Mentorship from Afar: Dr. Fletcher Models Challenging Clinical Assumptions

Dr. Fletcher (: 00:05

if I make it into heaven, it's going to be because I push the team approach in visionary rehabilitation amongst the medical. I often say that my big role as the physician is I use my credibility to talk people into participating in the team

Erika Andersen Ko (: 00:23

Low Vision is rewarding, but it's also complex. Practicing with support from a multidisciplinary collaborative community can fill your cup and provide pivotal insights. Inside the Low Vision Beyond the Clinic podcast and community, you'll hear from leaders, researchers, clinicians, and lived wisdom experts and their stories of change and growth. Whether you practice in a medical setting or education, team based or in solo practice,

This podcast connects you to the broader Low Vision landscape with fresh perspectives, practical strategies, and inspiration for the hard days. Welcome to Low Vision Beyond the Clinic. You belong here.

Erika Andersen Ko (: 01:05

Hi everyone, I'm your host, Erika Anderseon Ko. I'm a certified Low Vision therapist with over 20 years practicing in multidisciplinary settings.

I'm so appreciative to kick off the season with a beloved leader in our field who I, like many others, consider him to be an unknowing mentor from afar.

You're in for a treat today to hear ophthalmologist Dr. Donald Fletcher share how multidisciplinary collaboration changed his practice.

Erika Andersen Ko (: 01:35

I want to say a big thank you to CAER, the Colorado chapter of the Association for the Education and Rehabilitation of the Blind and Visually Impaired. They recently awarded me a microgrant to support the relaunch of this podcast. The grant itself was a tiny seed, but the message it sent was significant. It told me that the act of asking questions about how we grow as practitioners, how we collaborate across disciplines, and how we innovate is inherently valuable.

I'm grateful for CAER's support and for the broader work that AER and its chapters do to sustain practitioners in this field.

Erika Andersen Ko (: 02:14

Dr. Fletcher, you are described as one of the world's leading authorities on low vision rehabilitation as a clinician and a researcher in the field of retinal diseases and low vision rehabilitation. And yet at the same time, you're known for being approachable and making research and the nuances of clinical care relatable.

first Envision Conference in: 2006

you pulled out a ruler and you pointed to the ruler and you said, this is what I asked patients, how difficult is it? And I think it was like reading a medicine label. How difficult is it? And you moved your hand on the pointer you basically turned a rule of the Likert scale into a ruler that was like a tangible concrete example. And it blew me away. Do you remember this at all? I figured you wouldn't.

Dr. Fletcher (: 03:13

No, that sounds lovely. have done that. 2006, that's a little foggy in my memory. can't remember it too well, but I'm glad it worked well.

I thought analog scales, you know, it was called. So yes, I found it helpful. It wasn't my idea, but I thought it worked well.

Erika Andersen Ko (: 03:27

what really struck me about that was that in doing so, it blew me away because you were so down to earth, you were so creative, and you were so engaged in translating clinical concepts in an individualized way that was meaningful to that client, that patient right in front of you. And so that's so much what I'm seeking to do as a low vision therapist. But to see an ophthalmologist, like the lead authority figure in the medical model doing something like that felt so validating and inspiring to me.

And it also gave me permission to think about that there's room for both formal and informal assessment and vision rehabilitation care. And so from that time, kind of that demonstration kind of firmly established you as one of my unknowing mentors from afar. I'm sure there are so many other folks like me who view you as a mentor that you have no idea that we exist, but here we are. And so I wanted to ask you.

about a little bit besides being grateful for your mentorship and from afar and taking the time to participate today and just being very grateful for that. I wanted to start by asking you about multidisciplinary collaboration and how did it become an important part of your work?

Dr. Fletcher (: 04:32

Thank you for the invitation to be here and to talk about this subject and your kind words so far. I don't know whether I'm, as you described, know, a guru or something, know, many areas of life, the more you do, the better you get at doing it. And so I've been doing this for approaching 40 years. I've seen probably over 35,000 patients, vision patients so far, you know.

Maybe what he says, if I keep practicing, I'm going to get good at this, you know, the doctor really practice, you know. So I've been in practice and I've been practicing a long time, but very quickly in my career, I realized that the team approach was going to be critical to me helping patients optimally. I started out, you know, in a standard kind of low vision setting where, you know, the doctor prescribed magnifiers and it was an optical kind of solution. I had a friend, his name was Dan Wineapple, who

had choroideremia, like retinitis pigmentosa, who was a physiatrist. And he told me about how physiatrists use the team approach. he suggested that, you know, maybe it'd a good idea if in vision rehabilitation, we did the same thing that they did in orthopedic and neurological and so on rehabilitation. And that sounded great and logical. So I started looking for the members of a team that could be set up. I did my training in San Francisco, at the San Francisco Lighthouse and few other locations. And I quickly realized that, you

teachers of the visually impaired, orientation ability specialists, and other members had an important part to play that I wasn't going be able to do as the physician. And so I started to use this team approach. One of the challenges was that it wasn't being health care reimbursed at that time. And so Stan said, well, you should consider using occupational therapists.

