At your highest level, practicing means always looking for new knowledge, making connections between seemingly unrelated topics, and pushing the boundaries of what is possible. In this episode, Dr. Mark Eltis discusses practicing at your highest level. Dr. Eltis is an exclusive expert in the field of dry eye and glaucoma, and we'll be discussing how these two topics are linked. While previous conversations have covered dry eye, Dr. Eltis sheds new light on the topic and provides insights into its relationship with glaucoma. This episode is not only relevant for students who are studying optometry but also for optometrists who want to improve their knowledge and skills for board and fellowship. Apart from his expertise in the field, Dr. Eltis has also built a high-end practice in the Toronto area. He shares tips and tricks on how he accomplished this and offers advice to optometrists who are looking to build a similar practice. Join us as we delve into the world of dry eye and glaucoma with Dr. Mark Eltis and learn how to practice at your highest level.
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Practicing At Your Highest Level With Dr. Mark Eltis
As always, I am humbled and so grateful for all the support everybody who's been sharing, liking, commenting, reviewing and all of that stuff. It's been incredible. Thank you for all of that. In return, I'm always trying to bring as much value as I can to the show by bringing on incredible guests like Dr. Mark Eltis, whom I have here with me. I'm sure if you spend any amount of time on social media or if you attend any CE lectures, especially related to glaucoma, dry eye or the type of stuff we're going to talk about, you've seen Mark multiple times. You know that he's an amazing, highly trained, highly educated person.
To give you a quick rundown of who he is before we get started so you know the caliber of guests that we're dealing with, Mark is the newly appointed President of the College of Optometrists of Ontario. What an accomplishment. Congratulations on that. As a quick disclaimer, he's not speaking in that capacity in this episode.
He is also a newly appointed Canadian Ambassador for the American Board of Optometry. He is himself a fellow and a diplomate of the American Board of Optometry. He is also a member of a very prestigious group called the Optometric Glaucoma Society, a very exclusive group of only a handful of optometrists in Canada and over 150 optometrists across the world who have this certain level of training and expertise in glaucoma. It's incredible to have somebody like this on the show. It's been a long time coming, Mark. We've been talking about this for a while. Thank you so much for coming on. I appreciate it.
It's my pleasure. We had so much fun when we met in person as well. I'm looking forward. I don’t know if you're going to be at BCDO in 2023 but I hope to see you again.
I'm always there. Every year I go. Even if I'm not speaking or attending too many lectures, I always try to attend because I show support for our association. Also, it's one of the more fun events for me to network and reconnect with local friends. I'm glad to hear you'll be there. That's awesome. To set the agenda for our audience, we're going to want to talk about dry eye because that's one of your big specialties. You do a lot of talking on that.
Dry eye is, to some degree, a topic that's been exhausted in a lot of ways. Myself being guilty of that too. I talk about it a lot. We're going to also talk about glaucoma. You are one of these high-level exclusive experts in the field but we're also going to tie dry eye to glaucoma. I know you've done some work on that space.
For the students out there who are studying or even optometrists who are looking to become more highly trained in the fellowship and the board certification, we're going to talk about some of that too. One of the things I want to pick your brain about is you've helped to build this high-end practice out in the Toronto area.
I want to learn from you a little bit about how you've done that and what tips and tricks you have for ODs looking to build that type of practice. That's a lot of stuff. Let's start with dry eye and I'm going to defer to you a little bit. I don't have too many specific nitty-gritty questions. I want to start with what's exciting in dry eye. What are you doing that you feel like you want to help people?
If I were to make a comment about dry eye, especially for young optometrists and people trying to get into it from a practice even management standpoint, you don't need a lot of fancy stuff. Let's put it this way. Fancy stuff does not make you a dry eye expert. Like everything else, it's about the education of the doctor and the training. I still say sometimes that I started lecturing on dry eye in 2009 or right before I was in LA. I was giving a lecture and it’s still on youtube. I called it Keeping a Lid on it: The Underdiagnosis and Management of Blepharitis. At the time, everybody was like, “What are you talking about?”
I remember graduating in 2003 and people were like, “Dry eye is connected to the mucus membrane,” or this kind of thing. We understand the connection with inflammation. I remember speaking on it and people are like, “Why are you even talking about this? This isn't a sexy topic. This is boring.” Sure enough, at that time and shortly thereafter, people were making the connection between inflammation and dry eye.
At the time, it was funny. It wasn't even a given. It's one of those things that they say in life. First, people deny it or ridicule it. Once it's accepted, they're like, “It’s connected. What are you talking about? We're at that stage.” My point is that while it's amazing to buy all the high-tech toys and I believe in them, the toys don't make you a dry eye expert.
I tell people, “Think about going to the dentist. Do you know any of the equipment they're using or the differentiation between a certain drill or scaling tool? You don't.” Ultimately, these things are going to even out. Everyone's going to have an IPL or whatever it may be. What's going to make the difference? It's back to the basics, which is how you treat your patients, how they feel in your chair, what you know and what are your levels of expertise when it comes to these issues.
With the technology, you can be the first and it's great to be the first or one of the fewer or to be groundbreaking. There's always better technology but I don't think that makes the difference between a good doctor and a bad doctor necessarily. I’ve worked in offices in the past where I had very little technology, either for dry eye or glaucoma and I still made it work. I don't want people to think that if you don't have that stuff, you can't be an authority in the field.
Having technology in the medical field is groundbreaking. But that doesn’t mean that if you don’t have the stuff, you can’t be an authority in the field.
That's a great point to start with. I’ve started talking about dry eye much later than you. One of the important pieces of advice I got from a mentor at that time because I was like, “What do I buy? Which meibographer? Which IPL,” was, “Do you have a slit lamp? Do you have fluorescein?” “Yes.” “Good. You're good to go.”
That's extremely important. A lot of people get bogged down in trying to buy all the technology. Thank you. From an expert standpoint, that's very important. Let's say that you've been doing that for a while and are looking to upgrade. We're not talking necessarily about brands but what types of things should one have to think about elevating their practice in the dry eye space?
