.
We're still going to do the disruption thing, but there's a question in my head that is somewhat relevant to what you're talking about. Commoditization is a topic that has come up through these conversations. There's the idea that these eye exams are services that are being commoditized. The commoditization is the answer to the commoditization for us to raise the prices. Let's say, for the ease of numbers, I used to charge $100, and I'm going to charge $150 or even $200 now. You have this perception of my service not being a commodity that is somehow more valuable, at least from the outside, before the person even comes in to get their service. Is that an answer? Is that a terrible idea?
I don't think it's a terrible idea. I differ slightly on it. I would suggest setting the service price from an objective standpoint as possible. Determine what your cost to provide that service is, and determine what margin you want to achieve by that. That's your price. The minute that we start to put the expectation of what that price should be on what it should be perceived as valuable at, that's when we start to get back to second-guessing ourselves. We're traditionally undervaluing ourselves.
Canadian Optometry: The minute that we start to put the expectation of what that price should be on, what it should be perceived as valuable at, that's when we start to get back to second guessing ourselves.
If we start to play that game, which we already have and it's why we're probably having some of these conversations, I think we undervalue. We could remain objective, take our natural instincts out of the equation and say, "It costs me this amount of dollars to provide that service." Let's say you want to have at least a 100% margin. Double that. To that end, we should be valuing what that service is, the work that we put into getting it there, and the value that has to the patient.
Essilor had an eye exam. They discovered that he had AMD. What did he say? "I can't even put a value to that." We're looking at it from a different perspective rather than what will everybody pay. That's what we have gotten into. We have gotten into this competitive landscape, but the number on average per 10,000 households of optometrists in the country is still very low. There are still way more patients that go around that are not being serviced. I don't know if we need to worry about the perception. Individually, corporate or private, it’s us that are creating the optics of this competition.
That disruption conversation is an important one. I want to go back. You already said it yourself but I meant to mention this already. The reason that you are the right person to have this conversation is not only where you're working now but how you got there. You started eyeLABS years ago, which back then was unheard of. The fact that somebody started a specialty practice and not providing straightforward and comprehensive eye exams but specifically specialty medical services, I would call that brave and a form of disruption. You’re paving your path. Lots of people have started to follow that path over the years for sure. It has helped you become this expert and well-known name in the field.
This is the reason why I think you're the right person for this conversation. You talked about the disruption and stepping in the paint. Play an entirely different game. What does that look like? I'll speak personally. That would scare me. I imagine there are lots of others that would be afraid of doing that. It's a lot easier to follow the already paved path and the model that's already there, which even I'm doing for the most part, day in and day out. How does one go down a completely different route? How do you have the confidence to do that? How did you convince yourself that you're not making a complete mistake?
One of the ways to do that and one of the ways that you are certainly doing and I'm attempting to do as well is to pay it forward by creating the language. One of the reasons why I texted you in the first place is because we need to have this concept of specialization in the vernacular. It needs to be part of that conversation. If the younger minds that are exiting optometry school and moreover, the younger minds that are entering or wanting to endeavor to enter into optometry don't think, hear, know or experience that specialized optometry exists, I guarantee it won't exist.
There's a word in Japanese called karoshi. It refers to death by overwork or suicide by overwork. That word doesn't exist in the English language. The fact that it exists in the Japanese language can help to articulate how their culture had to deal with overwork and this whole other societal problem. If a word doesn't exist, then we aren't compelled to use it or bring it into our culture.
If optometry's culture doesn't reflect the ability to specialize, then we won't continue to build on that. On the concept or the theme of disruption then, the reason why I think that specialization is true disruption rather than telemedicine and optometry or online sales is that I still think that it’s capturing a traditional market. When I think of disruption in optometry, we step inside the paint or step outside the paint. How do we create new footprints and step into a different demographic more meaningfully and with confidence?
