Delegating objective refractions to staff makes good practice sense

Issue: June 1998

Delegation - a welcome word to some practitioners, a worrisome word for others. All doctors delegate some portion of the practice's duties to trained staff, but just how much can depend on the cost of new equipment, staff training and, perhaps most important, the doctor's comfort level.

In this feature, Primary Care Optometry News talked with three clinicians from different practice settings about how and when they delegate duties to staff and why objective refractions are a good place to start.

"Good practices, whether ophthalmology or optometry, are set up so that the doctor essentially serves as the organizer and coordinator of patient care," said J. James Thimons, OD, director of the Glaucoma Institute in New York. "The doctors do not personally develop the information in most cases, but they are responsible for all information gathered and for the patient's outcome."

Today, technology plays an important role in the decision to delegate duties to staff. "Technology has achieved a level of sophistication and reproducibility that makes it very useful for managing daily patient activity in an ophthalmic practice. I wouldn't have said that 10 years ago," Dr. Thimons said.

Why delegate at all?

Reasons to delegate duties in the optometric practice are as varied as the duties themselves, but several factors are clear in today's health care environment, said John F. Amos, OD. "First, it is an increasingly competitive marketplace due to the number of practitioners," he said. "Second, managed care has created an environment that places greater pressure on the clinical optometrist to see more patients in the same amount of time and still deliver high quality care."

Dr. Amos is professor and chairman, department of optometry at the School of Optometry, University of Alabama at Birmingham, and a participant in the faculty intramural practice, University Optometric Group. The optometrist, like other health care providers, he said, "has changed from being strictly a gatherer of data to one who increasingly finds himself or herself in the position of analyzing data collected by others."

What do you delegate?

Dr. Thimons believes a transition is needed if optometry is to continue to have a dominant presence in the primary eye care field. "Optometry needs to accept those technologies that are sensible, are efficient and allow doctors to continue to provide the highest level of care," he said. "There are hundreds of examples of technology out there, and autorefraction is only one. This technology is readily integrated and can be appropriately performed by office staff."

Although autorefractors allow trained optometric staff to perform objective refractions, that does not mean all optometrists embrace this possibility, Dr. Amos said. "Refraction is an issue that is somewhat emotional because it's the last bastion of the optometrist," he said. "Our patients want to see clearly, and the refraction is very important and something that must be done carefully and accurately."

Many doctors, he said, make this distinction by delegating only the objective refraction to trained staff.

"In most cases, autorefraction is only a beginning point and not a substitute for refraction," Dr. Amos said. "There's probably great support for delegating the objective portion of a refraction. It is a procedure that most optometrists are comfortable with, and it can be a real asset in terms of speeding up the process of subjective refraction."

Doing it successfully

Richard F. Noyes, OD, in private group practice in Marion, Iowa, believes staff delegation is one reason his office delivers patient care efficiently.

"Our vision of the future of medicine is that we must be more efficient in the way we gather data," he said. "The doctor will ultimately be responsible for interpreting and reporting results to the patient, but the methods for gathering data will have to become more efficient. Autorefraction blends nicely into that."

In his practice, Dr. Noyes is one of three optometrists who rely on about 20 paraoptometrics to perform objective refractions and other tests deemed appropriate by doctors on patients. "Before I see patients, their glasses are neutralized by a computerized lensmeter and they are autorefracted at the same time," he said. "With an objective refraction, there is a slip of paper with data that comes in attached to the patient's chart for when he or she sees the doctor."

Dr. Noyes said by having trained paraoptometrics perform an objective refraction, the amount of time an eye exam requires is not reduced, but the doctor's time certainly is. His practice has used autorefractors for nearly 10 years, and he currently has three autorefractors in the office.

How to delegate

Once you have an autorefractor, the next step involves training staff to perform an objective refraction. According to Dr. Amos, "A lot of this also depends on the ability of staff to learn. Any good staff member will ask the doctor to double-check the data, and this is also an opportunity for him or her to learn."

Dr. Thimons, who works in a private practice and a large primary care practice, said incorporating autorefraction depends in part on the size of the practice. "I think where it's most difficult is in the solo practice because the patient volume is such that it's difficult to substantiate this kind of expense," he said.

In his private practice, Dr. Thimons employs a hand-held autorefractor from Nikon, which is especially helpful for working with children or patients who are poor refraction candidates. "We scan the pupil and get a reasonable starting point for analysis," he said.

In the larger practice, Dr. Thimons finds an autorefractor helpful in organizing data for all patients regardless of the reason they are in the office. "I think doctors miss out when they say they're only going to refract new patients," Dr. Thimons said. "I do it as a routine for return patients because frequently their vision has changed. You can easily look at the refractive component and decide that's not the issue and go on. We use it for more than straight refractions - we use it as a quick diagnostic tool."

Dr. Thimons said the time he saves by having staff perform objective refractions is time he chooses to spend with the patient. "I don't shorten my exam time, but I talk to patients about medication use or problems, and I re-educate them about the need for continued eye care," he said.

Finally, Dr. Noyes offers this advice to clinicians who are hesitant to delegate objective refraction: "Autorefraction is just a tool, like a retinoscope is a tool," he said. "It gives you one more piece of data that is helpful in determining an accurate prescription for a patient."

For Your Information:

John F. Amos, OD, may be contacted at School of Optometry, UAB, 1716 University Blvd., Birmingham, AL 35294; (205) 934-0366; fax: (205) 934-6758.

Richard F. Noyes, OD, may be contacted at 1065 East Post Road, Marion, IA 52302; (319) 377-2222; fax: (319) 377-2967. Neither Dr. Amos nor Dr. Noyes has a direct financial interest in any products mentioned in the article, nor is either a paid consultant for any companies mentioned.

J. James Thimons, OD, may be contacted at SUNY College of Optometry, 100 East 24th St., New York, NY 10010; (212) 780-5012; fax: (212) 780-4980. Dr. Thimons did not disclose whether he has a financial interest in any products or if he is a paid consultant for any companies mentioned.