I found an occupational therapist that actually had ⁓ experience ⁓ in vision rehabilitation and turned out that she played a very important part of the team. So right now, almost 40 years later in InVision here in Wichita, we have a really good team and we love working with each other and everybody has an important part to play. So we have the physician, we have occupational therapists.

We have orientation ability specialists. By the way, my youngest son is an O &M specialist, so it's in the family. And we have physical therapists, and then the counselors and the support groups and all of the people involved, whether they be from the blindness rehabilitation community, educational community, or from the healthcare community, have important parts to play. It really is wonderful because I can't have a patient come to me

with any kind of weird, wonderful problem and have me say, gee, you know, I don't think we can help you. Of course, team is going to help. And the daily response I see as I have patients coming in and ⁓ graduating from the program is just heartwarming and exciting. So I haven't lost the passion for this. I love this work as much now as I did 40 years ago when I got started in it.

And so the team approach is, if I make it into heaven, it's going to be because I push the team approach in visionary rehabilitation amongst the medical. I often say that my big role as the physician is I use my credibility to talk people into participating in the team and letting the team help them. So I use whatever stick of a stick of authority I have as the doctor to say, I'm prescribing this team approach and you need this, you know, so that's.

I think my most important role in this whole process is to be a salesperson for just the value of having everybody in the team participating in their care.

Erika Andersen Ko (: 08:01

When you last in twenty twenty four at the study group, you were talking about O and really looking at how you were pushing O and what your responses were for the referral rate. So I'm going to circle back that back to that later. But I felt like that was a great example of you using that power to promote and really sell. And I don't know that I've ever heard anybody else say that, say it as frankly

As a physician, is my brain gig is selling the other disciplines and therapies in the need. And I really love that. I think Dr. Joe's used to say he was never wrong because he wasn't done with anything until everyone else said it was working. So it was just an ongoing process.

Dr. Fletcher (: 08:38

That's a good comment.

I had a funny little story today. The last thing I saw talking about a team member, the security guard that sits down at our front desk, but he's his name. He's this big burly guy who's just a soft teddy bear. And he just loves us up here on the second floor. So he sees all the patients coming by the second floor. He gives us wonderful sales approach. Oh, you're going to love them. They're fantastic. You so an important part of the team is the security guard.

What a sales approach. Everybody's in the team and involved in security guard actually has an important role to because everybody says, ⁓ buddy who sure sells you guys great. thinks you're wonderful.

Erika Andersen Ko (: 09:14

I think even as we're laughing and both smiling about this, I think it's actually really significant. I have heard so many folks, I talk about inaccessibility and the feeling of first walking into a medical setting. And for folks who have a diagnosis of a progressive disease or in vision impairment, we deal with people who, or just vision rehab that have experienced maybe trauma related to having a life altering condition. And so as they come into the building,

A lot of times their nervous systems are already going. They have a lot of fear. reminds them of something big in their life. So if they can have a buddy who greets them and invites them in and that warmth conveys it's a safe space you're going to be taken care of. This is a team. You're going to love it. Even though it sounds funny in the storytelling, I think it's really powerful and significant to frame that first entry point and contact as something that's positive and collegial and like a family that you want to be a part of.

Dr. Fletcher (: 10:09

insignificant. I agree.

Erika Andersen Ko (: 10:10

Okay. So tell me a little bit, do you have any stories of, you're full of stories, so do have any stories about examples of when working with a clinician in a different discipline changed your practice?

Dr. Fletcher (: 10:21

boy, how many hours do we have?

Erika Andersen Ko (: 10:24

I

know, I know, I have the timer going.

Dr. Fletcher (: 10:26

So definitely almost every member of the team has changed the approach that I take to low vision rehabilitation. Speaking of orientation mobility just recently, this was a topic that came up at the study group in San Francisco that we run that for 20 years we've got together and

discussed cases, difficult cases. So we get together as clinicians and researchers and discuss ⁓ problem cases. And a couple of years ago, somebody was talking about the difficulties that patients with macular degeneration ⁓ had with mobility, rotation of mobility. And kind of the clinical dogma was that, you know, if you've got a full peripheral field, you don't have mobility problems. So

If you are a glaucoma patient or retinitis pigmentosa, of course you're going to have mobility problems, but macular generation patients, don't have mobility problems. And so I fell into that trap of an assumption and assumptions are dangerous. And so I'm always saying, you've got to be careful with your assumptions. And so I said, okay, well, let's look at this. And so I started asking my mobility, I mean, so my macular generation patients with full peripheral field, if they had mobility problems.