When I did it, there were still dinosaurs outside my window. I was worried about the comet coming to kill us all. It was a time when I happened to see a version of this when I was doing my residency many moons ago. I saw glaucoma care was being provided by an optometrist in a practice. I thought, "This doesn't exist in Ontario. Why can't it?" I saw versions of it in ophthalmology because I worked so closely with ophthalmology in a lot of my different practices.
I was able to see. It was part of my personal experience that I was able to envision how to create it. It was still a leap of faith and all those things. I don't expect 100% of optometrists that are graduating to want to specialize. That's not what I'm suggesting. The Pareto distribution of 80/20 is likely going to happen. If we don't have a pathway and if we don't create value behind it, then that number won't grow as quickly as it needs to.
If we don't have a pathway and if we don't create value behind it, then that number won't grow as quickly as it needs to.
As it does continue to grow, what happens when the public starts seeing us as specialists in our particular domain within optometry? Our patients and the public become better informed as to what we do. All boats will rise. Tides will rise. The necessity of competing on the same battlefield starts to dissipate. I don't look at any of my colleagues as competitors, whether they're next door or across the country. Not in the least. Let's know who we are. We're working together. How do we better increase this basket size? We diversify.
That's such a great answer. I was asking you a question that I would ask if I had you in a different context. We're having this conversation in a different episode of this show, "Give me the goods on what your decision-making process was," but that's not the conversation we're having now. The conversation we're having is about the future of the profession. You're right that if we're not talking about it and if we're not using the words, then we're not creating that space or that opportunity for future optometrists to step into. That's what we need to do.
I googled that word while you were talking. You're bang on 100%. Karoshi is death by overwork or whatever you said. I never heard that word before. There are a lot of words like the independent specialist and the idea of having a specific dry eye clinic that does nothing else other than ocular surface disease. These things didn't exist before. It doesn't mean they can't exist or shouldn't exist.
These are the ways that we can continue to broaden our horizons and grow the profession. Otherwise, we're trying to grow this market share by doing the same thing over and over. It doesn't make a lot of sense. It might work, but it will take longer versus, "Let's open this whole new door and explore it." You've done the ocular disease thing. Are there any other aspects of that specialty type of approach that you've seen other ODs are doing?
I can certainly name names but generally speaking, the specialty contact lens area is one of the most exciting opportunities. It perfectly aligns our work in refractive care and physical and visual optics to disease. It's a beautiful marriage. I don't know if I told you this but once upon a time, I used to have low-vision services. I provided low-vision services in another practice. The appetite for low vision doesn't seem to be very high but the demand for it is increasingly high. It's going to continue to grow, unfortunately. Those are the two areas. I see some colleagues that are doing it.
To be honest with you, when I get messages on IG or email and when people are reaching out to me, it's very often younger colleagues that are looking to figure out, "How do I build a dedicated and specialized practice?" That's number one. Number two is, "Is it even possible? Am I having pipe dreams?" When I joined Prism when we merged our entities and I took over the optometry services there, part of my mandate was growing out the specialty arms of eye care at Prism at a national perspective or level. That's the goal long-term.
One of the first things that I created internally was a fellowship program to bring on an optometry colleague that wants to either provide specialty dry eye services. That's going to expand specialty contact lens services. We're going to have an intro program which we will eventually expand and get accredited potentially. Who knows? Long story short, it's trying to expand and diversify our offerings so that the public sees it. It's not just the language of our younger colleagues but it's also the language that our public is using with us It's adding that into the vernacular.
That's very important. If we're talking about the perception the public has of our profession, we need to make sure they're hearing these words and seeing that we offer these services. Going back to the specialty contact lens thing, for years, I didn't do a residency. For years, students would ask me, "Did you do a residency? If you went back, would you?" I would always say no because I wanted to come back and start my business. Over the years, that has changed. I've changed it too. If I did a residency, it would be in specialty contact lenses because I see that too. There's a massive value in that.