Everything works in concert. IPL will help in most cases, for instance. However, you need to take an individualized approach. That's the other aspect maybe, which I was starting to talk about but didn't zero in on. You need to assess all levels. Let's say a mechanized expression, not to name particular brands, you need something that does that. Maybe they're afraid for whatever reason of certain techniques. There's low-level life therapy or something else that can be used which fits a patient's needs and also, their comfort level.
Not everybody's a candidate, for instance, for certain techniques but they are for others or even something more basic. I still start with expression, debridement and some microblepharoexfoliation. For me, that’s the starting point where I get to assess things and see it manually and see what's happening and how the patient responds to things touching their eye, being close and how they respond to certain things.
If you hook them up to them and you start something very elaborate and they're not even okay with you getting close to their eye, we have a problem. That's where I'm at. You can take it up to the next level. That trust builds, especially if you're going to do something which has even some mild side effects. You may not have that level of trust yet and that could break apart the situation.
I remember I watched an old lecture I used to give on dry eye. Even when we were using tea tree oil more commonly, I don't use it as much anymore for Ocrevus treatments and others. I don't start with the tea tree oil because it can be a little bit more aggressive. People can be like, “I don't want to do the cleaning because it burns.” Sometimes even though you want to go and throw everything but the kitchen sink at them, you may want to start a more stepwise approach to build that trust and confidence and get the buy-in from the patient.
I’ve had those patients where we're like, “We're going to do radio frequency and extraction on you,” and the patient's like, “I can't have anything near my eyes.” Some patients will tell us up front, “I’m bad with anything around my eyes but I'm going to try to tough it out.” You see them squirming and laying in the chair. It's funny. I give them a lot of credit for going through it. This stuff with dry eye, not to take anything away from you Mark and your expertise in it but we hear it a lot. There are lots of discussions around the dry eye. Am I right? You wrote an article or something about the connection between dry eye and glaucoma. There’s an overlap there. Tell me a little bit about that.
It's my two loves, dry eye and glaucoma. The connection is that, first of all, you know everybody has dry eye pretty much. It's an epidemic on its own. I see it in five-year-olds. I'm sure you do. That's not new probably to anybody who's focused on the field. What we neglect to think about is with glaucoma, why do people go blind? Is it that we don't have treatments? For the most part, we do have treatments. It's patient nonadherence, let's say. People are not taking their medications or not coming back for follow-ups. Why? It's not that glaucoma is necessarily painful if we're talking about POG or NTG. It's that the treatment can be uncomfortable like burning, stinging or ocular surface disease.
That's part of the dry eye world. If you improve their dry eye symptoms, you're more likely to have a patient who's going to take their medication. You can do multiple things like non-preserved medication but also treating their ocular surface. The dry eye blepharitis and meibomian gland dysfunction will probably make them take their glaucoma medication more consistently. My main point is if someone has glaucoma and they more than likely have dry eye, treat the dry eye because that's probably your best bet to prevent vision loss. They're going to become more compliant with their medication.
Glaucoma: If someone has glaucoma and they more than likely have dry eye, treat the dry eye because that's probably your best bet to prevent vision loss. They're going to become more compliant with their medication.
It's funny how you said it. A lot of times in the beginning, people would be like, “No, that doesn’t make any sense.” Later, when it all comes to it, they’re like, “Of course, that makes sense.” It seems so obvious. I don't do a whole lot of glaucoma. I'm going to be very upfront here but one of the biggest complaints that patients have is that the drop sting or their eyes get red. What's happening on the ocular surface that we can perhaps help to minimize?
Supporting the ocular surface with dry eye treatments and things makes a lot of sense. It seems almost too obvious to even talk about but it's not. It's still something that needs to be brought to light. What's the response that you've been getting? What do you recommend to ODs to start to do a bit more?
It's nothing complicated. You're taking a glaucoma patient or suspect because I see a lot of suspects. I tell my patients, “Ninety percent of you who are being monitored for glaucoma are never going to have it.” The problem is if you're in that 10% or we can argue about the exact percentage but if you're in that small percentage, you can lose vision. Unfortunately, I’ve seen a handful of patients who were in that category who weren't followed at my office but were seen by other places. Some of it's the patients not following up as much as they should have but sometimes it's also doctors being a little more blasé about following up 3 to 6 months if needed.
90% of you who are being monitored for glaucoma are never going to have it. The problem is if you're in that 10%, you can lose vision.
Sometimes I tell patients, “I know it can be costly and annoying but if you're in that category of the patient that's going to have more rapidly progressing glaucoma, you have an issue.” This is another misconception about glaucoma. It's a slow-moving disease. It is, except in times when it's not. It's hard to tell. You can say, “Higher myopes have a risk or certain patient demographics,” but we can't be 100% sure. I leave it to the patient.
I'm not one of those people that pulls the trigger on treatment very quickly. I talk about it with a patient. That connects to my earlier point about dry eye. If you want to be a glaucoma-focused optometrist, patient education and the relationship with your patient are probably paramount because you need to explain to them, “It's usually a slow-moving disease. I don't think you have it but one can never be 100% sure. Even with all the technology, OCT, HRT, corneal hysteresis, all that stuff and the most advanced visual field machine, there's still that level of uncertainty.”
“How do we mitigate that risk? I can see you more often and we can discuss the risk and benefits of putting you on treatment, which is lifetime or observing very closely.” I compare it sometimes to the stock market where I say, “If you watch it for 1 day or 2, you're not getting a sense of what's happening. More readings over time tell you what's happening.” It's like the Berkshire Hathaway CEO says, Warren Buffett, “Stocks all over the place in the long-term is where you see the reality of what was happening.”
That's the same thing in glaucoma where I can do an OCT two days in a row and one can look like in the red zone and the other one can look perfectly normal. Which one is true? Probably the 3rd one or the 4th or the 5th. If we do them in sequence and we don't wait six months, then we're going to panic if all of a sudden they were perfect in testing one. At testing two, it's like you've lost all this RNFL, supposedly. You're like, “We got to treat it.” No, we should have watched it more carefully to get more data points.
If there's ever any voice of reason in the world of the crazy stock market, it's him. It makes sense that you have to look at the big picture but also, to get that big picture, you got to have people keep coming back. You got to get those multiple data points. Without that, you can't choose the right course of action. What would you suggest for somebody similar to what I was saying about dry eyes somebody who's looking to maybe do a bit more glaucoma? I don't do any or very little other than monitor certain things. We have the technology. I don't spend as much time seeing the patients who have those conditions. What would you say to me to get me more into it? What should I be doing to be helping those patients who have glaucoma to treat it more in my office?
