Lens material part of Rx???

[Pete Hanlin]

In the June edition of EyeCare Business (page 44), there is a Q&A segment concerning a doctor who works for an optician. Seems the OD would prefer his patient's lenses to be polycarbonate. However, the Optician routinely "convinces" the patients to purchase CR-39 (or some other material). The doctor is concerned that he will be partially liable if the patient is injured as a result.

The first answer provided (by Joseph Gill) indicates that the doctor is probably not at risk- but should keep records of his poly recommendation nonetheless. What caught my eye was the second answer given (by Pamela Miller, OD). She indicates:

"I would simply write 'polycarbonate' on the Rx form. No optician has the right to change the doctor's written prescription."

Having read the applicable Florida laws on this matter (i.e., prescriptions), I fail to see how the lens material could be considered to be part of the prescription. Putting aside the fact that spectacles are not even considered medical devices (as opposed to contact lenses), the choice of material has nothing to do with "determining the refractive state of the eye." In duplicating a written Rx, the state does not specify that "recommendations" from the original Rx must even be transferred to the copy! (The required elements being: 1.) Client Name; 2.) Prescriber's Name; 3.) Date of Original Rx; 4.) Sphere Power; 5.) Cylindrical Power; 6.) Axis; 7.) Prism Power; 8.) Reading Power)

If there is a legal expert among us who can demonstrate that ignoring a doctor's recommendation is illegal, I'd be grateful for the knowledge.

Pete

[Texas Ranger]

Pete, I'm with you...what do your doctors think? I don't think a recommendation of material or lens design or thr pd off the phoropter, etc. are part of the rx, and then we are allowed to adjust for vertex distance, which though it can help the pt see better, will allow the doctor or tech to read a power other than that prescribed in the lensometer. I do have a pedi ophthalmologist who doesn't want kids in poly, because they are 'too expensive" and "scratch too easily". so go with cr-39, all he writes on the rx is "shatter-resistant", and definitely don't put AR on any kid from his office. We also have doctors prescribe things that can't even be done..a +4.50 add with the trifocal at +3.25, yeah right?? The reality is that unless you are making single vision distance and single vision near lenses, the pts glasses will not be made as they were refracted. And the near is rarely refracted with the pts eyes in the reading position, except perhaps in a trial frame, then you'll likely get a few degrees axis difference. So, really what's it to the doctor if the pt has lenses that they see, function and enjoy, what they're made of, how big they are, how much they cost, how long it takes to make them, etc. They were paid for their professional services, which does not involve opticianry. Al.

[Darris Chambless]

Hey Pete,

I took an on-line test that said I should be a lawyer or a physician does that count? :-) Actually I know a little about this subject from the legal standpoint as I've had to look into the legalities and liabilities in order to bring in a doctor.

In a licensed state for opticians each professional works under his or her own license and is responsible for the outcome of the professional decisions made by said professional. In other words the OD would not be responsible for any further outcome if something were to happen based on the lens materials used by the licensed optician.

In an unlicensed state only if the optician works "for" the OD can the OD be held liable for decisions made by the optician. This is because it is looked upon as the decisions made by the "practice" not the individual. Therefore if it is the doctors practice it is the doctors decision.

If (like myself) you are an independent optical you would then relate back to the idea of the practice and its liability. If the glasses are not made in the doctors office it is the responsibility of the optical and its officers that fill the script should something happen because of material suggestions or materials used.

You are correct in your assessment that the material is not a part of the actual script as defined by law. Actually when a doctor DOES specify a material on a script they are taking responsibility for that suggested material and hence responsible for any outcome due to said suggestion (just like when they prescribe UV and scratch coat :-). So if they want the liability then by all means ;-)

Dr. Pamela sounds like a Peter Jennings type. Talking without having the proper information in front of her (but it sure sounded good to her at the time :-)

If you need specifics let me know and I'll get them for you.