If there happened to be students out there tuning in, that would be my take on doing a residency. I have almost gotten to a point where I regret not doing it because I want to implement so many things into our practice. I just don't have experience with it. Anybody out there who's got specialty contact lens experience and wants to work with me should do a little self-promotion here while I'm at it. We already answered this to some degree but it doesn't hurt to ask it outright. The question I ask all the other guests is this. What is your definition of private practice versus corporate practice optometry?
A lot of these guests I had on were part of certain entities. I would ask. Where do FYI, IRIS, and so on fall on this spectrum? I know you don't like that necessary. A few people said that they don't necessarily like that binary distinction. When they would give me the answer, I always took it because they were mostly falling into the corporate bucket, and they didn't want to be labeled as that. I know you have a different take on it. Tell me what you think about the whole private versus corporate, and how we should look at it.
The sentiment at a surface level in general is that private is generally equated with freedom to operate whereas corporate is equated to being hyper-controlled or having a hierarchical structure to it. I don't think that's necessarily a true reflection. Both private and corporate are points on the spectrum between freedom and control. I always get philosophical. I know you appreciate this, so we can talk about it. The difference is the degree of consciousness that these different modes of practice may exhibit.
In private practice, you may have a little bit more looseness to the structure of patient intake, patient marketing, point of purchase marketing, in-exam processes, and exit hand-offs. That whole process in private practice may be very different, a little bit more loosey-goosey, and certainly more variable across different practices, whereas, in a corporate environment, it's fairly structured. It's a little bit more refined. In some cases, it's very refined.
What I mean by consciousness is how aware are you as a doctor working in each of these environments of the degree of influence those practice modes exert on both you and your patients. You become more refined in the marketing of the practice and the processes of the practice. Dr. Daryan Angle at IRIS talked about the intake process and how you never have to repeat your complaint so it’s never heard again and as a patient, you feel heard. That's beautiful and wonderful, but that is architected and structured.
How you want to see it, both good and bad, subtract from your "freedom to operate." The notion of autonomy somehow sets in. Any of the corporate folks will say, "You have the autonomy to practice the way you want to practice." I don't know if that's necessarily true. Going back to the concept of language, what's the language of the practice? What's being mandated? What is the expectation of the corporate practice owner versus the private practice owner?
Those things all exhibit influence. We are a product of the environment of our inputs. Our outputs will reflect that input. The difference is in the degree of freedom that you have by virtue of your consciousness of what's being surrounded. It's a long answer, but that's how I see it. It's a fundamental degree of separation between consciousness.
Canadian Optometry: We are a product of the environment of our inputs and our outputs will reflect that.
I like the whole philosophical side of things that you bring in always. I didn't do this in the previous conversations because I didn't want to color it with my personal experiences but I'm open to discussing it with people. I'm sure that we have two different modes of practice. I'm sitting in the sublease practice next door to LensCrafters. The other practice is a private or independent practice. In the exam room, 95% of what I do if not more is the same as what I do in the other practice. We have the same technology and the same setup in the exam room.
The difference comes like I know that this patient should be going next door here. I know what lenses they carry next door. I like to recommend specific lenses to patients. I'll put the name of the lens down on the prescription that is specific or beneficial for this patient. Does it make sense for me to write the specific name of a different manufacturer that they don't carry? Of course, that does.
Could I say I'm doing the same thing I would do in the other office? Not exactly because I have that in my stream of consciousness if I'm using that phrase correctly that those are the lenses that they offer. I'm going to write that on the prescription for the patient. It does impact the way I practice a little bit. The handoff situation is entirely different here. While that's all true, this is my independent practice next door to LensCrafters. Anybody from LensCrafters would say, "You're an independent doctor. You practice however you want."
It is true to some extent, but there's always going to be that influence on some of the decisions that I make, whereas in the other office when I walk out the door, pretty much every frame that's on the board and every lens that we sell is a decision that I and my business partner have made for it to be there. That's the autonomy and the decision-making that goes into it. It is tricky. I deliberately ask it as a binary thing. I know it's not. There's a lot of overlap but it's to get people talking and sharing their thoughts. I don't know if you have any comments.
