Dr RX

[LandLord]

Who should recommend impact resistance to a child patient? Should it be written down on the prescription?

Should contact lens ok include solutions that are exclusive of those that the patient is known to be allergic or should the contact lens fitter whimsically decide on today's favorite solution?

1. I only dispense polycarbonate lenses to children.
2. No. It's unnecessary.
3. All C/L practitioners (optician/optometrist) should know or ask the patient which solution he/she is allergic to.

npdr: If I get into the habit of blindly following what is written in the comments, I am likely to stop thinking. And as long as I am legally responsible for the result of my dispensing, I will use my own clinical judgement, backed up by my $2,000,000 professional malpractice insurance. I will not rely on prescriber comments.

[AdmiralKnight]

So it isn't a blanket indifference to written specific prescriptive information. If that is true, then should a dispenser who doesn't have a medical history and data be the one to judge which prescriptive information to ignore and which to follow? And if you do, does the dispenser always portray that prescriptive information as excessive to belittle the prescriber?

It sounds like you're taking this a bit personal here, npdr. We're not talking about looking at scripts and automatically chucking the recommendations out the window. We're talking about when it's appropriate and when it's not for the prescriber to suggest, and specifically WHAT is suggested. The problem lays when there's a suggestion on the script that makes absolutely no sense. Obviously there's a reason for these suggestions, but without knowing those reasons, as professionals we SHOULDN'T blindly follow them. When a specific high end lens is suggested for a low script, and we know they won't see better out of it than they will out of a lens half the price, we should be questioning these suggestions. There have been many examples so far on this thread, specifically things like older ODs recommending things that are old, and/or don't even exist anymore, and the worst being specific brand suggestions.

Obviously there are suggestions that need to be followed. I got a little 4 year old girl in the other day with a first FT rx, and had I not followed the specific fitting instructions on the Rx, they wouldn't have worked properly for her. THESE make sense, and you'ld be hard pressed to find a DO who won't follow them. It's when the suggestions go against what we know as a profession, is when it becomes muddled. And believe us, we're not grouping every OD in this. It's not an OD bashing thread, but a serious concern that needs to be discussed.

[bhess25]

personaly i love it when the doctor writes things like "polycarbonate, AR, trans, polorized"..its a great selling tool..

we always ask our doctors to recomend these things for a few reasons...

1. He's a doctor...people tend to listen to doctors more than an optician...if he makes the recomendation a person is more likely to buy the upgrade just because he said so.

2. They have these products on their minds when picking frames, and begin to ask more questions about them...therbye giving us the oportunity to explain the benifits of each option.

3. Its so much easier to say "Your doctor recomended a good Anti reflective coating as well as polycarbonate lenses", in my experience people have been more likely to just buy them without any further sales involved, making the whole process move along faster and giving the patient a better pair of eyewear.


thats my take anyway.

-Billy

[AdmiralKnight]

Eeeehhh, I see it completely the opposite, and had a good chat with the 4 ODs I work with. We had specific problems, for instance they'd come out of the exam room and first thing I was told was "Well, Mr Jones' frame is in good shape, so all we need are new lenses." And right from there you've slammed a door shut. Dr Says I don't need a new frame. Most ODs (from my experience, at least) will be the first ones to tell you they aren't fully up to date when it comes to the newest technology, so then we'd have cases of them walking out of the exam room with specific lens suggestions, and upon review of the Rx, proves not to be the best option, specifically when the frame hadn't been chosen yet. I'm not ragging on anyone here, and it took more than one upset patient for me to approach the ODs with my concern, but they were very receptive to it. One even went as far to say "ODs are notorious for underselling themselves."

Be confident that you know your job. Sure, it's a bit easier to get a patient into a specific lens, or coating, if the Dr mentions it before hand, but if you're confident in your abilities, and BELIEVE what you're offering your patients is good for them, you won't have a problem. Besides, that's what you were hired for. :)

[bhess25]

Eeeehhh, I see it completely the opposite, and had a good chat with the 4 ODs I work with. We had specific problems, for instance they'd come out of the exam room and first thing I was told was "Well, Mr Jones' frame is in good shape, so all we need are new lenses." And right from there you've slammed a door shut. Dr Says I don't need a new frame. Most ODs (from my experience, at least) will be the first ones to tell you they aren't fully up to date when it comes to the newest technology, so then we'd have cases of them walking out of the exam room with specific lens suggestions, and upon review of the Rx, proves not to be the best option, specifically when the frame hadn't been chosen yet. I'm not ragging on anyone here, and it took more than one upset patient for me to approach the ODs with my concern, but they were very receptive to it. One even went as far to say "ODs are notorious for underselling themselves."

