Looking for a fun way to start your next local society meeting and incite a heated discussion at the same time? Stand up and proclaim, “I delegate refractions. Anyone have a problem with that?” Once the anticipated barroom brawl subsides, follow it up with, “Oh, and I also delegate contact lens fitting.”
In this profession, any discussion that involves taking the phoropter out of the doctors’ hands immediately becomes personal. This is likely because refraction has become synonymous with the core services we provide. Similarly, as contact lens practitioners, the process of fitting lenses means that no one, and I mean no one, is allowed to touch our slit lamps!
Personally, I believe refraction itself can be delegated, but prescribing cannot. The art of writing a prescription involves understanding and interpreting the patient’s refractive responses in the context of their complete ocular and systemic history, while refraction can be performed by any trained individual using standard equipment. Chances are, you are the best one in your practice to understand your patient’s unique needs and therefore should be the one to interpret.
Divide and Conquer
In these times of having to “do more with less,” “work smarter, not harder” and any other current business cliché you’d like to add, it makes sense to delegate more—and more smartly. Reserve your time for the parts of the fitting process that require your expertise in particular. Below, I explain using the example of disposable soft lenses for healthy patients.
With contact lenses, “fitting” can be thought of as choosing a lens that is most appropriate in terms of meeting the needs of a particular patient. After the selection is made, lens performance is evaluated and, if deemed satisfactory, the lenses are then dispensed. Lens performance is typically reexamined during a follow-up; timing after the initial appointment varies depending on the patient, lens and the doctor’s clinical bias.
So, which part of the above scenario can be delegated? In my view, all of it. (State laws may vary, so be sure to check yours.)
• Choosing the lens type. While this part would seem to be the most difficult to delegate due to the wide variety of lens types available, in reality it’s the easiest.
For routine, non-pathology cases, many of us have a “go-to” contact lens. If you were to ask your staff, “Which lenses do you think I’d pick for a patient who is -2.00 OU with 44K’s, in perfect health with great eye and systemic history?,” you will likely get the same lenses you would have chosen. This is because your staff has probably seen you prescribe your “go-to” lens of choice—and been successful—so many times, that they’ll choose the same one. Even if you do not let your staff choose the lens, this part of the fitting process happens in a nanosecond anyway, so it’s something you can easily relay to your staff.
• Evaluating the fit. The thought of delegating this part of the process usually draws the most ire from doctors but, again, if you approach it logically, it shouldn’t. You were trained to properly evaluate how a lens fits, and you can train someone else to do it. And honestly, the quality of lenses we have available today is so improved over what you may remember from optometry college that if you choose the correct lens in the step above, it’s going to fit most of the time.
If for some reason it doesn’t, your staff can be trained to pick the next logical choice, just like you were. Is the lens too big? Pick a smaller one. Is it too tight? Pick a looser one. Is the VA not what you expected, or is the patient uncomfortable? Again, you were trained to problem-solve and there’s no reason you can’t train someone else. Of course, in trickier cases, you may need to step in, but the majority of the time, properly trained staff should be able to do just fine.
• Discharging the patient. This is the part that I believe equates to prescribing based off of a technician’s refraction, as discussed earlier. At this point, you can simply double check the fit and acuity if necessary before releasing the patient. The heavy lifting—running back and forth between the stock room and exam room, taking the lenses in and out, waiting for the lenses to equilibrate and evaluating them—has already been done.