Smith started to think about optometry as a career during his teenage years. He’d been a spectacles wearer from the age of nine and had an interest in science subjects at school.
He initially applied to study medicine at university and did work experience in a hospital but found the environment was not for him as it was more chaotic than anticipated.
‘I quite like being in a room where I know all the kit works and it’s all in place. So, I changed my line and applied to optometry, but of course I missed the deadline by then,’ he explains.
Smith took a year out and worked on reception at his local opticians where he says he learned a lot about working in an optical practice.
After completing his degree in Manchester, Smith did his pre-registration at Boots Opticians before spotting an advert for a job at Doncaster independent Edwards and Walker.
Smith has spent his entire career as a qualified optometrist within an independent setting and most of this time has been as a practice owner too.
‘When I qualified as an optometrist, the first thing my pre-reg supervisor said was “Go and find yourself a practice.” And at 24 I did. It
didn’t really occur to me that it wasn’t a normal career path. I didn’t really know any better, so I just went and found a practice. I found four in two days. I went around York and Lincoln, and this was the last one I went into at about five o’clock. I basically just said “I’m looking for a practice to buy” and then this was my first job as a qualified optometrist.’
Smith worked at the practice while details of the sale were arranged and took over when the owner retired.
‘At that age, you’ve got this wonderful naivety that you just get on with it and you make mistakes and you get things right eventually,’ he says.
He says owning any business involves long and short-term challenges, which is just ‘part and parcel’ of the job.
‘You weigh-up the hassle of all that stuff against the freedom it gives you and what the alternative is, which is working for someone else and having to do what they want to do rather than doing what I want,’ he adds.
Smith says he worked long days when first taking over the practice but now achieves a healthy work-life balance, spending time with his wife and teenage sons, who share his hobbies of cycling and gardening.
‘I listen to a podcast by a lady who wrote a book about the top regrets of the dying and the top one is always “worked too hard.” You’ve got to bear in mind that you’ve got to live. I could spend every second building this place and doing everything, but you do have to step back a little bit.
‘The main pressure I put on myself more than anything else is, as a business owner, you’ve always got in the back of your mind thoughts about being profitable and surviving. No matter how far away from that you are, it’s always there,’ he adds.
Smith has considered expanding the practice many times but always comes to the conclusion that he would spend less time being an optometrist if he did.
‘I like chatting to people. I like solving people’s problems and feeling like someone’s walking out of the room better in some way,’ Smith says.
Independent nature
It is the joy in helping patients that has informed Smith’s outlook on providing eye care, which he aims high on by investing in equipment.
Inspired by the technology available at the practice during his pre-reg, Smith took out a loan on top of the one to buy the practice and purchased some kit.
Around four years after taking over the practice, Smith started a doctorate and realised he could provide more than a sight test or a contact lens check.
This sparked a career of learning with independent prescribing (IP) and glaucoma qualifications to follow the doctorate, plus new services such as a dry eye clinic and foreign body removal.
‘It’s a completely different mindset to sitting there doing sight tests all day. There is much more freedom and it’s much more interesting,’ he adds.
‘I’m glad I did the doctorate before I did IP because I had a background of knowledge behind me at that point and it makes it a lot more useful. Initially you don’t prescribe much. Now, I prescribe all the time. The glaucoma qualifications have changed quite a lot of what we do because the pattern tends to be that you will detect someone’s pressures going up and you’ll look at their OCTs and you’ll often decide to do treatment.
‘A lot of these people will hopefully never see a hospital because we’ll manage them in the community to a point where they’re never at risk of sight threatening disease.’
Smith adds that he’s just agreed to mentor new IP optometrists in Lincoln, who will get experience in community optometry and at a hospital.
Smith says he is a restless person, who would not have been content sitting in a testing room for 40 years and then retiring.
He has undertaken education on selective laser trabeculoplasty and YAG and would like to see laser treatments available in community optometry practices.
‘We are ideally placed to provide treatments like that,’ he says. ‘No patient wants to go to a hospital, they want to keep as far away from hospitals as they can and they clog up hospital departments.’
Knowledge sharing
Research is an area of the profession Smith has ventured into recently, which provided him with a new way to improve patient care.
‘I wasn’t very happy with the current treatments of blepharitis. I was seeing a lot of people with demodex and giving them tea tree oil-based products but when I saw them the following year, they still had demodex. I had a distinct feeling that it didn’t actually work,’ he explains.
Smith decided to explore further and discovered papers that looked at the benefits of using ivermectin 1.0% cream as a treatment for ocular demodicosis.
‘I had a couple of patients who I tried everything with, so I thought, “well let’s give it go.” I explained to the patient that it was an off-label treatment but there’s a huge amount of data on it and the data suggests it works,’ he adds.
The results, he says, were ‘miraculous’ as patients presented with no symptoms after two months and it did not come back when they stopped using the cream.
Eventually Smith accumulated a good amount of data so he started to take images of patients before and after treatment. He got in touch with Professor James Wolffsohn, who was his supervisor for his doctorate, and asked if it was worth pursuing further. He said yes and Smith ended up with a published study that involved around 70 patients.
‘It eradicates demodex and it doesn’t come back quickly. It does come back eventually, so you do need to periodically re-treat people,
but it’s incredibly successful and far better than anything else,’ Smith adds.
Adding these treatments and investing in technology is part of what fuels Smith’s motivation to keep learning and getting joy out of the results.
‘We updated our intense pulse light machine about a year ago. I’ve just got a new instrument for measuring non-invasive tear breakup time. I’m always on the lookout for what the next bit of kit is and how you can incorporate it into practice,’ he says.
Smith has always been passionate about science as a way of learning about the world and jokes that he’s unsure whether that comes from a strong work ethic or a mild pathology.
‘I don’t often finish a cup of tea if I’m sitting in the garden. I love the idea of sitting in the garden, looking at the flowers and the bees. But I’ll make it halfway down that cup of tea and I’ll see something that I haven’t done. It’s the same with optometry. There’s always something I haven’t done yet but I love it. It’s not something I wish I didn’t do. I find it exhilarating to constantly be trying to do new things.’
Smith is part of a WhatsApp group with other optometrists who share knowledge and discuss case studies, all with different specialisms.
‘It’s incredibly valuable to learn how other people have managed things because as a sole practitioner, you sit in your chair looking at something and you think “I’ve seen those before,” but then you remember someone posted about it and what they did. These things will eventually come across your door and you’ll need to deal with them.’
Individual character
In the future, Smith envisions more opportunity from the NHS such as monitoring and managing stable glaucoma patients in the community.
‘Community optometry is perfectly placed to do these things as long as you’ve got the skills. You’ve got to upskill everyone and then that requires hospitals to be providing placements, so it’s not easy. But I think the way forward is to take people out of hospitals and treat them in the community.’
Smith may be 20 years out from thinking about retirement but practice succession has crossed his mind. He says he’d like freedom leading up to retirement rather than an abrupt ending.
‘It’d be nice to ultimately work with someone who’s a 20 year younger version of me who’s equally ambitious. It would be nice to continue this truly independent practice. It’s a real asset to optometry to have places with individual character,’ he adds.