And I was amazed and shocked at how much I was missing. My assumption that they didn't have problems was just absolutely wrong and incorrect. And the decrease in contrast and low luminance problems and so on had lots of people having falls and narrowing their scope of travel, especially at night with full peripheral fields. there's one where a good question from an orientation mobility specialist.

raised my awareness and totally changed the way I practice. And I'm now realizing I'm trying to embark on how can we best, you know, offer mobility services for somebody with a full peripheral field? Because that's not standard O know, White Canes involves in a lot of these patients' situations. So I learned a lot from that member of the team, from an O specialist.

Erika Andersen Ko (: 12:18

that's a great story. And I'll just tell you as a little aside, after you talking about this and A and O it's something I had wondered about a lot too. I went back and I had a client with A ⁓ who was going to do a travel trip. Her focus in retirement is international travel. And she wanted to go to Columbia and she wanted to go on the level two tour, which required it was a little bit more active. So they rate the tours in the senior.

tour program and she wanted to go on level B and she said, you know, if she's I'm worried about a fall. She's like, but if I take a white cane, they're not going to let me on the trip. And, you know, regardless of ADA, I don't want to be viewed as like that. I can't do all that's possible. So while that's a whole thing there, I asked her, well, what would you think about trekking poles? And she was I was like, would you be willing to do O training, which she only associated with white cane travel, if we could do trekking poles?

And if they don't bring up white cane, if we say we're not going to talk about that right now, could we do, would you be willing? And she did, and it was transformative. And she did her trip and she had a wonderful time. And then she called her and talked to her post-trip. I was like, how'd it go? And she was like, you know what, Erika? She's like, those trekking poles, I use them now for curbs. Do you know they can help with curbs? And I just loved it. And she was macular degeneration

2070.

Dr. Fletcher (: 13:34

Everybody's an individual and square pegs and round holes kind of thing, know, everybody has to be treated individually. Whatever works, whatever the hook is, whatever the hot button is to get somebody interested in learning what is appropriate for them.

Erika Andersen Ko (: 13:45

Yes, exactly. But that's the kind of creative thinking I think that you inspire in clinicians in the way that you're open to asking questions. part of what I wanted to feature here so much, because I think it's really instrumental in helping us be open to the sites of other disciplines and perspectives and how we're all needed. We all belong at the table. And speaking of tables, I want to talk about the big table at the Low Vision Rehab Study

Dr. Fletcher (: 14:11

A little over 20 years ago, Ron Cole, Gus Coleman-Brander and I were sitting down at a table over lunch and they're both well into their 90s now. And so it's kind of falling on me to take the total lead in the study group. But we were saying how it's frustrating as a low vision clinician to not have a lot of colleagues to discuss things with because often in low vision practice, you're just kind of lone wolf out by yourself. so the...

we dreamed up the idea of having a study group where we could get people to come together, where we could discuss problem cases and ideas and share ideas and bounce off each other. So Smith-Kettlewell is where I've done my research for many, many years. So it's a research institute. So we invited clinicians together and of course, Smith-Kettlewell has got the researchers. So I started with clinicians and researchers, mainly optometrists and ophthalmologists, but we expanded into...

occupational therapists and orientated ability specialists and teachers that are visually impaired and so on and so forth. it became part of a bigger group and bigger circle. Anybody's invited. But basically it's clinicians and researchers. And the clinicians, you know, have problems. so the researchers will suggest ideas to have how to study and have be disciplined about trying to get this information. And then the researchers will suggest ideas. And as clinicians, we try to anchor them in clinical reality.

Does that pass the so what principle kind of the same? Discussions. It's been going on 20 times now. The first weekend in February was the first Friday and Saturday in February, unless the Super Bowl weekend, which it happens to be next year. So Super Bowl is in San Francisco that first Friday, Saturday. So I'm not going to compete with Super Bowl in 20, but it's something we've enjoyed doing. And I've I've.

There's no registration fee and I guarantee everybody that they're going to get their money's worth if they come and join in the group. For people that do low vision rehab and have experience, it's not for how you get started in the field, and we share back and forth, no set agenda. I moderate the whole meeting and we bounce around all over the place like a pinball machine and we have a lot of fun together for a couple of days.

