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I listed the use of scribes (or chairside assistants) as one of my top practice
management misconceptions a few weeks ago. The practice of having a technician
record data for the doctor in the exam room seems quite common in ophthalmology
practices, but almost unheard of in optometry, so I must draw the conclusion
that most ODs don’t feel there is much to gain. In my experience, using scribes
results in one of the largest increases in clinical efficiency that I’ve ever
seen. It is indeed practical and I encourage any eye care practitioner who is
fairly busy to adopt the procedure.
Delegation as an income producer
I’ve utilized scribes in my practice for 20 years and I’ve helped many clients
add them to their clinical routine. The whole point of delegation of any
clinical duty to a staff member is to save doctor time, and doing so allows the
doctor to see more patients per day. Scribing is no different; it’s simply
delegation of a very time consuming task. Regardless of whether the record is on
paper or electronic, if you added up all the time spent on record keeping in one
day, it is quite significant. Saving 10 minutes or more per patient would allow
doctors to compress their schedules and see many more patients per day, without
working any harder! Nothing increases gross and net income faster than seeing
more patients per day.
Even if a practice does not have a great backlog of patients, it still makes
sense to adopt maximum delegation techniques because doing so allows the
practice to see all the patients it has in fewer days of the week. This advanced
time management allows the doctor to have large blocks of time free to work on
practice management projects and build the practice.
In addition to the major benefit of increasing revenue through delegation and
efficiency, there are many more advantages that you might not have thought of:
Additional efficiencies are realized if the scribing technician is
trained in both clinical pretesting and optical dispensing. That is the case
with all technicians in my practice. This creates an excellent patient
service touch, namely one staff person calls the patient into the clinic,
performs all pretesting in various exam rooms, stays with the patient during
the doctor portion of the exam and then carries out frame selection, contact
lens training or any additional special testing. The patient is never left
alone in the office and the patient and technician build a nice rapport.
The doctor does not have to search for a technician at the end of the
exam. Before I started using scribes, I spent half my life looking for a
technician or optician to take over for me. I’m not sure where the staff
was, but they were always busy or missing. I’d either have to start a frame
selection myself (not good) or I’d have to leave the patient and hope
someone would assist him. Just walking patients out to optical takes a huge
amount of time. Having the tech in the room with me solves the problem.
The scribe hears the consultation first hand. I don’t have to hand off
the patient to an optician and repeat everything I just discussed in the
exam room; my tech hears everything and simply carries it out. The best hand
off is no hand off.
The scribe assists with contact lens fitting. Having a tech on hand
makes the contact lens fitting process very streamlined. I have all the data
I need at the end of the eye exam, why not just fit the patient immediately
while they are still in the chair? I tell the tech what trial lenses to
apply and I leave to see another patient. In the meantime, the tech puts the
lenses on the patient’s corneas, lets them settle, takes acuity, performs an
over-refraction, educates the patient about the lenses and discusses fees. I
pop back in and check the fit with the slit lamp and we are done.
Having a tech in the room is immensely helpful when I need an instrument
or supply from another room, or I need another patient record, or I want to
arrange a referral appointment with another doctor, or whatever. I don’t
have to page anyone for help.
Additional medical testing is carried out by the scribing tech as
needed. I don’t even instill eye drops very often, I just tell the tech what
to use and I leave the room.
Records are better. I used to rush and scribble when I kept the records
myself. Techs have plenty of time to record everything that occurs in the
exam process so the record is neater and more complete. They circle the
procedure and diagnosis codes, record all instructions, indicate recall
dates, enter all fees, write up all Rx copies – they do it all.
Patients are impressed. The importance of the eye exam is elevated when
a technician sits in to assist and record. Hearing the routine findings
spoken out loud, even something simple like the refractive results, is
educational and impressive to the patient.
In my practice, the technician pages the doctor (on a silent vibrating
pager) when the pretesting is complete and the patient is ready to be
examined. Doctors don’t page techs; techs page doctors.
Just do it
Of course it helps to do some planning and training before asking your techs to
scribe for you, but in the end it’s really much easier than you might think.
Just reassure your staff that you know their skill levels and you won’t
embarrass them or throw very advanced terminology at them that is over their
heads. You can still reach over to the record and make a drawing or jot a down
few notes that you don’t want to speak out loud. I found it was helpful to
redesign the exam form to assist technicians with recording and to allow me to
see the pretest data. It also helps if your exam routine is fairly fast.
If scribing works for you it is very likely that you will need to hire more
staff members, but the increased revenue production will greatly exceed any
additional payroll cost. I remember when I first tried the technique in my
practice my office manager was worried that we might run short of technicians to
start workups or to dispense eyewear. I didn’t let that stop progress; I just
told the manager that if she ever really needed a tech, she knew where she could
find one – in my exam room! I said, “just knock and the door and call her out;
I’ll be fine by myself and I’ll understand that you needed help.” It was hardly
Best wishes for continued success,
Neil B. Gailmard, OD, MBA, FAAO
Editor, Optometric Management Tip of the Week
Dr. Gailmard's new book, Practice Management in Optometry: A Blueprint for Success Based on the Optometric Management Tip of the Week, is now available on Amazon.