You're in a perfect position to speak to both of those experiences. The question you're going to ask yourself about how independent you are is, "Is there something that you can't do?" It's not you specifically, Harbir, but anybody here. Whether you're in private practice with an independent owner or you're in a corporate setting, the answer probably for everybody is yes. There is probably something that you can't do, not because it's illegal or because you can lose your license but because the practice doesn't facilitate it, allow it, discourages it, etc.
The question you're gonna ask yourself about how independent you are is: is there something that you can't do?
If the answer to that is, "Yes, there's something that I cannot do," then you have to acknowledge that there's a degree of control and influence over what you're doing. To paint corporate with an automatic brush is a bit shortsighted and narrow. Take that for what it is. It's not to say that corporate is better or private is better, but we are all being influenced to a degree.
That's perfect. Here's where I want to take the conversation now. I'll let you share if you feel like we have missed anything. I wanted to start to lean toward new grads and students who are coming into the industry. They're trying to make their decisions, "Where should I practice?" It's hard when you have no experience other than in school. Looking at that spectrum, there will be different modes of practice along that spectrum from highly controlled and very little autonomy even though they will say, "You can practice however you want within the confines of what we have set up."
Are there things within that setup that you can't do that you wish you could do? Is that the way you want to continue to practice moving forward? On the other side, there's almost entirely complete freedom or at least freedom in this sense of if I had a young grad come in and say, "I want to do low vision," let's figure out how we could bring it in. If you want to do low vision now, I can't help you. If you want to do low vision moving forward, let's plan how we can do it.
There's a spectrum. There are extremes to that. Deciding what type of practice you want to be in is a big thing that new grads, young ODs, and even season ODs should be thinking about when they're making the decision of where to work. In that light of making decisions of where to work, the question that I ask all of the guests is that there are a lot of these incentives being put out there like bonuses, high salaries, and forgivable loans.
A young grad comes out and sees FYI saying, "We will give you $50,000 to pay off your student loans." I don't know exactly how the process works. I apologize. The term is a forgivable loan. I imagine you don't have to pay the money back other than you have to work there. Do you see that as leverage for the student or the new grad? Do you see that as potentially clouding their judgment and their decision-making? It's not to pick on FYI but anybody who's offering those incentives.
It's plain and simple. I see it as bait. I don't think it's true leverage. It's the optics of leverage. What does a new grad come out with in terms of concerns or worries? Their stresses are their loans, "Where am I going to work to pay off those loans?" A few ODs reach out to me saying, "I'm not worried about paying my debt." You could frame it however you want to frame it but it's clear what the motivation is to the recipient of that.
With that in mind, it's leverage. Is that a bad thing? I don't necessarily think it's a bad thing if they have the ability to offer that and make a business model that makes sense. Economies of scale will allow it. My opinion is that I've always treated any new coming student-doctor that wants to join our team with a meritocracy. I developed a fellowship program. You need to do three months of fellowship before you get officially indoctrinated into our specialty team. That's it.
Part of that is you will receive payment for that fellowship at a particular rate but there's no free pass. I'm not looking for 100% of the people. I want the people that want it. I would like those that are in it for the right reasons. I've taken the opposite approach. I'm not handing it out. I have a list that we keep of people that want to join. That list is ever-growing. As I put this out there, I'm realizing that I should probably dial this back. I look at that.
In the same country and the same market space, we have colleagues that are willing to do whatever it takes to become a specialist. On the other side of that spectrum, we have, "Here's $50,000. I'll pay your debt." I'm not saying that's not right or it's disingenuous but from my optics or the way I see it, and I don't know if I'm reading this right, you might see it the same way and I won't call you out on that, it seems to be plain as day to me. I don't know if there's any way to see it differently.
