Optometrists are sharply divided on whether they should allow staff to refract. About half of the doctors in our National Panel, Doctors of Optometry survey say that O.D.s should not be allowed to delegate refraction. But nearly as many say they should be allowed. Proponents say that delegating refraction makes an office run more efficiently. Others disagree. Those doctors say it undermines the very foundation of optometry.
Although nearly half say it"s OK, only a few doctors actually delegate refraction-fewer than 1 in 10. Here, we"ll review what our panelists had to say about this hot-button issue. (See also the point- counterpoint article on delegating refraction, "Which is Better?", March 2001.)
Close Call
Opinion on this debate is almost evenly divided. The answer: 54% say staff should not be allowed to refract, and 46% say they should.
In many states, staff simply may not refract. The laws don"t allow them. But the question isn"t can or can"t they; it is should they be allowed to refract?
Some panelists say refraction is the cornerstone (or the bread-and-butter) of optometry. "Optometry should never delegate refraction. In fact, it should be unprofessional conduct for an optometrist to delegate this service," says John C. Heiby, O.D., of St. Clairsville, Ohio. "Refraction, at one time, was the highest level of art performed by optometrists. Were that gone, we would become second-class ophthalmologists and overeducated opticians within one generation."
Says Thomas Gaunt, O.D., of Alexandria, Ind.: "Let us not delegate away so carelessly those skills which our predecessors fought so hard to get included within the scope of our practice."
Other optometrists don"t look at delegating refraction as an infringement on the dominion of the O.D.; rather, they think others simply don"t have the qualifications that O.D.s have. "The staff does not have enough optical expertise to make decisions on final prescriptions," says optometrist Lorie Lippiat of Salem, Ohio.
"Will you ever be able to find a technician that can refract as well as yourself?" asks Martin Gresak, O.D., of Moundsville, W.Va.
Another element of refraction is talking to and observing the patient. Some doctors say this interaction is indispensable. "Refraction is more than data collection," says Santa Ana, Calif., optometrist Jon Kendall. "It is the subtle recognition of the patient"s tone of voice when performing it, looking for signs of over-minusing but asking the patient the right questions. This is the "art" of refraction."
Optometrists call it art, but they use a scientific method: "I alter the refraction tests depending on job type, how [the patient is] doing in school, headaches, trouble driving at night, poor sports performance. Is their focusing slow or fast? Any accommodative spasm? There are just too many variables to delegate this," says Blake Peterson, O.D., of Cleveland, Tenn.
Other panelists point out that they simply like having the time to spend with patients. And this reaps additional benefits. If you perform a good refraction, patients will appreciate both the expert service and positive visual outcome. This builds patient loyalty, they say.
See You Later, Delagator
Although he himself doesn"t delegate refraction, one Ohio optometrist says, "I believe an intelligent, motivated employee could learn to refract, especially using automated equipment."
Adds Elkton, Md., O.D. Gerald Resnick: "A well-trained staff enhances patient care." His staff does pretesting which includes auto-refraction, auto-keratometry, non-contact tonometry and visual fields. "No final analysis is done by the staff," he says. "That is the doctor"s responsibility." Dr. Resnick educates staff on preliminary findings to improve their understanding of patient care.
Many panelists who approve of delegating refraction echo the strategy of optometrist Robert L. Fait of Burlington, Wisc.: "My staff does auto-refraction and checks refraction on an auto-refractor. I then fine-tune with the phoroptor."
Larry Gunnell, O.D., of Wichita Falls, Texas, does not delegate refraction, but will have staff do spherical over-refraction or assist in troubleshooting with spherical contact lenses.
Performing the initial refraction is fine with some O.D.s, but "staff shouldn"t be allowed to write the final prescription," says Joan Frank, O.D., of Indianapolis.
Peter Dodge, O.D., of Harrisburg, Pa., takes a (half-jokingly) practical point of view: "Since O.D.s don"t get paid s*** for refraction, it must be delegated in order to make optometric practice cost-effective."
When it comes down to it, most of our panelists won"t put refraction on the line. Though nearly half said it"s OK for O.D.s to delegate this function, only 9% actually do it. And, evidently, many of them are double-checking the results.
Did You Get What You Paid For?
Doctors have differing strategies about acquiring diagnostic equipment. Says Peter Dodge, O.D., of Harrisburg, Pa., "I no longer buy equipment that I know is not cost-justifiable just to say that I provide better care. I spend more time with each patient and charge for that." He refers patients out for specific tests when warranted.
There"s no denying that high-tech equipment impresses patients, though. "The use of modern, advanced instrumentation is an integral part of a patient"s perception of their quality of care," says optometrist Robert C. Brooks of Charleston, S.C. "Diagnostic instrumentation should be placed in a setting that highlights the importance of testing provided. A well-designed pre-testing room is as important as the instrumentation itself."
But bottom line, many doctors have a hard time achieving a return on their investment.
"The problem is that managed care has done two things which are difficult to overcome," says Lansdowne, Pa., optometrist Michael Maizel. "First, they decide what a patient may or may not have done and, second, the patient feels cheated when they pay out of pocket for a non-covered service."