The first thing I'd say is you don't need to have all the fanciest equipment but it's great if you do. I’ve been using OCT and HRT, not in my clinic necessarily but for a time I was sending out to another clinic where they were doing the testing where I didn't have the equipment. Glaucoma's not like something like a retinal detachment.
Generally speaking, you don't need the result on the same day. If it takes a couple of weeks to get the OCT or a month, it's probably not a big issue. If it is, you probably shouldn't be holding onto it anyway. The thing is so people understand the back-to-the-basics. I was taking a lot of courses at Berkeley on this. They were emphasizing a more back-to-basics approach with the photos and looking at the optic nerve.
Don Hood at Columbia is the opposite approach where with an OCT, you can pretty much tell glaucoma without looking at anything else, maybe the visual field but that's it. I tend to not adhere to one school of thought exclusively. I'm like, “Look at the images and yes, have the technology to help you.” The research shows that if you're a glaucoma specialist ophthalmologist, you can do just as well with imaging, 3D photos, stereoscopic photos and visual field as you can do with OCT. Certainly, myself included, are not that good. I would benefit from the OCT and all the other fancy tools.
What I would say is to use everything that you have. You don't have to be a hero. You don't have to diagnose it off a photo. If you're not sure about the OCT, there's nothing wrong with sending it out to a specialist to get an opinion. A lot of the time, I’ll tell you that I still get an opinion before putting on a borderline case on medication. If we're going to initiate lifetime treatment, I don't mind having that second opinion.
This is the thing that people don't get. When you go into a lecture and everybody's so sure about what glaucoma is and isn't, you're probably not in the best lecture circuit. When I’ve gone to Optometric Glaucoma Society meetings and you get experts from Harvard and Johns Hopkins, they tell you that they weren't sure or they show you where they made a mistake or they explain, “I thought this person didn't have glaucoma for 5 or 10 years. Looking back, it was obvious that they did.”
The thing is that it's a very difficult disease to diagnose. You may not be right at first. The issue is that it's okay. As long as you're monitoring close enough, it won't make an impact on the patient's vision. If you're too arrogant about knowing when it is and isn't or you're not doing enough testing, that can be the issue. Once the vision loss is there, then it becomes too late. Early on, if there are a few drops in the points on the OCT or some peripheral visual field defect, the patient's life isn't going to change. What will change is if you miss the big stuff.
The take-home message I feel like is simply getting the data points and monitoring the patients closely if you feel like there is a risk of developing glaucoma or progressing. That's the number one most back-to-basics thing. It's funny you mentioned the photographs. When I was doing one of my clinical rotations at an ophthalmology practice in Florida, one of the ophthalmologists was older even at that time. I'm sure at that time, he was in his 60s or 70s so he'd been practicing in the old days before a lot of these technologies had come around. He would look at a photo and a nerve and say, “I see this.”
He would look at it for ten seconds whereas we, as the students, would be blinding the patients in the slit lamp for ten minutes trying to see all the details that he was seeing and was able to pick up things that we were only able to compile after visual field, OCT photos, all the stuff together. It's cool and special to see the way that the brain works of somebody who's got that experience.
Let's talk about boards your board certification and a diplomate of the American Board of Optometry. That's different than me taking the board's exam to become an optometrist. You do a lot to talk to a lot of students and you help them get through that whole thing. You talked about the board process, like the KMK board process. Being an ambassador for the American Board of Optometry, you're also helping people go through that process. How do you become a diplomate? How do you do all these things?
Let's start with the student side of the conversation then we'll work our way to optometrists people who already graduate and working who want to elevate their training. From the student perspective, I'd love to have a section here where I could share this with students about, “Here's what you could do. Here's what Dr. Eltis has to share with you to prepare for boards.” You're talking about the psychology of it.
That's important because there's such a psychological aspect to it beyond just understanding the information. I’ll leave it to you before I give away the punchline here. Tell us what you'd like to share with students and what can we impart to upcoming optometrists here to make sure they're well prepared.
In terms of academics, if you study for long enough and there are wonderful programs out there like you mentioned KMK, you can get the training in terms of the information that's going to be on the board exam. What students don't focus on or people don't talk about is the psychological aspect. That can be the silly things.
The theme of our conversation is glaucoma and dry eye like, “That makes sense. Why doesn’t anybody talk about that?” It's the simple things like do you have the clothing you're going to wear for your board exams? Do you have whatever equipment you need? Do you know how to get to the place you're going to be to? I guess in 2023, it'd be in Charlotte for the NBOs. Do you know how to get there? Did you arrive one day before and get to that place so you know how to arrive?
The reason I mentioned these things is that they seem like, “That's pretty easy and simple.” As a former examiner for national boards in Canada and the US, I’ve seen how students can get derailed if they're not in the right frame of mind when they enter the exam room. It doesn't take much. Anything that flusters you or gets you out of that zone can be an issue when you're talking about a practical examination.
Students can get derailed if they're not in the right frame of mind when they enter the exam room. It doesn't take much. Anything that flusters you or gets you out of that zone can be an issue when you're talking about a practical examination.
What you need to do is get everything in order, everything from what you're going to eat the night before and not studying or staying up late or getting into some panic or getting into an argument with somebody that day off. These are all things that will make a huge difference when you're taking your actual exam.
The second thing I would say, even putting the practical aside or for anything that requires this level of thinking and preparation for months, is you were going to get confused or the fog of war on how well you're doing. I’ve seen a lot of students give up halfway through even a written examination. They've told me so or in a practical exam, losing their focus and being demoralized, going from one station to another because they think they did disastrously and it's over. Most of the time, that’s not true.
It's weird because I’ve had that feeling too as a student where I think that things have gone badly and in the end, they didn't. Your mind will start playing tricks on you. I liken it to the fog of war where you don't know what the enemy is doing. You feel like it's hopeless but yet you don't know you're potentially advancing or things are going much better than you think.
It's in the confusion, chaos and emotional challenges that these situations present, your mind will not give you information as it truly is in the world. We all have that when we're angry or we have some life crisis. We're not perceiving information the way it truly is. We're perceiving it through the filter of our experience.
