Vol. 2, No. 2: Fall/Winter 2006
A Mentor and Caregiver
by Jeremy Shere
Community Outreach Director Jeff Perotti enables student interns at IU’s four rural optometry clinics to learn by doing in a busy, real-life setting.
It’s 7:15 in the morning, and optometrist Jeff Perotti is on the road again. As Community Outreach Director for the Indiana University School of Optometry, Perotti gets around, spending two days per week working and teaching at one of the School’s four rural optometry clinics located throughout southern Indiana. This morning, Perotti and fourth-year optometry student Liz Newman are headed south on Route 37 to spend the day at the Campbellsburg Family Health Center, a rural clinic about an hour southeast of Bloomington.
Campbellsburg’s population of around 600 is largely older and underinsured, making quality health care a luxury that, until recently, many residents simply could not afford.
When the Campbellsburg Family Health Center opened seven years ago as part of a federal initiative to improve rural health, a routine appointment to see the doctor was suddenly no longer out of reach. Through a combination of federal and state grants, and revenue generated from patient visits, the Center is able to offer a variety of public health programs, including smoking cessation, heart health, and general health education. The Center also does what it can to make its services available to people with limited or no insurance. Fees for visits work on a sliding scale depending on the patient’s income and resources. Pharmaceutical companies provide free drug samples and cut rates on medications.
“The local emergency rooms and physicians’ offices refer a lot of patients to us that don’t have insurance,” says Patty Zink, the Center’s Director of Community Services. “We see a lot of people who haven’t had any medical care for years and who might have diabetes or hypertension and not even know it. We see a lot of migrant types and unemployed people and we try to figure out how to help them put the pieces back together.”
The School of Optometry became involved in the rural health initiative in November of 2000 when a Health Services Block Grant from the State Department of Health enabled the School to purchase equipment and provide faculty optometrists for clinics in Jeffersonville, English, Clay City, and Campbellsburg.
Perotti manages his piece of the Campbellsburg health-care puzzle in the Center’s largest office—a corner space outfitted with the tools necessary for comprehensive eye care: eye charts, medication, a phoropter (the machine that looks like a giant pair of goggles used to determine lens strength), and a slit lamp— an illuminated microscope that allows the optometrist to examine the eye under high magnification.
The grant has even allowed the Campbellsburg eye clinic to go high tech with a cutting-edge retinal camera that takes highly detailed digital photos of the retina (the area at the back of the eye the health of which is crucial for clear vision).
It is in this room, during the six to eight hours a week that he spends at the clinic, that Perotti does some of his most valuable teaching. There are no lectures or textbooks, no PowerPoint slides or anatomical demonstrations of the inner workings of the human eye. Instead, Perotti teaches by example. More accurately, Perotti allows his students to demonstrate their skills in a busy clinical setting. His pupil on this day is Newman, who spends one day a week at the clinic gaining the sort of experience that is simply not available elsewhere.
“What makes this such a great opportunity is that I’m the only intern here,” Newman observes as she checks instruments, straightens eye charts, and prepares to see the day’s first patients. “This is a real-life experience in terms of how quickly I see patients and how many I see. At the IU clinic in Bloomington there would be at least one or two other interns sharing the patient load, but here it’s all up to me, so I need to learn how to be efficient, keep things going, and build a good rapport with patients.”
For the next six hours the patients come in a steady stream. From their perspective, Newman, with her white coat and friendly but professional manner, is not a student but a fully competent optometrist. Having grown up in a small town in southern Indiana, Newman relates easily to her patients.
“Go ahead and put your chin up there for me and look straight ahead,” Newman tells Julia Knight, a silver-haired woman in her late sixties. Knight, whose Medicare insurance does not cover eye care, had recently switched to “line” bifocals—the kind with an opaque, linear separation between the lenses’ top and bottom halves. When she had gone to see another optometrist from a private eye clinic who fitted her for the new glasses, she was told that the pressure in her eyes was high—an early sign of glaucoma, which causes vision loss by damaging the optic nerve at the back of the eye.
“How has that medication that Dr. Petty [Dr. Ryan Petty, a former rural health clinic student and current Paoli optometrist who often helps with further diagnostic testing for rural health clinic patients] gave you been working?” Newman asks. Knight looks a bit worried and hesitates before answering. “Are you remembering to take it?” Newman gently prompts.
“I’m remembering,” Knight says, her accent a blend of the region’s country twang and the speech of Knight’s native Ireland, from where she emigrated as a girl. “But sometimes I’m not sure if I’m getting the drops in my eye or not.”
“Try putting the medicine in the refrigerator,” Newman says. “That way it’ll feel cold when you put the drops in and you’ll know when it’s in there.”
Knight smiles. “I’ll try that,” she says. “Although Dr. Petty told me to put the medicine only in my right eye.”
The door opens and Perotti enters. Newman hands him a chart and the two confer briefly. Knight looks on a bit anxiously. This visit, plus her previous visit to the private eye clinic, have strained her limited finances. As Newman observes, Perotti sits across from the elderly patient and explains that her pressures have dropped to normal levels in both eyes even though she’s been using the medication only in her right eye. After only a few moments it becomes clear that Perotti is a gifted teacher both as a caregiver and as a mentor to future optometrists.
“If the pressure had changed only in your right eye, the one where you’ve been putting drops, but not in the other eye, then that would suggest that the medicine was really working, right?” Perotti explains. His tone is friendly but firm, his words carefully chosen. Knight nods in comprehension. “But since your pressure has gone down and it’s the same in both eyes, that’s a pretty good sign that the drops aren’t working. So let’s do this: try the new drop in the same eye and then come back in four weeks and we’ll see.
“That isn’t too long to wait?” Knight asks. “What if my pressure gets worse?”
“One good thing about glaucoma is that it’s a slow disease,” says Perotti. “It doesn’t change things overnight or even over a few weeks. It usually takes months and sometimes years, so you’ll be fine.” He reaches into a drawer and pulls out a box of medication. “Here you go.”
After Knight gratefully pockets the free sample and leaves, Perotti and Newman discuss her case, debating the merits of the new medication and the possibility that Knight’s lowered pressures were the result of natural fluctuation during the course of a day. Perotti points out several telling details on Knight’s chart as Newman nods.
Although the nature of their relationship is officially teacher–student, Perotti speaks to Newman as to a colleague. He is direct about what Newman missed and what she might look out for with future patients. Perotti is equally forthright about what Newman has done well.
“My teaching style is to be honest and not worry too much about hand-holding,” Perotti explains several hours and seven patients later. “Some students don’t like that initially, but once they’ve worked with me for a while they realize that I’m not concerned with personality issues because we have a lot of patients here and so a lot of the teaching I do is sort of on the fly, ‘you need to look at this,’ ‘you need to review this,’ ‘you need to take care of this.’ What’s really important, I think, is patient communication. I work hard at trying to explain things to patients in a way that’s clear and helpful without being condescending. That’s something I try to model for my students.”
During the drive back to Bloomington, Perotti and Newman reflect on the patients they’ve seen, including a 22 year old whose peculiar headaches and retinal swelling indicate a possible brain tumor. Exposure to this kind of case, Perotti says, will prove invaluable down the road when Newman graduates and enters the profession.
“There’s nothing like learning by dealing with real eye problems with patients who are depending on you to make them better,” Perotti says. “Same goes for teaching. The best way I can teach my students is by working with them and showing, not just telling, how it’s done.”
Jeremy Shere is a freelance writer in Bloomington.