Darris "Should I become a lawyer?" Chambless

[Bob Rihl]

Pete:
Around here, only the really young, still wet-behind-the ears Optometrists ever put lens material or pd or anything like that on the RXs. After they grow up, they quit doing it. MDs never do it.
I DO wish that more MDs and ODs alike would give me a VA and a VD (not the kind I got in New Orleans), like they all used to. This way, I'd have a rough idea of what power to grind on higher RXs and what to expect from ANY Rx. How many times have I spent a half-hour of valuable time trying to figure out why somebody can't see, only to call the Doc and hear "Oh, she's got Flxxscvnmniytinkitis and we can only get her up to 20/70." How many times have I gotten an RX for a +9.75, called the Doc for the missing Vertex distance, and after 20 minutes of going trough the chain of command, had the Doc get on the phone and say, "a WHAT??" ZOUNDS!!!!!


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[Dave Nelson]

I had a customer last week who came in and said the Dr. would'nt "give" her bifocals, and compounded the rx into readers. That drives me crazy. It takes grade 2 arithmetic to come up with a reading rx, but Einstein himself coul'nt reverse the reading rx into bi's. I get this quite often, along with requests from the Dr. to make "computor glasses" and supplies an add that may or may not already be reduced for intermediate. Please, just supply the numbers, I can figure out when readers, bifocals, tri's intermediates ect. are needed/wanted, what material to make them with, and how to add/subtract the numbers.

[Jeff Trail]

Pete,

I guess you have to look at it from each perspective.. the OD's (majority) do not really know what is available on the optical side (lens, materials, indexes, brands, etc., etc.) so their answer's tend to be limited to their experience...as posted some asking for impossible addition combinations etc. etc.
The opticians also are limited somewhat (not all of course) in what is available, since things change so fast now adays in optics.. that and they tend to spend the majority of their time selling,fitting & dispensing.. of course thats where they make the "money"..I wish they would expand more but most are limited by time and $$ and get into a rut of using just a "hand full" of designs ...either by "chain" limitations or just getting "used" to doing it a certian way all the time..
While the lab guys have to really be up on whats available in what design, material and brand and index...where you have your "frame facts" I have my "bible" as well the "lens data" book.. its about 1200 pages of everything available all the specs and manufacters out there when it comes to lens.
The things that complicate it is when you start trying to "control" every aspect of any RX ... If you are going to control it (OD) you BETTER know what every design is available in and what base curves, additions materials etc. etc. .. which no OD or MD I know does, why should they? You go to med school all those years for refracting and pathology ..NOT dispensing..
I guess I look at it from two of the perspectives as a retailer (well was) and as the wholesaler, If you don't know then it's best to let the people who do know make the correct choices for the patient...
I go to all my accounts on a regular basis and the only thing I tell the OD's they should get in the habit of saying is, if it is appropriate then mention, to the patient that they may want to try a PAL or high index or polarized etc. etc. ... then leave it to the optician to explain the benefits of those things.. thats what we ARE supposed to be doing :)
Last but not least you might find this funny.. I had two "older" OD's that ALWAYS used to put "varilux" on every script, not which one but just the word "varilux" then when we would call and ask "which Varilux?" they would always say the same thing.."what do you mean?".. I would have to explain to them that was just the brand name and you have a multitude of choices in designs under the Varilux name.. and then they would always say I meant a PAL design.. they were just in the habit of if they wanted a PAL they called ALL of them "Varilux".. It took me a gazillion calls before they stopped doing it and just wrote PAL.. but everytime I called they said "you know what I mean" but since it was written on the RX form I still had to call everytime
I would think that it would be to everyones benefit to let each part of the chain do EXACTLY what they are BEST at doing.. just one humble lab rats opinion

Jeff" you want fries with that SV?" Trail

[Blake]

