A Sit Down – with Dr. Hannu Laukkanen
This post appears as part of a series called Sit Down – candid conversations with real people detailing their journeys and experiences with Vision Therapy.
A Sit Down – with Dr. Hannu Laukkanen
For the benefit of our readers, can you explain how you are involved in Developmental Optometry?
I am a clinical professor at Pacific University. My training is in optometry, but I also have a post-optometric Masters in Education. I serve as Chief of our Vision Therapy Services and teach courses at Pacific University and in Europe related to developmental optometry. I am also involved with research related to developmental optometry.
Your name is very unique. What can you tell us about your heritage?
My parents were displaced as a result of the Second World War. My family’s ancestral lands in eastern Finland were lost as a result of war reparations to the Soviets. My parents moved to the U.S. in 1948 while in their 40s with three kids in tow, speaking no English. A few years later, my appearance was described as: “the new world surprise.” I was raised in a very rural community 20 miles upriver from Astoria, Ore. As a small farm kid, I milked cows twice a day and did farm chores until I left for the University of Oregon. Whereas I learned hard work habits on the farm, I had not acquired good study habits because I breezed through all my previous schooling without having to study. My initial direction was to pursue dentistry, but for a variety of reasons it lost its appeal during my undergrad studies.
Your bio reads that you received a Bachelor of Science degree from the University of Oregon in 1974, and didn’t attend Optometry School until many years later. Were you in pursuit of a different career in the interim?
Not really knowing what I wanted as a career, I married my high school sweetheart and we moved to Scandinavia to travel, grow and to explore our ancestral roots. I scored a job as a clinical chemist for the University of Helsinki Hospital in an endocrinology lab and assayed hormones for hospital patients and for research studies. My wife wanted to go to graduate school, so we moved back to Eugene after a couple of years of work and fancy-free travel in Europe and Africa. I also enrolled in graduate school and got a job in a neuroscience lab that was exploring visual pathways in the superior colliculus via single cell recording. I became absolutely fascinated with complexity of the visual system. My preference was working with humans rather than cats, so I made a really great decision and applied to the College of Optometry at Pacific University.
What was your motivation to enroll in graduate school, and specifically, Optometry School?
Now older and more mature in professional school, I gained additional skills for success. Those included dedicating myself to scholarly excellence, taking advantage of opportunities, and perseverance. Despite my relatively weak reading skills, studying became more and more fun because I was so fascinated by the intricate workings of the visual system and enjoying top-tier academic success. Having two children while in school was also motivational. Both my wife and I worked during my school years. While she worked as a full-time journalist, I worked weekends and summers as a commercial diver and salesperson to help ends meet. Developmental optometry and pediatrics rapidly became my absolute favorite area, because of what I had previously learned about neuro-plasticity and brain mechanisms of behavior from my earlier neuroscience experience–plus my own visual deficiencies. Although none of my known ancestors had been nearsighted, I gained several diopters of myopia after age 25. I attribute this to having to study intensely for the first time in my life, plus a series of stronger and stronger minus prescriptions from fellow student refractions. When evaluating the etiology of my very late, onset myopia, I cannot rule out one of my many personality quirks: my fussy need to see even the most intricate details crystal clearly.
Who have been some of the biggest influences in your career?
One of my pivotal student opportunities was the SUNY VT clinical internship. Despite having to leave my wife and kids, I applied, was accepted, and got to spend the summer in NY seeing VT patients with lectures from VT rock-stars such as Marti Birnbaum, Arnie Sherman, Harold Solan, Irwin Suchoff, Ken Ciuffreda, Sydney Groffman, Jeff Cooper, etc., etc. What I learned was that my Pacific VT education from Paul Kohl, Bill Ludlam, Harold Haynes, and others had prepared me very well beforehand, but the SUNY internship added depth to my understanding and opened doors for me later. During the small lectures at SUNY, I was able to fully exercise one of my most educationally beneficial behavioral traits–one that I am sure was quite irritating to my classmates. “Question the question, question the source, and question the potential implications.” I have endeavored to try to pass on this very annoying trait to my students. A former marine biology/optometry student paraphrased one of my core tenets succinctly for me: “optometric excellence evolves from being a really good filter feeder; you have to always be receptive and filter a lot of volume to capture the choicest morsels (enduring truths)”.
