Modern Refraction Faces a Fiddler on the Roof

Are optometrists clinging to tradition to the detriment of their practices?


Modern Refraction Faces a Fiddler on the Roof

Are optometrists clinging to tradition to the detriment of their practices?

Louis J. Catania, O.D., F.A.A.O., Atlantic Beach, Fla. John McGreal, O.D., St. Louis, Mo. Richard Edlow, O.D., F.A.A.O., Towson, Md.

A FIDDLER ON THE ROOF. Sounds crazy, no? But in our little profession of optometry, every one of us is a fiddler on the roof trying to scratch out a pleasant, simple tune without breaking our necks. It isn't easy. You may ask, why do we do it? We do it because optometry is our home. And how do we keep our balance? That I can tell you in one word: Tradition!

(Paraphrased from the Broadway musical Fiddler on the Roof based on the writings of Sholem Aleichem.)

Some optometrists love refraction and some don't. But like it or not, refraction is optometry's most prevalent diagnostic function. It accounts for more than 80% of the services an average optometrist provides, and it is responsible, either directly or indirectly, for more than 90% of the revenue generated in an average optometric practice.

If refraction is such an integral part of optometry, why do most O.D.s perform it exactly as it has been performed for almost 100 years? Indeed, while other aspects of optometry have advanced exponentially, refraction has remained stagnant. Why? Tradition! Change refraction, and “… our lives would be as shaky as… as… as a fiddler on the roof,” or so many O.D.s think.

Yet the 21st century healthcare system is not the little village of Anatevka in 1905, and O.D.s need to take a serious look at the role of refraction in vision care. It will continue to be our most prevalent service because patients' visioncare needs will remain their paramount issue. What will change, however, is the art of good refractive care.

Hot button issues

The hot-button issues surrounding refraction can be grouped into six general categories:

► New technologies, including refractive and record-keeping
► The role of technicians
► Delegation
► Economics and practical matters
► Competition from hi-tech and corporate practices, ophthalmologists and opticians
► Third-party mandates from government and private entities.

Before we take a closer look at these categories, let us acknowledge that some O.D.s will recognize the changes occurring in these areas and adapt to them by redefining their approach to refraction. Others, however, including those who “love” refraction, may question the legitimacy of these issues, continue to perform traditional refractions and willingly wrestle with the challenges that lie ahead.

Whether you consider it unwise to retain the traditional refraction, it is important to respect all practitioners' points of view, as well as encourage discussions of evolving solutions. This dialogue may lead some O.D.s to adopt certain portions of the modern refractive philosophy and help them hedge against the inevitable changes occurring in the healthcare system.

New technologies

The traditional phoropter will be replaced by far more sophisticated technologies, such as refined optics systems, nanotechnology, Web-based programs, distributed and artificial intelligence systems and, ultimately, genetic mapping for prescribing to correct vision. These technologies are in the future, but in clinical practice today, we already have sophisticated, computerized, electronic automated refracting systems and wavefront aberrometers. The accuracy of these devices is equivalent to and more predictable than objective and subjective refractions performed with standard phoropters.1 These systems can perform simultaneous photopic and scotopic refractions, adjust chart illumination, vary and measure contrast and perform other tests not possible with a standard phoropter. These systems conserve precious, costly office space while maximizing capacity and flow efficiency.

Advanced clinical technology will communicate information not through a human conduit (doctor, technician, written words) but through electronic information transfer systems (electronic health records [EHR]), and it will include database analysis and algorithm programming, as well as all business management functions. The information technology systems needed to accomplish these practical tasks are already in use at the clinical level and will continue to proliferate.

These current and evolving refractive technologies, as well as all diagnostic technologies and the necessary EHR systems, will account for a greater proportion of generated revenues than in the past. The associated expenses will require commensurate increases in gross income to sustain profitability, particularly in the area of refractive care because of its prevalence as an optometric service. With competitive forces increasing, offsetting higher costs by increasing professional fees won't be feasible or adequate. The only reasonable response is to increase productivity in the delivery of refractive care.

Technicians in optometry

Trained technicians have become such an integral part of healthcare professions that they could not function without them. Such dependence could be construed as undesirable. Given the explosion of technologies, the unrelenting increase in patient morbidity and needs, the everexpanding business aspects of modern healthcare practice and increasing professional responsibilities, especially in optometry, however, healthcare providers can no longer meet clinical demands without technicians.

Any functions that don't require interpretation, professional judgment and decision-making are areas where trained technicians can provide enormous efficiencies without compromising the quality of care or the patient's perception of care. In our experience, patients will almost always feel they are receiving proper care, as long as they are reassured that:

1. The doctor will evaluate all data gathered by a technician.
2. All technologies are programmed to the doctor's specifications.
3. The doctor will interpret the data and decide on the most appropriate therapy or care regimen.
4. The doctor will discuss and counsel each patient on their condition and care.


One of the most contentious topics in optometry is delegating the subjective portion of the refraction to a trained technician using automated technologies programmed to the doctor's specifications. This frees up more time for the doctor to counsel patients and, certainly, to see more patients. Given the increasing economic and market pressures facing optometry, any means by which doctors can increase time efficiency and increase or simply retain patient volumes is beneficial. The threshold question is: Does this delegation compromise the quality of a refraction?

If regulations governing health care were to become so stringent as to dictate how many patients must be examined during a specific time frame, that question would become moot. That scenario, which is not entirely unlikely, would indeed carry the risk of compromised quality. Rather than take this negative viewpoint, however, we can analyze subjective refraction in an alternate way vs. what tradition has dictated.