When confusion, chaos, and emotional challenges are present, your mind will not give you information as it truly is in the world.
That's my first message to students. You have to not give up. You have to keep fighting no matter what happens or what happened or what you think has happened, ignore it and proceed like nothing has happened and you're in the moment. Otherwise, in most of these situations, you’ll regret it because you were still in the game and you think you're not.
That's a huge piece of advice. I forgot to mention that you are formerly an examiner for the Canadian and American Board exams. Your input here is invaluable coming from that perspective. In theory, it's easier said than done. It’s like, “Wash your mind of that. Let's move on.” That mindset is very important to have. Having the memory of a goldfish is very important to have in so many aspects of life like in business education or wherever. Any practical tips for a student in that situation? You're in part three doing the practical side and came out of one room and you're like, “I think I messed that up.” How would you suggest to somebody to wash your mind off that and move on to the next?
The easiest way to do it is to say, “It doesn't matter if you failed the previous section. It doesn't matter what you do in this one. You might as well do well. Practice for the next time you're going to take it.” You're probably going to do a lot better because there's less on the line. The only thing you shouldn't do is say, “Forget it. It doesn't matter.” Even if you say, “I failed the previous section or whatever it is. I’ve got too many things wrong in the written part or I screwed up retinoscopy,” who cares? Do this. Practice for the next time you take it then.
I guarantee you, most of the time, you did fine in the previous section. If you want, I’ll share my absolute best tip. This is something which the rules change every year. It depends on which board exam you take. Even in school, it's never a good idea to redo a section in a practical exam. Even teaching at Waterloo or all these board examinations, I’ve never seen anything good come out of someone redoing a section if they allow you to do It.
The reason why is that you get points for the process. You are thinking about it methodically. When you redo it, you're focused on what you missed but you end up not doing all the other stuff correctly. The timing. You're forgetting that now you have less time so you're more under the gun. In all the time I’ve taught and I’ve been teaching academia for many years, I’ve never seen anything good come out of redoing a practical. I'm seeing it at that particular moment. In that same examination period, if you've got five minutes left, you're like, “I did this poorly. I'm going to redo it.”
You probably did fine. I’ve never seen someone redo it with a need to redo it. When it's disastrous, people run out of time and that's another concept of controlling the clock. You need to watch the clock. That's something where lecturing these things. I'm constantly watching the clock. Sometimes I’ll throw in a story and I’m like, “I’ve got less time to finish everything else. I need to know how I'm going to bring myself to that 50 minutes or 1 hour.” It's the same thing in examinations where you need to understand where you are relative to where you need to end. The last thing you want is to run out of time.
The last thing you want is to run out of time.
I feel like the time component is a deliberate thing in a lot of cases where they're deliberately putting in a bit of a time crunch to force you to think a little more quickly. Going back to your thing about redoing, it's important to trust that you prepared yourself and trust your process of thinking enough that going back is not going to help you any more than doing it the first time over. That's a key piece of advice. It's so easy to second-guess yourself in those situations.
It's been years since I’ve been in that position but going over it the second time would not help me. Go through it once. Trust that you've prepared yourself well enough. If it didn't work out, then you get a chance to do it again at another time. That's great advice. Thank you for sharing that. Let's move on to the optometrist who wants to elevate their training. Fellowship or a diplomate of the American Board of Optometry. Tell me a little bit about that process. What would you share with somebody who's looking to go into that area of specialty?
I remember even after a few years of practice before I started teaching, I got a little bored. The truth was I was doing the same thing every day. I had my little interests but I didn't know more than what I was taught in school. The thing is people sometimes think, “I don't want to do all that. It's going to be a lot of work.” I’ll be honest. It’s not that the average optometrist or patient is going to say, “They're a this or that or have this title.” No one will recognize that unless they're doing research into what it means. Your career is going to change things.
When I started my first paper on blepharitis, I was like, “I didn't know anything about this.” I didn't know about the research. Every time I write a paper, I find out how little I knew about a specific topic. The truth is that in a field such as ours, there's not enough time in one's lifetime to know about BV or low vision, glaucoma or dry eye. There are too many things. As much as you can dive into it, what interests you, you can focus on, for instance, a fellowship in the American Academy of Optometry.
That’s a nice place to start because you can write papers towards your fellowship and you’re focusing on things that you care about and that you’re interested in like case reports. You’re going to fall in love again with what you were interested in and dive deeper into it. A lot of the time, doctors ask me, “How do you sell the glaucoma testing or dry eye stuff?” I'm not selling. I believe in it. I'm confident in what the patient needs. I explain it to the patient. No selling is required.
If the patient doesn't want it, that's fine. I know the next patient will want it or the patient after that. I'm not the type of doctor who pushes. The only time I will even give a rebuttal is when it's a matter of making sure the patient understands the risks of not doing whatever I suggested. Once I'm clear that they've understood it, I don't try to push. I don't feel it's getting anywhere and that's what's needed. Certainly, even if you look at it from a business standpoint, I don't believe in that. I don't want to cheapen the process of seeing a doctor by me pushing anything. I explain what they need or what I think would be good for them or options.
Sometimes I tell them, “You don't have to do the glaucoma testing now. You have a family history but no other risk factors. You have a bit of mild dry eye these days. Everyone does. This is what we can do. If you don't want to do that, that's okay. I want you to have an awareness so that when you're having the symptoms, you're like, ‘Dr. Eltis told me this is an issue. I can revisit it and take it to the next level.’”
That's the way to go. I'm connecting that to the additional qualifications because you can respond when patients push back on something and say, “Glaucoma usually is high pressure. I don't have high pressure.” You can learn from doing research that about half of glaucoma patients have high pressure and NTG, Normal Tension Glaucoma, is a big deal, especially in certain populations. In the Japanese population, 90% of glaucoma patients never have a pressure above the statistical norm. If you understand those things, you can articulate why you're doing certain things and you can protect your patients from vision loss.
Glaucoma: If you understand important research about NTG, you can articulate why you're doing certain things, and you can protect your patients from vision loss.