After receiving your Doctorate of Optometry in 1984 from Pacific University, why did you decide to remain at Pacific University as a teaching fellow and later as a professor?
My passion for developmental optometry along with the SUNY internship credentials was a gateway to additional VT jobs and interesting practice experiences. My post-graduation plan was to move to Alaska and do pediatrics and VT. Fortunately or unfortunately, the Alaska economy tanked around the time of my graduation in 1984. Post oil-pipeline residents just flooded out of Alaska in caravans like lemmings. I realized with record high unemployment there, starting a VT practice that was dependent upon discretionary family income was suicidal. I was about to graduate, my wife was pregnant, and we had no health insurance. That was when Dean Bleything posted a flier for teaching fellowship opportunities. Although teaching had not been on my sonar, a teaching fellowship offered health insurance, so I applied and was hired. I discovered that I really liked teaching, despite the fact that it had been financially very difficult for our family of four to survive on my $14,000/year teaching fellow salary. Because my wife worked as a newspaper reporter, and I also worked as a vision therapist in a private practice (with Dr. Bradley Coffey), I re-upped for another year. Happily during my second teaching fellowship year, I was asked to be an attending doctor in VT Clinic and was paid more. The following year, I was offered a full-time appointment as an associate clinical professor of optometry. My first decade of teaching was almost entirely clinical teaching in vision therapy, pediatrics and primary care in many of our different clinics. In retrospect, this was a foundational crucible for my development. I got to solve a huge number of diverse clinical problems without having to physically spin the dials or disparate the vectograms myself. I could play the role of the semi-objective observer and mentally process evidence and look for relationships. Seeing a large number of patients helped me understand a wide range of behaviors from normal to abnormal, and to recognize subtle but important patterns in individual data and human performance. Even though I am not an animated classroom presenter, when I transitioned into didactic teaching (classroom standup lecturing), I was able to bring extensive therapy room/exam-lane cred with me to the podium.
Rumor has it you’re a highly detailed and passionate professor in the area of perceptual testing. Can you explain why you feel this is such an area of importance within Developmental Optometry?
My most challenging course to “sell” to each entire optometry class has been visual-perceptual testing and treatment. Not only is this area very challenging to master cognitively, but traditionally only a minority of optometry students perceive it as important, or even see themselves offering it in their future practice. Prior to matriculation, pre-optometry students rarely have the opportunity to shadow an optometrist or therapist involved with the area. For those programs that do expose optometry students to diagnosis and management of perceptual problems, it is typically very late in the optometric curriculum, well past the critical period when students have already decided what is and what is not important to the practice of optometry. Whereas we have general consensus as a profession related to management of acuity, refractive, oculomotor, and accommodative/vergence deficits, the same agreement does not necessarily extend to visual-perceptual management. An absolutely enigmatic dichotomy within our profession lies within the models we use to diagnose, treat, and manage learning problems related to vision. Purely clinical versus academic approaches can be dichotomous. For me, it was best exemplified by Drs. Bill Ludlam and Harold Haynes, who co-taught strabismus and amblyopia for decades at Pacific and were important mentors to me. Bill was clinical, dynamic, entertaining, whip-smart, and an-in-your-face raging bull in the academic china shop. Harold, on the other hand was always theory-based, academically brilliant, and the consummate polite Southern gentleman who eschewed making generalizations from a limited number of data points. I wish I were able with words to capture how entertaining and enlightening their disagreements really were, but each indelibly contributed to my growth. Harold revealed the beauty of mathematics in functional care, and how statistical means could be harnessed to support what we were doing in both the exam and therapy rooms. Bill instilled me with an unshakable confidence that therapy works, a fierce pride in being a vision therapy provider, and boldness to unapologetically confront opposition.