Glad to know I'm not the only one that sees Rx's with "Varilux" on them. Unless the person is currently wearing a Varilux, I just take it as a recommendation from the doc... and then ignore it. Interestingly, it's the same few MD's that feel it is necessary to put that on the Rx, even when the patient has never worn a multifocal lens. How in the world is the doc able to determine that no other lens design will work when none have been tried? Perhaps I should do like Jeff, and phone the doc's office to ask "which varilux?".
The only time I've seen a doc "prescribe" a base curve was when he wanted me to match the current BC, which is logical. As far as PD's, I learned how to measure them on day one. We did have a doc's office refuse to give us a patient's PD over the phone because of privacy concerns (I don't remember why my coworker had to call for it in the first place). Anyway, I always measure the PD myself, if only to double check the doc ;-)

To paraphrase Al Gore, I know of no "controlling legal authority" that requires opticians to use the lens material, etc. listed on the Rx. Of course, a prudent optician will want to know WHY it was recommended.

I feel like I just spent a dollar to get my 2 cents in...

Blake

[Texas Ranger]

Blake, We have docs that have "match base curves" printed on their rx form; you stated that that is "logical". I don't think so, take for instance the progressive myope who starts wearing glasses at 12 yrs old with a -1.00 sph, in 2 yrs they're a -3.50,2 yrs go by and they're a -5.50, 2years go by and they're a -7.25. So, are we to keep making all of these glasses on a +6.00 base curve? I don't think so. When I started, all lenses were plus cylinder form and the base curve was the ocular surface. now the base curve is the front surface. But maintaining the ocular surface similarity is still a good idea. But "maintain same base curve" is a cop out to the doctors ignorance of what they are asking, and it is not in the best interest of the patient. Al.

[Jeff Trail]

Al,

I tend to agree with you more.. and to take it a step further, the reason behind "matching" base curves most often is that when changinf an RX you tend to have new locations of flashes of reflections that the patient just is not used to seeing in that location.. I do not know how many times I have been in an OD's office showed where this was the problem ..just by giving a frame a little more tilt will solve it or face forming...
As for "matching" a curve (base) what happens if you changed indexes ? Even though you could have TWO exact base curves the ocular curve would not be the same EVEN if it was the same corrective power do to the index of the material. Since most of my accounts have been with me for years I have been changing them gradually as needed.. and I do (where possible) stock as many curves as possible to make the changes easier..ex: in FT28 I have the .50 through 4 and 6.25, 7.25 and 8 and 8.75..
I always thought that ocular curve was more important then base curve since reflections were usually the biggest problems, well and oblique power problems when the optician got this new idea that going "flatter" for cosmetics makes it look better
All in all I still think having the "basic" knowledge on corrective lens makes a big difference on how you would make your choices...

Jeff "put that -7 in a wrap frame" Trail

[Blake]

I see what y'all are saying about base curves. When I said matching BC's was logical, I was thinking of a few specific cases where a patient had a problem because a different BC had been used, and they were told to see the doc again, who wrote a new Rx specifying "match base curve". Everything else being equal, that usually solved the problem.
Guess I should have been more specific...

[Pete Hanlin]

If I were an Optometrist (heaven forbid :D), I would want to make sure the OCULAR curve was being kept consistent (which would in effect be in keeping with Al's post concerning the flattening of base curve as the script becomes stronger minus).

I "think" this is what OD/MDs were originally asking for years ago when they still understood optics (not to imply that some, if not many, still do ;)).

Pete




[This message has been edited by Pete Hanlin (edited 06-29-2000).]

[Bob Rihl]

Maybe I'M behind the curve. I have ALWAYS been under the impression that when the Doc writes "same base curves" he's referring to the OCULAR curve. Why would anybody care about the outside curve?
When I got into the business, ALL single vision lenses were supplied in plus cylinder form, as were many bifocals, the Ultex bifocals ( A, AL, B, E, K ), and we'd order the lens as "Plano base, -2.00 base, -4.00 base, -6.00 base, etc" meaning what the inside curve should be. Those Plano base Ultex A's that we used for cataract jobs are the ones that really PO'd the surface grinders.
So when the Doc says "same base curve" you have to clock the INSIDE curve, and then figure out what the new OUTSIDE curve should be in order to keep the inside the same with the new RX.

