Fifteen percent of all glasses made in the United States will have to be remade.1 Thats a big number and I admit to contributing my fair share. But we all have remakes. Spectacle rechecks, remakes and difficult patients are all facts of life in our profession.

A few remakes say nothing about your skills as an optometrist, but how you handle those remakes may say everything about your practice and the care you provide. This article discusses ways to avoid the need for remakes and three possible strategies to deal with them when they do arise.

An Ounce of Prevention
The optical laboratory industry divides remakes into three categories: laboratory error, doctors changes (or doctors error) and product warranties. The only cause for remakes that we can control is the doctors change. Of course, the best way to handle these remakes is not to have them. In other words, what can you do to verify a prescription before it goes from the phoropter to the Rx pad? These suggestions can help you reduce prescription changes and limit the number of remakes in your practice:

Verify a prescription. You likely have all the tools you need to verify a prescription, but do you use them on every patient? When you dilate your patients, take a few extra minutes to check the cycloplegic refraction. It reveals the patients true resting refractive state, which is why surgeons also want this information prior to LASIK surgery.

Use a trial frame. When was the last time you picked up a trial frame? (Ill never forget the time I filled in at a commercial store and had to wipe the dust off a trial frame in front of the patient.) If you havent used a trial frame since optometry school, you might consider using one with remake-prone patients. You should also use at least one objective measure of refraction, such as retinoscopy or autorefraction, to eliminate a lot of uncertainty about a patients prescription.

To reduce the number of remakes in your practice, verify the prescription, use a trial frame and double check demanding prescriptions.

Patients who accept a trial frame have their chance to report a problem. Because these patients are aware of this, they are more likely to learn to adapt to their new prescriptions when their glasses arrive. Also, patients who have never used trial frames during an exam will likely appreciate the extra time you spend with them.

Double check demanding prescriptions. We all know the clichs about lawyers and engineers being critical observers. But in addition to demanding personalities, be on the lookout for demanding prescriptions. Patients most prone to remakes include pseudo-myopic patients and patients who have high amounts of astigmatism, large myopic shifts and hyperopia accompanied by headaches. It may not be possible to cycloplege or trial frame every patient. So, be on the look out for these at-risk patients.

The Spectacle Check
Regardless of our efforts to prevent spectacle remakes, some patients will have problems with their glasses. These problems are often due to unrealistic expectations on the part of the patient.

However, dont view these patients as problems. Instead, show these patients how much you care about them by how hard you try to solve their problem. About 90% of my spectacle checks simply need further education and a little reassurance. Speaking of education, use these patient encounters as a second chance to educate your patients that they made the best choice when they chose your practice.

To minimize your frustration with spectacle checks, train your staff to help you solve problems. As soon as a patient reports a problem with his new glasses, an employee should use the lensometer to verify the prescription and should check the interpupillary distance (PD), seg height, base curves and material.

Next, your optical staff should adjust the frames on the patients face and discuss how the patient normally wears and uses the glasses. If a patient uses her glasses improperly, it could cause visual problems. For example, a patient who wears her new progressive lenses way down on her nose will certainly have trouble reading. Proper education, instruction and adjustments by your optical staff could eliminate a large percentage of your spectacle recheck visits.

If the patient still has problems even though the glasses were made and are worn correctly, have your staff clearly mark the PD and seg height on the lenses, if appropriate. Delegate the patients acuities to a staff member and ask him or her to present this data to you before you meet with the patient. In most cases, youll be able to diagnose the problem before you walk into the exam room. Its much easier to handle a disappointed or frustrated patient if you have already discovered the problem.

Anger Management
Spectacle rechecks cost chair time, and frustrate the doctor and the patient. Sometimes that frustration can boil over in the exam room. Most of these patients have spent several hundred dollars in your office. They may be angry and skeptical of your skills because they have a problem with their prescription. If they dont know about your patient-friendly remake policy, they may fear they will be out some serious money. Perhaps they are even worried that something could be wrong with their eyes.

Try to put these patients at ease from the beginning of the exam. Listen to their problems and reassure them with a positive comment such as: Ill take care of it, or These problems are usually easy to solve. Lets take a look. Once my patients learn that I am on top of the problem and they wont lose the money they spent on their glasses, they usually relax.

A few patients have become belligerent despite my best efforts to reassure them that well find the problem. These patients are often more interested in placing blame than in solving the problem. How many times have you heard a patient say, My last doctor screwed up my prescription? Indeed, even many wholesale optical labs like to call a prescription change a doctors error.

But of course it takes two people to do a refraction. I usually like to remind angry patients that the eye exam is a cooperative process that involves two people: the optometrist and the patient. For example, I tell them: Remember that we found this prescription together. Im relying on your responses to help you find the prescription that will be best for you.

Sometimes the patient complicates his own refraction. Weve all had people in our chair who simply cannot follow our instructions during the refraction. Yet, these same people will yell the loudest if their prescription is not perfect. Occasionally, its the opposite. Patients try too hard and the result is a bad prescription. These over-achievers may be anxious about the refraction because they had problems with their last exam.

Nevertheless, its our job to help patients and care for them, regardless of whos at fault for the remake. I like to explain that we will try again, together, to find a new prescription that might be better. Then, I go through my instructions for how to run the refraction. Without fail, these patients were anxious about the exam during their first visit. They thought they were helping when they scrutinized every lens repeatedly until they all started to look the same.