Can you further detail the VMPM and VIP models?
The disparate worldviews that were embodied by Harold and Bill’s are manifest still. Within VT the visual-perceptual motor model (VMPM) is the more clinical of the two models, and is more common amongst private practitioners. The VMPM practitioner is more likely to be a critical observer of a wide range of patient behavior(s), less reliant upon standardized tests or testing for understanding the problem, and more interested in how a patient understands navigates “space” and solves a problem rather than in how the patient ranks numerically against others who have answered the same problem. In contrast, the visual information-processing (VIP) model is more formal, quantitative, paper-pencil based, and more product-oriented. The VIP model is more common in academic clinics is more likely to rely upon standardized tests and standardized testing environment for diagnosing, understanding, and managing perceptual problems. Administration of the Wold-Pacific Copy Test could be used to illustrate the differences between the VMPM and VIP model approaches. Prior to giving the test, a VIP-model practitioner would be concerned with the details of setting up a proper standardized test environment. This might include the proper sized room, a table and chair that matched the size of the patient, the specified writing instrument (a pencil – not a pen) and lined-paper that matched norm gathering for the test, etc. The instructional set used during the test’s normative development would be read to the patient with as much fidelity as possible. The patient’s copying would be carefully timed and once completed, the score would be compared to normative data for age-matched peers to obtain a product or a quantitative rank. VIP-based results interpretation is more dependent upon what the test author thinks the test actually measures. It has a bias toward deductive diagnosis: “a poor score on this test means this patient has a visual-fine motor deficit.” The VMPM practitioner would be less likely to require a formal standardized test environment with precise instructional wording. Being more process-oriented, there would be less concern with the patient’s numerical score and more interest in how the challenge was solved and how pricey of a process was it for the patient. During testing, the VMPM practitioner would be attending to a wide variety of behaviors such as body posture, how was the patient holding the writing instrument, was the working distance changing, did facial expression reveal a great expenditure of effort, etc.? Qualitative factors would be central to the VMPM assessment. What did the handwriting look like, did it follow the lines, and how was the spacing between words in the beginning versus the end? An important binary question for the VMPM-oriented practitioner is whether the patient demonstrated the requisite skills and ability to complete the task and how costly was it for the patient? VMPM interpretation is more biased towards inductive interpretation: “given the behaviors observed on this test, this youngster is very likely to struggle and score poorly sustaining attention on parallel academic tasks that require prolonged attention and sensory-motor integration.” From the perspective of a mossback optometric educator, enticing all optometry students to understand both models, has been challenging. Each model has its own characteristic strengths and weaknesses, and understanding those differences is very important in my view–regardless of whichever model is ultimately favored.
How do you apply the VMPM and VIP models in clinic?
In our pediatric clinics, the VMPM model of clinical examination and interpretation predominates for children less than seven years old. For older children in our VT clinics, I try to encourage novice clinicians to follow the VIP model approach. I believe novice clinician data to be much more reliable and valid when testing and the test environment is standardized, and the original test-administration protocols are closely followed. For student clinicians, developing fundamentally sound assessment habits early on is valuable, as is the understanding how the physical and psychological test environment can affect visual performance results. Other professionals, such as teachers, occupational therapists and physicians, are more likely to trust standardized testing and better understand our results when they are framed in the context of Z-scores, Standard Scores and percentiles, etc. Given the context of our increasingly outside-regulated and interdisciplinary patient care, I foresee developmental optometry more and more adopting these standard performance metrics for communicating with non-developmental optometrists. I see the acceptance of vision therapy as a viable treatment option growing in the medical community. Earlier this year an MD expressed amazement why many of his colleagues regularly refer to physical therapy and occupational therapy, but not to vision therapy. Anecdotal prejudices ebb away slowly; we must continue to do what we do well, continue our solid research, and then endlessly communicate those successes to all who will listen. My educational methodology related to clinical assessment is that the VIP approach is easier to teach than the VMPM approach and less difficult for students to initially master. Prior to beginning clinic experiences, optometry students are thoroughly marinated in the reductionist “medical” model of care that emphasizes: “diagnosis the deficit and prescribe the best treatment.” As an attending doctor in VT clinic, I try to open up the student medical mindset by having interns recall what they learned about both models from me in class. I ask students to describe which elements from each approach may best succeed in revealing why a patient is being assessed in our clinic and the best work to solve the patient’s problem.