Erika Andersen Ko (: 16:12

I have always thought of it as since I heard about it. I have always thought of it as like the low vision mastermind and I have pined and pined to go. And it was only when I was in private practice that last year after wanting to go for like 15 years, I was I was able to attend. And the way you opened up the meeting, I just loved and want to share that everyone sitting around this large conference table and clinicians like me and I was sitting next to I think Dr. Colin Brander and of course, a little

gobsmacked about that, but you asked the question, everyone, ⁓ you asked everyone to share something they had learned over the past year and it was immediately democratizing. Everybody has something that they've learned in the past year. So if you're taking the time and the commitment to go to this, you've been learning something in the past year, but you've been paying attention to something and to hear all those voices and what you did in that moment to shift the power differentials and to shift people from different disciplines.

having a sense of belonging and something we could all share in common is that we're all learning something related to this field. And I thought that was really powerful.

Dr. Fletcher (: 17:14

I thank you for verbalizing something. Yes, that was my idea, but I couldn't have said so well. That's exactly what the whole point is. And that gives everybody a voice, everyone a chance to participate. And I want to force them into being present and mindful what's going on by having to speak themselves. And so I make everybody talk and it can be something, you that you think is trivial, but it may be significant to somebody else. And so we've learned an awful lot by making everybody think about.

And it helps yourself. What have I learned in the last year? So you have to think about it yourself. And so I love that portion of it. I share the enthusiasm that that is a good start for the meetings.

Erika Andersen Ko (: 17:52

Yes, there is a book by Priya Parker called The Art of Gathering. is a professional, I'm gonna miss the word now, conflict management specialist and resolution specialist and she's worked like with the UN, but she also does things like help people create more present and meaningful gatherings, something as small even as a birthday party. And so she talks about, you think about what you want the outcome to be, the feeling that you want to create among those you have gathered.

and then you work backwards from there. And I think that that's what you do in this rehab study group. And so I wanted to ask you, you had sent out a request that participants from the last 20 years would share with you things that they have learned or how the group has been meaningful to them and the impact that it's had. What have you heard?

Dr. Fletcher (: 18:36

That was an idea of one of the Smith-Kettlewell colleagues that I had since it was the 20th anniversary. eclectic would be the word. There's lots of different kinds of feedbacks. I haven't tabulated it yet, but I'll have to tabulate it and rebroadcast it on the Mechanical Ophthalmology Lister so that everybody can see it. I need to actually send another request so can get a few more responses because my sample's not huge so far, but it's interesting how people have, you know,

not only taken away gems for their practice, but gems for living life, you know, and what I've learned ⁓ from low vision patients that has application in my life as a fully sighted person.

Erika Andersen Ko (: 19:17

Yes, yes. Well, I will tell you the year that I attended, there was some spicy conversation. I don't know if it's always spicy, but it was definitely spicy the year I was there for the article on the effect study, eccentric viewing training. And there was a lot of conversation. think it's one of those topics in low vision in which there's the researchers and there's clinicians and conversations can sometimes feel like a big gap between the two. And and so

in that conversation, I think it was Dr. Wittich who brought the example of, or who brought the article to discuss. And then out of that, it's been interesting because there's been kind of ongoing discussion from actually the discussion that started there because Dr. Wittich brought up the article to discuss. And so one of the things that came out of that was a response to about clinicians' perspective that was published as a letter to the editor.

And then you motivated me this idea of learning from each other and that it could be just easy and accessible. That we could just invite people basically to a party, a gathering and saying, hey, let's talk about these things. And that clinicians feel lonely and want to have these deep dives and not just clinicians, but researchers. So I did these small virtual focus groups, call them to have clinicians, other clinicians talk about what their experience was in screening for eccentric viewing training. But it was inspired by

the low vision rehab study group and we came up with a clinical tool. And so that was kind of one of the impacts that I had was let's ask other folks, what has your experience been? How do you screen out folks for eccentric viewing? We can agree, you know, this is the finding of the research is so important. Hey, it's not for everyone. And all the clinicians I know, we don't use it for everyone. And so what have we learned? And we can create something that can be a clinical tool that can then circle back and say, well, what other research do we need? And as a way to kind of work in tandem.

So how have you seen in these conversations the bringing together of those kind of different perspectives of researchers and clinicians and being able to bridge the gap?