A recent description in the literature advances the concept that the subjective refraction is not, in fact, the patient's comparative analysis with resultant objective data points in the refraction.2 Rather, it represents the doctor's subjective analysis of that objective data from which the doctor establishes a treatment plan.
When viewed from this perspective, the data-gathering portion of the modern refraction can be delegated to a trained technician with direct supervision (direct physical availability) by the responsible doctor to ensure the patient's safety and avoid abuse. Some traditional optometrists may argue that the comparative analysis of lens options, whether labeled subjective or objective, must be performed by the doctor to ensure the quality of refractive care. We can debate this subjective argument (pun intended), but proponents of the traditional position must weigh whatever incremental compromised care they might perceive against the current and real impending practical risks to which optometric practices and optometry at large will be exposed.

Numerous state laws, as well as regulations adopted by state boards of optometry, prohibit optometrists from delegating certain professional activities, most notably subjective refraction. Adopting the concept of subjective refraction as described above, which is performed by the doctor and not the patient, requires no changes in existing regulations.

Economics and practical matters

With reimbursement decreasing and practice costs rising, practice survival lies in seeing more patients, i.e., increasing revenues. This is not a new challenge for the health professions, but the U.S. healthcare crisis has taken it to a new level. A discussion of marketing and practice growth are beyond this article's scope, but practice efficiencies and quality of care, the essence of the modern refraction, are critical ingredients for increasing patient volume. A practice won't grow if it doesn't provide an efficient, accurate refraction.

Simply stated, patients want time with their doctors, and doctors want more patients. With time and volume as the variables, a time-efficient process with a caring, competent doctor becomes the winning formula. A quality encounter with the doctor after an efficient, hi-tech data-gathering experience invariably leads to a happy patient and more per-patient revenue, as the doctor can spend more time discussing the outcome and related beneficial eyecare options with the patient. This ultimately leads to a growing practice, usually through the most important practice growth factor, word-of-mouth.

Professionally, the bottom line is to increase the operational productivity of the modern refraction without compromising its quality. This delicate balance can only be achieved by the use of more efficient technologies that are delegated to train technicians under the doctor's direct supervision. This allows the doctor to do less data-gathering, spend more time counseling patients, and, ultimately, see more patients, increasing per-patient profitability, while perhaps, even improving the quality of the refraction through better communication with the patient.

Marketplace and professional competition

Optometrists who believe that retaining the traditional refraction will differentiate them from hi-tech and corporate practices may be correct, but that differentiation is fraught with danger. The obvious need for efficiencies in refraction will render such comparisons moot in the not-too-distant future. Modern practices will survive, and place increasing pressures on practices that retain traditional, inefficient methods of operation.

Practices that maximize efficiencies and incorporate modern operational systems will increase their patient volumes and improve the quality of their care. Although they might not be able to increase their professional fees commensurate with their rising costs, these modern, hi-tech practices, through increased operational productivity, will not be as adversely affected by decreasing reimbursement as traditional practices. What's more, with more patient volume, they will likely realize associated economies through increased sales of eyeglasses and contact lenses.

The most insidious issue in this discussion is optometric paranoia, which generates almost irrational fears that the optometrist will be replaced by independent refracting technicians or opticians and satellite refracting centers run by ophthalmologists or corporate enterprises. Such fears have frozen many practices into a traditional model with the false belief that laws and state board regulations will protect them from change. Not so. The only thing that will protect optometry from marketplace and competitive pressures is professional progress, increased operational productivity and the highest quality refractive care.

Third party mandates

Given the crisis occurring in healthcare financing and the bipartisan political climate for fiscal reforms in the healthcare system, regulations governing delivery-of-care efficiencies are almost inevitable. Therefore, the two areas that must be addressed to positively adjust healthcare economics are reimbursement and operational productivity in delivery of care. When these corrective measures are applied to refraction, O.D.s may experience pain. For all practitioners, reimbursement will be an ongoing battle that will require direct political action for self-protection and survival. Self-imposed adjustments in practice efficiencies will also be necessary.

Ultimately, right or wrong, support for traditional refraction will wane as new technologies, technician support and delegation are introduced to enhance operational productivity and increase patient volumes to offset reduced reimbursement while improving the quality of refractive care.

“There is no other hand”

Health care is changing rapidly, and the technologies and strategies necessary for effective and efficient changes in refractive care are in our grasp.

Whether you choose to fully embrace them or adopt them one by one, you must keep these changes in clear view, as each of us tries to “scratch out a pleasant, simple tune without breaking our neck. It isn't easy.”

On the other hand… well, as Tevye exclaims in Fiddler on the Roof , “No, there is no other hand!” OM

1. Nissman SA, Tractenberg RE, Saba CM, et al. Accuracy, repeatability, and clinical application of spherocylindrical automated refraction using time-based wavefront aberrometry measurements. Ophthalmology. 2006Apr;113(4): 577.e1-2. Epub 2006 Mar 9.
2. Catania, LJ. Delegating refraction. Primary Care Optometry News. 2011;16(9);4.

Dr. Catania is with Nicolitz Eye Consultants in Atlantic Beach, Fla. He does clinical research; consults for ophthalmic companies, such as Marco, and professional journals; and writes and lectures worldwide.
Dr. McGreal is director of the Missouri Eye Associates, a medical and surgical private practice in St. Louis. He is an internationally recognized speaker and educator, and has no financial interest in the technologies mentioned in this article.
Dr. Edlow is the chief executive officer of the Katzen Eye Group in Towson, Md. He is a frequent author and lecturer on practice management and technology implementation and an optometric advisor to Marco. Send comments to