Optometrists today have many unique and different career paths available to them. In this article series, we’ll be engaging with optometrists from various common (and not-so-common) practice modalities to get a firsthand perspective on what optometry is like in their setting.
Today, we’re interviewing three optometrists who share their extensive experience practicing in various pediatric settings. Kara Gerger, OD, FAAO, Kelsey A. Carriere, OD, FAAO, and Jacqueline Pokusa, OD. All three doctors are residency trained in pediatric optometry and are also alumnae of the New England College of Optometry.
What advice would you offer to optometrists considering a career path in pediatrics?
Dr. Gerger: Go for it!! If peds is something that is of interest to you, it is a wonderful and rewarding corner of optometry where we could really use a few more smiling faces! Children under 18 account for almost 25% of the US population, but Pediatric Optometrists are relatively few and far between compared to our colleagues who treat adults. If you aren't already, practice and become REALLY GOOD at retinoscopy (and cover test and BIO on moving targets . . . just to name a few)!! Peds relies very heavily on objective testing, so you have to trust yourself and then project competence, clarity, and compassion to your patients and their families. Similar to academia, people typically choose pediatric optometry because it is a passion, not for competitive compensation. Although it is an incredibly important specialty, we often earn much less than those who cater to the adult population; however, it remains a highly sought-after skill set.
Dr. Carriere: A residency is invaluable! My residency gave me the opportunity to experience pediatrics from a variety of clinical perspectives and taught me just as much about how I wanted to practice, but also how I did not want to practice. Take time during residency to seek out different practice modalities to find which niche of pediatrics is best for you. This could be hospital/medical-based practice, private practice, vision therapy, school-based clinic, pediatric contact lenses, low vision or CVI, etc. Pediatrics is extremely rewarding. You make connections with your patients that may not happen in other practice modalities. I’m often seeing them multiple times a year and watching them grow up, and I have the ability to truly affect their lives!
Dr. Pokusa: My advice would be to get really clear with yourself on your motivation for pursuing a pediatrics focus. Kids and babies are adorable, but that absolutely cannot be the main driving factor for your career choice!
Is further training required for optometrists to successfully work in a pediatric setting?
Dr. Gerger: In my opinion, yes, particularly if you intend to present yourself as a Pediatric Optometrist (rather than "an optometrist who sees kids"). In contrast to the significant number of ocular disease-based residencies, Pediatric Optometry only has around 30 residency programs. These are further subdivided by program emphasis, with medical-model and vision therapy/behavioral optometry as the two main arms. As is typical with all residency-trained optometrists, your residency training is likely to move you to the top of the resume pile for prospective employers. This seems to hold particular weight for those employers seeking Pediatric Optometrists, as residency demonstrates a commitment to working with children as well as the level of expertise required to navigate such a multi-faceted specialty. Often, a job description will specifically mention that residency training is required for pediatric-based jobs.
Dr. Carriere: Further training is definitely not required, but it sure is helpful. I think this all depends on the type of practice you want to work in, and how willing they are to work with your training and skillsets. I work with an incredible team of 11 pediatric ophthalmologists and 8 pediatric optometrists. Of our optometry team, two did not complete a residency. They are just as knowledgeable, successful, and valued members of our team!
Dr. Pokusa: In pediatric care, I believe the doctor must check the ego at the door. At a minimum, you must be able to identify and quickly refer out any case that doesn't fit the expected presentation or response to treatment. This requires a good grasp of the fundamentals and literature relevant to pediatric optometry and ophthalmology. You will need sharp clinical acumen, solid objective exam skills, and excellent communication with family and other providers. There is definitely a need for cultural competency as it relates to the culture of little ones and of families. I don't know whether I could have achieved all of that—especially as it pertains to atypical cases—without a residency, which is why I chose to pursue one. If you plan to work with mostly typically-developing children, to stay on top of the literature, and to refer out any perceived outliers, then this can probably be done effectively without residency training.
What is the most rewarding aspect of working with pediatric patients?
Dr. Gerger: Wow . . . that's actually a very tough question to answer because peds is incredibly rewarding even on the most challenging of days!! My job might look like all fun and games, with stickers on my nose, light up toys, singing, movies, and a whole discussion about "washing out the tickle drops (proparacaine) with special eye doctor water (cyclo and tropicamide)," but at the end of the day, I still pinch myself knowing that more than once I have not only changed but helped to re-shape an entire life for the better. Amblyopia is of particular clinical interest to me, and I still find it so powerful that we can make a lasting change in the life of a child if we just know how and when to look. Perhaps it is because I have practiced in areas of our country where "limited access to care" isn't just something we talk about in the classroom (it is real and it is difficult) . . . but I never tire of watching the transformation a child has once they can truly see the world around them.
Dr. Carriere: It’s always extremely rewarding when a patient makes positive strides with learning, school, or even socially because of the changes we’re able to make with their vision. Something as simple as a pair of readers for a kid with accommodative issues can take them from hating to read to reading above grade level. Prescribing tinted contact lenses for a child with albinism can make them feel less different because they don’t have to wear sunglasses indoors. Kids are so proud of themselves when they succeed, and most families truly appreciate the impact you have on their lives!
