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 By Neil B. Gailmard, OD, MBA, FAAO, Editor August 24, 2011 - Tip #496 
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What aren't you delegating?

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Most optometrists delegate what is commonly referred to as pretesting, but how we define what goes into "pretesting" varies widely. Is it possible that you are not delegating enough and the amount of doctor time that goes into your exams is making your practice inefficient? Let's look into three specific tests that can give us a clue about your delegation model.

The following three procedures are often performed by the optometrist on a routine basis, but they could easily be handled by a technician. It may take a little re-organization and some determination, but delegating these areas can save well over an hour per day of doctor time; maybe two hours! When consolidated and added up over a month or a year, that much time can allow you to see many more patients or use your time more effectively to manage your practice.

Consider the following procedures as a test of your delegation model. If you are strong in delegation, the doctor will rarely perform these services. If you currently have a doctor doing one or more of these procedures on a frequent basis, I'd take it as a signal that there may be other areas that could be delegated better.

Visual acuity

Many optometrists take entrance visual acuities on most exams performed. I really don't get it. This is a fairly time-consuming test when you consider patient instructions, listening to the responses, with and without the habitual Rx, right eye, left eye, far, near and recording the data.

Restructure your exam routine so a technician takes acuity. Train your technicians to measure acuity properly and to avoid rookie mistakes, such as memorizing letters and getting a glimpse of the line with the stronger eye before occluding. With a little experience, the tech will be as accurate as the optometrist. You can either place an acuity chart in the pretest area or my preferred approach is to have multiple exam rooms and let the tech use one before the doctor comes in.

Routine tonometry

I understand the process of why ECPs may not delegate tonometry, but it's no excuse and the potential time-saving is big enough that you should take steps to change this.  There is no question that Goldmann applanation tonometry is the standard of care, and because the instrument is typically mounted on the slit lamp and the test requires some technique, it's often done by the doctor. That's fine for your glaucoma and suspect patients, but because we want screening pressures on everyone, it's smart to invest in an instrument that will let your staff do it. Ideally, I like tonometry to be done as a pretest and I'd like it to be very accurate and comparable to Goldmann findings. I also want the test to be easily performed by technicians of various skill levels. Here are some options:

  • Use a non-contact tonometer. I've heard all the comments about how much patients hate the air puff but it is a myth perpetuated by doctors who don't have one. The new generation of quiet, gentle NCTs are very accurate and easy. There are even some good models that are integrated into an auto-refractor to save space.
  • The Icare tonometer is a good option.
  • Train a tech to use Goldmann applanation, tonopen or others. I don't care for this option because I prefer tonometry to be done before my portion of the exam and I would rather not use a corneal anesthetic at that stage because I do not want any disruption of the epithelium.

Contact lens insertion

I realize that if you don't use scribes, it's often easier and faster for the doctor to locate trial contact lenses in the inventory and apply them to the patient's corneas then to try to find an available technician. That's one of several good reasons to use scribes, because the time savings in contact lens fitting is huge. And if you know a patient is coming in for contact lens work then by all means use a technician in those cases. The optometrist can literally do another comprehensive eye exam while a technician inserts trial lenses for a patient and educates him or her about disposal periods, lens materials, care and handling. Follow that with measuring visual acuity through the contacts and an over-refraction and by then the doctor is ready to check the fit.

Have your staff learn how to insert contact lenses for patients by having them practice on their own eyes and on co-workers. Most offices have some down time and this makes a great project.

Best wishes for continued success,

Read Past Tips Neil B. Gailmard, OD, MBA, FAAO
Editor, Optometric Management Tip of the Week

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Send questions and comments to neil@gailmard.com.

Dr. Gailmard offers consulting services to eye care professionals through Prima Eye Group; information is available at www.primaeyegroup.com.

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