Be confident that you know your job. Sure, it's a bit easier to get a patient into a specific lens, or coating, if the Dr mentions it before hand, but if you're confident in your abilities, and BELIEVE what you're offering your patients is good for them, you won't have a problem. Besides, that's what you were hired for. :)

I agree they shouldnt ever offer specifics...I wouldnt ever ask a doctor to offer specifics because of them not being up to date on the newest technology...I do however see your point...and i agree on the ability thing, I usualy dont have any problems getting a patient to buy anything, but it does expedite the selling process in most cases...i think a good understanding between you and the doctor on what to offer is almost a requirement, in order to keep the above from happening.

so i guess it just depends on the relationshsip between the doctor and you, and also how you like to present things to your patients.

[Dannyboy]

If the dr wrote it then it is part of the Rx. The doc must have it well documented of why he has ordered it. Florida is very grey in all of this but I would only follow the obvious such as material selection in one eye people, sports and children. The rest is a sales gimmick...in the same realm and schemes of the prescribers capture rate...

Dannyboy:shiner:

[Barry Santini]

I think this whole matter, and the difficulty in reaching a consensus of what's considered "appropriate" to write as "part" of the "Rx", reveals why refractive findings *should not* be considered *medical* in nature.

Refractive parameters are simple refocussing, against which the client's vision is very fluid and therefore subject to change.

So why....why... should refractive parameters (and/or any other comments or suggestions) be revered as "set-in-stone, do-not-modify or deviate", with the imprimatur of medical importance and authority?

Discussion, please...

Barry

[Uncle Fester]

So why....why... should refractive parameters (and/or any other comments or suggestions) be revered as "set-in-stone, do-not-modify or deviate", with the imprimatur of medical importance and authority?

Discussion, please...

Simple- Too many lawyers in a sue happy society.

[AdmiralKnight]

The thing is Barry, we're not talking specificly about refractive findings. Most people when getting an exam, will not just get a refraction, but a health checkup as well. npdr brought up some good points on things like a patient being allergic to a specific type of solution etc etc. Things are mentioned in the exam process that might not be mentioned to you, and the OD might very well give the exact same suggestion as you would if you had the same information. I have absolutely no problem with ODs suggesting things on their Rxs, but don't treat them as part of the Rx unless you can show me that it's medically necessairy.

[chip anderson]

Patient presents to optician (U.S. definition) wants a pair of glasses for playing piano or golf, or working underneath cars, or seeing a precise distance (as from a lathe he runs). Do you see anything wrong with an optician modifiying the focal length in specialized glasses? Or do you feel only an O.D. is smart enough to modify focal lenghts after origional distance/near Rx has been written?

Chip

[Stonegoat]

Hi Chip,

It's funny your name is Chip as you seem to have quite a large "chip" on your shoulder.

Anyway, I personally prefer the optician to consult with me before making any changes. Here is why. One of the opticians in town is in the habit of placing trial lenses in front of my prescriptions, which always causes a problem. For example I may prescribe a -4.50 (20/20-) instead of -4.75 (20/20), for distance if the patient is presbyopic and spends 90% ++ of their time working in a confined space. The optician will then have the patient look across the street and trail the -0.25 D. The patent says, wow...that does seem clearer...then comes back to me, thinking I messed-up. I hate that.

[For-Life]

Hi Chip,

It's funny your name is Chip as you seem to have quite a large "chip" on your shoulder.

Anyway, I personally prefer the optician to consult with me before making any changes. Here is why. One of the opticians in town is in the habit of placing trial lenses in front of my prescriptions, which always causes a problem. For example I may prescribe a -4.50 (20/20-) instead of -4.75 (20/20), for distance if the patient is presbyopic and spends 90% ++ of their time working in a confined space. The optician will then have the patient look across the street and trail the -0.25 D. The patent says, wow...that does seem clearer...then comes back to me, thinking I messed-up. I hate that.