Do you find yourself favoring one model over the other?
Although my didactic approach tends to highlight the differences between the two models, my definitive goal is the understanding that a blended-model approach is almost always best in developmental patient vision care. In my experience, the most important factor in assessment—regardless of model, is practitioner familiarity with each assessment tool. When a clinician thoroughly knows a test forwards and backwards, he/she is more relaxed when administering it, more sensitive to behavior/nuances in performance, and likely to extract maximal information about the patient most efficiently.
In a results-based model, how do you explain possible visual inadequacies when a child is struggling in school, yet their perceptual test scores are at age level or above?
At times, I have been accused of “messing with” medical-model-oriented students via Socratic questions. One of my favorites is an example where a patient demonstrates “mild visual deficiencies” but the visual-perceptual test results fall into the “normal-to-above normal range?” This is despite the fact that the youngster is not performing up to his/her potential academically. Do you offer this patient the option of vision therapy to ameliorate the “mild visual deficiencies?” Almost always the medical-model-oriented student will say “NO.” I try to encourage that student to think more deeply about the example. First assume that other obvious problems causing the under performance have been ruled out. I next ask if it is possible that a combination of “mild visual deficiencies” could cumulatively be responsible for the school struggles? Then I hand the student the classic JT Tassinari article on the impact of multiple mild failures in several visual performance areas. I always parrot that Dr. John Streff taught me: “When vision is working well, it guides and leads. When it is not, it interferes.” I also try to point out that for a very bright child, “normal” performance on a perceptual test is actually “below-normal” performance for that child. Based upon my past success with such cases, I present a VT treatment intervention scenario to the child and parents, but don’t guarantee success. I encourage them thoughtfully decide if vision therapy is an intervention they want to pursue. Compared to other interventions, VT is cost-effective, plus it is rare not to see improved quality of life from VT intervention with such cases.
As a professor, you have influenced so many future doctors, and by extension, have had an impact in lives of many people whom you have never met. Upon reflection, how would you characterize that impact?
Looking back into a nearly three-decade-long rear-view mirror, I feel very blessed to have played a role in improving and changing many lives of both of patients and students. This year, I was pleased as punch to see three former patients from my VT service named as high school valedictorians in our community. There is always a special joy in my heart when I see former students excel and spread their wings. It is always a happy day for me when I hear that a former student is providing quality vision therapy for patients—some I would never have predicted. In a bigger sense, as an educator one of my most cherished goals is to facilitate a passion for life-long learning, self-improvement, and patient-care excellence. Although that goal is still a work in progress, there have been some encouraging successes along the way. My former students include wonderful optometrists, neurologists, neuro-ophthalmologists, several who have gone on to earn PhDs, and many who have earned leadership roles. I believe in the Chinese proverb that states: “a teacher whose students do not exceed his/her own abilities is not a success teacher.”
Some Closing Thoughts – It was very exciting when Dr. Laukkanen agreed to help me kick off 2014 with this interview, and for that, I wish to extend to him my deepest gratitude. His vast knowledge base and passion for his students are both fine qualities that shine through brilliantly in his answers. This interview was certainly my pleasure. Please join me in wishing Dr. Laukkanen, his family, and his students the absolute best! 🙂