I see it the same way. As we were talking about before, I try to ask the questions in a way that didn't come off as biased. Sometimes I can't help it but I try to ask them a little more in a neutral fashion to get a genuine answer from the guests and potentially even tease out an answer that they might not give otherwise. I feel that way. I do feel like when you come out of school, you're likely going to be a little naive, but not everybody.
Even when I started practicing, I felt like I was taken advantage of to some degree by being offered things and promised things upfront. For a little while, it was true. Shortly after, I realized that this is not going to pan out the way it was laid out to me when I came out as a new grad. I managed to step out of that situation. I feel like there's a potential for a lot of new grads to end up in situations where they're being promised something. Also, perhaps not being told the full truth or they're not asking the right questions to uncover the full truth, whatever it might be.
It's very important for these younger ODs to make sure they're asking repetitively or aggressively to make sure they know exactly what situation they're getting into and not get locked into something that they're going to be unhappy with. I'm also sharing my opinion. I get it. You have to pay your debt. That's fine. If that is the most important thing you have to do, then you do it.
If I could still pay the debt if I go here or I might get less money but I might get more experience, in my case, a better experience, culture and environment wins every single day of the week. I took less money for sure to be in that environment. I still think that's the right way to go. That's what we're trying to cultivate here. It's not that I don't pay my ODs well but I try my best to make sure when they come to work that they're happy to be here first, and then they're happy that they're getting paid after that.
I couldn't agree with you more. I understand the frame of mind that new grads and new doctors are in but I don't particularly care for that.
I could go on about that. I appreciate that you touched on this earlier when you were talking about using the language that will allow current optometry students and prospective optometry students, more importantly, to see that there are these other opportunities within the profession and maybe help them choose their path. Let's go to that prospective optometry student or maybe an undergrad student who's looking at potential career choices. What advice would you have for that person if they are thinking about going into optometry?
You touched on such an important thing. Before I go to the advice that I would give them, I would even go so far as to talk about the selection of those lucky folks or smart individuals that are getting into optometry schools in Canada. The selection criteria or the manner by which we attract interest to our profession is crucial. I don't know if we have given any attention to that. How are we attracting optometry students? How are they being introduced to the idea of optometry?
Canadian Optometry: The selection criteria and the manner by which we attract interest to our profession is crucial.
Generally, it's through their community of optometrists perhaps at a younger age. Maybe it's their parents that want them to be in the healthcare profession. How are UW and Montreal attracting and then selecting that intake? That is very much our future. You can see it. Universities are migrating, student populations are changing, and people are coming in from everywhere across the country to Waterloo and Montreal. We need to think about how we're marketing the profession to the public. It ultimately comes down to that.
To your point about what I would say to that prospective student, what I would say is, "How much do you want it? More importantly, what do you want to do with it?" Ultimately, if you think you have what it takes to get in, then you will probably get in but how are you going to pay it forward? My experience with the students over the last ten years has changed from, "I want to graduate and get into practice right away." That was where it started versus now, "I want to graduate. I'm thinking about residency in one of the various areas. I'll probably go to the States to do this and then come back to Canada. Maybe I won't but I want to practice with specialty contact lenses," or whatever subspecialty they choose.
I hear that more and more. Are we listening as a profession to the younger folks that are coming out the gate? If we're listening, what are we doing about it? How are we investing in it? It is wonderful to have an investment in the School of Optometry in Montreal as well as its diagnostic labs. It's great. I see tremendous value in that and respect that. We need more investment in the public consumption of our profession, not just what we're providing to them at a community level but how we're marketing it. Let's not just invest in our schools. Let's invest in a national campaign, not just from the CAO. Colgate did more for dentistry than dentistry did for dentistry. Let's call it what it is.
That's wonderful. I like that because I was going to ask you who's going to put the money up for that. It sounds like if Colgate did it for dentistry, then who is it?