I do not want to offend you here, so please take it as me asking questions and not criticizing your work. I do not know you nor have you ever examined my eyes; therefore, I cannot judge the quality of your exams.

But, was it the Optician who made the mistake in that case? If the patient is seeing better with the -4.75 then maybe that is what should have been written. Now, of course you gave him a -4.50 for a reason, but maybe that patient wanted the better distance vision over the reading. Or, maybe the patient did not understand from you that if you give him a -4.75 he may see better in the distance but worse in the reading.

I find some ODs spend a lot of time with patients selling them on AR, their brand of PAL and so forth, but little time explaining what the real RX means.

Just something to consider.

[AdmiralKnight]

Hi Chip,

It's funny your name is Chip as you seem to have quite a large "chip" on your shoulder.

Anyway, I personally prefer the optician to consult with me before making any changes. Here is why. One of the opticians in town is in the habit of placing trial lenses in front of my prescriptions, which always causes a problem. For example I may prescribe a -4.50 (20/20-) instead of -4.75 (20/20), for distance if the patient is presbyopic and spends 90% ++ of their time working in a confined space. The optician will then have the patient look across the street and trail the -0.25 D. The patent says, wow...that does seem clearer...then comes back to me, thinking I messed-up. I hate that.

That's a fair point. I rarely use test set lenses, usually only when troubleshooting a problem, or showing what, for instance, a reading script would be like. However, that's a bit different than what Chip was talking about. I don't see a problem with, as Chip put it, modifying focal points. We're using the original script, just translating it to a specific distance not recorded on the Rx.

[Barry Santini]

One of the opticians in town is in the habit of placing trial lenses in front of my prescriptions, which always causes a problem. For example I may prescribe a -4.50 (20/20-) instead of -4.75 (20/20), for distance if the patient is presbyopic and spends 90% ++ of their time working in a confined space. The optician will then have the patient look across the street and trail the -0.25 D. The patent says, wow...that does seem clearer...then comes back to me, thinking I messed-up. I hate that.

And in this case,I see your point. But...

If this same client is dispensed a combination of:
1. poly lenses
2. lenses that ANSI tolerance out at -4.37 sph
3. a client pre-disposition toward tilting their head back when they drive at night (or in bad weather)...

...They're gonna come back to *me* and want to know why *this* pair of progressives is unsatisfactory for driving, particularly at night!

Here...clearly, two different pairs of eyewear are needed to be discussed by the refractionsist with client, and written down as well.

Otherwise, the diagnoistic/CSI time, labor and materials for the remake are billable to whom?

Just another view, eh? (but consistent with my experience)

Barry

[Stonegoat]

I agree the refractionist should determine what is needed and fully educate the patient. Many, if not most patients that have problems with PALS, etc, were simply not educated properly. I spend a great deal of time educating my patients on what to expect with their new glasses, and what the limitations of a specific Rx/design may be. Because I have spent the time determining what is best, I don't appreciate someone planting "trouble" seeds in my patients' minds. I have had several patients come to me concerned, even after I explained things fully to them during the exam, because of the "over-refraction" the optician typically does. I then have to spend several minutes explaining things and doing an over-refraction of my own to demonstrate why things are the way they are.

I understand opticians want to refract.....but don't be over-zealous. I perform about 4000 refractions/year...and am pretty good at what I do.

[HarryChiling]

Well in the states that shouldn't be happening as over refraction would be considered practiceing optometry, however placing a trial frame in front of a patient does happen.

I am also very curious why it would be OK for the doctor to intentionally undercorrect and not document on the Rx that this is happening, but it seems to be OK to want to write material suggestions? I know there have been many times I have chased my tail lookign for a reason why the patient wasn't 20/20 when the doctor could have passed that information along.

Chip,

As far as compensation goes, I do it and don't care who thinks I should or shouldn't as I can always prove that it was what the doctor ordered and what the patient wanted.

[CME4SPECS]

Hi Chip,

It's funny your name is Chip as you seem to have quite a large "chip" on your shoulder.

