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Low Vision | Jan 2022

From Cane to Canine

Ophthalmologists could benefit from guide dog training.

Authors’ note: To protect the privacy of the guide dog owners and trainers interviewed for this article, names have been changed (including those of the guide dogs). Some events have been compressed, dialogue reconstructed, and details changed for narrative purposes.

I (C.L.X.) distinctly remember the first time that I saw a guide dog in action. I was 8 years old. A blind woman and her glossy black labrador retriever weaved seamlessly through crowds at the airport. “Look!” I yelled to my family. The dog turned to glance at me before continuing on its way. Only in medical school did I realize how much harm that simple distraction could have caused.

For owners with vision loss, guide dogs can promote confidence, independence, and more meaningful social lives. Using a white cane can help with navigation, but it does not confer the same social benefits as having a guide dog.

“Usually when people see a blind person on the streets with a white cane, they stay away, but a dog makes everyone smile. And with a cane you feel like you are bumping around and cautiously moving through life. But with my dog, I’m effortlessly floating through the world,” Sarah, a 24-year-old guide dog owner, explained to us.

In the long term, guide dogs can be cost-effective for people with vision loss.1 An Austrian study concluded that yearly medical expenditures were lower for individuals who owned guide dogs compared with those who did not. The investigators speculated that the underlying reason for this difference was that guide dogs promote independence and overall well-being in their owners, leading to downstream positive health outcomes.


Despite all the benefits that guide dogs have to offer, up to 1 million visually impaired people in California who would qualify for a guide dog may not know it—largely because of an oversight in medical education.3 Ophthalmologists are trained on pharmaceutical and surgical methods for slowing progressive vision loss. Most of them, however, receive little education on guide dog use and referrals.4-7 Because ophthalmologists’ education places less emphasis on lifestyle changes and resources for patients, the emotional and physical support that blind people may need in their daily lives is often left to families and friends to provide.3,8

During the COVID-19 pandemic, we have been privileged to connect with guide dog owners and trainers over the phone to learn about the unique psychosocial and emotional benefits of guide dog ownership.

“I usually dress in black and stay on the sidelines, so it came as a shock to be thrust into the spotlight at 18 years old when I got my first guide dog, Sadie,” Lily, a 23-year-old guide dog owner, told us. Taking Sadie with her to college, Lily was amazed at how easily she could navigate the campus. “Holding Sadie’s harness forced me to stand tall, with my shoulders back. It increased my confidence both physically and emotionally.” Lily only found out that she might qualify for a guide dog at the recommendation of her orientation and mobility trainer—a specialist who teaches people with vision loss how to use a white cane. “My ophthalmologist never recommended a guide dog,” she said, “and he didn’t know details about the application process when I asked.”

Lily was fortunate to find an orientation and mobility trainer who taught her how to use external cues and a cane to navigate through the world.9 These same cues allow guide dog owners to know where to direct their dogs—and they are so important that most guide dog applications request that candidates submit a video demonstrating these skills. However, not everyone with vision loss is able to work with an orientation and mobility trainer—the type of health care provider through which most guide dog referrals are made. If, therefore, patients see only an ophthalmologist for their care, they may not get an opportunity to get a guide dog.9


What lies behind the lack of referrals for guide dogs, and how can this issue be addressed? Many well-intentioned ophthalmologists are unfamiliar with the benefits of guide dogs and the details of the application process. This makes sense, considering that most ophthalmology residency programs offer no guide dog instruction to medical trainees.4-7

The University of California, San Francisco (UCSF), however, provides 1 day of guide dog instruction and offers a model to follow.4

“The guide dog training sessions involve hands-on activities, such as blindfolded residents being led around by guide dogs, and presentations with personal stories from guide dog owners and details about the selection process,” Jacque Duncan, MD, an ophthalmologist at UCSF, explained to us. According to Dr. Duncan, guide dogs are not a common topic of conversation among ophthalmologists—but she would like them to be. She sees a need to increase awareness of the benefits of guide dogs and enable more ophthalmologists to provide patients with referrals.

Dr. Duncan endorses the implementation of mandatory training in residency programs and at ophthalmology clinics to provide education on the eligibility criteria for guide dog applications, proper referrals and application assistance, and guide dog etiquette. Carrie, a field service representative for the Guide Dog Foundation, agrees. “Implementing these sessions can be done at [a] low cost and [with] high efficacy, and guide dog foundations are always looking for more opportunities to teach and to provide resources,” she said. Residency program directors could spearhead guide dog workshops and hire volunteers from guide dog foundations to teach ophthalmology trainees and attendings. There are three guide dog schools in California and many more across the country that frequently send volunteers on community outreach.10