That's a great correlation or segue to make there. I appreciate that. As you were saying that, I was like, “This is going to be perfect.” We're going to start talking about how you talk in practice but having those qualifications can often help you make a bit more of an impression on the patient. How about outside of patient care? What about other aspects?
Talk about doing research or writing papers. There's a certain type of person who's going to be interested in that. I'm not one of those people but what would you say to that person? Maybe they have a bit of an inclination for writing articles or doing research themselves. How can they get started or dive further into that?
If you see a case that interests you, keep it aside and then the research comes after. You can see a case. You don't have to have done something monumental. The truth was that a lot of the cases I used were simple cases that you see in practice like a primary open and glaucoma case, blepharitis or common things. Contact lens microbial keratitis. I talked about corneal ulcers. They're like, “This is cool.”
After you've recorded the case, then you go into the research. You have to go to PubMed, read articles, select them and then write a paper, which is not the easiest thing. It's like when my students at Waterloo complain about having to write a paper for their course. What I tell them is, “You're never going to learn as much. When you listen to a presentation, you absorb 5%, 10% of it or maybe 15%. When you are writing a paper, you will never forget that stuff because you keep going through it. You're reading the article that you have to put into your paper.”
I have to think of how it relates to everything you've researched in your case. When I'm going to a lecture about something I’ve already written a paper on, that is a lecture that is so easy to give because I know it inside out. When I'm preparing a lecture because it's needed on a topic and I’ve never written about it or talked about it in great detail or thought about it, it's a lot harder. You always feel like, “I hope they don't ask me about this.” I'd say, “That's a great question. I'm not sure.” My latest paper, which took me years to write, is about the long-term outcomes and recent advances in refractive surgery.
I’ve written a two-part piece and it's in the Canadian Journal of Optometry. It's because everybody keeps asking me at parties or anywhere I go, “What do you think about LASIK or the long-term outcome?” I was like, “This is a great question. I need to do my research on it.” Yes, it takes a long time but I feel excited and so confident to talk about that. If you're thinking about it, even elevating your career, like on being online or having a presence is important. Also, differentiate yourself from other doctors.
Having speaking engagements and writing is how patients find you. Even other professionals. You see it in law and accounting. They're publishing papers or articles because that's how people find you online and it sets you apart. People get to know you. They feel they understand what you're about or they sense a higher level of qualifications by reading these things or watching you speak. A TV interview or these things will also elevate you in the eyes of patients. Rightly or wrongly, I'm not saying that everybody that has written something and has made an appearance on whatever media is more qualified. I'm simply saying that that is a way to differentiate yourself from the average practitioner.
Glaucoma: There is always a way to differentiate yourself from the average practitioner.
I can imagine how much work that must be, the research, writing the article and all of that, the journal, although I was thinking maybe ChatGPT might be able to speed things up a little bit. Write an article that makes me look like a specialist in corneal refractive surgery.
You always get those doctors. I see it all the time. It's hurtful because you go through all these things and they say, “We're triple board certified. You're not even board certified.” It's not because you passed the licensing examination. That's not board certified.
I passed three parts of the board exam.
It's true. A lot of the public may not know or understand the difference but some people do. I say this as a dinosaur. In the end, there is a big difference between filming yourself on Tiktok or Instagram because you read a snippet from someone else's article and being in front of 1,000 people speaking about a topic and answering questions live. I will tell you that especially in social media, a lot of certain personalities will get a speaking gig because they do have a large following. It is a big difference to speak live in front of a huge audience and answering questions in real-time than it is being in front of a screen scripting your response or taking 50 takes of it.
That was not on the list of topics for us to discuss but that's a big one. I have a lot of respect for our colleagues in our profession or other professions who are out there on social media and building their presence. I'm doing that myself so I understand what goes into it but you're right. It's not a fine line. There's a pretty clear dividing line between social media content and online content versus being an expert and speaking in front of other people who are experts or well-educated and informed on that topic so they can ask you questions that will be hard to answer in a lot of cases. I’ve been in that position too.
Going back to what you said, I'm like, “I'm not sure I’ll have to look into that.” It's not a comfortable place to be. It takes guts to put yourself in that position. I’m not trying to pump my tires here but knowing how many times you've put yourself on those stages, there's a difference. I'd like to make sure that our colleagues know that too. I respect that when you educate yourself to this level and go out there to teach other people who are already educated in this area. That's a whole different ballgame. Good for you and thanks for doing it.
One other thing I wanted to talk about, which you already teased for us, was the practice, specifically high-end practice. Some people might take that the wrong way. We are talking about high-end in a couple of different ways or high-level practice. Let's talk about what that maybe means on the clinical side to have a high-end practice and what it means on the retail side. I'm trying to build up the higher end of the retail side of my practice. We have these mid-level mainstream frames and brands and stuff. We're slowly trying to work our way up to having a bit more of a boutique and high-end practice. I'd love to hear your take on that. Let's start with that because that's the side that I'm most concerned about. I'm being selfish here. Tell me your thoughts on that and we'll go from there.
It all comes down to the same thing. At the risk of being a broken record, if you've ever flown first class or you've gone to a nice boutique, even if you haven't bought anything, you go into Louis Vuitton or something like this, what is the difference? What is being offered? It's customer service. I’ll even split it into two parts. Those who know me know I like Disney. What's the difference when you go to Disney? Why is their customer service so world-renowned? Is it that they're offering you gold when you walk in and Dom Perignon on arrival? No. It's two things.
I’ll start with Disney because it's the motivation of the staff. People who work for Disney love Disney. If you can get even a little bit of that for your staff, you're already a step ahead. They are happy to be there. You travel a lot too. I'm sure you've hit I don't know which airline, let's say the equivalent of Star Lines Gold or whatever that is. When you walk into that lounge, what is different? What's different between that and the pizza shop at the airport? The difference is the greeting, the serenity and the little things that can be helped. If you ask the person of the attendant, “Is this flight delayed or not,” they can look it up for you. That smile. They're generally in a good mood, hopefully.
It depends on which airport but certainly, the level of care is higher than at the food court in the airport, the chaos that you have there and the level of, “I'm doing this as a job,” as opposed to, “We're treating you like a VIP.” It doesn't cost much more. You need the caliber of an employee but it doesn't cost much more even as the doctor to treat your patients as a VIP. I'm not talking about offering them incredibly expensive things but it's your time, care and attentiveness.