Dr. Fletcher (: 21:12

Well, that's an excellent question. bridging that gap between clinicians and more basic researchers is something that I want to foster. talking about team approach, team approach is very important in research as well as in clinical practice. And the association I've had with researchers at Smith-Ketterwa has made me a much better

clinician as they ask me difficult questions. You know, that's your assumption. Have you measured it? discipline myself to get some protocols and measure it. And number of times I've been surprised that my assumptions are wrong. They need more than two hands to count all the major things that I've absolutely had wrong before I started measuring it and looking at that the numbers is a good case in point in my personal case.

you called it spicy discussions. I jokingly at this last meeting, there's two of my research colleagues that like to pick on the clinicians a bit. so when the topic came up, they were sitting beside each other and I referred to them as Waldorf and Stattner, the Muppet critics that are up on the balcony and so everybody thought that was a great...

I'd like to look at everybody else. But it's in a spirit of respect and open communication that we have this good time. And there's been a lot of studies that have come out of that as clinicians and researchers have realized that they can help each other. You know, I'm not good at grant writing and I don't want to become good at grant writing. So I'm very happy to have the researchers do the grant writing and tag along.

At this stage of micro I certainly don't have to be the first author on a paper and I don't want to spend a lot of time writing, but some of the research guys, they love to write and they're very good at doing it. So I can add my two cents worth. But for clinicians looking for a PhD that is interested in the scientific method and can tell you how to set up a study with good controls and measuring the right variables, asking the right questions is infinitely valuable. And I would recommend that for

any clinician, you want to make yourself a better clinician, find a friend who's a researcher and you'll find yourself much more disciplined as you look at it, critically look at yourself and your practice. On the other hand, very few researchers are so flush with research subjects that they aren't delighted to have a clinician come along and supply them with research subjects. So it's a marriage made in heaven. The researchers love to have lots of subjects for their big insights for their studies.

the researchers, hope they're not so arrogant. And of course, you know, lot of MDs think that MD stands for Medicus Deatus, you know, and on a pedestal and walk on water. And so, yeah, get off your platform here. There's a lot of things as MDs and ODs and so on that we don't know. And so to admit that, you you need some help from somebody who's a little bit more rigorous in their discipline study design and so on is a piece of humble pie that you got to take to the table.

you know, we're not trained well in most ophthalmology programs and optometry schools to do research. So you're talking about team approach. So clinical team approach, definitely research team approach to, this is what the study group has tried to foster. And I would encourage any clinician that wants to become a better clinician to team up with somebody that wants to do research with them. Then usually it's not hard to find somebody that is delighted to take a sample population and talk about questions and.

And as Art Jampolsky, the founder of Smith Kettle, used to say that key to good research is asking the right questions. And so that's what you want to do is you want to get down, sit together and look at the questions and see what question do I want to answer. You can do research and answer questions that don't have any values, know, that basic SOET principle again. If it doesn't pass the SOET principle, then why bother doing the research study or whatever.

Erika Andersen Ko (: 24:58

I love it. You know what I would love to do is like at this Envision conference coming up in May is I have been talking to Michael up Can we do like Dr. Fletcher does at the low vision rehab study group and ask these open ended questions? So I'm wondering if we could have so what groups that are during the off time of presentations where we have people from different backgrounds together and say, okay, what's, what's

What's the so what principle in the questions you're asking yourself about your clinical practice and the research that you're reading about?

Dr. Fletcher (: 25:26

That's a high form of flattery.

Erika Andersen Ko (: 25:28

Well, Dr. Fletcher, thank you so much for sharing your insight and your enthusiasm.

⁓ Thanks again for your time and your mentorship from afar, and I look forward to learning more from you throughout the years.

Erika Andersen Ko (: 25:42

Wow, the magical mentorship of Dr. Fletcher. 40 years in, and he's still challenging his clinical assumptions with ease and charm, and declaring that his greatest contribution is being a salesperson for the team, servant leadership. Dr. Sletcher's example pushed me to challenge my own assumptions this past year. I reached out to researchers about questions on eccentric viewing and central field loss. And through the process, I've said rest in peace to eccentric viewing training and evolved to a different approach.

I'll share that story later in the season. You can experience a spirit of Dr. Fletcher's mentorship at the So What Groups Envision now offers. This year, Envision added a dedicated discussion group track that includes CE. There will be questions and camaraderie. It will be warm and inclusive just like Dr. Fletcher. The best part, the conversations continue post-conference through virtual gatherings. I'll share updates throughout the season. There's a great lineup ahead.

Nine interviews are already recorded, including conversations on psychologically informed practice, and an interview with Sam Seavy from The Blind Life. Here's what I'd love from you: a story of clinical growth, a piece of research or an insight that helped you pivot in your practice. Whether you have one year of experience or 20, those stories are a gift. Our field needs more examples of real life learning. You can reach me in the contact form at LowVisionBeyondTheClinic.com.

If this episode was useful, share it with a colleague. Until next time, I wish you good moments of connection that fill your cup.