Establishing partnerships between ophthalmology departments and guide dog foundations would also streamline guide dog referrals from ophthalmologists. This may have a crucial secondary benefit because there currently are not enough guide dogs for all the people who qualify. Increasing awareness and referrals could help guide dog schools gain greater backing from medical establishments, potentially enabling them to obtain the funding and support needed to train more dogs.11

Training ophthalmologists to understand guide dog eligibility criteria could help to increase the number of guide dog referrals and thereby improve patient quality of life. However, the rest of the population must be trained, too. Everyone should learn why behavior like yelling out to a guide dog is dangerous. Training should include teaching people why it is important not to distract a guide dog from its work (eg, by petting, feeding, or taking photos); offering assistance while understanding that the person may not need or want help; and speaking directly to the person and not the dog. One guide dog owner we spoke to recently brought her guide dog to a conference, and a group of teenagers pointing and exclaiming caused her dog to lose concentration and walk straight into a beam.

This is an area where residency programs also have the power to make a change. Beyond implementing mandatory training for ophthalmologists, programs could produce a handout with general etiquette advice to be posted around their clinics for staff to read and share with the public. Furthermore, workshops, such as those for UCSF residents, could be integrated into the public health education system to allow wider dissemination of this crucial information. Just as schools mark Breast Cancer Awareness Day or Autism Awareness Day, they should also celebrate International Guide Dog Day (April 25) by inviting volunteers from guide dog foundations to teach students about vision loss and guide dog use.


Imagine how many people might be able to regain confidence and stand taller like Lily if ophthalmologists reframe their focus on patient quality of life. The Centers for Disease Control and Prevention estimates that roughly only one of every 100 people who could benefit from a guide dog currently has one.3 It may be ambitious to train that many more guide dogs, but greater awareness and better training in the health care community could go a long way toward ensuring that as many individuals as possible are paired with guide dogs. Everyone with vision loss deserves a Sadie—and they should all be given the chance to step out confidently into the world, guide dog at their side.

The authors wish to thank Jacque Duncan, MD; Laurel Braitman, PhD; and Jennie Ho, MSN, RN, for their valuable input during the research and writing of this article. The authors also extend their deepest gratitude to the many guide dog owners, guide dog trainers, and puppy raisers who were interviewed for and helped inspire this piece.

1. Glenk LM, Přibylová L, Stetina BU, Demirel S, Weissenbacher K. Perceptions on health benefits of guide dog ownership in an Austrian population of blind people with and without a guide dog. Animals (Basel). 2019;9(7):428.

2. FAQs. Guiding Eyes for the Blind. Accessed May 7, 2021. www.guidingeyes.org/about/faqs

3. Fast facts of common eye disorders. CDC. June 9, 2020. Accessed May 7, 2021. www.cdc.gov/visionhealth/basics/ced/fastfacts.htm

4. Curriculum. UCSF Department of Ophthalmology. Accessed May 7, 2021. https://ophthalmology.ucsf.edu/ophthalmology-residency-program/curriculum

5. Residency overview. Shiley Eye Institute, University of California, San Diego. Accessed May 7, 2021. https://shileyeye.ucsd.edu/physicians/residency-overview

6. Residency program: ophthalmology. Stanford. Accessed May 7, 2021. https://med.stanford.edu/ophthalmology/education/residency-program.html

7. Ophthalmology residency training program. UCLA Health Eye Care. Accessed May 7, 2021. www.uclahealth.org/eye/ophthalmology-residency-training-program

8. What are the benefits of a guide dog? Aspire Charity. July 23, 2019. Accessed May 7, 2021. https://aspirecharity.com.au/what-are-the-benefits-of-a-guide-dog

9. Orientation and mobility training: the way to go. Texas School for the Blind and Visually Impaired. Accessed May 7, 2021. www.tsbvi.edu/an-introduction-to-dr-lilli-nielsens-active-learning-1/100-tools/2371-orientation-and-mobility-training-the-way-to-go

10. Guide dog resources. National Federation of the Blind. Accessed May 7, 2021. https://nfb.org/resources/guide-dog-resources

11. Qiu S. New organization helps meet demand for guide dogs. The Seattle Times. June 15, 2014. Accessed May 31, 2021. www.seattletimes.com/life/lifestyle/new-seattle-based-organization-trains-guide-dogs-for-visually-impaired

Christine L. Xu
  • MD Candidate, Stanford University School of Medicine, California
  • cxu7@stanford.edu
  • Financial disclosure: None
Ashley P. Stevenson
  • MD Candidate, Stanford University School of Medicine, California
  • ashpalm@stanford.edu
  • Financial disclosure: None
Edward H. Wood, MD
  • Assistant Professor of Vitreoretinal Surgery, Stanford University School of Medicine, California
  • ehw@stanford.edu
  • Financial disclosure: None
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