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[Jeff Trail]

Bob,

You know that.. I know that and by the postings a few others BUT it sure isn't that way with the vast majority of OD's, MD's and even opticians I know and work with..
I think I have explained it about a million times about base curves, powers and indexes and oclular curves and they still get this "huh?" look when I talk about it again... Some still havn't figured out why exactly the ocular curve changes from index to index when still using the same amount of power.. I swear!!
Usually when I do a pair and then the OD has this bright idea that it's the "base curve" is why the patient is having problems, and never even consider that when you change an RX you actually change the ocular curves which means you also change the reflective patterns on the lens .. they thought I am crazy when Igot a few calls and I asked them to describe the problem, they did and then I told them to take their hands cup the side of the frame on the patient and then see what they say...TADA they came back amazed I figured out the problem and OVER the phone.. told them to either correct it with face forming or panto or a little of both..
Amazing (since they won't spring for a good AR) that CORRECTLY fitting a frame solves some problems :)

Jeff " bend it till it snaps" Trail

[karen]

I believe Dr. Pamela Miller is what is considered as the "recognized authority" on the subject of Duty to Warn.(at least that is what the OLA lit says :) ) She lectures pretty extensively on the subject and in conjunction with the OLA has published things like "Informing the patient" and such about poly. She does also have a degree in law so there may be something to what she says. it may just be California law. She happens to practice in my territory so I am pretty familiar with her stuff

[Barry Santini]

I think that the Prescriber has the resposibility to recommend what he/she thinks is optimal for the patient. They also, as US lawyers have proven, have a fiduciary repsonsibility to make the patient aware of such a lens choice as polycarbonate.

But with prescriber's alos dispensing, we enter a grey area on ethics. This is obvious to me and lay people, but not to the magazines in the industry who point out the add'l profits made when the "DR" makes the recommendation in the exam and on the prescription.

If you are a Dr, then the form you fill out are presciptions. But Eyeglasses ARE NOT medicinal devices anyomore than telescopes or binoculars are.

I too would love VA's on the presciptions. But this means more time. And HMO-based healthcare is the "kryptonite" against spending more time with the patient in thye exam room.

I feel discussing Poly with each person is important. But I also discuss the scratching problem, which will presist as long as poly is 6-10 times more impact resistant.

Ulimtately, the person's satisfaction depends on how "I" interpret the RX,materials choice and fit. I just wish the exams were done better. They are way too sloppy around here.

As far as all this discussion and emphasis on Base curve, material choice and progerssive/aspheric design goes, I say:

"If patient's were *that* discriminating, then refractive surgery (and Mc Donalds) would not be as popular as it is.

Hamburger anyone??


Barry Santini
ABOM



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I think the man who said "the customer is always right" was only interested in profits, and not the TRUTH

[Diane]

I am going to respond to the issue of keeping same base curve. In the good "new" days, we understand base curve as the curve on the front surface of the lens.

I attempt to "teach" opticians in continuing education courses that what the doc really means when he/she writes "KEEP SAME BASE CURVE" is "KEEP THEM FROM COMING BACK TO MY CHAIR"...

This means no disrespect to the doctor, but does require that we communicate with the prescribing doctor and understand what they mean. Keeping the same ocular curve is what they in reality mean and want. Some of them (unfortunately) just don't write it that way. Out of respect for them, just call them, or if you get a lot from a particular doc, have a REAL understanding with them. It avoids a lot of miscommunication down the road.

Just a thought.

Diane

[Thumper]

Pam Miller,O.D.J.D. is correct. An optician should never change a written prescription without first discussing it with the prescribing doctor.

In our office, we have a flow chart indicating the best possible lens material and brand with the various prescriptions so that all personnel are thinking and prescribing the same way.

The multitude of lens materials on the market should be a shared domain between the doctors and the opticians, similar to the physicians and pharmacists to ensure the best outcome for the patient.

Too bad most of the opticians on this board are bashing the doctors rather than educating them as pharmacists do.

Some doctors acutally do enjoy the optical side of the profession and try to prescribe from the chair the exact lens brand and material which they feel is best for the patient.