I went to the dentist before. I had a wisdom tooth extracted. The funny part about this was this doctor thought I couldn't tell he was somewhere else and didn't care about me. He was answering my questions. It wasn't that he wasn't giving me the answer but I could tell from their tone and the eye contact or lack thereof that they were thinking about what they will watch on Netflix that night. I'm touching on different elements. It may not be as structured as you would've hoped but it's about caring for the person serving you and being invested in the outcome.
Glaucoma: Being a doctor is about caring for the person serving you and being invested in the outcome.
It's about the perception that they are offering you their full attention and time, that they care as much about what's going to happen with that pair of glasses as you do. The truth is that if you're talking about accessories, for instance, a dry eye mask or a drop, when I first started selling drops, there were six times the price of something you can find in the pharmacy. I thought people were going to come back, complain and ask for refunds all the time. It's only happened a couple of times out of thousands of sales. Why? It’s because they perceived the value in the product. I’ve explained it. You can't do high-end sales like low-end. You can't be like, “Here's a drop. It is $60. Buy it.” That's not going to work.
If they don't find that you've invested the time in explaining their dry eye and situation, why this is the right drop for them? Opening it up and showing them how to use it. This takes a little bit of time. It can be staff as well but it's that extra investment of time. You can't have five-minute exams at no charge in a high-end area or somewhere where they're going to invest that time, energy and effort. You can't combine those two elements but why do you want to go into that space? It's because that's how you're going to differentiate your practice.
Starbucks does not want to be Tim Hortons. It never tries to. Everyone knows the coffee is $7 as opposed to $1 but they're willing to pay that to say, “I want the no cup, no coffee, no sugar, no anything, latte.” For whatever value they place on that, that's what you're offering in that practice. I have a lot of patients coming in for 2nd, 3rd and sometimes 10th opinions and they say, “I'm scared to get my pressure checked. I don't want anything close to my eye. What can you do for me?”
I understand from my regulatory body experience because people are going to say that in the comments. The standard of care is the glaucoma tonometry visual field. If a patient declines that level of care, you can do what they are comfortable with. Document properly and take into account all the regulatory stuff but give them that tailored service. If a patient walks in and says, “No, you have to have the air puff test. You're not a patient at this office.”
Aside from that being problematic in many respects, you're not giving them that tailored experience and not being sympathetic. I’ve seen surgeons too. I had a patient come back and say, “Thank you so much for sending me to that specific surgeon because he understood my specific anxiety and concerns and addressed it to the best that it could be addressed.” I'm not saying tell them, “Don't worry, surgery isn't going to hurt,” or this thing when it's not true. I'm saying, “We can put you under general anesthetic if you are too anxious to have the cataract surgery otherwise,” or this kind of thing.
As far as when we're talking about building a high-end practice and leveling up, in your opinion, the number one thing perhaps many people are missing is the service aspect of it, providing that high level of service. That creates the impression of higher quality and everything else beyond that. I’ve heard different offices will do different things like have a concierge or greeter. Do you think that's important? Do you have something like that at the practice that you're at?
It depends on what you consider concierge but I answer my emails. I make it available to patients after hours. Frankly, it saves you a lot of grief. You don't want them to have a complication or have an issue and then connect it to you. If you look at the research and lectures, why do patients complain about doctors or sue doctors? It's a perceived lack of interest or care on the part of the doctor. That's number one. Not dilating this thing is another major issue but it's a perception that the doctor didn't care about me or the outcome.
For instance, I had a flash and floater on the last patient on a Friday. I explained to them. I said, “I'm doing everything I can to prevent this from being an issue. We looked at the back of your eye and there's nothing there. However, there's always that chance early in a retinal tear. It can be missed with all the technology, dilation, opt dose and whatever else you have. If you think something's changing, go to emergency right away or message me right away. If I don't answer, go to emergency.”
The thing is if the patient has a retinal detachment and they go to emergency, they're not going to say, “That doctor didn't care about me. They didn't even think about this could happen. They missed it.” No matter what the doctor at emergency says or no matter what happens after that, they say, “I was warned about this.” It comes back to one of the things I constantly say to students.
It's better to explain first than apologize later. There's a complete difference between you saying, “It's going to be hard to adapt to that minus nine,” from a patient coming back and saying, “It's a little tough. I’ve worn it for a couple of days and I'm still not adapting.” You say, “It's tough with a minus nine.” It's a different experience for the patient.
On that note, as far as adaptation and prescribing, having that conversation with patients ahead of time is extremely valuable because they know that it's going to take time. A separate little clinical tip that I’ve found super helpful over the years is trial framing is huge. I started never trial framing and doing it sometimes. Over the last few years, I trial frame most people's prescriptions, sometimes for the actual function of making sure that they're comfortable. People with a lot of sills and stuff like that will make some minor adjustments through there.
A lot of times, it's the perception of giving that patient that extra step and level of care saying, “Here's what your new glasses are going to look like. I want to make sure that you like this before we prescribe it for you.” Even if it's a minus 150 and they're going to be fine, that goes a long way. Doing those little things throughout every part of that patient journey is what's going to elevate that level of care.
The thing is that some doctors do a quick exam and they like seeing patients having a short interaction. I love that longer interaction. If I'm seeing a patient every 45 minutes, it's going to be a different experience. You can offer more services but also discuss them and there's going to be buy-in to whatever they may need. You can mention dry eye and other services that you provide. That's another way to differentiate yourself. The revenue will come because they're buying into those treatments. It's not like you can simply have a staff member at the front.
I remember going to a dermatologist. I was there for a while. Everybody that walked out the receptionist said, “The doctor recommends this cream, lotion and shampoo for you.” It’s the script. Everybody that walked out got the same pitch. That doesn't work as well as you individualize treatment and care when you say, “No, I'm suggesting this dry eye treatment or procedures for you or this glaucoma test because,” and that's a different thing. There's staff, which is excellent. We have some to explain specific side effects or specific procedures to an extent but the doctor also needs to invest their time and energy into the patient to make the patient buy into additional care.
