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by Dr. Aaron Salzano

Dr. John Streff was a giant in the world of vision therapy, and fought for the expansion and progression of our field.  A 1950 graduate of Chicago College of Optometry, he served as a professor at Southern College of Optometry, was Director of Vision Research at the Gesell Institute of Child Development, and won various awards throughout his career for his pioneering work in developmental optometry, including COVD’s AM Skeffington Award. Dr. Streff passed away in 2010, but his legacy of keen observation in clinical practice lives on and continues to drive the cutting edge of vision therapy.

In a 1994 article in the Journal of Behavioral Optometry entitled “Viewpoints: The Value of Observation,” Dr. Streff emphasizes the importance of observational skills during standardized testing. He firmly believed in the importance of evidence based, standardized practice, but saw the clinician’s observations as always pushing the border of what was proven. Dr. Streff was all for going against the grain if his finer judgment told him otherwise. In the article, he recalls an exophoria that was improved with a plus add at near, which I would now quickly categorize as a Pseudo-CI, but research at the time had not verified this finding. Therefore, Dr. Streff went with his gut for the best treatment method, rather than relying on what was conventional wisdom at the time.

We live in an age that is increasingly bent on evidence-based practice, which I believe is a wonderful thing. There is nothing wrong with going down diagnostic decision trees all day, but I think clinicians need to be careful to not just check off boxes. If there is something negative about evidence-based practice, it is that it steers clinicians away from being curious.  It is much easier to follow the cookbook of diagnosis and treatment than to sit and think about where your observations are leading and where to go next. Really, Dr. Streff is warning ODs to avoid getting into the cycle of testing with a confirmation bias.

Optometrists need to know their research forward and backward, but they also need to be aware of how the pieces fit together, and that is where observation and curiosity come into play. You have likely heard that when bankers train to spot counterfeits, they don’t study common counterfeit methods; they just get to know the real thing so well that any discrepancy stands out to them. The same applies in optometry. We need to get to know the research and testing methods so well that when our observations don’t agree with these tests, the alarm begins to sound in our minds. From there, curiosity leads us into new pursuits of knowledge, and ultimately better patient care will arise as a result.

I remember sitting in a first year Systemic Disease class, and Dr. Dennis Smith told the class to walk every patient back into the exam room.  Dr. Smith, like Dr. Streff, was no stranger to the power of observation. The way a patient walks can tell you a lot about their habitual posture, inner ear function, and their peripheral awareness. I think many optometrists, young and old, forget to take in the whole picture, and just end up examining a couple eyes in their chair. This is often done out of a desire to see, and help, more patients, but the drive for efficiency can end up causing us to quell the inner voice that says “something wasn’t quite right on that cover test.”

While standardized tests can be thought of as the raw material of an examination, observations are the mortar that brings form and life to the examination.

I think this is Dr. Streff’s point, to trust your observations as a clinician and don’t fall into the trap of going through the motions. Optometrists need to remember to be curious, to rely on what we are finding and try new methods to make sense of our results. However, this isn’t done by neglecting proven methods and evidence-based research, but by integrating these standardized tests as materials we can use our observations to mold together new and better treatments to help a wider variety of patients.

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