I believe knowledgable opticians like those posting on the board can obviously make solid decisions of lens choices.

Unfortunately, many of the employed "opticians", especially at large chains have only been trained to sell options and have not been trained in the art of opticianry. Too bad the optical field is so fragmented.

[don A]

You know, I must admit that I hadn't read the article but felt obligated to respond in a general way. I must agree with some of our colleagues that it is in the best interest of the optician to communicate with the prescribing doctor concerning Rx. I have made it a point to verify any questionable word, number, or signs with the prescribing doctor. In most cases the doctors office also gives me a heads up on that patient (if you know what i mean). Overall, I begin to establish some form of rapport with the area ODs & MDs.

don "everybody wins" A.

[This message has been edited by don A (edited 06-29-2000).]

[Joann Raytar]

Hey, I made it to apprentice member. The way the week has been this is a welcome accomplishment.

You have a point Don. In the past I have found that touching base with Docs does benefit both offices in the end. If you talk things through with the Doctor often both of you end up with a little extra knowledge and the patient feels well cared for. The "He Said, She Said" game only ruins a patients confidence in everyone.

[Barry Santini]

The idea that the optician should never change the written RX, and also amintain an educative relationship with the Dr., "like pharmasists & Physicians", is questionable at best.

I wonder how much "education" would go on if physicians "competed" with pharmacists in dispensing medications.

If & when the refracting Dr.'s recommendations are in the *best* interest of their patient, and not his pocketbook, then I agree that discussion should ensue if the recommendation needs to be discussed modified.

As I see it, this can only occur in an ethical manner when the prescriber/recommendor DOES NOT dispense.

I think any reasonable person can see the conflict of interest that may result in the way eyeglasses and contacts are "prescribed" today in the US

My 2 cents

Barry Santini
ABOM

[Pete Hanlin]

Thumper said,

"Pam Miller,O.D.J.D. is correct. An optician should never change a written prescription without first discussing it with the prescribing doctor."

I agree... however, lens design/material is not defined by any legal authority that I've seen as being part of the prescription. Consider, for example, a prescription with the phrase "red frames only" at the bottom. The phrase is spurious because it does not relate to refractive power.

Thumper further observed:

"Too bad most of the opticians on this board are bashing the doctors rather than educating them as pharmacists do."

This is unfortunate. As most of you know, I have always been in the employ of ODs. Fortunately, the ones I've worked with and for have been ethical, pratical, knowledgeable individuals. However, I've seen some who are clueless, sanctimonial, SOBs too (of course, I've seen a lot of "Opticians" who were like that as well ).

In reality, Opticians should communicate with the ODs whose patients enter their offices- not so much to ask permission but to inform the doctor of how their prescription was implied. One of the CECs I teach addresses the need to communicate in writing when problems arise with ophthalmic devices and/or prescriptions.

Unfortunately, for every OD who is willing/able to give and take knowledge with an Optician, there are several who don't want to be bothered. I suppose that's why some of our OptiBoard colleagues feel the way they do about ODs.

Pete

[This message has been edited by Pete Hanlin (edited 06-30-2000).]

[Darris Chambless]

Hey everyone,

A few things I must point out on this subject with regard to facts concerning prescription and interaction between professionals.

About Pamela Miller as posted by Karen "She does also have a degree in law so there may be something to what she says." Karen, you would actually be amazed at what many lawyers "don't" know but will talk as authorities about. I had some legal questions that I asked of two lawyers that specialize in optometric law and work for the TOA. Not only did these legal eagles not know the answers to my questions but had no clue that the house bill (which passed in Texas Sept. 1, 1999) I was talking about even existed and even told me that there was no such thing. Being the sort of person I am I faxed them a copy of the actual house bill :-) You would figure that being specialists in optometric law they would want to or need to know these things, but they didn't.

