On HBO’s “Real Time with Bill Maher,” Maher periodically does a segment called “I Don’t Know It for a Fact...I Just Know It’s True.” These are often hysterical; I encourage you to check them out on YouTube.
In specialty contact lens prescribing, some things definitely fall into this category. For instance, lenses that aren’t paid for are always uncomfortable, or when patients make multiple complaints, the real problem is the last thing that they say. We know these things to be (almost always) true, but that is not really what I am talking about. I am speaking more generally of our true understanding of the scientific and clinical facts of specialty contact lens prescribing.
Is That a Fact?
In modern medicine, we are always trying to live in the evidence base. Everything that we recommend to our patients should have the weight of the evidence behind it, but that doesn’t always happen. The evidence changes or is nonexistent. We need to keep up with the ever-developing evidence base because things change from time-to-time—sometimes quickly—and if we don’t keep up, we end up making recommendations to our patients that are not the best options available.
We can offer options that the evidence base has clearly debunked. Or, we can follow evidence that later turns out to be wrong.
Consider keratoconus. When I was in optometry school, back when the extent of our technology was hitting the ground with a stick, we thought that we had to push against the cone to manage keratoconus. We didn’t know it for a fact…we just knew it was true. Well…guess what? It was not true. In fact, it was the exact opposite of being true. Yet, I still see patients who have been told by other prescribers—in 2019—that we need to push against the cone. Really?
Sometimes, things that we just know are true prove to be untrue, and our patients can pay the price. From blood-letting to treating stomach ulcers by reducing stress to cone pushing, medicine has many times fallen to its knees under the weight of its own arrogance and hubris.
Experience Can Fill the Gaps
How do we get to this point? The ugly truth is that a great deal about medicine—in our case, specialty contact lens practice—is not amenable to conclusive investigation that would otherwise guide the evidence base. So, in many cases during a typical day, we have to go with the anecdotal base. There, I said it; it had to be said. Ban me from the network, if you must.
Yes, many things that we tell our patients are drawn from our clinical experience and from our own biases and not from any peer-reviewed journal. Nobody wants to peel back that curtain, but it is true.
The lenses and the care solutions that we recommend are often based on our biases about which lenses and solutions work best in which situations rather than on some body of evidence in the clinical research. We are guided by data sometimes but not other times.
For example, work has been done and published on addressing midday fogging in scleral lens patients. The evidence from clinical case reporting suggests a strategy, but do we really know for sure? Have there been prospective, double-blind trials that have been repeated successfully? No! So, why do we pretend to know the answers?
We do what we think is best based on the information that we have. We don’t know it for a fact…we just know it’s true.
That being said, we need to check ourselves before we wreck ourselves. Let’s be more humble about what we know for a fact. CLS