Colgate needs an eye drop out there. Let's not reach outside of the optometry walls. We have enough corporate optometry enterprises. Let me put that out there. Let's get FYI, IRIS, and all the big groups to put those dollars together. Let’s get a national campaign that goes toward marketing our profession to the degree that it needs to be marketed to the end user so they fully understand what we can do, how we can do it, how fantastic, and more importantly, how indispensable we are. I got off what we would say to the students. I got back to the industry. What I would say to the students though is this. Be passionate, be sure that you want to do something with it, and be willing to put in the work because an easy ride will probably be just that easy at the beginning, but it may not end up that way.
Given that you assume the students who have chosen the path to go into optometry are smart, passionate, ambitious and so on, I assume you would tell that prospective student that it's a good decision for them to go into optometry. Is that what you're saying? I don't want to put words in your mouth.
You read it right. It is a fantastic profession. I still think that the future is bright. I don't see dark clouds. That's also part of my personality. I'm all about reflecting bias. I see an opportunity where I can find it. When there's no opportunity, I create one. That's the mindset that you need to have. It's not going to be for the person that gets dissuaded easily. That could be said about life as well. You have to be willing to deal with a very rapidly changing landscape but that's not unique to optometry.
Dentistry and veterinary sciences have gone through their turmoil. Look at the human resource market post-COVID. I don't think anybody can escape the fact that everything is going to be changing rapidly. What do you want to do with it? That is the question, but I am and will always be an advocate for our profession. We have a wonderful opportunity to do far more than what we're doing now. The question is how fast we can get there. Once we get there, where do we go next?
My sense is that young people are looking for a dynamic profession, somewhere they can grow and try to potentially challenge themselves. If they have a skill, the gig economy is such a big thing. I find even within optometry that we almost have our little gig economy. If you have a skill or a talent, you're artistic or creative, you're good with media, you're a good speaker, or you have good medical acumen in different ways, there are a lot of opportunities to grow in these different aspects of it and still be an optometrist. That's a cool thing about the profession for sure.
I'm speaking with my personal experience in mind here. I'm like you in that sense. You make of it what you will. If you come in, and you don't have that dynamic personality and don't feel like you want to do anything outside of the box, then you might come in and think it's a stale profession. You're spinning dials as we have done for a hundred years. If you have that type of personality where you want to go out and change things, then you might find it quite welcoming.
Like you, I've connected with so many people virtually and in person. It's cool to see what so many different people are doing in the profession. We need to showcase that more for sure to the young people who are thinking about going into optometry. We need them to see that it's not just sitting in a dark room spinning dials. It's so much more than that.
Maybe it's on the industry. Maybe it's on us individually as optometrists and the CAO somehow, but going back to what I was saying earlier, one of the throughlines of all these conversations is we all have to pull in the same direction here. We all have to think about how we are projecting the profession, not just to the public but to the young potential students in the future too. Before we wrap up, do you feel like we touched on the independent specialist thing enough? Do you feel like there's something else you want to add? Did we miss anything?
I think we hit it. I feel like I'm a bit of a vehicle for some of the conversations that I had independently. We covered a lot of the single-person messages. Here's the thing. The independent "associate" or the non-owner still occupies the largest percentage of the optometry demographic in Canada and the US as well. We are that voice. We just don't have a consolidated hierarchy to structure our voice. We have our provincial associations and international associations.
It's so important that if you're a part of the practice now and you have an owner that listens, use that voice. Carry your voice up and make sure you're heard. That's part of it too. There's a bit of disenchantment with our ability to affect change. If you're part of a practice where they listen well, then that's not always the case. Leverage that, use that and speak up. Bring a specialty into your practice or at least voice it. That's the way that this is going to move. At least that's how I've seen it.
It's so important that if you're a part of a practice right now or you have an owner that listens, use that voice, carry your voice up, and make sure you're heard.