Mrs. Miller is correct with regard to altering or changing an Rx, but Pete listed those things that are legally defined and required as a prescription "(The required elements being: 1.) Client Name; 2.) Prescriber's Name; 3.) Date of Original Rx; 4.) Sphere Power; 5.) Cylindrical Power; 6.) Axis; 7.) Prism Power; 8.) Reading Power)" Mrs. Miller is probably unaware of or has overlooked this legal fact and is using the term prescription as meaning everything included on the written Rx form.

"Pam Miller,O.D.J.D. is correct. An optician should never change a written prescription without first discussing it with the prescribing doctor." Mrs Miller doesn't say anything about discussing changes. What she says is, as stated in the article exert by Mrs. Miller "I would simply write 'polycarbonate' on the Rx form. No optician has the right to change the doctor's written prescription."

Legally no doctor has the right to specify anything past the parameters of what is defined as a legal Rx without also taking legal responsibility for their recommendations. In other words if what they specify doesn't work then they are responsible for remaking or paying to have lenses remade if the office filling the script wishes to push it (in most cases the offices filling the script won't do anything) But the prescribing doctor is legally responsible AND it's in writing and signed by said doctor. I can't think of a more iron clad case against a doctor as to holding them responsible for remakes can you? ;-)

Finally, I have to say that I agree with Mr. Santini when he says "I wonder how much "education" would go on if physicians "competed" with pharmacists in dispensing medications." He hit the nail right on the head. Since physicians are basically not allowed to own their own pharmacies, or labs or anything else for that matter they have to rely on the information given them by the pharmacists and drug reps. Since OD's and MD's can and often do dispense we are considered competitors and therefore are not always given all the information we need to begin with (but they will specify a material of bifocal type on the written Rx ;-)

There have been many times that I've needed to speak with doctors to confirm information only to have them not return my calls. There are only three doctors in this town that will call me back to confirm anything. The rest don't think I'm important enough until I send one of their patients back to them with problems which I clearly define to the patient were the fault of the prescribing doctor ;-)

Well that's about all I can think of for now. Take care everyone and I'll talk to you later.

Darris C.

[Texas Ranger]

Pete, as one of the more santimonious old sobs about,I'd like to say that for years, we spent personal, verbal,and written updates to doctors on new technologies, created a nice rapore with several, nebver experienced any of that "he said, she said" mess, all was happy in camelot! Then several years ago, consultants such as Bill Borover etc, led a charge through the AAO and started a "trend" of ophthalmology dispensing, and like overnight, we no longer had nice referal relationships and information sharing and respect. We had "competitors" who had seemingly lost their ethics and care for their pts, unless their own shop was doing their work. They don not accept phone calls from us anymore, do not discuss rx problems, still expect us to pay for their, or their tech's refracting errors and blame us for any and all problems. This situation has cost these doctors and our shop many patients; the pts don't like being pressured to buy from the doctor and the doctors have worked to ruin their trust in our work, in order to show their shop's services as better. So, hey, there's lots of other competitors who gladly step in. Those pts who really like our shop just ask us to refer them to another doctor who does not have a conflict of interest. We're only too happy to do so. And not too surprisingly, most patients experience greater satisfaction when they see an independent optometrist, as opposed to an eye surgeon. IMHO Al.

[EyeManFla]

I have never had a second thought about calling a Doctor and questioning what he or she puts on an Rx. And you know what, 99% of the time they are very good at going with YOUR suggestions. The problem with those little 'suggestion' check offs is that many of the so-called 'opticians' in the chain stores tell people that they 'must' have it because the Doctor said so. The sad part of that is, without that 'suggestion' that chain store 'optician' wouldn't have the brains to give the patient what they needed in the first place.
As my Doctor here has said, when it comes to lens materials,a good Optician is always your best expert!

So it is written...so it shall be done......

[karen]

Darris, do you know if the laws regarding this vary from state to state? Now because you have sparked my curiosity I want to find out more about this subject ( see, this is where that hero thing came from. I love it when these messages make me think harder :) ) Any suggestions on where I can start and get accurate info???
Thanks in advance!

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Because I'm the princess, that's why