Anyway, I personally prefer the optician to consult with me before making any changes. Here is why. One of the opticians in town is in the habit of placing trial lenses in front of my prescriptions, which always causes a problem. For example I may prescribe a -4.50 (20/20-) instead of -4.75 (20/20), for distance if the patient is presbyopic and spends 90% ++ of their time working in a confined space. The optician will then have the patient look across the street and trail the -0.25 D. The patent says, wow...that does seem clearer...then comes back to me, thinking I messed-up. I hate that.

That's called refracting, and if you don't have a license to refract, then you shouldn't be doing that.

[Stonegoat]

CME4Specs,

....One would think....

[CME4SPECS]

CME4Specs,

....One would think....

I understand your postition in the above scenario.
In the state of California, a prescription contains the dioptric power of a lens...that's it.

[AdmiralKnight]

I disagree with how this optician goes about doing it, but without knowing all the information, I can't fully fault him either. If I have a patient come in who has a new Rx, and never had any trouble with PALS before suddenly start having problems, I have to trouble shoot. Basics like checking Rx, PD, Base curves, etc etc are a given, making sure the adjustment is correct as well. Sometimes (not very often, mind you) after going through all that, the patient can still be having trouble. This is when I'll take out the test set. I don't go into any detail with them to what I'm doing, just ask some basic questions, and I'll only ever use a +/- 0.25, maybe a 0.50. If they see improvement at that point, I call the OD to figure out what to do. I've ALWAYS hated when people badmouth other practices. I've got it from both ends, and it's horrible. In retail, I've had people come back from the ODs office saying their glasses were made "TOTALLY WRONG!!" and have them only be off by a 0.12. On the other hand, working in an ODs office, I've had people who have taken their Rx elsewhere come back telling me the Rx was wrong. This is horribly unprofessional. Even if a HUGE mistake was made, don't take it upon yourself to tell the patient. Call whoever is 'responsible' and discuss it with them. That way you're both on the same page.


...Long story short, I don't change Rx's, and I don't badmouth people hehe :D

[bblaker]

I think this topic is very interesting....
As to what Harry said about liability issues if I document on an Rx for a specific material ex. Poly due to the fact that a patient has vision loss secondary to a corneal ulcer in one eye, and they have been removed from SCL and an optician decides that this -7.00 needs to be in a 1.67 for better cosmetic's, then have a injury to the patients good eye that could have been prevented with the appropriate lens rest assured I will not lose that case. It would be like going to the pharmacy and filling your anti arrhythmia meds and the pharmacist changing your meds for something that they think would work better....then you die because the pharmacist didn't know you had an elongated QT wave and gave you a med with that will make it worse..... It doesn't work like that for a reason

But I understand the optician rational on the subject too... a truly qualified optician is more than capable of making great decisions in lens care to our patients and obviously by the fact that many of you are active in this board show that you are understanding of the consequence of material changes etc...But many dont either, so I feel obligated for the more problematic patients to spell it out to assure it gets done right...
I rarely notate more than the Pt Rx on the RX but, when I do it is usually for a very good reason, whether I mentioned it to the patient or not decisions on there visual needs are accessed from the second I read the patients occupation to the time they walk out my door , I would think twice about considering it a suggestion b/c when it comes down to it if you don't fill it how it is written, then whatever comes afterwards is your responsibility....
I also have never minded a call from a concerned optician wanting to know if this 3D anisio patient could benefit from slab off, sometimes its an oversight, but sometimes the patients is legally blind in that eye due to AMD so it wouldn't make a difference....
If nothing is written other than numeric RX than it is open to suggestion.

[HarryChiling]

I think this topic is very interesting....
As to what Harry said about liability issues if I document on an Rx for a specific material ex. Poly due to the fact that a patient has vision loss secondary to a corneal ulcer in one eye, and they have been removed from SCL and an optician decides that this -7.00 needs to be in a 1.67 for better cosmetic's, then have a injury to the patients good eye that could have been prevented with the appropriate lens rest assured I will not lose that case. It would be like going to the pharmacy and filling your anti arrhythmia meds and the pharmacist changing your meds for something that they think would work better....then you die because the pharmacist didn't know you had an elongated QT wave and gave you a med with that will make it worse..... It doesn't work like that for a reason