Dr. Pokusa: Working with these little ones is often highly entertaining and rewarding. My inspiration comes from the lasting impact one can make; consider the example of correcting amblyopia or strabismus, or of controlling myopia progression, and the positive results that can last a lifetime. I also love to sing with the kiddos and to hear about what's new in their lives, and am genuinely happy in my heart when they make progress with their treatment plan as well as grow and learn as individuals.
What is the biggest challenge?
Dr. Gerger: As much as I would love it, peds can't be all "prize box and stickers" . . . you WILL have tough days, and the reasons will be many. With children, not only do you have to consider the patient, but you must also consider their parents, siblings, aunts, uncles, grandparents, family friends, etc. This can add a level of complexity to your exam as well as your treatment plan. Children may have free will, but they aren't in control of their own medical decision-making, compliance with treatment, or their finances. You may have a parent OR an employer who isn't sympathetic and understanding to the amount of time that is required for a proper pediatric exam, you may have to tell a parent that there is something wrong with their child, you may encounter people who insist that it is impossible to perform an eye exam on babies and young children (because they can't read), and oftentimes, you will have a patient who isn't the least bit cooperative—but you still have to get your job done! There are many challenges to this particular area of optometry, but most of us who practice Pediatric Optometry would say that the good far outweighs the difficult! We wonder how many of our adult-practice colleagues get pictures colored for them, or thank you hugs, or updates years later on how they are doing?
Dr. Carriere: The most difficult part of pediatrics is often the parents. It can be very challenging when you feel like you’ve provided a thorough exam, comprehensive explanations, and stressed the importance of following your recommendations, but the child comes back for a follow up having not done a single thing because the parents did not feel they needed glasses, or think that they “see fine.” It’s easy to get emotionally attached to some of these patients and to know you’ve done everything you can when they are lost to follow up and will likely grow up to have poor vision. All you can do is provide the best care you can and hope the rest works out!
Dr. Pokusa: You must have the willingness and ability to be a level-headed presence and an advocate in sometimes tragic situations (think non-accidental trauma, terminal illness, and other challenging circumstances).
How is your clinic time allocated during the week? Can you briefly walk us through a “day in the life” of your typical work routine?
Dr. Gerger: That's the thing with kiddos . . . there is no such thing as a 'typical' clinic day!
Dr. Carriere: I work in a fast-paced medical practice. A typical clinic day consists of anywhere from 25-30 patients scheduled every 10-15 minutes. I’m lucky to have 2 very well trained ophthalmic technicians that work up patients before I go in for my exam. A large majority of the day consists of comprehensive exams or follow-ups for patients with refractive error, amblyopia, or strabismus with ages ranging from 2.5 to 21 years old. We have a large population of patients with juvenile arthritis and other systemic diseases with ocular manifestations, so there are usually a few of those exams in the mix. There may also be urgent exams for patients with red eye, iritis, hyphema, corneal abrasions, or other issues requiring same-day exams.
As the contact lens provider in our practice, I have a dedicated day every week for seeing specialty contact lens patients. These days can include anything from infant aphakia, high or irregular refractive error, post-trauma or scarring, keratoconus, myopia management, low vision such as albinism, or any other specialty fits or follow-ups.
Dr. Pokusa: In a pediatric hospital setting, the day typically begins quite early, with first patients at 8 am or earlier. Meetings, image rounds, and lecture series often occur before patient care starts, so one or two mornings per week are dedicated to the didactic training of residents, fellows, and technicians. Throughout a patient care day, there might be an ophthalmology or pediatric resident or medical intern shadowing for all or part of the day. I think of it as working as a part of a true team, as you might need to call in a technician for a B-scan or call another department for a stat referral at any time during your day, and it's important to be able to work well with others in a dynamic atmosphere. Patient demographics for an optometrist in pediatric hospitals can range from premature babies who have recently been discharged from the NICU to individuals in their late teens or early 20s. Many patients will have a genetic diagnosis or be in the process of being worked up for some suspected genetic or other medical conditions. Many also have developmental delays and special psychosocial considerations. Common ocular problems include refractive error, failed screening at pediatrician or school, amblyopia, strabismus, pseudostrabismus, chalazion, hordeolum, preseptal cellulitis, conjunctivitis, ocular injury, history of prematurity. There are a multitude of other conditions that you might encounter frequently, and every day there is something new to learn.
Conclusion
Optometrists practicing in a pediatric setting provide vital eyecare to the patients they serve. Many times parents may not be aware of their child’s underlying vision problem. Ensuring optimal, binocular visual function is essential for a child’s behavioral and cognitive development, as significant repercussions can result when undiagnosed visual problems persist into the adolescent age range.
Optometrists interested in pursuing a career path in pediatrics have the option of starting while still a student. Many 4th-year externship rotations are available throughout the country, allowing students to gain better insight into whether or not this practice modality is right for them. New grad ODs can also opt to pursue one of the many unique pediatric residency programs available as well.
Practicing in some pediatric settings (eg. hospital-based or community health) may also qualify optometrists to participate in the public service loan forgiveness (PSLF) program. As the cost of optometric education continues to rise, a growing number of today’s optometry students may likely consider PSLF as a means to offset the financial burden of becoming an OD.
Be sure to also speak with other colleagues, faculty and professional mentors to see if a career path in pediatrics is right for you.