A lot of times, doctors have that pushback. When I talk to them about implementing dry eye or myopia management by having more of these conversations, the pushback is, "I don't have enough time in the exam room.” It does take more time. I would be lying to be like, “No, it's not going to take you any more time to have this extra conversation on top of what you're already doing.” It does take more time. It started by taking honestly 10 or 15 minutes sometimes to have a long conversation about all the things related to the dry eye that I wanted to tell the patient initially.
I streamline it down to maybe five minutes. If I want to have a good in-depth conversation about dry eye, I have images and all these things that I have set. The same with myopia management. I’ve streamlined it down to a few minutes of conversation with a parent. If it's going to go beyond that, we know what to do next. What's your feedback or suggestion to those doctors who are like, “I don't have the time during my eye exam to add this aspect?”
First, I'd say it's okay not to do dry eye or glaucoma stuff. You can send it to someone else. You can have an associate who does that stuff. That's okay. No one says you have to. As long as the patient's getting the ultimate treatment they need or you're making the referral, that's perfectly fine. Inter-optometric referrals are something we don't do enough as a profession. I know all my BV. I tell patients right away I don't dabble in BV. If you've got something beyond the most basic BV issue, I'm sending it out.
Same with low vision. I don't do neurorehabilitation. I don't waste a patient's time and I know what I know well. I don't want to dabble because I don't want to be that guy where I'm not going to do the right thing. Another expert will say, “He should have done this or that.” I don't want to get into that situation. The other thing I’ll say is for young practitioners, having someone in your practice who does a lot of social media helps. A lot of patients say even at that time that they're not ready to plunge into the dry eye treatment or you have to structure it for a different schedule, whatever procedure or technique you're going to do.
That's where you can say, “I post a lot of my techniques online.” This is where you can look and direct them to the information or your articles. This is where all that stuff makes a difference. It's one thing to direct them to some show about dry eye or other doctors. It's another thing for them to see what you've been doing, what you are passionate about and how you implement it in your office. It makes them feel more comfortable. It's not on your time. The internet is 24 hours a day at their convenience.
Leveraging social media and other online platforms is huge. It has to be done. I do an eCommerce digital branding lecture and that's one of the most important take-home messages. I'm up at whatever time in the morning and get the kids ready, take them to school, go to work, commute home, then it's dinnertime, bedtime for the kids. Next thing you know, it’s 9:00 PM and I'm sitting on a couch.
Am I going to call somebody and be like, “Can you explain this procedure to me?” No, I'm going to go online. If I’m going to buy something, I go online. This is the case for so many people. If you're not presenting at least the basics of what you do on a good website and social media, you're missing a massive opportunity with a good chunk of the population. It’s very important.
My social media is tailored more for patients. I think about my fellow practitioners and it's for fun. When I say it's for patients, it's more for existing patients if they want to see what I'm up to, what I'm doing and what's new. Someone's not going to look at your Instagram or TikTok and be like, “I want this person as my doctor.” They're probably not in the same jurisdiction. They're halfway around the world. I don't think that's so effective. I do think a patient of yours whom you've mentioned a technique or your passion about this particular topic or myopia management and that's what you're into, can look and say, “I get it. I see. It's for this and that.”
A lot of their questions are answered in their time. They can do their research and compare it to other doctors as well and they can see a difference. We've all seen those web pages where there is generic writing about conditions. It falls flat to me. I can't say from a patient perspective but you're like, “I can tell this is from a generic response.”
Social media adds that personal touch. It's a piece of the puzzle. Sometimes it is but often it's not going to be the one thing that draws a person in. Let's say they got the same information from the website. There are 3 wonderful websites for 3 nice-looking clinics. They all offer the three same techniques. My next step is, “Let's see what their social media account looks like.” That's how I function and I know I'm not alone. I can go there and get the personal feeling behind the scenes.
If your social media is very generic looking or it has been put together by some media company or whatever social media that you've outsourced, then I'm going to weigh that out with, “Here I see the doctors are making videos of themselves and talking and telling me more about what they do,” versus the generic looking, very nicely polished feed. I'm likely to go with that one where I’ve gotten to see what the doctors are about. It's a nice little piece of that puzzle, for sure. Mark, in every episode, I end with two questions. Before we get into those questions, I want to ask you. How can people get in touch with you? Where can they find you?
Speaking of social media, I try to be active. Everything from LinkedIn to Instagram and Facebook. That's where I post stuff at practice. If you look me up online, look up my name. You can find me. Just google.
Remember, most people are reading and not watching. It's the same question that I ask every guest at the end of every episode. Number one is if we could step in the time machine and we could go back to a time in your life that was difficult, you're more than welcome to share that moment if you'd like to. More importantly, what advice would you give to younger Mark at that time?
I’ll make it very clinically relevant. When I was in school, my biggest regret as an optometry student was not asking enough questions. When I was in the clinic and the clinician tried to show me something, I felt like I needed to be like, “Yes, I see it,” when I didn't see anything. I felt like my grade was going to be affected and I'm not going to pass and I'm going to fail and my life is going to be over. The truth is looking back, it didn't matter. I should have taken that clinical time saying, “No, I don't see it. Can you show me again? I don't understand this concept.” That would've propelled me forward.
Glaucoma: One of the biggest regrets an optometry student can have is not asking enough questions.
I did a lot of my learning by doing my fellowship and diplomate. That was another learning experience for me. Even during boards, you learn new stuff, doing the preparatory stuff but I wish I would've in clinic asked more questions and allowed myself, even if it's a mean supervisor and say, “How come you don't know this? You should know this by now.” Who cares? What is the worst they were going to do?
I remember the worst grade I got in clinic one day was something that wasn't my fault. The supervisors took it out on me and gave me a 5 out of 10. What does it matter? I could have asked more questions on other days and gotten so much further ahead in my education by not being afraid of them saying, “You don't know that? I'm going to give you a 5 out of 10.” Is that 90 on a day where you didn't learn anything? In your 1st year in practice, you have taken a 7 on that day with the information rather than a 9 because that 9s not going to do anything for you.
I was very guilty of that. I'd never asked questions. A lot of times, it leaves you in a tougher spot down the road. That's great advice for students and even for optometrists. If you're at a lecture and CE, don't be afraid to look silly. There's no such thing as a dumb question. Almost always, honestly, if you have a question, somebody else has it too. Instead of being afraid and making yourself look silly, look at it the other way. You're helping someone else by asking that question. It's a different way to look at it.