I'll throw this out there as well. I talk about specialization. The Canadian College of Specialties in Optometry or the CCSO is a group that is moving this agenda forward on a national level. We're still in our infancy. There's still a lot of work to be done. The CCSO has a fellowship program that is being developed. That is hopefully going to be the first step forward toward a recognized specialization in optometry. That's close to happening in low vision. Ocular surface disease and dry eye disease will be hopefully on its heels.
That's great work. Tell me where can people look that up? How can they connect if they wanted to learn more about that?
CCSO-CCSO.ca is the website. Google Canadian College of Specialties in Optometry. I said, "Google," not OpenAI because if you do OpenAI I and type that in, it will probably create a whole subspecialty program. I don't know if you've looked up OpenAI.
I have not.
It's a web. You will get lost in that.
I don't know if I should look that up.
Don't do that.
Search the Canadian College of Specialties in Optometry. I want to echo what you've said a few times. I'm a business owner but when I present these conversations, I don't have just the business owner perspective in mind yet. A lot of my questions are going to come from that. I'm always thinking about the associates and the other independent practitioners across the country. I don't know what kind of modality you might be practicing in but it's very important for us individually and collectively to know that we have a voice. It's important to share it. I don't think that you have to practice a certain way or be stuck in a rut or whatever the case.
Now than any other time, at least in my recollection, the associate has so much power. If somebody came to me and said, "I'm going to leave unless you change this," I would change it today because it's hard to get good associates. If you feel like you're a good associate and a good doctor and you have something important to say, make sure it's heard. That's ultimately saying all pull in the same direction to make it, so our profession continues to grow.
If there's anybody out there who feels like their perspective has not been shared yet, and this is the seventh installment in this series, I'm happy to do more interviews to shed more light on our profession and the direction we're heading. Please be sure to get in touch with me @HarbirSian.OD on Instagram. You can go to The2020Podcast.com and Info@The2020Podcast.com.
I'm pretty easy to find online. I'm sure you know that by now. If there's anything you've found valuable in this conversation, please be sure to share it. Throw it up on Instagram, LinkedIn, or wherever. Text your friends, share the link with them, and let them know that Dr. Maharaj was on here sharing his amazing insights. I'm excited to share more of this with our colleagues. Thank you for tuning in. Thanks again, Dr. Maharaj, for being here.
Thank you so much, Harbir. I always had a wonderful time chatting with you. I love what you've done with this whole platform. I have a lot of respect for you for putting it out there in the first place. That's fantastic work. Hopefully, your audiences can chime in whenever you put this out on IG, etc. What's your subspecialty? What do you want to do full-time if you could? Put that in the tagline. Let's see what we can drum up.
Thank you so much. Thanks again, guys. We will see you in the next episode.
Important Links
Dr. Richard Maharaj - Previous episode
Dr. Kerry Salsberg - Previous episode
Dr. Daryan Angle - Previous episode
Rick Gadd - Previous episode
@HarbirSian.OD - Instagram
About Dr. Richard Maharaj
Dr. Richard Maharaj is the director of interventional dry eye services at the Prism Eye Institute a leading medical and surgical eye care and research institute with multiple locations in Southern Ontario.
He obtained his Doctor of Optometry from the University of Waterloo School of Optometry and is an active Fellow of the American Academy of Optometry. He is a clinical adjunct faculty for the University of Waterloo School of Optometry, the Canadian Association of Optometrists Section Chair for Ocular Surface Disease, Editorial Board Member for The Journal of Dry Eye and Ocular Surface Disease, and Chief Education Officer at MyDryEye.ca and co-founder for the Canadian Dry Eye Summit - a national conference dedicated to educating eye doctors in dry eye disease management.
He also serves as the chief scientific officer for AI4Eyes, developing artificial intelligence diagnostics for eye care. In 2018, he was honoured as one of the Top 40 Canadian Optometrists under 40 by Johnson and Johnson Vision Care. As a published international speaker and clinical scientist on diseases of the ocular surface and the psychology of health care, he remains an active member of both national and international professional associations.