But I understand the optician rational on the subject too... a truly qualified optician is more than capable of making great decisions in lens care to our patients and obviously by the fact that many of you are active in this board show that you are understanding of the consequence of material changes etc...But many dont either, so I feel obligated for the more problematic patients to spell it out to assure it gets done right...
I rarely notate more than the Pt Rx on the RX but, when I do it is usually for a very good reason, whether I mentioned it to the patient or not decisions on there visual needs are accessed from the second I read the patients occupation to the time they walk out my door , I would think twice about considering it a suggestion b/c when it comes down to it if you don't fill it how it is written, then whatever comes afterwards is your responsibility....
I also have never minded a call from a concerned optician wanting to know if this 3D anisio patient could benefit from slab off, sometimes its an oversight, but sometimes the patients is legally blind in that eye due to AMD so it wouldn't make a difference....
If nothing is written other than numeric RX than it is open to suggestion.

Maybe you missed my point, I was suggesting like in the case that started this thread if the doctor wrote down HI-INDEX, since their is a material available that is about 10 times stronger than hi-index, specifically poly and trivex; if I were to dispense it as written who holds the responsibility for the duty to warn? Am I to say to a judge that the doctor prescribed it, or the doctor recommended it?

Also in the case of the AMD in the one eye being legally blind wouldn't it be prudent of you to document on the Rx the best corrected visual acuity or in this case just write balance so that the opticians doesn't focus his attention on why this eye is haveing a hard time seeing? Or worst yet chargeing the patient for a slab off? I think writing suggestions like materials and progressive designs on the Rx is an innapropriate waste of time and energy, you would provide your patient with better service to provide data that would be more relevent to the optician making a more informed recommendation on lenses, for instance diagnosis? Best corrected visual acuity?

Don't mean to sound like I am busting your chops here doc, but this situation is a little different than the dumb optician scenario you layed out above.

[bblaker]

I understand but there are hippa regulations to about disclosure of info and the necessity to have it. If I start writing VA or blind OS , AMD OD...IS it truly necessary for the optician to have a diagnosis when the instruction for materials etc is written on the RX? And what if the marginal optician says"No you dont need any power in that eye because it says you have AMD" Then who is it fault for hippa violations the optician or the OD for writing irrelevant info on the RX to the ordering and dispensing of glasses?
I guess then it boils down to who has the better lawyers! The lawyers always win...

Maybe you missed my point, I was suggesting like in the case that started this thread if the doctor wrote down HI-INDEX, since their is a material available that is about 10 times stronger than hi-index, specifically poly and trivex; if I were to dispense it as written who holds the responsibility for the duty to warn? Am I to say to a judge that the doctor prescribed it, or the doctor recommended it?

Also in the case of the AMD in the one eye being legally blind wouldn't it be prudent of you to document on the Rx the best corrected visual acuity or in this case just write balance so that the opticians doesn't focus his attention on why this eye is haveing a hard time seeing? Or worst yet chargeing the patient for a slab off? I think writing suggestions like materials and progressive designs on the Rx is an innapropriate waste of time and energy, you would provide your patient with better service to provide data that would be more relevent to the optician making a more informed recommendation on lenses, for instance diagnosis? Best corrected visual acuity?

Don't mean to sound like I am busting your chops here doc, but this situation is a little different than the dumb optician scenario you layed out above.

[chip anderson]

Patient comes in, has Rx which is filled as written. Then patient brings up another vocational or other specialized need. Like say he is a presbyoptic painter and uses a roller 2.4 meters above an out from his eye. Would the optician be "fudging" if he also made the patient a quadrafocal with the upper segment focusing 2.4 meters away. Or would this be something in your opinion the doctor should make the calculations on. Presumeably all opticians and lab personell can take a distance Rx and made whatever mathematic adjustments needed for this, it's not rocket science and if the doctor has already made phyical exam and prescribed lenses for the "usual and customary" distances and needs, why not?

The patient will know what the glasses are for and not for and won't attempt to go hang gliding in them.

Chip

[bblaker]

I am recalling a story that went something like this,
Doctor has a patient, rancher, prescribes glasses makes not recommendation of materials, gets cr-39, patients rodeos for a favorite pastime, eye gets injured, rancher sues doctor not optician for neglect to inform....Rancher wins