As a presenter, we're so excited. We're waiting for people to ask questions. There isn't any such thing as a dumb question. It's usually the people who ask questions in the gotcha moment that don't know what they're talking about. It's the people who are honestly asking questions. It's usually an excellent question. As a presenter, it energizes us that to get questions and we love it.
As a presenter, it feels good to help answer and clarify something for somebody in the audience. I’ve never had a question where I was like, “Come on. I talked about this for an hour.” I never feel that way. It's always like, “I'm happy to. Please.” The fact that somebody's going to leave here knowing a little bit more than when they came in makes you as a presenter feel so good from a couple of different perspectives.
You're being so altruistic by asking this question. You're helping someone else in the audience. You're helping the presenter feel good. You're a superstar instead of coming out thinking that maybe you're dumb or something for asking the question. Student, new grad or veteran OD, it's important to ask those questions. The second of the two questions is, with everything that you've accomplished, Mark, to this point and everything you're doing, how much of it would you say is due to luck and how much is due to hard work?
That is an exceptional question. I was thinking about that. What everyone needs to realize and this is not optometry related is that they sometimes will see social media. I post all my accomplishments. I don't post all the rejections but that's normal. I will say this. I’ve been practicing for many years. I'm a dinosaur. In my professional career, you cannot imagine the number of rejections or perceived injustices in the sense like, “I deserve that and someone unqualified got it or someone got it because of a connection.”
That's happened to me more times than I can even remember. The thing is it can seem after a while that it's hopeless or you're never going to make it. The thing is that in the end, if you keep at it and I'm talking about many years, I'm not talking about 1 or 2 years, eventually, you'll be rewarded. We were talking about some of the things I’ve been proud to achieve or that's happened to me. That's not a last year’s situation. That's a 20-year situation.
What I want people to understand, especially students and anybody reading this is it's not that some people have it all figured out and they get one achievement after another or one offer after another. Pushing through that rejection, those times of total humiliation and complete unfairness are going to get you ahead of life.
Some people have it all figured out, and they get one achievement after another or one offer after another. But pushing through that rejection, those times of total humiliation and complete unfairness are going to get you ahead of life.
That's incredible to share. Thank you for sharing that. It's a shame we don't share enough of that on social media. I suppose that's not the right platform to share. Although some people do it to get a bit of pity and get a lot of likes for that reason too. There's a whole different thing there. Social media generally is a highlight reel. People get caught up in watching Mark become the President of the College of Optometrists, the ambassador for this thing, as well as part of this elite society for glaucoma. They say, “Everything's working out for this guy.” No, it's the years of work that you've put in and then you start to get lucky.
The answers I’ve heard or I like to think for myself is the harder you work, the luckier you get and the more opportunities you create for yourself. A lot of times, I’ve heard people say to me, “You're always in the right place at the right time.” That's offensive because I'm like, “You don't know how many wrong places I’ve been in to end up in the right place this time.” It's all part of the process for sure. Thank you for sharing that. Any other final words of wisdom you'd like to share before we wrap up?
I wish I could share all the failures and rejections. Social media, which I love, has an excellent part but also has a negative side. You always have to understand that, yes, there's luck, which you touched on. I’ve usually been lucky when I’ve done the preparation and they say luck is when preparation meets opportunity. I have my regrets and I’ve done stupid things. Things haven't worked out or there have been people who will try to backstab you or ruin your career and all these things.
I’ll say this, which is another point on the same theme. If people aren't attacking you in some way, trashing you or speaking poorly about you, you're doing nothing right. They may be correct that you did something wrong. You have to be open to that criticism. I'm simply saying for most of us who are thinking about what we’re doing and are not like, “I'm doing everything right,” and who have that introspection, the reality is people will be jealous.
Not everybody who's liking your post is celebrating you or people who are watching your story. Half of those people never say anything positive. I know they're not watching it because they love me. The thing is you have to understand that when you are in a position or you're going places, people are going to try to bring you down. That's the nature of the world and you have to accept it. Know that there's nothing you can do about it and keep moving forward. If there is criticism even from an enemy or someone negative, you can consider it and judge it by its validity or lack thereof and then move forward.
Wonderful advice from a very experienced optometrist from the clinical perspective, research perspective and all of those. If you are pushing boundaries, you're going to probably make people uncomfortable. You'll likely get some of that “hate.” How you move forward is all going to be about how you deal with that. Thanks for sharing that, Mark. Thank you for taking the time. I appreciate it. You had incredible amounts of insight to share. No matter whether somebody's reading, if they're a student, a new grad, a veteran OD or something else and they're in the research side of things, they're going to find value in this whole conversation. Thank you for that. I appreciate it. It's been great to finally do this.
My pleasure. It was wonderful to speak with you again. Honestly, from a selfish standpoint, I can't wait to see you at BCDO and party again because you're way cooler than I am. You elevate me with your presence.
That's very kind of you. My wife would laugh at you for saying that but thank you. That's awesome. Thanks again, Mark. I can't wait to see you there, for sure. Thank you, everybody, who's reading this episode of the show, Canada's number one optometry show. I appreciate all the support. There's so much value. Whatever part you found valuable, please take a screenshot, throw it up on Instagram or share the link on LinkedIn or share it with a friend through a text message. Let everybody know that Mark was here and talking about all these great things. Stay tuned for the next episode coming very soon.
Important Links
Keeping a Lid on it: The Underdiagnosis and Management of Blepharitis – YouTube
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About Dr. Mark Eltis
With twenty years in practice and 14 years in academia, Dr. Eltis has presented and published internationally and has been sought as an expert for national television and print. He is the current president of the College of Optometrists of Ontario (provincial regulatory body) and the Canadian Ambassador for the American Board of Optometry.
Dr. Eltis is a member of the Optometric Glaucoma Society (OGS) and a ACOE team chair for residency site evaluations. He has been a consultant for academic institutions overseas, law firms, and a subject matter expert for competency evaluations.
Dr. Eltis has also been a previous examiner for NBEO and the Canadian board examinations. He is a Fellow of the American Academy of Optometry and a Diplomate of the American Board of Optometry. Dr. Eltis has practiced in New York, California, and Toronto.