Limited Warranty, Limited Satisfaction?
The standard in our profession is to offer a patient at least one free recheck. I sometimes find this frustrating because no other medical profession offers free follow-up care. However, these free spectacle checks allow patients to discuss their concerns with us, and they let us show patients that we care about solving their problems. I find that nine out of 10 spec-checks can be resolved with patient education. However, if the problem cannot be solved through discussion and patient education, how should you handle remakes?

There are three basic philosophies for handling spectacle remakes:

Limited warranty. Offer a free recheck for the first month (or for 90 days, or whatever time you desire). After that, the patient is responsible for any exam fees, remake or Rx adjustment. The advantages: You wont feel the pinch for every remake, plus it discourages patients from asking for unnecessary rechecks. The disadvantage: A limited policy can alienate patients who have genuine but hard-to-fix problems.

Unlimited warranty. Another name for it: Total patient satisfaction. Patients can come in any time for rechecks and remakes. The disadvantage: You lose time and money in the short term. The advantage: You win customer loyalty as well as the holy grail of private practice, good word-of-mouth. Advocates of this policy say that when the customer is always right, the business always wins in the end.

Some practices make it their goal to satisfy every patient with unlimited guarantees and unlimited warranties. I worked part-time in several commercial practices during the first four years of my career, and found that customers commonly abused unlimited guarantees and warranties. I once saw a patient taunt the staff at an optical by claiming that he would try a frame for a few days because he could bring it back. This might be an acceptable strategy for a national commercial store, but is it wise for small business?

The flex-warranty that bends the rules. My practice takes a more moderate approach than the unlimited warranty. We do everything we can to satisfy every patient, but we put restrictions and limits on our warranties. However, we only enforce our policies in extreme situations. Our policies are simple: No cancellations on spectacle orders and no cash refunds. We offer patients one free spectacle recheck within 30 days, and we will remake or adjust a prescription one time within 30 days. We also offer a one-time, one-year no fault break guarantee. (See A Sample Remake Policy.)

But we are not rigid or inflexible when a patient has a problem. We remind patients what our rules are, but we will gladly bend them or break them as we see fit. Our patients love it when we break the rules for them! But the written office polices (signed by every patient) also serve as our safety net when a belligerent patient backs us into a corner.

A Sample Remake Policy
In addition to granting their permission to file with insurance, patients must sign our office policies at the beginning of each visit. The following paragraph, which outlines our spectacle remake policy, is just one part of this document. In five years of practice, not one patient has ever cancelled a visit or refused to sign the office policy because of the no-refund clause on spectacles.

Despite this requirement, we rarely enforce our own office policies. Rather, we hold the policies in reserve to protect the practice in those rare occasions when patients try to abuse our services.

We will start your custom spectacle order immediately. For this reason, cancellations on spectacles are not permitted. All glasses are custom crafted for each patient with their unique prescription. Also, all spectacle lenses are custom cut to fit the frame each patient has selected. Therefore, patients may not switch frames after their lenses have been cut. For all of these reasons, cash refunds are not possible. At the doctors discretion, patients who are not satisfied with the vision in their new glasses will have their prescription adjusted at no cost, within 30 days of the original purchase date. Cash refunds are not available on progressive lenses. However, any patient who fails to adapt to their new progressives will have their prescription remade one time into a lens of their choice at no additional charge.

Our policies are in writing to protect us from the patients who would abuse our services. (Its difficult to provide outstanding care to a patient who wants to take advantage of your services.) Regardless of what policies are best for your practice or how strictly you enforce them, have them in writing. Patients will know your rules in advance, and your practice will run smoother because patients, staff and doctors will be working from the same written agreement. A doctor with no office policy appears mean-spirited when he or she refuses a remake in the absence of any type of signed office policy.

Does this philosophy sound arbitrary or prejudicial? We believe its just the opposite. In spirit, we give our patients an unlimited warranty and total customer satisfaction. But in practice, we enforce our limited warranty only when necessary.

Calling it Quits
What if youve done everything possible to satisfy a patient, but the patient still has problems? Even if you follow a limited warranty policy, you should never simply give up on a patient. Telling patients you cannot help them or, even worse, asking them to take their business elsewhere, does not solve the problem. What if the problem really is not in the patients head? What if you missed something?

If I have done two remakes for a patient and she calls back again complaining of poor vision, I typically refer her to a specialist. (And I use the word specialist when talking with the patient.) A referral is in the patients best interest. Maybe we arent clicking, maybe there is a communication problem. Or maybe an undiagnosed medical problem, such as diabetes, is causing problems with the prescription. I tell the patient that we will remake the glasses a third time (breaking my own rule) if the specialist finds a different prescription, but this remake will have to be the last one.

A second opinion is always a good course of action. By referring a patient to a specialist, you begin to draw the situation to a conclusion. The patient hopefully will find some help for his problem. If the problem is in the patients head, the patient is likely to realize this if the specialist informs him that nothing is wrong.

In the end, the doctor always takes the blame for a spectacle problem, regardless of whether the patient is able to faithfully cooperate in his or her own care. But does it really matter whose fault it is? In every case, its our job to do everything possible to help our patients make good choices during the refraction and to provide them with the best care at all times.

However you handle spectacle rechecks and remakes, be sure to have some type of policy. Your policy will say much about your practice and could greatly affect your reputation in the community. Its easy to be everyones favorite optometrist when things are going well, but its a true measure of your people skills, optometric talents and business savvy to manage your practice when difficult spectacle remake situations visit your office.

Dr. Milburn is in private group practice with his wife, Dr. Annamarie Milburn. They have practice locations in Medina and Wooster, Ohio,

1. Dan Lundberg, laboratory consultant for Digital Vision Inc. Personal communication. October 20, 2005.

Vol. No: 143:03Issue: 3/15/2006